Difficulties and advances of incisional hernia repair after hepatobiliary and pancreatic surgery / 中华消化外科杂志

Abdominal incisional hernia is caused by poor healing of myofascial layer of abdominal wall and abdominal visceral organs protruding through the defect after abdominal surgery. The incidence of abdominal incisional hernia is 5.0%?20.0%, even higher after hepato-biliary and pancreatic surgery. Although great progress has been made in the methods of abdominal incision closure, hernia repair technology and materials, the overall incidence, repair effect and prognosis of abdominal incisional hernia are still not significantly improved. The incisional hernias after hepatobiliary and pancreatic surgery are relatively more complex, and the difficult problems of surgical repair are more prominent, including effectively controlling basic diseases, choosing a better surgical method, reasonably using a variety of abdominal wall defect closure and reconstruction techniques, and reducing the risk of postoperative complications. Relevant guidelines for abdominal incisional hernia repair and abdominal closure have been issued and updated all over the world. In order to improve the treatment of incisional hernia after hepatobiliary and pancreatic surgery and improve the prognosis of patients, the authors summarize the difficulties and new progress in the repair of incisional hernia after hepatobiliary and pancreatic surgery.

Abdomen abierto y cierre temprano de la pared abdominal / Open abdomen and early closure of the abdominal wall

El abdomen abierto es una opción terapéutica en pacientes críticamente enfermos. Se utiliza cuando el cierre de la cavidad abdominal no puede o no debe ser realizado. No obstante, su utilidad como parte de una estrategia tradicionalmente aceptada ha disminuido, en la medida en que se han incrementado las secuelas en la pared abdominal, en especial la hernia ventral. Los procedimientos requeridos para la reconstrucción anatómica y funcional de la pared abdominal, como parte del tratamiento de una hernia ventral, revisten una alta complejidad y constituyen un nuevo escenario quirúrgico. Igualmente, conllevan incertidumbre respecto a su naturaleza y posibles complicaciones, además de que condicionan mayores gastos al sistema de salud. Para evitar los problemas del cierre tardío de la pared abdominal, se han desarrollado alternativas para superar el abordaje tradicional de "tratar y esperar", hacia "tratar y reconstruir" tempranamente. El objetivo de la presente revisión es realizar una descripción de los principales avances en el tratamiento del abdomen abierto y el papel del cierre temprano de la pared abdominal, haciendo énfasis en la importancia de un cambio conceptual en el mismo

The open abdomen is a therapeutic option in critically ill patients. It is used when the closure of the abdominal cavity cannot or should not be performed. However, its usefulness as part of a traditionally accepted strategy has diminished, as sequelae in the abdominal wall, especially ventral hernia, have increased. The procedures required for the anatomical and functional reconstruction of the abdominal wall, as part of the treatment of a ventral hernia, are highly complex and constitute a new surgical scenario. Likewise, they lead to uncertainty regarding their nature and possible complications, in addition to conditioning higher expenses for the health system. To avoid the problems of delayed closure of the abdominal wall, alternatives have been developed to overcome the traditional "try and wait" approach to "treat and reconstruct" early. The objective of this review is to describe the main advances in the treatment of the open abdomen and the role of early closure of the abdominal wall, emphasizing the importance of a conceptual change in it

Application value of transversus abdominis muscle release technique in giant ventral hernia repair / 中华消化外科杂志

Objective:To investigate the application value of transversus abdominis muscle release technique in giant ventral hernia repair.Methods:The retrospective and descriptive study was conducted. The clinical data of 72 patients with giant ventral hernia who were admitted to Beijing Chaoyang Hospital of Capital Medical University from January 2017 to January 2020 were collected. There were 47 males and 25 females, aged from 29 to 79 years, with a median age of 56 years. All patients underwent ventral hernia repair with transversus abdominis muscle release technique and preperitoneal/retro-muscular polypropylene mesh reinforcement. Observation indicators: (1) surgical situations; (2) postoperative complications; (3) hernia-related quality of life. Follow-up was conducted using outpatient examination and telephone interview to detect postoperative complications at postoperative 1, 6 and 12 months. Follow-up was up to January 2021. Measurement data with normal distribution were represented as Mean± SD, and comparison within groups was analyzed using the paired t test. Measurement data with skewed distribution were represented as M (range). Count data were described as absolute numbers. Results:(1) Surgical situations: all 72 patients underwent ventral hernia repair with transversus abdominis muscle release technique and preperitoneal/retro-muscular polypropylene mesh reinforcement successfully. The operation time, volume of intraoperative blood loss and mesh size of the 72 patients were (105±46)minutes, (55±15)mL and (680±225)cm 2, respectively. (2) Postoperative complications: 72 patients were followed up for 12 to 48 months, with a median follow-up time of 16 months. During the follow-up, 7 of the 72 patients were diagnosed with seroma by abdominal computed tomography (CT) scan at postoperative 1 week, the size of which was (460±130)mm 2. The 7 patients with seroma were followed up and results of abdominal CT scan at postoperative 6 months showed that the seroma was completely absorbed. Two of the 72 patients had postoperative intestinal obstruction, which was considered as postoperative paralytic ileus. After conservative treatment, the 2 patients were improved 2 weeks after operation. None of the 72 patients had surgical site infection, intestinal fistula or hernia recurrence. (3) Hernia-related quality of life: the score of hernia-related quality of life of 72 patients before operation and at postoperative 12 months were 40±12 and 73±17, respectively, showing a significant difference ( t=12.527, P<0.05). Conclusion:Transversus abdominis muscle release technique in the giant ventral hernia repair is safe and effective, which can improve hernia-related quality of life of patients.

Técnica extraperitoneal comparada con IPOM plus: Análisis de costos evitados para optimizar el manejo de la hernia ventral por laparoscopia / Extraperitoneal technique compared to IPOM plus: Analysis of saved costs to optimize the management of ventral hernia by laparoscopy

Introducción. Analizamos los costos en el reparo extraperitoneal de la hernia ventral por laparoscopia, desde la perspectiva del sistema general de salud de Colombia, con el fin de mostrar los beneficios de dicho abordaje y su impacto económico, al compararlo con la técnica más implementada, el IPOM plus. Métodos. Se realizó un análisis económico de costo-beneficio, desde la perspectiva del Sistema General de Seguridad Social en Salud (SGSSS) de Colombia, comparando los costos del reparo de hernia ventral con la técnica extraperitoneal, TAPP o TEP, versus el IPOM plus. Se tomaron como costos de referencia lo establecido en el manual tarifario del Instituto de Seguros Sociales. Los datos fueron analizados con Stata V.15 Resultados. Se recolectó y analizó información de 109 procedimientos; 59 del grupo extraperitoneal TAPP/TEP y 50 del grupo IPOM plus, realizados durante los años 2015 a 2018, por el grupo de pared abdominal de Clínica Colsanitas, identificando un ahorro del 69,8 % o resultados de costo-beneficio a favor del grupo extraperitoneal.Discusión. El abordaje extraperitoneal en el reparo de hernia ventral se consideró una estrategia de alto costo-beneficio para el sistema de salud, validado por la experiencia del grupo de pared abdominal de Clínica Colsanitas, al compararla con el abordaje habitual. Teniendo en cuenta que los insumos utilizados para la disección no cambian, la prótesis utilizada para cada una de las técnicas representa un costo importante a considerar, tanto para el sistema como para las instituciones de salud

Introduction. Costs in the extraperitoneal repair of ventral hernia by laparoscopy were analyzed from the perspective of the general health system of Colombia, in order to show the benefits of this approach and its economic impact, when compared with the most implemented technique, IPOM plus. Methods. A cost-benefit economic analysis was performed from the perspective of the General Social Security System in Health (SGSSS) of Colombia, comparing the costs of ventral hernia repair with the extraperitoneal technique, TAPP or TEP, against IPOM plus. The reference costs were taken as established in the rate manual of the Social Security Institute. Data were analyzed with Stata v.15.Results. Information from 109 procedures was collected and analyzed; 59 of the extraperitoneal group TAPP / TEP and 50 of IPOM plus group, carried out during the years 2015 to 2018, by the abdominal wall group of Clinica Colsanitas, identifying a saving of 69,8 % or cost-benefit results in favor of the extraperitoneal group.Discussion. The extraperitoneal approach in ventral hernia repair was considered a high cost-benefit strategy for the health system, validated by the experience of the abdominal wall group of Clínica Colsanitas, when compared with the usual approach. Given that the inputs used for dissection do not change, the prosthesis used for each of the techniques represents an important cost to consider, both for the system and health institutions

Análisis multicéntrico del reparo de la hernia ventral en instituciones de IV nivel, 2015-2019 / Multicenter analysis of ventral hernia repair in IV level institutions, 2015-2019

Introducción. La cirugía de hernia ventral implica una situación de complejidad, dadas las múltiples variables que se deben controlar para estimar los posibles factores determinantes del éxito quirúrgico y la aparición de complicaciones. Según la literatura científica mundial, la incidencia de hernia ventral se estima entre el 10 y el 15 %, y la tasa promedio de complicaciones de esta cirugía varía entre el 10 y el 37 %. El objetivo del presente estudio fue describir la experiencia y los resultados de la cirugía de hernia ventral en dos instituciones de IV nivel, en el periodo de enero de 2015 a marzo de 2019.Métodos. Se trata de un estudio observacional, descriptivo y de cohorte histórica, de pacientes mayores de edad sometidos a corrección de hernia ventral en las Clínicas Colsanitas en los últimos cinco años. Los datos se tomaron del registro estadístico de las instituciones en mención. Resultados. Se incluyeron 612 pacientes en un periodo de cinco años, la mayoría de los cuales era de sexo femenino, con sobrepeso, y predominantemente, con defectos combinados mediales; la tasa general de complicaciones fue del 20 % y, el porcentaje de infección del sitio operatorio, de 9 %; para el desarrollo de esta infección, la técnica de separación de componentes se encontró como un factor de riesgo (p=0,01; RR=2,9; IC 95% 1,32-6,5). En este estudio, no se analizó la recidiva como factor de los diferentes resultados. Conclusiones. Existen pocos datos en la literatura nacional sobre los resultados de este tipo de procedimiento quirúrgico. Es por ello que se procuró brindar a la comunidad científica los resultados de morbimortalidad de esta muestra de pacientes intervenidos por hernia ventral en los últimos cinco años

Introduction: Ventral hernia surgery involves a complex scenario, given the multiple variables that must be controlled to estimate the possible determinants of surgical success and the appearance of complications. Ac-cording to the world literature, the incidence of ventral hernia is estimated between 10% and 15%, and the average complication rate of this surgery varies between 10% and 37%. The objective of this study was to describe the experience and outcomes in ventral hernia surgery in two insti-tutions of IV level, in the period from January 2015 to March 2019.Methods: This is an observational, descriptive and historical cohort study of patients undergoing correction of ventral hernia at Colsanitas Clinics in the last five years. The data were collected from the statistical record of the mentioned institutions.Results: A total of 612 patients were included in a five-year period, most of whom were female, overweight, and predominantly with medial combined defects; the overall complication rate was 20%, and the percentage of op-erative site infection, 9%. From the development of this infection, the component separation was found as a risk factor (p= 0.01; RR= 2.9; CI95% 1.32-6.5). In this study, recurrence was not analyzed as an outcome factor.Conclusions: There is little data in the national literature on the results of this type of surgical procedure, which is why we tried to provide the scientific community with the morbidity and mortality results in our population of patients operated for ventral hernia in the last five years.

Evisceración abdominal postraumática en un niño / Post-traumatic abdominal evisceration in a child

Introducción: Se considera un paciente politraumatizado aquel que presenta dos o más lesiones, de las que al menos una puede comprometer su vida o vaya a originar secuelas invalidantes. Una conducta inicial adecuada puede reducir la mortalidad de pacientes como el que se presenta, pues la atención inicial debe ser ordenada y sistemática; siempre se deben identificar y tratar con prioridad, las lesiones que comprometen la vida del paciente. Objetivo: Presentar un caso, que por su interés y singularidad en el mecanismo de acción, expone la secuencia de actuación que se llevó a cabo por cirujanos generales, fuera de un servicio de cirugía pediátrica. Caso clínico: Se reporta el caso de un paciente masculino de 6 años de edad, que acude al cuerpo de guardia politraumatizado y presenta una avulsión músculo cutánea abdominal con evisceración intestinal, al sufrir caída en movimiento con traumatismo abdominal penetrante con biela de pedal de una bicicleta. A pesar de no contar en la institución de atención, con servicio de cirugía pediátrica, se impuso la cirugía de emergencia por las condiciones del paciente. Conclusiones: Luego de laparotomía inicial con reconstrucción de la pared abdominal y cierre primario con puntos de seguridad, el paciente evolucionó de forma estable. Fue remitido para un servicio de terapia intensiva pediátrica, donde y evolucionó sin complicaciones, hasta su egreso(AU)

Introduction: A polytraumatized patient is considered to be one who presents two or more injuries, of which at least one may compromise his life or cause disabling sequelae. An adequate initial behavior can reduce the mortality of patients such as the one that occurs, because the initial attention must be orderly and systematic, the lesions that compromise the patient's life must always be identified and treated with priority. Objective: To present a case, which due to its interest and uniqueness in the mechanism of action, exposes the sequence of action that was carried out by general surgeons, outside of a pediatric surgery service. Clinical case: We report the case of a 6-year-old male patient who came to emergency, polytraumatized and presenting an abdominal skin muscle avulsion with intestinal evisceration, he suffered a fall during movement with penetrating abdominal trauma with a bike pedal crank. Despite not having a pediatric surgery service in the attending institution, emergency surgery was imposed due to the patient's conditions. Conclusions: After the initial laparotomy with reconstruction of the abdominal wall and primary closure with security points, the patients evolves in a stable way, he was referred to a pediatric intensive care service, where he evolved without complications until discharge(AU)

The Principled Approach to Ventral Hernia Repair / El abordaje basado en principios para el reparo de la hernia ventral

La estandarización de la reparación de la hernia ventral sigue siendo difícil de alcanzar. Los cirujanos utilizan una gran cantidad de técnicas, herramientas y tecnología para reparar defectos similares. Sin embargo, existen principios basados en la evidencia que deben aplicarse a todas las reparaciones, independientemente de la técnica que permita la estandarización y mejores resultados. Se proponen seis principios como base para la reconstrucción compleja de la pared abdominal

Standardization of ventral hernia repair remains elusive. Surgeons use a plethora of techniques, tools, and technology to repair similar defects. Nevertheless, evidence-based principles exist that should be applied to all repairs irrespective of technique allowing standardization and improved outcomes. Six principles are proposed as the basis for complex abdominal wall reconstruction

Reconstrucción de la pared abdominal con colgajo miocutáneo transverso de recto abdominal / Abdominal wall reconstruction with transverse rectus abdominis myocutaneous flap

Los defectos de pared abdominal son un desafío para los cirujanos plásticos. El sarcoma de partes blandas es muy recidivante y hay que hacer amplias exéresis con margen oncológico y como consecuencia quedan amplias zonas por reconstruir. El colgajo transverso de recto abdominal es una opción reconstructiva de esta región con buenos resultados estéticos y funcionales. El objetivo del trabajo es mostrar los resultados de la reconstrucción inmediata de la pared abdominal luego de una amplia exéresis oncológica. Se presenta una paciente femenina, mestiza, de 60 años, con diagnóstico de sarcoma de partes blandas, que abarcaba todo el hemiabdomen ínfero izquierdo hasta límites del reborde costal izquierdo, comprometía aponeurosis, el músculo recto izquierdo, y pequeña parte del peritoneo que se reparó. Se decidió una amplia exéresis y se planificó la reconstrucción con un colgajo miocutáneo transverso de recto del abdomen. Se utilizaron mallas de polipropileno. Se logró la reconstrucción inmediata del defecto oncológico con buenos resultados estéticos y funcionales(AU)

Abdominal wall defects are a challenge for plastic surgeons. Soft-tissue sarcoma is very recurrent and it is necessary to make extensive exeresis with oncological margin and, as a result, there are large areas to be reconstructed. The transverse rectus abdominis flap is a reconstructive option for this region and with good aesthetic and functional results. The objective of the work is to show the results of the immediate reconstruction of the abdominal wall after an extensive oncological exeresis. We present the case of a female patient, mestiza, aged 60 years, with a diagnosis of soft-tissue sarcoma, which encompassed all the left inferior hemiabdomen to the left costal margin limits, compromised the aponeurosis, the left rectus muscle, and a small part of the peritoneum that was repaired. A wide exeresis was decided and the reconstruction was planned with a transverse rectus abdominis myocutaneous flap. Polypropylene meshes were used. The immediate reconstruction of the oncological defect was achieved with good aesthetic and functional results(AU)

Reconstrucción de la pared abdominal mediante la técnica de separación de componentes / Component separation technique for the repair of abdominal wall defects

Antecedentes: La reconstrucción de la pared abdominal tiene como fin restaurar el soporte estructural, otorgando una cobertura estable y optimizando la apariencia estética. La técnica de separación de componentes consiste en el avance medial de un componente muscular y fascial inervados, para reconstruir defectos en la línea media, logra un cierre sin tensión y ayuda a recrear la dinámica de la pared abdominal. Objetivo: El objetivo del siguiente trabajo es presentar la experiencia del Hospital de Carabineros en la reconstrucción de tales defectos utilizando esta técnica y evaluar la tasa de recidiva. Material y método: Estudio retrospectivo de pacientes operados en el Hospital entre 2010 y 2015. Se describe la técnica quirúrgica utilizada.Resultados: Se presenta una serie de 6 pacientes operados en dicho período. El tamaño promedio del defecto fue 272,8 cm². Se utilizó la técnica clásica de separación de componentes y en algunos casos modificaciones para preservar perforantes. La cirugía tuvo una duración de 185 min en promedio. No se han presentado recidivas a la fecha entre los pacientes operados (seguimiento promedio 16,8 meses). Conclusiones: La técnica de separación de componentes repara defectos extensos de manera anatómica, autógena y devolviendo la funcionalidad a la pared abdominal. Es un procedimiento que no está libre de complicaciones, sin embargo, en nuestra experiencia los resultados son estables en el tiempo sin evidenciar recidivas. Se recomienda una adecuada evaluación y selección de cada caso.

Background: The component separation technique is a type of rectus abdominis muscle advancement flap that allows reconstruction of such large ventral defects. The advantages of the component separation technique are that it restores functional and structural integrity of the abdominal wall, provides stable soft tissue coverage, and optimizes aesthetic appearance. Aim: To report our experience in abdominal reconstruction using this technique. Material and methods: Review of medical records of 6 patients subjected to an abdominal wall repair using the component separation technique. Results: The mean size of the abdominal wall defect was 272.8 cm². The classic technique or a modification to preserve perforator vessels were used. The mean surgical time was 185 minutes. After a follow up of 16.8 months, no relapses were observed. Conclusions: In this experience the component separation technique had good results and no relapse of the defect was observed.

Repair of complex abdominal incisional hernia with acellular dermal matrix / 中华普通外科杂志

Objective To evaluate the repair of abdominal complicated incisional hernia using acellular dermal matrix (ADM).Methods Retrospective analysis was made on 7 cases with abdominal complicated incisional hernia treated by ADM in our hospital from January 2008 to June 2010,among them there were 4 males and 3 females.Age ranged from 43 to 83 years and the median age was 53 years.Two concurrent indirect inguinal hernia cases were repaired and concurrent gastrointestinal tract problems including 2 small bowd fistulas were operated one stage in 5 cases.Mean diameter of hernia ring was ( 11.6 ± 2.8 ) cm,ranged from 9.2 to 16.5 cm.5 cases were repaired by using intraperitoneal onlay mesh,others using total extraperitoneal prothesis.Results All patients were operated on successfully.Average time was (33 ±12) min.Blood loss was (16 ±4) ml.Hospital stay was 7 - 12 d.7 patients repaired by ADM fully recovered.There were no chronic pain,paresthesia,pneumonia and urinary tract infection cases,no incision swelling,seroma or infection.All patients were followed up with median time of 14 months,ranging from 5 to 26 months.There were not hernia recurrence,nor surgical site infection during follow-up period.Conclusions For the repairing of abdominal complicated incisional hernia,the application of acellular dermal matrix is safe and effective method especially in those of incisional hernia complicated by infection.

Components separation technique for large abdominal wall defect / 대한외과학회지

Repairing large incisional hernia with abdominal wall reconstruction is a technically challenging problem for surgeons. We report our experience of large midline incisional hernia which was repaired successfully with components separation technique. A patient with incisional hernia, 35 x 20 cm in size, underwent operation following standard components separation technique. The aponeurosis of the external abdominal oblique muscle was longitudinally transected from the rectus sheath, and the external abdominal oblique muscle was separated from the internal abdominal oblique muscle. With further separation of the posterior rectus sheath from the rectus abdominis muscle, closure of the abdominal wall was attained without tension. The post-operative course was uneventful with minor wound seroma. The patient discharged safely, and no further complication in terms of recurrence and wound problem has occurred. Components separation technique could be a possible and effective treatment option for repair of large abdominal wall defect.

Experiencia con la técnica de Clotteau-Prémont en hernias de pared abdominal: reporte preliminar / Experience with Clotteau-Prémont's technique in abdominal wall hernias: preliminary report

Introducción: las hernias posincisionales representan por lo menos un tercio de las hernias de pared. Existen diferentes técnicas de reparación que incluyen el uso de material protésico, lo que ha contribuido a disminuir la recidiva. Sin embargo, ante el rechazo o infección se requieren otras técnicas con tejido autólogo, dado que el uso de material protésico en un ambiente contaminado está contraindicado, pues el riesgo de infección y recurrencia es inaceptablemente alto. Objetivo: comparar dos técnicas de tratamiento para las hernias de pared abdominal en términos de complicaciones posoperatorias y recidiva, para determinar las alternativas en el cierre de pared abdominal en pacientes con hernias ventrales. Material y métodos: se realizó estudio observacional, longitudinal, retrospectivo, de casos y controles pareados, no aleatorizado, en pacientes con hernia de pared, entre enero de 2000 y enero de 2004. Se estudiaron 30 pacientes divididos en dos grupos de 15 pacientes cada uno, pareados por sexo, edad y tipo de hernia: grupo A, pacientes tratados con malla; grupo B, pacientes tratados con técnica Clotteau-Prémont. El seguimiento posoperatorio fue de por lo menos cinco meses. Se evaluó y comparó el índice de complicaciones y recidivas. Resultados: no hubo diferencia entre ambos grupos en complicaciones o recidiva (p < 0.05). El tiempo de seguimiento promedio fue de 18.9 ± 8 meses para el grupo A y de 15 ± 7.9 meses para el grupo B. Conclusiones: la técnica de Clotteau-Prémont es un procedimiento factible y seguro en pacientes seleccionados.

BACKGROUND: Incisional hernias account for at least a third of abdominal wall hernias. There are different techniques of repair that include the use of prosthetic materials, which has lowered the hernia recurrence rate. Nonetheless, its use in case of rejection or infection requires other techniques with local tissue. The use of prosthetic material in a contaminated environment is contraindicated because the risk of infection and recurrence rate is unacceptably high. METHODS: In order to compare two repair techniques for abdominal wall hernias in terms of complications and recurrence to be used as an alternative for hernia repair in patients with abdominal wall hernias, we conducted, between January 2000 and January 2004, an observational, longitudinal, retrospective, non-randomized matched control case study in patients with abdominal wall hernia. A total of 30 patients were studied and were divided into two groups of 15 patients each. Subjects were matched for sex, age and hernia type (group A, mesh treated and group B, Clotteau-Prémont treated) who had at least a 5-month postoperative follow-up. Complication and recurrence rate was assessed and compared. RESULTS: There were no differences between the two groups in complications or recurrence (p <0.05). The average follow-up time was 18.9 +/- 8 months for group A and 15 +/- 7.9 months for group B. CONCLUSIONS: Clotteau-Prémont's technique is a safe and feasible alternative procedure with indications in selected patients.