Peritoneal flap technique for abdominal wall expansion in the management of complex ventral hernias: a multicentre study from India.

INTRODUCTION: Large abdominal wall hernias often require techniques for wall expansion to improve surgical outcomes. The peritoneal flap hernioplasty (PF) is one such technique that utilizes the hernia sac to reconstruct the abdominal wall, however, with limited published data. It is a modification of the Rives-Stoppa mesh repair where a part of the bisected hernia sac is utilized to reconstruct the anterior fascia and the other part for the posterior fascia. We present a collated retrospective analysis of the outcomes from three centers performing PF with or without transverse abdominis release (TAR) in patients with complex ventral hernias. METHODS: The PF was performed in patients with incisional hernias, both midline and lateral. The primary outcome measured was hernia recurrence. The secondary outcomes were to evaluate pain, surgical site infection, seroma, hematoma, wound dehiscence, pseudo-recurrence, Clavien-Dindo score for complications, and the patient's reported quality of life. The quality of life was assessed by oral questionnaires in the follow-up period. RESULTS: We analyzed 63 patients (38 female, 25 male) with a mean width of hernia defect of 11 cm SD 4. Based on the European Hernia Society (EHS) classification 42 patients were W3 and 21 were W2 hernias. Fifty patients had a midline hernia, while the rest of the patients included transverse, subcostal, and rooftop incision hernias. The classical peritoneal flap procedure was done in 29 (46%) patients, while the peritoneal flap with TAR was done in 34 (54%) patients. Four patients had symptomatic seroma (6%), seven superficial surgical site infection (SSI) (11%), one deep SSI (1.5%), one skin necrosis (1.5%), and one anterior peritoneal flap necrosis (1.5%). No patient required postoperative ventilatory support. The mean pain score on day one was 3/10. There was no recurrence in the mean follow-up of 17 months (range 5 to 49 months). Overall, 58 of 63 (92%) patients reported being satisfied with their surgery. CONCLUSION: In our multicentre study, we found the PF technique with or without TAR for midline and non-midline ventral hernia leads to satisfactory outcomes in terms of low recurrence, low rate of complications, and a good quality of life in the medium to long term. It appears to be a useful technique in the surgeon's armamentarium to repair W2 and W3 hernias needing expansion of abdominal domain.

Application of bridging mesh repair in giant ventral incisional hernia.

Achieving ideal abdominal wall reconstruction in giant ventral incisional hernia has been a challenging for surgeons. This study aimed to verify the safety and efficacy of bridging repair by comparing it with primary fascial closure (PFC) repair in the treatment of giant ventral incisional hernia. We retrospectively analyzed the clinical data of 92 patients with giant ventral incisional hernia who underwent mesh repair at our medical institution from January 1, 2014 to December 31, 2020. Patients were divided into 2 groups: the bridging repair group with 40 patients in whom repair was completed using the bridging technique and the PFC group with 52 patients in whom primary fascial closure was achieved and all patients underwent mesh reinforcement during the operation. The main outcome measures were recurrence rate and morbidity, especially intra-abdominal hypertension (IAH). Follow-up time of both groups lasted at least 24 months after surgery. After a median of 46 months and 65 months of follow-up, respectively, in the two groups, bridging repair did not increase the long-term recurrence rate (2.56%) in the larger defect area group compared to the PFC group (1.96%). There were no significant differences in perioperative morbidity, IAH, incidence of postoperative chronic pain, and sensory impairment of the abdominal wall between both groups. The application of bridging surgery in the treatment of complex giant ventral incisional hernias is safe and effective and does not significantly increase the postoperative recurrence rate.

The changes in abdominal wall muscles following incisional hernia wall reconstruction.

PURPOSE: The objective of incisional hernia surgery is to achieve the restoration of abdominal wall anatomical and physiological functions. This study aims to investigate the impact of abdominal wall reconstruction on abdominal muscle alterations by measuring the preoperative and postoperative changes in abdominal wall muscles in patients undergoing incisional hernia repair. METHODS: For patients undergoing open incisional hernia abdominal wall reconstruction, preoperative and postoperative abdominal CT scans were analyzed at a minimum of 3 months post-surgery. 3D Slicer software was utilized for measuring preoperative and postoperative changes in abdominal cavity volume, abdominal muscle volume, as well as muscle volume, cross-sectional area, and abdominal circumference at specific levels. The acquired data were subjected to statistical analysis using SPSS software. RESULTS: A total of 40 patients meeting the inclusion criteria underwent open incisional hernia repair surgery. Some of these patients required component separation technique (CST) due to the larger size of the hernia sac. The abdominal muscles surrounding the hernia ring were defined as the "damaged group," while the remaining abdominal muscles were defined as the "undamaged group." Measurements revealed a significant increase in the volume of rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles in the damaged group. Similarly, there was a corresponding increase in the volume of rectus abdominis, external oblique, internal oblique, and transversus abdominis muscles in the undamaged group. CONCLUSIONS: After abdominal wall reconstruction in incisional hernia patients, not only is their anatomical structure restored, but the overall biomechanical integrity of the abdominal wall is also repaired. The damaged muscles are subjected to renewed loading, leading to the reversal of disuse atrophy and an increase in muscle volume.

Abdominal wall defect repair with component separation technique for giant omphalocele with previous relaxing incisions on the abdominal skin.

BACKGROUND: The repair of large abdominal wall defects that cannot be closed primarily is quite challenging. The component separation technique (CST) is a surgical approach using autologous tissue to close large abdominal wall defects. The CST requires extensive dissection between the abdominal skin and the anterior sheath of the rectus abdominis muscle. Subsequently, incisions are made at both sides of the external oblique aponeurosis, releasing the external oblique muscle from the internal oblique muscle, and then the right and left rectus abdominis muscles are brought together in the midline for defect closure. However, impairment of blood flow in the abdominal wall skin and necrotic changes are recognized as potential complications. CASE PRESENTATION: The CST was performed in a 4-year-old boy with a large ventral hernia who had undergone skin closure with abdominal wall relaxing incisions for the primary treatment of giant omphalocele in the neonatal period. Given his history of incisions on the abdominal wall, he was speculated to be at high risk for postoperative skin ischemia. Dissection was therefore kept to a minimum to preserve the blood supply from the superior and inferior epigastric arteries and perforating branches of those arteries through the rectus abdominis muscle. In addition, care was taken to adjust the muscle relaxant dosage while monitoring the intravesical pressure, ensuring that it did not exceed 20 mmHg to avoid impaired circulation in the abdominal wall caused by abdominal compartment syndrome. He was discharged 23 days after the surgery without any complications, and neither recurrence of the ventral hernia nor bowel obstruction was observed in 4 years. CONCLUSIONS: A giant omphalocele with primary skin closure was treated by applying the CST. The procedure can be performed safely while preserving the blood flow to the abdominal wall, even in patients with a history of relaxing incisions on the abdominal skin. The CST is expected to be effective for repairing the large abdominal wall defects seen in giant omphalocele when primary closure is not possible.

Component Separation: A Case Report of Hybrid and Synthetic Absorbable Mesh Use for Complex Large Ventral Hernia Reparation.

Ventral abdominal hernias are a common abdominal wall defect in the United States. We present a 50-year-old Caucasian male with a large (>18 cm) abdominal wall defect. An extensive complex abdominal wall reconstruction with advanced bilateral fascial flaps/component separation and repair of the abdominal wall defect was planned to restore the appropriate abdominal wall anatomic contour. The use of double mesh in large abdominal wall defects is still a relatively new documented technique. Only two case series detail the same technique used on this patient, with no articles on using a hybrid mesh with a synthetic absorbable mesh. This case uses an underlay and onlay mesh technique, with a hybrid mesh, Tela Biologics (Malvern, PA, USA), under the muscle, in this case, intraperitoneal bridging the gap. The anterior rectus sheath was reinforced with intercepted 0-Ethibond sutures (Ethicon/J&J, Bridgewater, NJ, USA) and then reinforced with a synthetic absorbable mesh (PhasixTM, Becton Dickinson, Franklin Lakes, NJ). The outcome with this patient shows more research should be conducted on considering long-term results with the types of mesh and the question of whether there are additional benefits when using two different types of mesh and their placement in the sandwich technique.

Impact of combined component separation technique and shoelace repair on big medline abdominal wall defect.

BACKGROUND: Closure of large anterior abdominal wall defects, regardless of their etiology, is challenging. There is no standardized information describing definitive management. Therefore, we conducted this study to illustrate our experience on large midline abdominal wall defect repair using an effective modified reconstructive technique. METHODS: This retrospective study was conducted at Al Naqib Hospital in Aden/Yemen between 2012 and 2019. Twenty-six patients with large midline abdominal wall defects of various etiologies underwent surgical repair using a combination of shoelace repair and the component separation technique. The procedure involved bilateral longitudinal division of the anterior rectus sheet and creation of a posterior layer by approximation of the medial edges of the divided rectus sheet (shoelace abdominoplasty) and anterior external oblique muscle aponeurosis separation (component separation technique) to approximate the lateral edges of the divided rectus sheet and move the rectus muscles toward the midline for constructing the anterior abdominal wall layer. The posterior and anterior layers and bilateral separated sheets were covered with a polypropylene mesh in all patients, except in those who underwent emergency damage control surgery. RESULTS: Four, one, and two patients developed seroma, skin necrosis and chronic pain, and post-surgical wound infection, respectively. No recurrent herniation was recorded during the median follow-up of 5 years. CONCLUSION: This technique is effective in restoring the integrity of the abdominal wall in large midline abdominal wall defects and has an acceptable aesthetic appearance. In our study, minimal complications were reported, and no cases of recurrent hernias were diagnosed during follow-up.

Double-Breasted Anterior Rectus Sheath Turnover Flap.

The management of the open abdomen follows wound management with temporary abdominal closure prior to definitive closure while concurrently managing patient nutrient and fluid losses. This case report describes the successful use of double-breasted anterior rectus sheath turnover (DART) flap for early open abdomen closure to facilitate oncological management. The patient is a 47-year-old female with uterine smooth muscle neoplasm whose laparotomy wound was complicated with abdominal wound dehiscence and intra-abdominal infection. The abdomen could be closed with no fistula formation, iatrogenic bowel perforations, or overlying skin necrosis, and a follow-up showed no hernia occurrence. In conclusion, the DART flap provides a simple and autologous option for early tension-free midline closure of the open abdomen with acceptable intra- and postoperative complications.

Endoscopic transversus abdominis release in the treatment of midline incisional hernias: a prospective single-center observational study on 100 patients.

BACKGROUND: For W2-3 incisional hernias of the midline, a component separation is often needed to achieve closure of the fascia during repair with a mesh. Posterior component separation has been initially performed via open surgical approach, but more recently interest in minimally invasive reconstruction has grown. The aim of this work is to describe the technical aspects of endoscopic hernia repair with posterior component separation and to assess its feasibility in midline incisional hernias, based on the analysis of the results. METHODS: We prospectively evaluated and analyzed patients with midline incisional hernias who underwent endoscopic posterior component separation by transversus abdominis release (TAR). RESULTS: A group of 100 patients was operated between April 2017 and September 2021. The median follow-up was 27 ± 13.5 months, mean age 59 ± 10.2 years, ASA 2.5 ± 0.7; 94% of patients had comorbidity. There were 7 (7%) complications observed in the early postoperative period-retromuscular hematoma (1), infection of the retromuscular space (4), and thrombophlebitis of superficial veins (2). In 4 (4%) patients, late complications were observed-persistent seroma (3) and chronic pain (1). There were no hernia recurrences in the follow-up period. CONCLUSION: The use of TAR endoscopic separation can reduce the number of unfavorable surgical site events, compared to the published data on a similar open surgery, while maintaining a low recurrence rate.

Reverse TAR may be added when necessary in open preperitoneal repair of lateral incisional hernias: a retrospective multicentric cohort study.

BACKGROUND: The best approach for lateral incisional hernia is not known. Posterior component separation (reverse TAR) offers the possibility of using the retromuscular space for medial extension of the challenging preperitoneal plane. The aim of our multicenter study was to compare the operative and patient-reported outcomes measures (PROMs) using two open surgical techniques from the lateral approach: a totally preperitoneal vs a reverse TAR. METHODS: A retrospective cohort study was performed since 2012 to 2020. Patients with lateral incisional hernia treated through a lateral approach were identified from a prospectively maintained multicenter database. Reverse TAR was added when the preperitoneal plane could not be safely dissected. The results obtained using these two lateral approaches were compared, including short- and long-term complications, as well as PROMs, using the specific tool EuraHSQoL. RESULTS: A total of 61 patients were identified. Reverse TAR was performed in 33 patients and lateral retromuscular preperitoneal approach in 28 patients. Both groups were comparable in terms of sociodemographic and comorbidities variables. Surgical site occurrences occurred in 13 cases (21.3%), with 8 patients (13.1%) requiring procedural intervention. During a median follow-up of 34 months, no incisional hernia recurrence was registered. There was a case (1.6%) of symptomatic bulging that required reoperation. Also 12 patients (19.7%) presented an asymptomatic bulging. No statistically significant difference was identified in the complications and PROMs between the two procedures. CONCLUSION: The open lateral retromuscular reconstruction using very large meshes that reach the midline has excellent long-term results with acceptable postoperative complications, including PROMs. A reverse TAR may be added, when necessary, without increasing complications and obtaining similar long-term results.

The combination of the three modifications of the component separation technique in the management of complex subcostal abdominal wall hernia.

PURPOSE: The purpose of this study is to present a concept combining three modifications of the component separation technique (CST) in one procedure as an original solution for the management of complex subcostal abdominal wall hernia. METHODS: Between January 2010 and January 2020, seven patients presenting at the high-volume academic center with complex subcostal hernia underwent surgery in which three modifications of CST were combined into one procedure. Major complex subcostal hernia was defined by either width or length of the defect being greater than 10 cm. The following were the stages of the operative technique: (a) the "method of wide myofascial release" at the side of the hernia defect; (b) "open-book variation" of the component separation technique at the opposite side of the hernia defect; (c) a modified component separation technique for closure of midline abdominal wall hernias in the presence of enterostomies; (d) suturing of the myofascial flaps to each other to cover the defect; and (e) repair augmentation with an absorbable mesh in the onlay position. RESULTS: The median length and width of the complex subcostal hernias were 15 cm (10-19) and 15 cm (8-24), respectively. The overall morbidity rate was 57.1% (wound infection occurred in three patients, seroma in two patients, and skin necrosis in one patient). There was no hernia recurrence during the median follow-up period of 19 months. CONCLUSION: The operative technique integrating three modifications of CST in one procedure with onlay absorbable mesh reinforcement is a feasible solution for the management of complex subcostal abdominal wall hernia.

An Integrated Surgical Management for Giant Dermatofibrosarcoma Protuberans of Anterior Abdominal Wall.

Giant dermatofibrosarcoma protuberans (DFSP) is a very rare dermal sarcoma whose diagnosis and management are important because of the high local recurrence but low metastatic potential. Complete surgical excision of giant DFSP in a single stage is difficult but has a high cure rate. A 47-year-old man presented with a gradually increasing large (18 x 15 x 7 cm) DFSP in the epigastrium. A 3 cm circumferential wide local excision (WLE) with microscopic tumor-free margin confirmed by frozen section was performed. Immediate single staged tension-free primary closure of resultant defect was done on the principle of abdominal wall reconstruction (AWR) in ventral hernia repair. This technique of anterior component separation and bridge meshplasty is functional, avoids multiple surgeries, is cost-effective, and can be done in a resource-limited setting in developing countries. A multidisciplinary and integrated surgical approach to treat giant DFSP over epigastrium, by three-dimensional WLE and immediate AWR with anterior component separation technique (CST) and bridging meshplasty, can be of immense help in managing such rare cases in developing countries.

Early outcomes of component separation techniques: an analysis of the Spanish registry of incisional Hernia (EVEREG).

AIM: To analyze the outcomes of component separation techniques (CST) to treat incisional hernias (IH) in a large multicenter cohort of patients. METHODS: All IH repair using CST, registered in EVEREG from July 2012 to December 2019, were included. Data on the pre-operative patient characteristics and comorbidities, IH characteristics, surgical technique, complications, and recurrence were collected. Outcomes between anterior (ACS) and posterior component separation (PCS) techniques were compared. Risk factors for complications and recurrences were analyzed. RESULTS: During the study period, 1536 patients underwent CST (45.5% females) with a median age of 64.0 years and median body mass index (BMI) of 29.7 kg/m2. ACS was the most common technique (77.7%). Overall complications were frequent in both ACS and PCS techniques (36.5%), with a higher frequency of wound infection (10.6% vs. 7.0%; P = 0.05) and skin necrosis (4.4% vs. 0.1%; P < 0.0001) with the ACS technique. Main factors leading to major complications were mesh explant (OR 1.72; P = 0.001), previous repair (OR 0.75; P = 0.038), morbid obesity (OR 0.67; P = 0.015), ASA grade (OR 0.62; P < 0.0001), COPD (OR 0.52; P < 0.0001), and longitudinal diameter larger than 10 cm (OR 0.58; P = 0.001). After a minimum follow-up of 6 months (median 15 months; N = 590), 59 (10.0%) recurrences were diagnosed. Operations performed in a non-specialized unit were significantly associated with recurrences (HR 4.903, CI 1.64-14.65; P = 0.004). CONCLUSION: CST is a complex procedure with a high rate of complications. Both ACS and PCS techniques have similar complication and recurrence rates. Operations performed in a specialized unit have better outcomes.

Evaluation of the Component Separation Technique for the Treatment of Patients with Large Incisional Hernia.

BACKGROUND: Incisional hernia remains a frequent complication of abdominal surgery. Results of surgical repair are disappointing with recurrence rates of suture repair being in the range of 5%-63% depending on the type of repair used, with better results using mesh implantation. For the management of such large hernias, interest has been generated in the Component Separation Technique. This technique relaxes abdominal wall by translation of muscular layers without severing the innervation and blood supply, with or without the mesh augmentation. This can accommodate for defects up to 25-30 cm in the waistline. MATERIALS AND METHODS: The study was conducted on 20 patients with "Large Incisional Hernia" with defect size >5 cm at its maximum width or with a surface area >50 cm2 operated upon with Component Separation. Clinical outcome was measured over a follow-up period of 3 months from the surgery in terms of recurrence and other local complications. RESULTS: There were 20 patients (3 men and 17 women; 70% of cases above the age of 50 years). Mean defect size was 9.5 cm (range = 6-20 cm). Average body mass index was 28.97 kg/m2 (range = 22-37 kg/m2). Mean duration of hospital stay was 9 days (range = 5-21 days). Early complications occurred in 15% (3/20) cases and postoperative abdominal compartment or recurrence was not reported over a follow-up period of 3 months. CONCLUSIONS: Component Separation Technique is a safe, easy, and quick option for patients with large hernias.

Successful closure of a large abdominal wall defect using endoscopic component separation technique in an infant with a giant ventral hernia after staged surgery for omphalocele.

BACKGROUND: The management of large abdominal wall defects, such as omphalocele or gastroschisis, remains a challenge for pediatric surgeons. Though several techniques have been described to repair those conditions, there is no procedure considered to be the standard worldwide. We report an infant girl with a giant ventral hernia after staged surgery for omphalocele in whom delayed closure of a large abdominal wall defect was performed successfully using "endoscopic component separation technique (ECST)" without serious complications. CASE PRESENTATION: A baby girl was admitted to our hospital because of a giant omphalocele, which had been prenatally diagnosed. The omphalocele was supraumbilical and included the entire liver. After staged surgery, a large abdominal wall defect was closed by skin, creating a giant ventral hernia. We performed endoscopic separation component technique (ECST) for the closure of her abdominal wall defect when she was 11 months of age. ECST was initiated with placement of a 5.0-mm port just above the inguinal ligament and under the external oblique muscle. The space between the external and internal oblique muscles was created by the insufflation pressure, and a second 5.0-mm port was placed at 1.0 cm below the inferior edge of the rib into the space. As the further dissection was carried, the aponeurosis of the external oblique muscle was identified as a white line, running vertically from the epigastrium to inguinal ligament. It was transected longitudinally using electrocautery over its full length. The same procedure was performed on the contralateral side and the abdominal wall was successfully closed. Postoperative course was uneventful. CONCLUSIONS: The technique of ECST, described here, is simple and safe for infants, and the cosmetic result is satisfactory.

Re-recognition of endoscopic Sublay repair / 中华消化外科杂志

Repair of abdominal hernia is in dynamic evoluation.Laparoscopic intra-peritoneal onlay mesh (IPOM) and open Sublay repair are still the best methods for the repair of abdominal wall hernia. The application of component separation technique has further widened the indications of IPOM and Sublay repair for the treatment of large abdominal wall hernia. Endoscopic Sublay technique theoretically combines the advantages of open Sublay repair and laparoscopic IPOM repair, but it has the disadvantages of iatrogenic destruction of the tendon septum and normal mechanical deconstruction, which requires strict specification of indications and further research.

Evaluation of the Sublay Mesh Repair Outcomes in Different Types of Ventral Hernia.

INTRODUCTION: Ventral hernia repair is one of the challenging surgical operations over time. Several surgical techniques for mesh repair have been described (onlay, inlay, sublay, and underlay repairs). It is suggested that sublay mesh repair has the lowest recurrence and surgical site infection in open anterior abdominal hernia repair. This study aimed to analyze the pros and cons of the sublay mesh in ventral hernia repair to evaluate the significance of this technique as a treatment modality. Hospital stay, acute postoperative complications, and the recurrence rate were the main areas of investigation. METHODS: A retrospective study on 79 patients with ventral hernias who were operated on with sublay mesh repair between January 2015 and December 2018 was conducted. Patients were admitted through the elective route. The study included fit patients with first-time ventral hernias (primary and incisional). Recurrent hernia, patients with decompensated cardiopulmonary disorders, and bleeding disorders were excluded from the project. The project pro forma includes patient's demographics, operative details, length of stay, postoperative complications, and follow-up up to 12 months. RESULTS: All patients underwent open mesh repair using the sublay technique. The ventral hernia was five times more common in females than males. The mean age of presentation was 44.8 years old. The mean operating time was 67 minutes and a one-day hospital stay. Paraumblical and incisional hernias represented the majority of cases. The component separation approach was added in three cases (3.7%). Simultaneous cholecystectomy was performed in two cases (2.5%). Only six cases (6.3%) developed wound-related complications, while two cases (2.5%) had a recurrence. CONCLUSION: The sublay mesh repair is a perfect choice for the repair of ventral abdominal hernia. It is associated with a smooth and short hospital stay and the least incidence of complications and recurrence.

The Effects of Preoperative Botulinum Toxin A Injection on Abdominal Wall Reconstruction.

BACKGROUND: Fascial closure significantly reduces postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR), but can be challenging in massive ventral hernias. METHODS: A prospective single-institution cohort study was performed to examine the effects of preoperative injection of botulinum toxin A (BTA) in patients undergoing AWR for midline or flank hernias. RESULTS: A total of 108 patients underwent BTA injection with average 243 units, mean 32.5 days before AWR, without complications. Comorbidities included diabetes (31%), history of smoking (27%), and obesity (mean body mass index 30.5 ± 7.7). Hernias were recurrent in 57%, massive (mean defect width 15.3 ± 5.5 cm; hernia sac volume 2154 ± 3251 cm3) and had significant loss of domain (mean 46% visceral volume outside abdominal cavity). Contamination was present in 38% of patients. Fascial closure was achieved in 91%, with 57% requiring component separation techniques (CSTs). Subxiphoidal hernias needed a form of CST in 88% compared with 50% for hernia not extending subxiphoidal (P < 0.001). Mesh augmentation was used in 98%. Postoperative complications occurred in 40%: 19% surgical site occurrences, 12% surgical site infections, and 7% respiratory failure requiring intubation, 2% mesh infection and no fascial dehiscence. Recurrence was identified in seven patients after mean 14 months of follow-up. Patients undergoing AWR with CST had more surgical site occurrences (29 versus 7%, p0.003) and respiratory failures (18 versus 0%, P = 0.002) than patients who did not require CST. CONCLUSIONS: In patients with massive ventral hernias, the use of preoperative BTA injections for AWR is safe and is associated with high fascial closure rates and excellent recurrence rates.

Minimally invasive component separation technique for large ventral hernia: which is the best choice? A systematic literature review.

BACKGROUND: Aim of the present systematic review is to compare the postoperative outcomes after minimally invasive anterior and posterior component separation technique (CST), in terms of postoperative morbidity and recurrence rates. METHODS: Nine-hundred and fifty-nine articles were identified through Pubmed database. Of these, 444 were eliminated because were duplicates between the searches. Of the remaining 515 articles, 414 were excluded after screening title and abstract. One hundred and one articles were fully analysed, and 73 articles were further excluded, finally including 28 articles. Based on the surgical technique, three groups were created: Group A, endoscopic anterior CST and closure of the abdominal midline by laparotomy; Group B, endoscopic anterior CST and closure of the abdominal midline laparoscopically or robotically; Group C, laparoscopic or robotic posterior CST with transversus abdominal muscle release (TAR). RESULTS: In group A, B and C, 196, 120 and 236 patients were included, respectively. Surgical and medical complication rates for the three groups were 31.2% and 13.7% in group A, 15.8% and 4.1% in group B, and 17.8% and 25.4% in group C, while recurrence rate was 10.7%, 6.6% and 0.4%, respectively. Statistically significant differences were observed in terms of surgical postoperative complication rate between group A versus B (p = 0.0022) and between group A versus C (p = 0.0015) and of recurrence rate between group A versus C (p = < 0.0001) and B versus C (p = 0.0009). CONCLUSIONS: Anterior CST with midline closure by laparotomy showed the worst results in terms of postoperative surgical complications and recurrence in comparison to the pure minimally anterior and posterior CST. Posterior CST-TAR showed lowest hospital stay and recurrence rate, although the follow-up is short. However, due to the poor quality of most of the studies, further prospective studies and randomized control trials, with wider sample size and longer follow-up are required to demonstrate which is the best surgical option.

The use of self-gripping mesh with anterior component separation technique in incisional hernia repair: A case series.

INTRODUCTION: Incisional hernia (IH) is a common postoperative complication that affects 10% of the patients who undergo abdominal surgery. The component separation (CS) technique is suitable for large and/or complex hernias; however, CS alone may not eliminate recurrence and is associated with an increased incidence of wound complications. Self-gripping mesh enhances tissue adhesion and contributes to a reduced risk of migration, chronic pain, and other complications. Here, we present three cases of IH that were successfully repaired by anterior CS (ACS) using onlay self-gripping meshes. CASE PRESENTATION: All three patients underwent surgery using the following technique: Briefly, a skin flap was created with release of the external oblique muscle and preservation of the perforating vessels. The linea alba was closed with absorbable interrupted sutures. A self-gripping mesh was trimmed and placed with a 4-5 cm overlap bilaterally from the closed linea alba using an onlay technique. For all patients, the postoperative courses were uneventful and there were no complications at the 3-month follow-up. DISCUSSION: The advantages of our technique include more sufficient abdominal reinforcement, technical simplicity, and minimal time required for mesh placement. The disadvantages are the potential risk of decreased blood flow of the skin flaps, wound infection, intestinal fistula, persisting or chronic pain, and difficulty with subsequent abdominal surgery. CONCLUSION: The use of self-gripping mesh with ACS can be performed without increasing the operative time or causing short-term surgical complications. This technique may be recommended for large IH because of its simplicity and secure abdominal reinforcement provided.