Keywords
ventral hernia - incisional hernia - laparoscopic hernia repair - robotic hernia repair
The European Hernia Society (EHS) defines ventral hernias (VHs) as “hernias of the
abdominal wall excluding the inguinal area, pelvic area and diaphragm.”[1]
[2] The EHS classification of VHs is provided in [Table 1].
Table 1
Definitions of VHs, set out by EHS[2]
|
Umbilical hernia
|
Primary VH with its center at the umbilicus
|
|
Epigastric hernia
|
Primary VH close to the midline with its center above the umbilicus
|
|
Incisional hernia
|
VH that developed after surgical trauma to the abdominal wall, including recurrences
after repair of primary VHs
|
|
Small VH
|
VH with fascia defect < 1cm
|
|
Medium-sized VH
|
VH with fascia defect 1–4 cm
|
|
Large VH
|
VH with fascia defect >4 cm
|
Abbreviation: EHS, European Hernia Society; VHs, ventral hernias.
Approximately 2 million VH repairs (VHRs) are performed annually worldwide.[3] In recent years, VH surgery has benefitted from surgical and technological innovation,
expanding the limits of what is considered surgically feasible. A wealth of data has
been generated over a short period of time. However, the quality of evidence is variable
and significant heterogeneity in practice exists.[4]
In this context, advancement has been made across the spectrum of VHR, from patient
selection and preoperative assessment, through to novel techniques of fascia advancement
and minimally invasive repair. Study in this field represents an intersection of biomechanics,
material science, and surgery. If a burgeoning relationship between these complementary
disciplines can be combined with rigorous clinical trials, we can be cautiously optimistic
that the therapeutic possibilities offered to patients will continue to improve.
Methodology and Limitations of Studies
Methodology and Limitations of Studies
A PUBMED search was undertaken to identify the guidelines addressing midline (primary
and incisional) VHR published by major surgical societies between 2016 and 2020. Guidelines
specifically addressing nonmidline VHR were excluded. The following guidelines were
included: European Hernia Society (EHS)/American Hernia Society (AHS)[1]; International Endohernia Society (IEHS)[3]; Society of Gastro-intestinal Endoscopic Surgeons (SAGES)[5]; and World Society of Emergency Surgeons (WSES).[6] The key recommendations have been distilled to allow comparison between the guidelines.
The review critically appraises the studies used to establish this guidance, identifies
areas where evidence is weak, and suggests avenues for future study.
This process has identified a paucity of high-quality data in VHR. Less than 3% of
published studies of VHs are randomized-controlled trials (RCTs)[7]; of the 76 studies in this literature review, 10 are RCTs.
Although primary VHs represent a distinct entity to incisional VHs,[8] analysis is often pooled. Forty-six of the 76 studies in this review combine analysis
of primary and incisional VHs. The proliferation of novel surgical approaches and
materials in VHR[3] has resulted in a large number of discrete techniques, limiting the total sample
size of each and again resulting in pooled analyses of disparate treatments.
The primary outcome measures of most studies (recurrence, patient satisfaction and
pain) suffer from lack of standardization in definition[9]
[10] and measurement.[11] Follow-up tends to be short relative to the usual time-scale of recurrence development.[12]
Patient Selection
Indications for VHR include symptom relief, cosmesis, and avoidance of future emergency
presentation. However, nonoperative management in the elective setting is safe.[1]
In a cohort study of 1,358 patients with VHs, 636 underwent watchful waiting. The
most common reasons for nonoperative management were lack of symptoms, patient comorbidities,
and patient's wish. After 5 years, 17% crossover to surgical repair, with 4% presenting
emergently. There was no difference in adverse events compared to those who underwent
initial operative management.[13]
Female gender, advanced age, defect size between 2 and 7 cm, and incisional and umbilical
hernias are more likely to incarcerate, supporting elective repair.[14] By contrast, obesity, smoking, and hemoglobin A1c > 6.5% are associated with increased
wound morbidity.[15]
A RCT of 118 patients with body mass index (BMI) 30 to 40 kg/m2 demonstrated that prehabilitation (nutritional counseling and exercise) resulted
in an increase in patients who were complication-free postoperatively.[16] The EHS/AHS guidelines advise weight loss to BMI < 35 kg/m2 and smoking cessation for at least 4 to 6 weeks prior to elective epigastric and
umbilical hernia repair.[1]
In select cases, this may involve a staged surgical approach: a case series described
15 patients undergoing laparoscopic sleeve gastrectomy followed by staged VHR with
favorable outcomes.[17]
The Carolinas Equation for Determining Associated Risks (CeDAR) equation was developed
through multivariate logistic regression to identify weighted risk factors for wound
complications in open VHR,[18] although its reliability has been questioned in other studies.[19]
The modified frailty index (mFI) is an additional predictor of complications and mortality
following VHR.[20] The factors included in the CeDAR equation and mFI are described in [Table 2]. Both CeDAR and mFI provide tools to aid in shared decision-making discussion with
patients.
Table 2
Features of CeDAR equation and mFI. The OR for surgical site infection in the original
CeDAR study are included
|
CeDAR equation
|
mFI
|
|
Tobacco use (OR: 2.17)
|
Diabetes mellitus
|
|
Previous ventral hernia repair (OR: 2.64)
|
Partially/totally dependent
|
|
Uncontrolled diabetes (OR: 2.01)
|
COPD/preoperative pneumonia
|
|
Presence of stoma (OR: 2.65)
|
Congestive cardiac failure
|
|
BMI > 26 kg/m2 (1.08 per unit BMI)
|
History of myocardial infarction
|
|
Presence of active infection (OR: 2.07)
|
History of angina/PCI
|
|
Hypertension
|
|
Peripheral vascular disease
|
|
Impaired sensorium
|
|
History of TIA/CVA
|
|
History of CVA with neurological deficit
|
Abbreviations: BMI, body mass index; CeDAR, Carolinas Equation for Determining Associated
Risks; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident;
mFI, modified frailty index; OR, odds ratio; PCI, percutaneous coronary intervention;
TIA, transient ischemic attack.
Mesh Selection
Mesh may be synthetic, biosynthetic, or biologic. Of synthetic meshes, medium weight
options are associated with fewest complications.[7] Polypropylene is an example of a commonly employed synthetic mesh. In contaminated
fields, synthetic mesh carries a prohibitively high surgical site infection rate of
19%[21] and is not recommended.[6] This led to the development of potential alternatives.
Biosynthetic meshes absorb over a period of 6 to 18 months,[22] with the theoretical benefit of reduced surgical site infection. However, this has
not been borne out in practice: biosynthetic mesh is associated with increased infective
complications compared to biologic and synthetic mesh in clean-contaminated and contaminated
surgery,[23] as well as high recurrence rates.[24]
Biologic meshes provide a collagen based extracellular matrix scaffold to promote
fibroblast collagen deposition, cellular repopulation, and neovascularization.[6] Two types exist: cross-linked and non-crosslinked, with the former being more durable.[25] Although a multicenter retrospective study found biologic mesh in the contaminated
setting to be associated a nonsignificant reduction in wound infection and recurrence,[26] this was not confirmed in a systematic review.[27]
The LAPSIS RCT assessing mesh use in the clean environment was concluded prematurely
due to excessive recurrence rate in the biologic group.[28] A cohort study found biosynthetic mesh to be superior to biologic mesh in elective
complex VHR.[29]
Biologic mesh is significantly more expensive than synthetic mesh.[30] At present, there is no strong evidence to support its use in contaminated cases.[1]
[3]
[7] It is not recommended for large defects in the clean setting.[22] Fundamental studies of biosynthetic and biologic meshes are presented in [Table 3].
Table 3
Key studies assessing biosynthetic and biologic mesh outcomes
|
Reference
|
Type of study
|
Sample size
|
Intervention
|
Comparison
|
Follow-up (mo)
|
Outcome
|
|
Sahoo et al 2017[23]
|
Retrospective cohort study
|
469
|
Biosynthetic mesh
|
Synthetic mesh
|
1
|
Biosynthetic mesh associated with increased surgical site infection (p = 0.03) and reoperation rates (p = 0.009) compared to synthetic mesh in clean-contaminated and contaminated cases
|
|
Renard et al 2020[24]
|
Retrospective cohort study
|
81
|
Biosynthetic mesh (Vicryl)
|
Biologic mesh (Strattice)
|
36
|
Biosynthetic mesh associated with increased early (p = 0.03) and late (p = 0.046) infectious complications and recurrence (HR = 0.091 p< 0.001) compared to biologic mesh in contaminated incisional hernia repair
|
|
Bondre et al 2016[26]
|
Retrospective cohort study
|
761
|
Biologic mesh
|
Synthetic mesh
|
15
|
Biologic mesh associated with nonsignificant reduction in infection complication (15.1
vs. 17.8%, p = 0.28) and increase in recurrence (17.8 vs. 13.5%, p = 0.074) relative to synthetic mesh in contaminated VHR
|
|
Lee et al 2014[27]
|
Systematic review
|
1,304
|
Biologic mesh
|
Synthetic mesh
|
23.2
|
In clean contaminated cases, biologic mesh associated with increased wound infection
rates (31.6%, [14.5–48.7%] vs. 6.4% [3.4–9.4%]) with similar recurrence rates. In
contaminated cases, biologic mesh associated with increased recurrence (27.2% (9.5–44.9%)
vs. 3.2% (0.0–11.0%) with similar wound infection rates
|
|
Miserez et al 2010[28]
|
RCT (prematurely closed)
|
257
|
Noncross linked biologic mesh (Surgisis Gold)
|
Synthetic mesh
|
12
|
Biologic mesh associated with higher recurrence across all study arms (laparoscopic
19 vs. 5%; open (11 vs. 3%) in elective VHR
|
|
Buell et al 2017[29]
|
Retrospective cohort study
|
73
|
Biosynthetic mesh (P4HB)
|
Biologic mesh (porcine cadaveric)
|
–
|
Biosynthetic mesh associated with reduced complication (p < 0.046) and recurrence (p < 0.049) compared to biologic mesh in elective complex abdominal wall reconstruction
|
Abbreviations: RCT, randomized controlled trial; VHR, ventral hernia repair.
Plane of Mesh Placement
The keys planes in VH surgery are described in [Table 4].[31] An appreciation of the relevant anatomy is central.[32]
Table 4
Planes for mesh placement in ventral hernia surgery, adapted from ref.[31]
|
Plane
|
Anterior relation
|
Posterior relation
|
|
Onlay
|
Subcutaneous tissue
|
Anterior rectus sheath and external oblique
|
|
Inlay
|
Mesh attached to edges of hernia defect
|
|
Retrorectus
|
Rectus abdominis muscle
|
Posterior rectus sheath
|
|
Preperitoneal
|
Transversalis fascia
|
Peritoneum
|
|
Intraperitoneal
|
Peritoneum
|
Abdominal cavity
|
The EHS/AHS guidelines advise sublay mesh placement for VHR.[1] This refers to mesh placed in either a retrorectus or preperitoneal location. A
retrospective cohort study of incisional hernia repairs found sublay placement to
improve recurrence and complication rates.[33] The MORPHEUS RCT evaluating primary VHR found preperitoneal mesh to be associated
with reduced complications and cost with no difference in recurrence compared to intraperitoneal
patch repair.[34] A further cohort study[35] and meta-analysis[36] evaluating both primary and incisional VHs found the retrorectus location to be
associated with reduced recurrence and wound infection rates.
By contrast, intraperitoneal mesh placement may promote adhesion formation. In a series
of 733 patients undergoing laparoscopic intraperitoneal mesh repair, 2% required reoperation
for bowel obstruction after mean follow-up of 19 months.[37]
Antibiotic Prophylaxis
The EHS/AHS, IEHS, and SAGES guidelines advise a single perioperative dose of antibiotics
if mesh is used for VHR.[1]
[3]
[5] The SAGES guidelines advise cephalosporin (+ vancomycin for patients with known
MRSA).[5]
A meta-analysis highlighted the paucity of data.[38] The single RCT did not find benefit to antibiotic prophylaxis; however, it included
only 19 patients.[39] The guidelines acknowledge that the strength of this recommendation is weak.
Preoperative Planning and Adjuncts to Abdominal Wall Reconstruction
Preoperative Planning and Adjuncts to Abdominal Wall Reconstruction
Preoperative Imaging
For simple elective primary VHR, the EHS/AHS guidelines recommend that clinical examination
should be sufficient. Ultrasound or computed tomography (CT) imaging may be considered
if clinical examination is inconclusive.[1]
For complex primary and incisional hernias, CT is helpful in preoperative planning[3]: to define defect size, loss of domain (hernia sac volume divided by total peritoneal
sac volume[40]), to predict requirement for component separation,[41] risk of complications,[42] and to guide adjuncts such as preoperative progressive pneumoperitoneum.[40] Loss of domain >15% is likely to lead to significant respiratory impact on return
of the visceral contents to the abdominal cavity,[43] while loss of domain >20% is associated with failure of tension-free closure.[44] Visceral fat volume is a significant predictor of recurrence, while hernia sac volume
and subcutaneous fat volume predict infection rates.[42]
The SAGES guidelines acknowledge the utility of preoperative CT in select cases; however,
they reiterate that CT is not able to detect intra-abdominal adhesions or assess abdominal
wall compliance, two key factors in operative planning.[5] The IEHS guidelines recommend that dynamic measurement of defect size at different
pressures of pneumoperitoneum improves quality of mesh size selection.[3]
Techniques to Allow Fascia Closure
Primary fascia closure (with sublay mesh) is associated with reduced recurrence rates
compared to bridged inlay mesh repair.[7] A number of techniques have been developed to extend the abdominal wall musculature
to permit this with large defects. The IEHS guidelines advise that these are likely
to be required for fascia defects of 8 to 10 cm.[3] Component separation techniques (CSTs) represent the best-studied examples of these
methods.[45]
[Table 5] presents a description of key CSTs.
Table 5
Description of component separation techniques
|
Technique
|
Description
|
|
OACS
|
Subcutaneous adipose tissue is dissected from the anterior rectus sheath to beyond
the linea semilunaris. External oblique is incised along its length and dissected
from internal oblique. Rectus abdominis is also separated from the posterior rectus
sheath[46]
|
|
p-OACS
|
Subcutaneous adipose tissue is dissected from the anterior rectus sheath to beyond
linea semilunaris at two distinct sites above and below the umbilicus. These two sites
are then joined to create a tunnel over external oblique. The release of external
oblique is completed as per the original OACS[47]
|
|
e-CST
|
Balloon dissection is used to create a space between external oblique and the subcutaneous
adipose tissue. Two further working ports are inserted into this space to incise external
oblique and then free it from internal oblique[48]
|
|
mi-CST
|
Optical port entry is used to insert a port deep to external oblique. The space between
external oblique and internal oblique is developed by carbon dioxide insufflation.
Working ports are then inserted and the procedure is completed as per e-CST[49]
|
|
TAR
|
Retrorectus space is developed to linea semilunaris. The posterior rectus sheath is
incised medial to linea semilunaris to reach transversus abdominis. Transversus abdominis
is incised along its length to reach the potential space between transversus fascia
posteriorly and transversus abdominis anteriorly. This space is developed laterally[50]
|
Abbreviations: e-CST, endoscopic anterior component separation; mi-CST, minimally
invasive anterior component separation; OACS, open anterior component separation;
p-OACS, perforator sparing open anterior component separation; TAR, transversus abdominis
release.
Open anterior component separation (OACS) allows fascia advancement by approximately
10 cm. However, the undermining of subcutaneous tissue and interruption of perforator
vessels leads to up to 40% wound morbidity.[51] This led to the development of alternative techniques. The perforator-sparing OACS
spares the periumbilical perforator vessels, with theoretical improvement in wound
healing. Endoscopic CST and minimally invasive CST further reduce tissue trauma with
intended reduction in wound morbidity.
As with other aspects of VHR, the evidence regarding CSTs is limited by heterogeneity
and lack of RCTs.[3] A systematic review found reduced wound complication rates in endoscopic or minimally
invasive CST compared to open.[52] Regarding transversus abdominis release (TAR), a meta-analysis reported no difference
in wound infection or rate of hernia recurrence between OACS and TAR.[53]
Although the IEHS guidelines acknowledge the lack of strong data, they advise consideration
of endoscopic/minimally-invasive ACS or TAR as an alternative to OACS to reduce wound
morbidity.[3] Importantly, when a CST is used, the associated weakening of the lateral abdominal
wall necessitates mesh reinforcement.[3]
Additional examples of techniques to improve fascia coverage include preoperative
Botox injection,[54] progressive pneumoperitoneum,[55] and tissue expanders. Indeed, Botox injection and progressive pneumoperitoneum can
be safely combined to achieve a significant reduction in the ratio of the volume of
hernia sac to that of the abdominal cavity.[56] These techniques have been evaluated in a systematic review.[57] All three are safe and may be used in combination with CSTs. However, there is insufficient
evidence for them to be recommended at present by the IEHS.[3]
In cases where tissue loss will lead to inadequate coverage of the repair, plastic
surgical input may be required for split-skin graft or flap reconstruction.[58] In cases with unstable skin coverage, flap closure appears superior to mesh alone.[59] This will require interdisciplinary work with the plastic surgery team.
Technical Considerations in Open Ventral Hernia Repair
Technical Considerations in Open Ventral Hernia Repair
Primary Ventral Hernia Repair
The EHS/AHS guidelines recommend that mesh should be used for all primary VHRs, regardless
of size.[1] A 2018 RCT found reduced recurrence rate when mesh was used to repair umbilical
hernias as small as 1 cm.[60] A Danish cohort study also found reduced recurrence rates for primary VHs <2cm when
mesh was used.[61] These findings were confirmed in meta-analysis.[62]
Subgroup analysis suggests that these findings hold for defects <1cm.[62] However, the EHS/AHS guidelines advise that suture repair alone may be considered
for these small hernias.[1] If a suture repair is performed, slowly absorbable or nonabsorbable sutures should
be used,[1] although two large Danish population studies found no difference in outcome dependent
on suture type.[61]
[63]
The mesh-defect overlap should be 2 cm for defect < 1 cm and 3 cm for defect 1 to
4 cm.[1] However, the data regarding this is conflicting. A systematic review and case series
found that for open repairs there was no significant association between degree of
overlap and recurrence.[64]
[65] By contrast, a cohort study found overlap < 1cm to be associated with increased
recurrence and in two RCTs (albeit designed to evaluate separate issues), overlap
of 3 cm was associated with reduced recurrence.[34]
[60]
There is insufficient evidence to guide a particular technique for mesh fixation,
although if the decision is made to fix the mesh, nonabsorbable sutures are advised.
With regard to defect closure over the mesh, the guidelines recommend closure although
again acknowledge that the evidence is weak.[1]
Incisional Hernia Repair
The higher recurrence rate associated with incisional VHR[8] supports the advice that all incisional hernias should be repaired with mesh.[66] Expert consensus supports sublay repair.[7]
Open versus Laparoscopic Ventral Hernia Repair
Open versus Laparoscopic Ventral Hernia Repair
The laparoscopic approach should be considered for hernia defects > 4 cm, in addition
to patients with defects 1 to 4 cm that are at increased risk of wound infection (e.g.,
obesity) and for patients with multiple defects.[1]
[3]
The SAGES guidelines advise the factors listed in [Table 6] as relative contraindications to the laparoscopic approach.[5]
Table 6
Relative contraindications to laparoscopic repair of ventral hernia, as per SAGES
guidance[5]
|
Significant adhesions
|
|
Recurrence hernia
|
|
Defect > 10 cm
|
|
Unusual location (e.g., subxiphoid, suprapubic)
|
|
Loss of domain
|
|
Presence of skin graft
|
|
Small defect: sac size ratio
|
|
Presence of enterocutaneous fistula
|
|
Required removal of large mesh
|
Abbreviations: IEHS, International Endohernia Society; SAGES, Society of Gastro-intestinal
Endoscopic Surgeons.
IEHS advises a greater defect size of > 15 cm as a relative contraindication.[3]
A Cochrane review[67] demonstrated reduced surgical site infection with the laparoscopic approach, with
no difference in recurrence rate. The laparoscopic technique was associated with a
higher risk of bowel injury, although this event was rare with a total of 7 enterotomies
in 642 cases (5 laparoscopic, 2 open). Limited to primary umbilical hernias, a meta-analysis
of 16,549 patients found the laparoscopic approach to be associated with reduced wound
infection, recurrence, and length of stay, although longer operating time.[68] The limitations of VHR data discussed in the introduction apply.
An advantage of the laparoscopic technique is that any nearby additional hernia defects
are visible at the time of the first operation and can be repaired using the same
mesh, avoiding the overlooked additional hernia as a cause of “recurrence.” On the
other hand, the lack of an abdominoplasty component with the laparoscopic technique
can result in a less favorable cosmetic outcome for larger hernias. The risks of intraperitoneal
mesh placement have been described previously.
Technical Considerations in Laparoscopic Ventral Hernia Repair
Technical Considerations in Laparoscopic Ventral Hernia Repair
The most widely performed laparoscopic technique is the intraperitoneal onlay mesh
(IPOM) repair: an intraperitoneal antiadhesion barrier-coated synthetic mesh is placed
to cover the defect, recreating the abdominal wall.[1]
[3]
The association between degree of overlap and recurrence is more established for laparoscopic
repair than open. Mesh overlap of >5cm was found to be associated with reduced recurrence
rate.[64] This approach is advocated by EHS/AHS.[1] A further study found mesh: defect area ratio to be the greatest predictor of recurrence;
a mesh: defect ratio of ≥ 16 significantly improves recurrence.[69] The IEHS guidelines recommend this threshold as the determinant of mesh size selection.[3]
In addition, the SAGES guidelines highlight that recurrence is reduced where the mesh
is fixed lateral to the rectus abdominis.[5] This also reduces the risk of injury to the epigastric vessels.
Various mesh fixation techniques for IPOM exist. The results of key studies are summarized
in [Table 7]; no single technique emerges as clearly superior.
Table 7
Summary of key studies evaluating different techniques of laparoscopic mesh fixation
in ventral hernia repair
|
Reference
|
Type of study
|
Sample size
|
Intervention
|
Comparison
|
Mean follow-up (mo)
|
Outcome
|
|
Reynvoet et al 2014[70]
|
Meta-analysis
|
4,300
|
Sutures + tacks
|
Tacks alone; sutures alone
|
29.1
|
No significant difference in recurrence (sutures + tacks 2.5% (1.3–3.7%); tacks 3.4%
(2.4–4.5%); sutures 0.9% (0–1.7%) or pain between different techniques
|
|
Baker et al 2017[71]
|
Meta-analysis
|
6,553
|
Sutures
|
Absorbable tacks; absorbable tacks + sutures; permanent tacks; permanent tacks + sutures
|
22
|
The crude recurrence rates were as follows: absorbable tacks + sutures 0.7%; sutures
1.5%; permanent tacks + sutures 6.0%; permanent tacks 7.7%; absorbable tacks 17.5%.
Statistical significance was not achieved in these differences
|
|
Brill and Turner 2011[72]
|
Systematic review
|
8,465
|
Sutures ± tacks
|
Sutures alone; tacks alone
|
30.1
|
No significant difference in hernia recurrence or prolonged postoperative pain. Sutures
associated with significantly higher SSI
|
|
Ahmed et al 2018[73]
|
Meta-analysis
|
466
|
Tacks
|
Suture
|
16.1
|
No significant difference in postoperative pain at 4–6 weeks (MD: 0.18; 95% CI: −0.48–0.85),
chronic pain (OR: 1.24 [0.65–2.38]) or recurrence (OR: 1.11 [0.34–3.62]), although
operative time was significantly lower with tack fixation (MD: −19.25 [−27.98–−10.51])
|
|
Sajid et al 2013[74]
|
Meta-analysis
|
207
|
Tacks
|
Suture
|
10.6
|
No significant difference in recurrence (OR: 1.54 (0.38–6.27). Tacks associated with
reduced operative time (MD: −23.65 [−31.06–−16.25]) and 4–6 weeks postoperative pain
(MD: −0.69 [−1.16–−0.23])
|
|
Khan et al 2018[75]
|
Meta-analysis
|
1,149
|
Absorbable tacks
|
Nonabsorbable tacks
|
30
|
No difference in recurrence (RD: 0.03 [−0.04–0.09]) or chronic pain (OR: 0.91 [0.62–1.33])
|
|
Eriksen et al 2011[76]
|
RCT
|
40
|
Fibrin sealant
|
Titanium tacks
|
1
|
Fibrin sealant associated with reduced acute postoperative pain on days 0–2 (p = 0.025) and resumed normal activity earlier (p = 0.027)
|
|
Eriksen et al 2013[77]
|
RCT
|
40
|
Fibrin sealant
|
Titanium tacks
|
12
|
Fibrin sealant associated with higher recurrence rates (26 vs. 6%, p =0.182), although not statistically significant. No significant difference in pain
at 1 year follow-up
|
|
Stirler et al 2017[11]
|
Prospective cohort study
|
80
|
Absorbable tacks
|
Titanium tacks
|
60.5
|
Early postoperative pain was significantly lower with absorbable tacks at 6 (p = 0.008) and 12 weeks (p = 0.008), but not at 18 months (p = 0.21)
|
Abbreviations: CI confidence interval; MD, mean difference; OR, odds ratio; RCT, randomized
controlled trial; RD, risk difference; SSI, surgical site infection.
The EHS/AHS guidelines advise mesh fixation with either nonabsorbable sutures or tacks.[1] The IEHS guidelines advise either suture fixation or a double-crowned tack technique.[3] The SAGES guidelines do not give specific advice regarding mesh fixation.[5]
Similarly, the data regarding the benefit of closing the fascia defect in laparoscopic
VHR (a technique termed “IPOM-plus”) is conflicting. These are summarized in [Table 8].
Table 8
Summary of key studies evaluating fascia defect closure versus defect nonclosure during
laparoscopic ventral hernia repair
|
Reference
|
Type of study
|
Sample size
|
Intervention
|
Comparison
|
Mean follow-up (mo)
|
Outcome
|
|
Nguyen et al 2014[78]
|
Systematic review
|
393
|
Defect closure
|
Defect nonclosure
|
20
|
Defect closure results in reduced recurrence (0–5.7 vs. 4.8–16.7%) and seroma rates
(5.6–11.4 vs. 4.3–27.8%)
|
|
Tandon et al 2016[9]
|
Meta-analysis
|
3,638
|
Defect closure
|
Defect nonclosure
|
34.8
|
Defect closure was associated with reduced adverse events (RR: 0.25, p < 0.001) and seroma (RR: 0.37, p < 0.001)
|
|
Gonzalez et al 2014[79]
|
Retrospective cohort study
|
134
|
Defect closure
|
Defect nonclosure
|
19.4
|
Defect closure was associated with increased operative time (p = 0.012). There was no significant difference in complications (p = 0.084) or recurrence (p = −0.095)
|
|
Lambrecht et al 2015[10]
|
Combined prospective and retrospective cohort study
|
194
|
Defect closure
|
Defect nonclosure
|
32.5
|
Defect closure was associated in increased complication rate (OR: 3.42, 95% CI: 1.25–9.33),
with no difference in seroma, pain at 2 months, pseudorecurrence or true recurrence
|
Abbreviations: CI, confidence interval; OR, odds ratio; RR, risk ratio.
The EHS/AHS and IEHS guidelines advise closure of the fascia defect where possible,[1]
[3] using nonabsorbable sutures.[3] The SAGES guidelines recommend defect closure at the surgeon's discretion.[5]
Although the standard laparoscopic technique remains IPOM repair ± fascia defect closure,
the potential adhesion-related complications of an intra-peritoneal mesh have prompted
EHS/AHS to advocate for sublay mesh placement.[1]
Enhanced-view totally extraperitoneal repair[80] is a novel technique that allows laparoscopic preperitoneal retromuscular mesh repair.
The initial port incision is used to enter the rectus sheath away from the hernia.
The retrorectus space is developed using balloon dissection. Working ports are inserted
into this space. The left and right retrorectus spaces are joined and the dissection
is continued toward the hernia sac. Sharp dissection is used to drop the hernia sac
into the abdomen. The fascia defect is closed and a mesh placed in the dissected retrorectus
space. A case series of 79 patients demonstrated the feasibility of this approach
with one recurrence after mean follow-up of 332 days.[80] A second case series of 11 procedures demonstrated that this approach can favor
the placement of large meshes with no major complication or recurrence after 7 months.[81] However, the data is not yet sufficient to be able to draw firm conclusions.[1]
Robotic Ventral Hernia Repair
Robotic Ventral Hernia Repair
Although preperitoneal mesh placement is achievable laparoscopically, this may be
facilitated using robotic assistance.[1]
[3]
[79] Several robotic VHR techniques exist ([Table 9]).
Table 9
Novel robotic VHR techniques and their more traditional equivalents[3]
|
Robotic technique
|
Equivalent open/laparoscopic technique
|
|
Robotic IPOM
|
Laparoscopic intraperitoneal onlay mesh repair
|
|
Robotic TAPP
|
Laparoscopic transabdominal preperitoneal mesh repair
|
|
Robotic VHR ± robotic TAR
|
Open retrorectus mesh repair ± transversus abdominis release
|
Abbreviations: IPOM, intraperitoneal onlay mesh; TAPP, transabdominal preperitoneal;
TAR, transversus abdominis release; VHR, ventral hernia repair.
The majority of the evidence regarding robotic VHR derives from case series. No studies
to date have sufficient size or follow-up to accurately assess recurrence rates, long-term
complications, or to suggest the superiority of one technique over another.[1]
[3] However, the methods appear promising.[3] Important studies assessing robotic VHR techniques are described in [Table 10].
Table 10
Summary of key studies of robotic VHR
|
Reference
|
Type of study
|
Sample size
|
Intervention
|
Comparison
|
Outcome
|
|
Gonzalez et al 2014[79]
|
Retrospective cohort study
|
134
|
Robotic IPOM-plus
|
Laparoscopic IPOM
|
Robotic IPOM-plus associated with nonsignificant reduction in recurrence (p = 0.095) and complications (p = 0.084), with a significant increase in operative team (p = 0.012) compared to laparoscopic IPOM
|
|
Kennedy et al 2018[82]
|
Retrospective cohort study
|
63
|
Robotic TAPP
|
Robotic IPOM
|
Robotic TAPP associated with reduction in complications without significant difference
in operative time compared to robotic IPOM
|
|
Carbonell et al 2018[83]
|
Retrospective cohort study
|
333
|
Robotic RVHR
|
Open RVHR
|
Robotic RVHR associated with reduced length of stay (p < 0.001), although with a greater rate of surgical site occurrences (mainly seromas)
(p < 0.001) compared to open repair
|
|
Bittner et al 2017[84]
|
Retrospective cohort study
|
102
|
Robotic TAR
|
Open TAR
|
Robotic TAR associated with significant reduction in length of stay (6 days (5.9–8.3
vs. 3 days [3.2–4.3]) but increased operative time (p < 0.01) compared to open TAR
|
Abbreviations: IPOM, intraperitoneal onlay mesh; RVHR, retromuscular ventral hernia
repair; TAPP, transabdominal preperitoneal; TAR, transversus abdominis release.
A limitation with robotic surgery is cost.[85] The cost of equipment (initial purchase and maintenance/disposables) often exceeds
$2 million.[3] Further studies into the long-term implications of robotic surgery are required
to facilitate cost–benefit analysis.[3]
Management of Emergent and Contaminated Cases
Management of Emergent and Contaminated Cases
The EHS/AHS and WSES guidelines advise that synthetic mesh repair should be used for
incarcerated VHs without strangulation.[1]
[6] In this setting, an RCT comparing mesh to suture repair for incarcerated paraumbilical
hernias demonstrated that mesh was associated with reduced recurrence with no increase
in wound infection.[86]
In cases of intestinal ischemia without necrosis and bowel resection without gross
enteric spillage, synthetic mesh repair can be performed without an increase in wound
morbidity.[6] The EHS/AHS guidelines state that this decision should be taken on a case-by-case
basis.[1] Although not unanimous, the main studies in this field support the safety of synthetic
mesh in this environment ([Table 11]).
Table 11
Key studies assessing use of mesh in emergency VHR (excluding contaminated cases)
|
Reference
|
Type of study
|
Sample size
|
Intervention
|
Comparison
|
Outcome
|
|
Haskins et al 2016[87]
|
Retrospective cohort study
|
2,449, emergency VHR
|
Mesh repair
|
Suture repair
|
Mesh repair was not associated with increased wound-related or additional 30-day morbidity
or mortality
|
|
Nieuwenhuizen et al 2011[88]
|
Retrospective cohort study
|
203, emergency groin and VHRs
|
Mesh repair
|
Suture repair
|
Mesh repair was not associated with increased wound complications relative to suture
repair
|
|
Choi et al 2012[89]
|
Retrospective cohort study
|
33,832, clean-contaminated and contaminated VHR (elective and emergency)
|
Mesh repair
|
Suture repair
|
Mesh repair was associated with increased complications relative to nonmesh repair
in clean-contaminated cases (OR: 3.56 vs. 2.52)
|
Abbreviations: OR, odds ratio; VHR, ventral hernia repair.
For the stable patient with bowel necrosis or gross enteric spillage during bowel
resection, if the defect is < 3cm suture repair is advised. If the defect is too large
for suture repair, WSES guidelines suggest consideration of biologic mesh if available.
If not, biosynthetic mesh or planned delayed hernia repair are both viable options.[6] However, the evidence for use of biologic and biosynthetic mesh is weak, as described
previously; this recommendation remains controversial.
For the unstable patient, open wound management is advised to avoid abdominal compartment
syndrome, with early defect closure following stabilization.[6]
A number of studies have demonstrated the feasibility of laparoscopy in the management
of incarcerated VHs.[90]
[91]
[92] A further study extended this to the strangulated setting for groin hernias[93]; reduced wound infection rates were found in the laparoscopic group without an increase
in recurrence. In the emergency setting, the WSES guidelines recommend that laparoscopy
may be considered to treat an incarcerated hernia. However, if strangulation or the
need for bowel resection is anticipated, the open approach is preferable.[6]
A further indication for laparoscopy in the emergency setting is to assess the viability
of spontaneously reduced bowel during open repair via hernia sac laparoscopy. An RCT
of 95 patients with inguinal hernias found hernioscopy reduced hospital stay and major
complications.[94] This could be extended to VHs.
Conclusion
Although there has been a recent increase in research into VHR,[4] there remain a number of issues that require well-designed RCTs to resolve. These
include:
-
Comparison of efficacy and safety of different CSTs and tissue expansion techniques.
-
Determination of optimal mesh fixation technique in laparoscopic VHR.
-
Assessment of benefit of fascial defect closure in laparoscopic VHR.
-
Comparison of novel laparoscopic and robotic techniques to standard IPOM.
-
Assessment of biologic mesh versus suture repair in contaminated cases.
In addition to these trial topics, improvement in preoperative risk stratification
and imaging assessment will improve patient selection.
This review highlights the complexity of VHR; novel techniques and materials develop
rapidly, while supporting data struggles to keep pace. The available evidence to guide
decision-making is often conflicting and relatively weak. Guidelines must rely heavily
on expert consensus.
In this context, challenging cases benefit from discussion in a multidisciplinary
setting including radiological, anesthetic, and surgical (both general and plastic
surgery) teams. Discussion should focus on consideration of preoptimization, probability
of postoperative respiratory impairment, the need for adjuncts to improve fascia coverage,
and optimal surgical approach. Careful assessment in this environment helps to bridge
the gap between currently available evidence and high-quality patient treatment.
