Laparoscopic ventral hernia repair: early follow-up of a randomized controlled study of primary fascial closure before mesh placement.

BACKGROUND: Suturing of the hernia aperture in laparoscopic ventral hernia repair has increased during the past decade. The primary aim of this is to restore the anatomy of the abdominal wall. Closure of the aperture, however, may cause additional tension in the abdominal wall which could increase postoperative pain. The aim of this study was to investigate whether suturing of the hernia aperture affects postoperative pain and hernia-site complications, including seroma, infection, pseudohernia, and mesh migration, 3 months after repair. METHODS: Some 192 patients with a midline hernia between 2 and 8 cm in transverse diameter were included in a randomized controlled double-blinded multicentre study. Patients were randomized to mesh repair with (intervention) or without (control) suturing of the hernia aperture before mesh placement. Patients completed the Ventral Hernia Pain Questionnaire before and 3 months after surgery. Abdominal wall pain and hernia-site complications were assessed 3 months after surgery. RESULTS: Ninety-seven patients were randomized to the intervention group and 95 to the control group. Among all patients, median age and BMI was 56 years and 31 kg/m2 respectively. Overall pain experienced decreased by 3 months after operation (P < 0.001). There was no difference between groups regarding hernia-site complications or pain experienced during the past week (13 versus 23 patients; P = 0.111). Seroma and pseudohernia occurred in 13 and 11 patients in the intervention and control groups respectively (P = 0.975 and P = 0.977). CONCLUSION: Restoration of the abdominal wall anatomy by suturing the hernia aperture before mesh placement does not increase the risk of hernia-site complication or pain 3 months after surgery. This implies that fascial suturing of the aperture can be justified if there are potential long-term benefits such as lower recurrence and/or complication rates. Registration number: ISRCTN51495042 (http://www.controlled-trials.com).

Management of diastasis of the rectus abdominis muscles: recommendations for swedish national guidelines.

BACKGROUND: Diastasis of the rectus abdominis muscle is a common condition. There are no generally accepted criteria for diagnosis or treatment of diastasis of the rectus abdominis muscle, which causes uncertainty for the patient and healthcare providers alike. METHODS: The consensus document was created by a group of Swedish surgeons and based on a structured literature review and practical experience. RESULTS: The proposed criteria for diagnosis and treatment of diastasis of the rectus abdominis muscle are as follows: (1) Diastasis diagnosed at clinical examination using a caliper or ruler for measurement. Diagnostic imaging by ultrasound or other imaging modality, should be performed when concurrent umbilical or epigastric hernia or other cause of the patient's symptoms cannot be excluded. (2) Physiotherapy is the firsthand treatment for diastasis of the rectus abdominis muscle. Surgery should only be considered in diastasis of the rectus abdominis muscle patients with functional impairment, and not until the patient has undergone a standardized 6-month abdominal core training program. (3) The largest width of the diastasis should be at least 5 cm before surgical treatment is considered. In case of pronounced abdominal bulging or concomitant ventral hernia, surgery may be considered in patients with a smaller diastasis. (4) When surgery is undertaken, at least 2 years should have elapsed since last childbirth and future pregnancy should not be planned. (5) Plication of the linea alba is the firsthand surgical technique. Other techniques may be used but have not been found superior. DISCUSSION: The level of evidence behind these statements varies, but they are intended to lay down a standard strategy for treatment of diastasis of the rectus abdominis muscle and to enable uniformity of management.

Vascular Complications After Radiotherapy in Head and Neck Free Flap Reconstruction: Clinical Outcome Related to Vascular Biology.

Radiotherapy as a risk factor for free flap failure has been widely debated. The purpose of this study was to investigate vascular complications in free flap surgery at a center advocating preoperative radiotherapy. On the basis of previous experimental studies, we also aimed to investigate temporal aspects of vascular complications in both arteries and veins. Furthermore, we aimed to study the effect of tissue plasminogen activator (tPA), because irradiated microvascular recipient vessels are associated with impaired fibrinolysis.A retrospective review was conducted for 344 consecutive head and neck microvascular reconstructions. Radiotherapy was administered previously in 283 (82%) of the cases, median dose 64 Gy. Flap outcome, vascular complications, and salvage attempts were identified, along with time elapsed from completed radiotherapy, described as early (<6 weeks), delayed (6-15 weeks) and late (>15 weeks) reconstructions.Total flap loss was more common in irradiated cases (P = 0.035), among which flap failure increased with time elapsed from the last radiotherapy session to surgery (P = 0.021). Among 30 registered vascular complications, venous thrombosis was the most common type and increased in delayed, compared to early, reconstructions (P = 0.012). Increased salvage rates were observed when tPA was administered intraoperatively (P = 0.015).The present study indicates that previous radiotherapy is a risk factor for head and neck free flap failure, especially in delayed reconstructions. This may be linked to previous findings of impaired fibrinolysis in irradiated microvascular recipient veins, which is further supported by the beneficial effect of tPA during salvage surgery. We emphasize the importance of early reconstruction after radiotherapy and suggest that there is a role for fibrinolytic agents during free flap salvage surgery in previously irradiated subjects.