Surgery for primary malignant tumors of the abdominal wall: experiences of three African surgical oncology units and review of the literature.

BACKGROUND AND OBJECTIVES: Tumors of the abdominal wall are uncommon but diverse. The surgical challenge is double. The tumor must be completely removed and the abdominal wall repaired. Our aim was to describe the indications, techniques, and results of surgery on these tumors in an African context. METHODS: Retrospective, multicentric and descriptive study conducted in three West African surgical oncology units. We included all abdominal wall tumors followed up between January 2010 and October 2022. Histological type, size, surgical procedure, and method of abdominal wall repair were considered. Survival was calculated using the Kaplan-Meier method and comparisons of proportions were made using the Student t test. RESULTS: We registered 62 tumors of the abdominal wall and we operated on 41 (66.1%). The mean size of the tumors was 14.3 ± 26 cm. Dermatofibrosarcoma and desmoid tumor were present in 33 and 3 cases respectively. In 31.7% of cases in addition to the tumour, the resections carried away the muscular aponeurotic plane. Parietal resections required the use of a two-sided prosthesis in 6 cases. In 13 cases, we used skin flaps. The resections margins were invaded in 5 cases and revision surgery was performed in all of them. Incisional hernia was noticed in 2 cases. The tumor recurrence rate was 12.2% with an average time of 13 months until occurrence. Overall survival at 3 years was 80%. CONCLUSIONS: Surgery is the mainstay of treatment for abdominal wall tumors. It must combine tumor resections and parietal repair. Cancer surgeons need to be trained in abdominal wall repair.

Can Hernia Sac to Abdominal Cavity Volume Ratio Predict Fascial Closure Rate for Large Ventral Hernia? Reliability of the Tanaka Score.

BACKGROUND: The hernia sac to abdominal cavity volume ratio (VR) on abdominal CT was described previously as a way to predict which hernias would be less likely to achieve fascial closure. The aim of this study was to test the reliability of the previously described cutoff ratio in predicting fascial closure in a cohort of patients with large ventral hernias. METHODS: Patients who underwent elective, open incisional hernia repair of 18 cm or larger width at a single center were identified. The primary end point of interest was fascial closure for all patients. Secondary outcomes included operative details and abdominal wall-specific quality-of-life metrics. We used VR as a comparison variable and calculated the test characteristics (ie, sensitivity, specificity, and positive and negative predictive values). RESULTS: A total of 438 patients were included, of which 337 (77%) had complete fascial closure and 101 (23%) had incomplete fascial closure. The VR cutoff of 25% had a sensitivity of 76% (95% CI, 71% to 80%), specificity of 64% (95% CI, 54% to 74%), positive predictive value of 88% (95% CI, 83% to 91%), and negative predictive value of 45% (95% CI, 36% to 53%). The incomplete fascial closure group had significantly lower quality of life scores at 1 year (83.3 vs 52.5; p = 0.001), 2 years (85 vs 33.3; p = 0.003), and 3 years (86.7 vs 63.3; p = 0.049). CONCLUSIONS: In our study, the VR cutoff of 25% was sensitive for predicting complete fascial closure for patients with ratios below this threshold. Although there is a higher likelihood of incomplete fascial closure when VR is ≥ 25%, this end point cannot be predicted reliably. Additional studies should be done to study this ratio in conjunction with other hernia-related variables to better predict this important surgical end point.

Preoperative botulinum toxin A injection in complex abdominal wall reconstruction- a propensity-scored matched study.

INTRODUCTION: Fascial closure during complex abdominal wall reconstruction (AWR) improves recurrence and wound infection rates. To facilitate fascial closure in massive ventral hernias preoperative Botulinum Toxin A (BTA) injection can be used. METHODS: 2:1 propensity-scored matching of patients undergoing AWR with and without BTA was performed based on BMI, defect width, and loss of domain using CT-volumetric analysis. RESULTS: 145 patients without BTA and 75 with BTA were comparable on hernia size (240vs251cm2, p = 0.589) and hernia volume (1405vs1672cm3, p = 0.243). Patients with BTA had higher wound class (CDC≥3 37%vs13%, p < 0.001). Patients with BTA had a higher fascial closure rate (92%vs81%, p = 0.036), received more components separation (61%vs47%, p = 0.042), lower wound infection rate (12%vs26%,p = 0.019) and comparable recurrence rates (9%vs12%, p = 0.589). Recurrences occurred more often without complete fascial closure compared to patients with (33%vs7%, p < 0.001). CONCLUSION: In patients with massive ventral hernias and severe loss of domain, preoperative BTA-injection improves fascial closure rates during AWR.

3D-Bioprinted Inflammation Modulating Polymer Scaffolds for Soft Tissue Repair.

Development of inflammation modulating polymer scaffolds for soft tissue repair with minimal postsurgical complications is a compelling clinical need. However, the current standard of care soft tissue repair meshes for hernia repair is highly inflammatory and initiates a dysregulated inflammatory process causing visceral adhesions and postsurgical complications. Herein, the development of an inflammation modulating biomaterial scaffold (bioscaffold) for soft tissue repair is presented. The bioscaffold design is based on the idea that, if the excess proinflammatory cytokines are sequestered from the site of injury by the surgical implantation of a bioscaffold, the inflammatory response can be modulated, and the visceral adhesion formations and postsurgical complications can be minimized. The bioscaffold is fabricated by 3D-bioprinting of an in situ phosphate crosslinked poly(vinyl alcohol) polymer. In vivo efficacy of the bioscaffold is evaluated in a rat ventral hernia model. In vivo proinflammatory cytokine expression analysis and histopathological analysis of the tissues have confirmed that the bioscaffold acts as an inflammation trap and captures the proinflammatory cytokines secreted at the implant site and effectively modulates the local inflammation without the need for exogenous anti-inflammatory agents. The bioscaffold is very effective in inhibiting visceral adhesions formation and minimizing postsurgical complications.

Atrophic change of the abdominal rectus muscle significantly influences the onset of parastomal hernias beyond existing risk factors after end colostomy.

PURPOSE: To investigate optimal risk factors, including atrophy of the abdominal rectus muscle (ARM) for postoperative parastomal hernia (PH) in patients who underwent end colostomy at left lower quadrant. METHODS: This single-institution retrospective study included 91 patients who underwent end colostomy between April 2004 and December 2015. The surgical and long-term outcomes among patients with or without PH were collected and compared. RESULTS: Altogether, 22 (24.2%) patients had a PH including 15 (68.2%) patients with a simultaneous incisional hernia. Univariate analysis showed that older patients (71 ± 11.9 vs. 64 ± 12.2 years, p = 0.03) and those with higher body mass index (BMI) (23.8 ± 3.8 vs. 20.9 ± 3.3 kg/m2, p < 0.001) had a statistically significant relation with having PHs. Relative atrophy of left abdominal rectus muscle was more frequently found in patients with PH (ratio of left side/right side; caudal level and medial side: 0.66 vs. 0.92, p < 0.01, caudal level and lateral side: 0.95 vs. 1.03, p = 0.04). Multivariate analysis revealed that BMI > 25 kg/m2 [odds ratio (OR) 9.05, 95% confidence interval (CI) 2.06-39.76, p = 0.003] and atrophy of the left lower medial portion of the abdominal rectus muscle (OR 12.85, 95% CI 2.49-66.39, p = 0.002) were independent risk factors for PHs. Neither the laparoscopic approach nor the extraperitoneal route of the colostomy was proven to correlate with a lower rate of PHs. CONCLUSIONS: High BMI and atrophic change of ARM were significantly associated with PH development. Surgical techniques for prevention of atrophic change of ARM are expected to reduce the incidence of PHs.

Repair of a medium-sized ventral hernia with the UltraPro Hernia System.

Mesh repairs are widely accepted as a suitable option for ventral hernia repair. Among the various devices and surgical approaches used for ventral hernia repair, the UltraPro Hernia System (UHS) is considered an effective method of open repair for patients with medium ventral hernia defects between 3 and 5 cm in diameter. However, few clinical studies on this system have been reported. We describe a simple and safe UHS mesh technique for open ventral hernia repair, which was performed successfully under local anesthesia in 23 patients with medium ventral hernia defects. Minor postoperative complications included seroma (n = 3) and a superficial infection (n = 1). There was no incidence of recurrence in 12 months of follow-up. Our results show that the UHS is simple and easily reproducible for medium ventral hernia defects between 3 and 5 cm in diameter.

[Minimally invasive correction of anatomical features of anterior abdominal wall and ventral hernias]. / Miniinvazivnye metodiki v korrektsii anatomicheskikh osobennostei perednei bryushnoi stenki i v lechenii ventral'nykh gryzh.

Conventional «open¼ procedures for ventral hernias and diastasis recti are widely known, used everywhere and have a great number of author's improvements related to surgeon's experience, availability of modern information, equipment and materials. K. LeBlanc and W. Booth (1993) reported IPOM-method with non-adhesive coating that is considered a milestone in surgery of anterior abdominal wall and ventral hernia. This technique has gained recognition among surgeons around the world due to its technical simplicity, minimal invasiveness and high reproducibility. However, certain disadvantages of this technique have been shown over the past time that justified advisability of searching for another methods of anterior abdominal wall reinforcement. Thus, E-Milos, LIRA, TESAR, eTEP, REPA, TARM, TARUP techniques are currently available. This review is devoted to technical features of these techniques, their potential advantages and disadvantages.

Port Site Hernias Following Laparoscopic Ventral Hernia Repair.

BACKGROUND: Port site hernias (PSH) are underreported following laparoscopic ventral hernia repair (LVHR). Most occur at the site of laterally placed 10-12-mm ports used to introduce large pieces of mesh. One alternative is to place the large port through the ventral hernia defect; however, there is potential for increased risk of surgical site infection (SSI). This study evaluates the outcomes when introducing mesh through a 10-12-mm port placed through the hernia defect. METHODS: This was a retrospective case series of patients who underwent LVHR in three prospective trials from 2014-2017 at one institution. All patients had mesh introduced through a 10-12-mm port placed through the ventral hernia defect. The primary outcome was SSI. Secondary outcomes were hernia occurrences including recurrences and PSH. RESULTS: A total of 315 eligible patients underwent LVHR with a median (range) follow-up of 21 (11-41) months. Many patients were obese (66.9%), recently quit tobacco use (8.8%), or had diabetes (18.9%). Most patients had an incisional hernia (61.2%), and 19.2% were recurrent. Hernias were on average 4.8 ± 3.8 cm in width. Two patients (0.6%) had an SSI. Fourteen patients had a hernia occurrence-13 (4.4%) had a recurrent hernia, and one patient (0.3%) had a PSH. CONCLUSION: During LVHR, introduction of mesh through a 10-12-mm port placed through the hernia defect is associated with a low risk of SSI and low risk of hernia occurrence. While further studies are needed to confirm these results, mesh can be safely introduced through a port through the defect.

A new technique for the 3D reconstruction of the incisional hernia: A pilot study.

PURPOSE: This study aimed to accurately evaluate incisional hernias with a new three-dimensional (3D) reconstruction technology, proving surgeons more information for intuitive and accurate judgments about incisional hernia to minimize the perioperative complications and recurrence rate. METHOD: This was a pilot study using a new technique, 3D reconstruction, based on computed tomography (CT) scans to measure abdominal wall defect, herniary area, herniary volume, abdominal cavity volume, and the volume of transverse, oblique, and recti abdominis in three patients with incisional hernias. RESULTS: The 3D reconstruction technique made automated segmentation of the bony skeleton, skin, outer abdominal wall, vessel, and hernia sac. The hernia sac, abdominal muscles, and their anatomic relationship were clearly illustrated in 3D reconstruction images. Moreover, abdominal cavity volume; herniary diameter, area, and volume; and the volume of transverse, oblique, and recti muscles could be evaluated through 3D reconstruction images. Surgeons can also freely combine, rotate, scale, and move the 3D reconstruction mode, modify the name and transparency of the 3D reconstruction model, and observe the internal structure of the tissue and the size, shape, and location of the lesion from multiple angles for better and accurate judgments. CONCLUSION: The herniary diameter, area, and volume and the volume of transverse, oblique, and recti abdominis can be accurately calculated through this 3D reconstruction technology. A three-dimensional vision of the abdomen through this technology can objectively and quantitatively evaluate the situation of incisional hernia, providing a more realistic means for diagnosis and treatment of incisional hernias.

Robotic-assisted ventral and incisional hernia repair with hernia defect closure and intraperitoneal onlay mesh (IPOM) experience.

BACKGROUND: The most common technique described for robotic ventral hernia repair (RVHR) is intraperitoneal onlay mesh (IPOM). With the evolution of robotics, advanced techniques including retro rectus mesh reinforcement, and component separation are being popularized. However, these procedures require more dissection, and longer operative times. In this study we reviewed our experience with robotic ventral/incisional hernia repair (RVHR) with hernia defect closure (HDC) and IPOM. METHODS: Retrospective chart review and follow-up of 31 consecutive cases of ventral/incisional hernia treated between August 2011 and December 2018. Demographics, operative times, blood loss, length of stay (LOS), hernia size, location, and type, mesh size and type, recurrence, conversion to open ventral hernia repair (OVHR) and complications including bleeding, seroma formation and infection were analyzed. RESULTS: Mean age was 63.9 years old, with median BMI of 31.24 kg/m2. Median hernia area was 17 cm2. Mean operating time was 142.61 min (SD 59.79). Mean LOS was 1.46 days (range 1-5), with 48% being outpatient, and overnight stay in 32% for pain control. Conversion was necessary in 12.9% cases. Complication rate was 3% for enterotomy. Recurrence was 14.81% after a mean follow-up of 26.96 months. There was significant association of recurrence with COPD history (P = 0.0215) and multiple hernia defects (P = 0.0376). CONCLUSION: Our recurrence rate (14.81%) compares favorably to those reported in literature (16.7%) for LVHR with HDC and IPOM. Our experience also indicates that IPOM is associated with satisfactory outcomes, low conversion and complications rates, and short LOS.

Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons.

BACKGROUND: No standardized written or volumetric definition exists for 'loss of domain' (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons. METHODS: A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed. RESULTS: Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery. CONCLUSIONS: Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.

Too big to breathe: predictors of respiratory failure and insufficiency after open ventral hernia repair.

INTRODUCTION: Increased intra-abdominal pressure in open ventral hernia repair (OVHR) is hypothesized to contribute to postoperative respiratory insufficiency (RI) or failure (RF). This study examines the impact of abdominal volumes on postoperative RI in OVHR. METHODS: OVHR patients with preoperative CT scans were identified. 3D volumetric software measured hernia volume (HV), subcutaneous volume (SQV), and intra-abdominal volume (IAV). The ratio of hernia to intra-abdominal volume (HV:IAV) was calculated. A principal component analysis was performed to create new component variables for collinear volume and hernia variables. RESULTS: There were 1178 OVHR patients with preoperative CT scans. Demographics included a mean BMI of 34.2 ± 7.7 kg/m2, age of 58.5 ± 12.4 years, and 57.8% were female. RI occurred in 8.3% of patients, including 4.0% requiring > 24 h respiratory support with ezPAP, CPAP, or biPAP (RI), and 4.3% requiring intubation (RF). Patients who developed RI had a higher BMI (33.8 ± 7.5 vs. 38.2 ± 9.1 kg/m2, p < 0.0001), older age (58.1 ± 12.5 vs. 62.8 ± 10.4 years, p = 0.0001), larger defects (140.9 ± 128.4 vs. 254.0 ± 173.9 cm2, p < 0.0001), HV (865.8 ± 1200.0 vs. 2005.6 ± 1791.7 cm3, p < 0.0001), and HV:IAV (0.26 ± 0.45 vs. 0.53 ± 0.58, p < 0.0001). Three PC variables accounted for 85% of variance: hernia volume PC consists primarily of HV (61.8%), ratio HV:IAV (57.7%), and defect size (50.1%) and accounts for 38.3% variance. Extra-abdominal volume PC consists primarily of SQV (63.7%) and BMI (60.8%) and accounts for 32.5% variance. Intra-abdominal volume PC is primarily IAV (75.8%) and accounts for 14.9% variance. In multivariate analysis, predictors of RI included asthma and COPD (OR 4.04, CI 1.82-8.96), hernia PC (OR 1.47, CI 1.48-1.98), EAV PC (OR 1.24, CI 1.04-1.48), increased age (OR 1.04, CI 1.01-1.06), and diabetes (OR 1.8, CI 1.11-2.91). Component separation, fascial closure, contamination, and panniculectomy were not associated with RI. CONCLUSION: The impact of defect size, BMI, HV, SQV, IAV, and HV:IAV on respiratory insufficiency after OVHR is collinear. Patients with large defects and a large ratio of HV:IAV (greater than 0.5) are also at significantly increased risk of RI after OVHR. While BMI impacts these parameters, it is not directly predictive of postoperative RI.

An Unusual Case of Left Spigelian Hernia Containing Part of a Fibroid Uterus and the Left Adnexa in a 66-Year-Old Woman.

BACKGROUND Spigelian hernia, or lateral ventral hernia, is rare and represents between 0.1-2% of all hernias of the abdominal wall. The presentation is variable, and the diagnosis may be challenging. This report is of an unusual case of Spigelian hernia that contained part of a fibroid uterus and the left adnexa. CASE REPORT A 66-year-old woman presented with an abdominal wall mass in the left lower quadrant. On physical examination, a provisional diagnosis of ventral hernia was made. Abdominal computed tomography (CT) imaging showed an unusual Spigelian hernia that contained part of a fibroid uterus and the left adnexa. Treatment using laparoscopic hysterectomy, left salpingo-oophorectomy, and hernia repair was successfully performed jointly by a general surgeon and a gynecologist. CONCLUSIONS To the best of our knowledge, the is the first reported case of Spigelian hernia that contained part of the uterus and the left adnexa.

[Preventative repair of postoperative ventral hernia considering the markers of connective tissue dysplasia]. / Opredelenie pokazaniia k preventivnomu éndoprotezirovaniiu na osnovanii markerov displazii soedinitel'noi tkani u bol'nykh s posleoperatsionnymi ventral'nymi gryzhami.

OBJECTIVE: To define the indication for preventive mesh implantation in patients scheduled for laparotomy. MATERIAL AND METHODS: There were 108 patients divided into the control (52 patients without anterior abdominal wall hernia) and the main (56 patients with ventral hernia) groups. RESULTS: Predominance of collagen type III over type I was observed in patients older 60 years in the main group. The maximum ratio of collagen types I and III was 1.4 in the main group. The minimum number of inter-fiber spaces (n=5) was noted in patients aged 30-40 years. The maximum density of connective tissue was 250 pixels per inch. CONCLUSION: Analysis of connective tissue structures revealed some important age-related features and markers of connective tissue dysplasia in the main group. An indication for preventive mesh implantation in patients scheduled for laparotomy was determined.

A 2-week wait referral diagnosed with post-sternotomy liver herniation in a background of adrenal myelolipoma.

Herniation of the liver through the anterior abdominal wall is a rare post-sternotomy complication. A 32-year-old woman had a 2-week wait referral due to abdominal pain, weight loss and upper abdominal swelling. She was known to have a left adrenal myelolipoma and had a mitral valve replacement 3 years prior to presentation with the postoperative period complicated by sepsis and poor wound healing. She had recently been started on metformin for type 2 diabetes mellitus and she had long-standing lower abdominal symptoms known to the gynaecology team. Investigations revealed hepatic herniation of liver segments II & III through the anterior abdominal wall while there was no underlying malignancy a benign left adrenal myelolipoma was noted.