Learning and implementation of TransREctus sheath PrePeritoneal procedure for inguinal hernia repair.

PURPOSE: The TransREctus sheath PrePeritoneal procedure (TREPP) was introduced as an alternative open and preperitoneal technique for inguinal hernia mesh repair, demonstrating safety and efficacy in retro- and prospective studies. However, little is known about the technique's inherent learning curve. In this study, we aimed to determine TREPP learning curve effects after its implementation in high-volume surgical practice. METHODS: All primary, unilateral TREPP procedures performed in the first three years after implementation (between January 2016 and December 2018) were included out of a large preconstructed regional inguinal hernia database. Data were analyzed on outcome (i.e., surgical complications, hernia recurrences, postoperative pain). Learning curve effects were analyzed by assessing outcome in relation to surgeon experience. RESULTS: In total, 422 primary, unilateral TREPP procedures were performed in 419 patients. In three patients a unilateral TREPP procedure was performed on both sides separated in time. A total of 99 surgical complications were registered in 83 procedures (19.6% of all procedures), most commonly inguinal postoperative pain (8%) and bleeding complications (7%). Hernia recurrences were observed in 17 patients (4%). No statistically significant differences on outcome were found between different surgeon experience (< 40 procedures, 40-80 procedures, > 80 procedures). CONCLUSION: Implementation of TREPP seems not to be associated with a notable increase of adverse events. We were not able to detect a clear learning curve limit, potentially suggesting a relatively short learning curve among already experienced hernia surgeons compared to other guideline techniques.

Intra-abdominal hypertension and compartment syndrome after complex hernia repair.

PURPOSE: Abdominal compartment syndrome (ACS) is a well-known concept after trauma surgery or after major abdominal surgery in critically ill patients. However, ACS as a complication after complex hernia repair is considered rare and supporting literature is scarce. As complexity in abdominal wall repair increases, with the introduction of new tools and advanced techniques, ACS incidence might rise and should be carefully considered when dealing with complex abdominal wall hernias. In this narrative review, a summary of the current literature will highlight several key features in the diagnosis and management of ACS in complex abdominal wall repair and discuss several treatment options during the different steps of complex AWR. METHODS: We performed a literature search across PubMed using the search terms: "Abdominal Compartment syndrome," "Intra-abdominal pressure," "Complex abdominal hernia," and "Ventral hernia." Articles corresponding to these search terms were individually reviewed by primary author and selected on relevance. CONCLUSION: Intra-abdominal hypertension (IAH) and ACS require imperative attention and should be carefully considered when dealing with complex abdominal wall hernias, even without significant loss of domain. Development of a true abdominal compartment syndrome is relatively rare, but is a devastating complication and should be prevented at all cost. Current evidence on surgical treatment of ACS after hernia repair is scarce, but conservative management might be an option in the early phase and low grades of IAH. However, life-saving treatment by relaparotomy and open abdomen management should be initiated when ACS starts setting in.

Strength of small-bites abdominal wall closure using different suturing methods and materials in an experimental animal model.

PURPOSE: Using small instead of large bites for laparotomy closure results in lower incidence of incisional hernia, but no consensus exists on which suture material to use. This study aimed to compare five different closure strategies in a standardized experimental setting. METHODS: Fifty porcine abdominal walls were arranged into 5 groups: (A) running 2/0 polydioxanone; (B) interlocking 2/0 polydioxanone; (C) running size 0 barbed polydioxanone; (D) running size 0 barbed glycolic acid and trimethylene carbonate; (E) running size 0 suturable polypropylene mesh. The small-bites technique was used for linea alba closure in all. The abdominal walls were divided into a supra- and infra-umbilical half, resulting in 20 specimens per group that were pulled apart in a tensile testing machine. Maximum tensile force and types of suture failure were registered. RESULTS: The highest tensile force was measured when using barbed polydioxanone (334.8 N ± 157.0), but differences did not reach statistical significance. Infra-umbilical abdominal walls endured a significantly higher maximum tensile force compared to supra-umbilical (397 N vs 271 N, p < 0.001). Barbed glycolic acid and trimethylene carbonate failed significantly more often (25% vs 0%, p = 0.008). CONCLUSION: Based on tensile force, both interlocking and running suture techniques using polydioxanone, and running sutures using barbed polydioxanone or suturable mesh, seem to be suitable for abdominal wall closure. Tensile strength was significantly higher in infra-umbilical abdominal walls compared to supra-umbilical. Barbed glycolic acid and trimethylene carbonate should probably be discouraged for fascial closure, because of increased risk of suture failure.

Reporting guideline for interventional trials of primary and incisional ventral hernia repair.

BACKGROUND: Primary and incisional ventral hernia trials collect unstandardized inconsistent data, limiting data interpretation and comparison. This study aimed to create two minimum data sets for primary and incisional ventral hernia interventional trials to standardize data collection and improve trial comparison. To support these data sets, standardized patient-reported outcome measures and trial methodology criteria were created. METHODS: To construct these data sets, nominal group technique methodology was employed, involving 15 internationally recognized abdominal wall surgeons and two patient representatives. Initially a maximum data set was created from previous systematic and panellist reviews. Thereafter, three stages of voting took place: stage 1, selection of the number of variables for data set inclusion; stage 2, selection of variables to be included; and stage 3, selection of variable definitions and detection methods. A steering committee interpreted and analysed the data. RESULTS: The maximum data set contained 245 variables. The three stages of voting commenced in October 2019 and had been completed by July 2020. The final primary ventral hernia data set included 32 variables, the incisional ventral hernia data set included 40 variables, the patient-reported outcome measures tool contained 25 questions, and 40 methodological criteria were chosen. The best known variable definitions were selected for accurate variable description. CT was selected as the optimal preoperative descriptor of hernia morphology. Standardized follow-up at 30 days, 1 year, and 5 years was selected. CONCLUSION: These minimum data sets, patient-reported outcome measures, and methodological criteria have allowed creation of a manual for investigators aiming to undertake primary ventral hernia or incisional ventral hernia interventional trials. Adopting these data sets will improve trial methods and comparisons.

Transrectus sheath pre-peritoneal (TREPP) procedure versus totally extraperitoneal (TEP) procedure and Lichtenstein technique: a propensity-score-matched analysis in Dutch high-volume regional hospitals.

PURPOSE: Results of the most commonly used inguinal hernia repair techniques often originate from expert centers or from randomized controlled studies. In this study, we portray daily-practice results of a high-volume, regional surgical group in the Netherlands, comparing TREPP (open (posterior) transrectus sheath pre-peritoneal) with Lichtenstein (open anterior) and TEP (endoscopic (posterior) totally extraperitoneal). We hypothesize that the TREPP shows more favorable outcome compared to the current gold standard procedures: TEP and Lichtenstein. METHODS: Between January 2016 and December 2018, 3285 consecutive patients underwent surgical treatment and were included for analysis. The outcome measures were postoperative pain, recurrence rate and other surgical complications. Propensity-score matching was used to address potential selection bias. RESULTS: After propensity-score matching, there was no statistically significant difference in postoperative pain in the TREPP group compared to the Lichtenstein group (TREPP 7.3% versus Lichtenstein 6.3%; p = 0.67) nor in TREPP compared to TEP (TREPP 7.4% versus TEP 4.1%; p = 0.064). There was no statistically significant difference in recurrences in the TREPP group compared to Lichtenstein (3.8% vs 2.5%; p = 0.42), nor in the TREPP versus TEP comparison (3.9% vs 2.8%; p = 0.55) CONCLUSION: This study compares TREPP with Lichtenstein and TEP in the presence of postoperative pain, recurrences and other adverse outcomes. After propensity-score matching, no statistically significant difference in postoperative pain or recurrences remained between either TREPP compared to Lichtenstein, or TREPP compared to TEP. Based on these results, TREPP, Lichtenstein and TEP showed comparable results in postoperative pain, recurrences and other surgical site complications.

Advanced glycation end products as a biomarker for incisional hernia.

BACKGROUND: Incisional hernia is one of the most frequent complications after abdominal surgery, with incidences up to 30%. A reliable biomarker for the prediction of this complication is lacking. Advanced glycosylation end products (AGEs), also known as non-enzymatic collagen crosslinks, are correlated with aging, smoking, hyperglycemia, hyperlipidemia and oxidative stress. In this study the accumulation of AGEs and the relation between AGEs and incisional hernia were investigated. MATERIALS AND METHODS: In an exploratory case-control study, 23 patients with incisional hernia after midline incision were compared with 17 patients without clinical or radiological signs of incisional hernia after midline incision, AGEs were measured using a Skin Auto Fluorescence (SAF)-reader. RESULTS: Twenty-three patients with a clinically significant incisional hernia and 17 control patients were included. The study groups had significant differences in mean BMI. There was a significant difference between mean AGEs in patients with and without incisional hernia after midline incision (3.00 ± 0.15 vs. 2.56 ± 0.11, T test p = 0.03). CONCLUSION: AGE accumulation measured in the skin indirectly with autofluorescence might be associated with incisional hernia. Prospective larger trials should confirm this finding.

Protective effects of growth hormone on bacterial translocation and intestinal damage in rats with partial intestinal obstruction.

OBJECTIVE: One of the reasons of bacterial translocation (BT) is the complete or partial intestinal obstructions (PIO) of the gastrointestinal system. In this study, we aimed to investigate the effects of recombinant human Growth Hormone (rhGH) on BT in rats with partial intestinal obstruction (PIO). MATERIAL AND METHODS: The rats were randomly divided into the 4 groups: Group I: Sham-operated (SO) (n = 12), Group II control PIO (n = 12), Group III: PIO with rhGH treatment for 5 days (n = 12), Group IV: PIO with rhGH treatment 5 days before PIO and 5 days after PIO (a total of 10 days) (n = 12). In the groups III and IV, the effects of 5 and 10 days administered rhGH were examined. RESULTS: The level of serum and of intestinal fluid IgA was significantly higher in the Group IV compared to the Group I, Group II and Group III. In the Group IV, the number of small intestinal goblet and colonic goblet cells, and the lengths of intestinal mucosal villi and crypt depths were statistically significantly higher than in Groups II and III. The rate of bacterial translocation was higher in the Group II: 100 % in MLNs, 41.6 % in blood culture and 50.8 % in the liver cultures, it was significantly higher compared to the other groups (p < 0.01). CONCLUSIONS: The study results demonstrated that administration of rhGH to the rats with PIO for at least 10 days decreased bacterial translocation (Fig. 3, Ref. 25).

The role of group education on quality of life in patients with a stoma.

Stoma education has been traditionally given in a one-to-one setting. Since 2007, daily group education programmes were organised for stoma patients and their relatives by our stoma therapy unit. The programmes included lectures on stoma and stoma care, and social activities in which patients shared their experiences with each other. Patients were also encouraged to expand interaction with each other and organise future social events. A total of 72 patients [44 (61.1%) male with a mean (± SD) age of 56.8 ± 13.6 years] with an ileostomy (n= 51, 70.8%), a colostomy (n= 18, 25.0%) or a urostomy (n= 3, 4.2%) were included in the study. Patients were asked to answer a survey (SF-36) face-to-face before the initiation of the programme, which was repeated 3 months later via telephone call. The comparison of pre-education and post-education SF-36 scores revealed a statistically significant improvement in all 8-scale profiles, but not in vitality scale, and both psychometrically-based and mental health summary measures. Analyses disclosed that married patients and those who were living at rural districts seem to have the most improvement in life quality particularly in bodily pain, general health and role-emotional scales and mental health summary measure. In our opinion, group educations may be beneficial for stoma patients, and stoma therapy units may consider organising similar activities.

Isokinetic strength of the trunk flexor muscles after surgical repair for incisional hernia.

PURPOSE: The repair of incisional hernias can be accomplished by open or laparoscopic techniques. The Biodex dynamometer measures muscle strength during isokinetic movement. The objectives of this study are to compare the strength of the trunk flexors between patients who underwent repair for incisional hernia and a control group, and to compare trunk flexion after two kinds of operative techniques for incisional hernias with and without approximation of the rectus abdominis muscles. METHODS: The trunk flexion of 30 patients after different operative techniques for midline incisional hernias and of 12 healthy subjects was studied with the Biodex isokinetic dynamometer. RESULTS: The mean torque/weight (N m/kg) for trunk flexion was significantly higher in the control group compared to the patient group after incisional hernia repair. A significantly higher peak torque/weight [coefficient 24.45, 95% confidence interval (CI) -0.05; 48.94, P = 0.05] was found in the two-layered suture technique without mesh compared to the laparoscopic technique after adjusting for gender. CONCLUSIONS: The isokinetic strength of the trunk flexor muscles is reduced after an operation for incisional hernia. There is some evidence that a two-layered suture repair with approximation of the rectus abdominis muscles results in higher isokinetic strength of the trunk flexor muscles compared to the laparoscopic technique.

Classification of primary and incisional abdominal wall hernias.

PURPOSE: A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. METHODS: Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. RESULTS: To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. CONCLUSIONS: A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.