Faculty Bibliography

INTRODUCTION/BACKGROUND:Closure of large hernia defects with minimally invasive surgery has long-been a challenge. Barbed sutures have helped us bridge this technical gap, but their off-label use is not well studied. MATERIALS AND METHODS/METHODS:We describe a suturing technique for minimally invasive ventral hernia repair (MIS-VHR) termed "progressive defect tensioning" and explore its theoretical advantages. Progressive defect tensioning utilizes barbed sutures to progressively and evenly re-approximate the fascia along the entire defect length. Tension is then sequentially applied to each throw, distributing the load across multiple anchor points along the closure. This redistribution of tension is explained using a physics model to depict its theoretical benefit. We also explore how biomechanical properties, such as tissue creep and hysteresis, impact closure of complex defects. RESULTS:Our initial, proof-of-concept cohort of 12 patients with hernias larger than 10 cm undergoing MIS-VHR had acceptable perioperative outcomes compared to the literature. CONCLUSIONS:Ultimately, progressive defect tensioning leverages the properties of barbed sutures and the biomechanics of fascia to achieve optimal tension distribution during MIS-VHR.

BACKGROUND:Randomized studies have endorsed nonabsorbable prosthetics for contaminated ventral hernia surgery, yet the broader applicability and impact on patient-reported outcomes are still questioned. Here, we evaluated the long-term outcomes of elective contaminated ventral hernia repairs (based on Centers of Disease Control and Prevention [CDC] wound classification) using real-world data from a multicenter US cohort, focusing on quality of life and postoperative pain. METHODS:The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective contaminated (CDC class II-IV) ventral hernia repair (2013-2023). After propensity matching, we compared long-term differences in patient-reported quality of life and pain scores (by HerQLes and PROMIS questionnaires) among those who underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh. RESULTS:A total of 1,073 patients were included, of whom 920 (86%), 56 (5%), and 97 (9%) underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh, respectively. Among them, the median age was 62 years (interquartile range [IQR] 53-70), and 523 (49%) were male. The median length and width of the defect were 20 cm (IQR 12-25) and 13 cm (IQR 8-16), respectively. A transversus abdominis release was performed in 716 patients (67% of all cases). In most cases, the mesh was positioned in the retro-rectus (85%) and/or the preperitoneal space (45%). Before and after propensity matching (n = 185), the change from baseline in HerQLes and PROMIS scores at 6 months and at 1, 3, 5, and 6 years was comparable between different types of mesh. Lastly, there were no differences in readmission, surgical site infection, or surgical site occurrence at 30 days. Recurrence at 1 year was also comparable among groups. CONCLUSION/CONCLUSIONS:In the long term, there were no differences in quality of life or pain scores with nonabsorbable, absorbable synthetic, or biologic mesh for elective ventral hernia repair in contaminated fields.

PURPOSE/OBJECTIVE:Recent guidelines indicate the use of mesh in UHR for defects > 1 cm, as it reduces recurrence, with 10% recurrence rate compared to up to 54.5% with primary closure. However, Nguyen et al. shows that primary closure is still widely performed in UHR, especially for small defects (1-2 cm), for which there is no published data to determine the optimal approach. In addition, previous meta-analysis by Madsen et al. comparing mesh repair with primary closure in UHR didn't exclude emergency conditions and recurrent hernias; also, didn't report subgroup analysis on hernia defect size. Thus, we aimed to perform a systematic review and meta-analysis comparing the mesh repairs vs. primary closure of the defect in an open elective primary UHR. METHODS:We searched for studies comparing mesh with suture in open UHR in PubMed, Scopus, Cochrane, Scielo, and Lilacs from inception until October 2023. Studies with patients ≤ 18 years old, with recurrent or emergency conditions were excluded. Outcomes were recurrence, seroma, hematoma, wound infection, and hospital length of stay. Subgroup analysis was performed for: (1) RCTs only, and (2) hernia defects smaller than 2 cm. We used RevMan 5.4. for statistical analysis. Heterogeneity was assessed with I² statistics, and random effect was used if I² > 25%. RESULTS: = 15%) in the overall analysis, with no differences after performing subgroup analysis of RCTs. No differences were seen regarding hematoma and hospital length of stay. CONCLUSION/CONCLUSIONS:The use of mesh during UHR is associated with significantly lower incidence of recurrence in a long-term follow-up compared to the suture repair, reinforcing the previous indications of the guidelines. Additionally, despite the overall analysis showing higher risk of seroma and wound infection for the mesh repair, no differences were seen after subgroup analysis of RCTs. STUDY REGISTRATION/BACKGROUND:A review protocol for this systematic review and meta-analysis was registered at PROSPERO (CRD42024476854).

AIM/OBJECTIVE:Minimally invasive inguinal hernia repair has become increasingly accepted, demonstrating superior outcomes over open procedures in postoperative complications. However, certain postoperative complications, such as seroma, remain a dilemma, with many attributing it to the management of the hernia sac. We aimed to perform a systematic review and meta-analysis comparing the reduction versus abandonment of the hernia sac during laparoscopic inguinal hernia repair. MATERIAL AND METHODS/METHODS:Cochrane, Scopus, SciELO, and PubMed were searched for studies comparing reduction and abandonment of the hernia sac. Our primary outcome was seroma. Secondary outcomes were overall complications, postoperative pain, surgical site infection, recurrence, hospital length of stay (LOS), and operative time. We performed a subgroup analysis of transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques. Statistical analysis was performed with R Studio. RESULTS:2388 studies were screened, and seven studies were included, comprising 3153 patients, of which 916 (29%) were in the abandonment group. We found higher seroma rates for the abandonment group (RR 1.52; 95% CI 1.22 to 1.89; P < 0.001). No differences were found in overall complications (RR 0.88; 95% CI 0.55 to 1.42; P = 0.61), postoperative pain (RR 1.15; 95% CI 0.46 to 2.87; P = 0.76), recurrence (RR 2.67; 95% CI 0.51 to 14.05; P = 0.25), operative time (MD - 4.45 min; 95% CI - 12.77 to 3.86; P = 0.29), and LOS (MD -0.06 days; 95% CI - 0.14 to 0.02; P = 0.14) between both groups. Subgroup analysis of seroma showed no differences between the groups when analyzing TAPP (19.3% vs. 13%; RR 1.65; 95% CI 0.91 to 2.99; P = 0.1) and TEP (9% vs. 4.3%; RR 1.69; 95% CI 0.62 to 4.6; P = 0.3) procedures. CONCLUSION/CONCLUSIONS:Our systematic review and meta-analysis support that hernia sac abandonment may be associated with increased early seroma rates following laparoscopic inguinal hernia repair, but limited data are available for technique-specific analyses.

AIM/OBJECTIVE:Posterior component separation using transversus abdominis release (TAR) is well established as an option for repair of large hernia defects. TAR can be performed robotically (rTAR) or open (oTAR) with limited data to demonstrate benefit and guide decision making. We conducted a systematic review and meta-analysis comparing rTAR and oTAR approaches for ventral hernia repair (VHR). MATERIAL AND METHODS/METHODS:We searched Pubmed, Embase, Cochrane, and Web of Science for studies comparing rTAR and oTAR for VHR. Hybrid rTAR was not included in our analysis. Our primary outcomes were overall postoperative and intraoperative complications, surgical site occurrences (SSO), SSO requiring surgical intervention (SSOPI), surgical site infection (SSI) superficial or deep, and fascial closure. Additional outcomes were operative time (OT), readmission, length of hospital stay (LOS). We performed sensitivity analysis to explore reasons for heterogeneity and outliers, and a proportional meta-analysis of conversion during rTAR. We performed a meta-regression exploring the relationship of BMI, hernia defect and mesh width rTAR/oTAR with the analyzed outcome within each study. RESULTS:for rTAR and oTAR respectively. We found lower overall complications (9% versus 24.6%; RR 0.43; 95% CI 0.26 to 0.73; P < 0.01) and intraoperative complication (5.9% versus 9.1%; RR 0.44; 95% CI 0.22 to 0.88; P = 0.02) rates for the rTAR group. There was no difference in fascial closure between the groups (99% versus 94.6%; RR 1.05; 95% CI 0.99 to 1.11; P = 0.11). rTAR presented lower SSI rates (2.5% versus 7.8%; RR 0.33; 95% CI 0.13 to 0.8; P = 0.01). No differences were found in SSO (16.3% versus 13.7%; RR 0.87; 95% CI 0.51 to 1.48; P = 0.6) or SSOPI (5.4% versus 8.9%%; RR 0.5; 95% CI 0.22 to 1.15; P = 0.1) rates. No statistically significant differences were found in superficial SSI (0.76% versus 3%; RR 0.36; 95% CI 0.07 to 1.75; P = 0.21) and deep SSI (0% versus 4.2%; RR 0.23; 95% CI 0.02 to 3.12; P = 0.27). Open surgery presented a lower OT (MD -67.7 min; P < 0.001), but robotic surgery showed a reduced LOS (-3.9 days; 95% CI -4.8 to -3.1; P < 0.001). No differences were found in readmission and 1 year recurrence rates. The proportional meta-analysis showed a conversion to open rate of 6.4 per 100 patients (95% CI 3.3 to 12 patients) during rTAR. Meta-regression presented no statistically significant influences of rTAR/oTAR mesh width and defect width relations and BMI, despite the analysis was limited by the low number of studies. CONCLUSION/CONCLUSIONS:Robotic TAR may be associated with lower intraoperative and postoperative complications, lower SSI, shorter LOS, and longer operative times when compared to oTAR. Given the limitations of the included studies, randomized trials are needed to better evaluate the impact of the robotic-assisted surgery for complex abdominal wall reconstruction. PROSPERO REGISTRATION/UNASSIGNED:CRD42024540991.

BACKGROUND:Randomized studies have endorsed nonabsorbable prosthetics for contaminated ventral hernia surgery, yet the broader applicability and impact on patient-reported outcomes are still questioned. Here, we evaluated the long-term outcomes of elective contaminated ventral hernia repairs (based on Centers of Disease Control and Prevention [CDC] wound classification) using real-world data from a multicenter US cohort, focusing on quality of life and postoperative pain. METHODS:The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective contaminated (CDC class II-IV) ventral hernia repair (2013-2023). After propensity matching, we compared long-term differences in patient-reported quality of life and pain scores (by HerQLes and PROMIS questionnaires) among those who underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh. RESULTS:A total of 1,073 patients were included, of whom 920 (86%), 56 (5%), and 97 (9%) underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh, respectively. Among them, the median age was 62 years (interquartile range [IQR] 53-70), and 523 (49%) were male. The median length and width of the defect were 20 cm (IQR 12-25) and 13 cm (IQR 8-16), respectively. A transversus abdominis release was performed in 716 patients (67% of all cases). In most cases, the mesh was positioned in the retro-rectus (85%) and/or the preperitoneal space (45%). Before and after propensity matching (n = 185), the change from baseline in HerQLes and PROMIS scores at 6 months and at 1, 3, 5, and 6 years was comparable between different types of mesh. Lastly, there were no differences in readmission, surgical site infection, or surgical site occurrence at 30 days. Recurrence at 1 year was also comparable among groups. CONCLUSION/CONCLUSIONS:In the long term, there were no differences in quality of life or pain scores with nonabsorbable, absorbable synthetic, or biologic mesh for elective ventral hernia repair in contaminated fields.

PURPOSE/OBJECTIVE:Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair. SOURCE/METHODS:A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma. PRINCIPAL FINDINGS/RESULTS:Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger's test showed the absence of publication bias in the study outcomes. CONCLUSION/CONCLUSIONS:This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair. PROSPERO REGISTRATION/UNASSIGNED:ID CRD42024517640.

BACKGROUND:Randomized studies have endorsed nonabsorbable prosthetics for contaminated ventral hernia surgery, yet the broader applicability and impact on patient-reported outcomes are still questioned. Here, we evaluated the long-term outcomes of elective contaminated ventral hernia repairs (based on Centers of Disease Control and Prevention [CDC] wound classification) using real-world data from a multicenter US cohort, focusing on quality of life and postoperative pain. METHODS:The Abdominal Core Health Quality Collaborative database was queried for patients undergoing elective contaminated (CDC class II-IV) ventral hernia repair (2013-2023). After propensity matching, we compared long-term differences in patient-reported quality of life and pain scores (by HerQLes and PROMIS questionnaires) among those who underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh. RESULTS:A total of 1,073 patients were included, of whom 920 (86%), 56 (5%), and 97 (9%) underwent repair with nonabsorbable, absorbable synthetic, and biologic mesh, respectively. Among them, the median age was 62 years (interquartile range [IQR] 53-70), and 523 (49%) were male. The median length and width of the defect were 20 cm (IQR 12-25) and 13 cm (IQR 8-16), respectively. A transversus abdominis release was performed in 716 patients (67% of all cases). In most cases, the mesh was positioned in the retro-rectus (85%) and/or the preperitoneal space (45%). Before and after propensity matching (n = 185), the change from baseline in HerQLes and PROMIS scores at 6 months and at 1, 3, 5, and 6 years was comparable between different types of mesh. Lastly, there were no differences in readmission, surgical site infection, or surgical site occurrence at 30 days. Recurrence at 1 year was also comparable among groups. CONCLUSION/CONCLUSIONS:In the long term, there were no differences in quality of life or pain scores with nonabsorbable, absorbable synthetic, or biologic mesh for elective ventral hernia repair in contaminated fields.