OPTIMIZATION OF THE CHOICE OF LAPAROSCOPIC AND OPEN ALLOPLASTICS IN CASE OF INCISIONAL VENTRAL HERNIAS

The aim of the work – to increase the effectiveness of surgical treatment of incisionalventral hernias (IVH) by optimizing the choice of laparoscopic and open allohernioplasty.Material and methods. The analysis of surgical treatment of 508 patients with IVH from2009 to 2020 was conducted. According to the Europenian Herniology Association(EGA) classification (Ghent, Belgium, 2008) IVH was distributed as follows: MW1-2R0 was diagnosed in 217 (42,7%), MW3R0 – in 291 (57,3%) patients. Diastasis of therectus abdominis muscles up to 5 cm was present in 217 (42,7%) patients, diastasis5-10 cm – in 127 (25%), diastasis greater than 10 cm – in 164 (32.3%) patients.Depending on the size of the hernia and the width of diastasis of the rectus abdominis,patients were divided into 3 groups.In group I, laparoscopic allohernioplasty was performed in 109 (21,5%) patients withsmall and medium-sized IVH with diastasis of up to 5 cm, in particular the developedlaparoscopic preperitoneal in 63 patiens and laparoscopuc retromuscular alloplastiesin 46 patients. The comparison group IIa consisted of 108 (15,1%) patients whounderwent open retromuscular allohernioplasty.In group II, 64 (12,6%) patients with large IVH and diastasis of the rectus abdominis5-10 cm underwent open allohernioplasty by «sublay» technique. The comparison groupIIa consisted of 63 (12,4%) patients who were performed the open method «onlay».In group III, in 82 (16,1%) patients with giant IVH and diastasis more than 10 cm ananterior component separation technique of the abdominal wall in combination withalloplasty with intra-abdominal placement of a mesh implant with anti-adhesive coatingwas performed according to the developed method. Comparison group IIIa consistedof 82 (16,1%) patients who underwent anterior component separation technique of theabdominal wall in combination with alloplasty «onlay».Results. For small and medium-sized IVH and diastasis of the rectus abdominis musclesup to 5 cm, laparoscopic allohernioplasty with preperitoneal and retromuscularplacement of a mesh implant and elimination of diastasis is optimal in comparisonwith open retromuscular allohernioplasty, contributes to a significant decrease in theincidence of seroma from 35,2% to 3,7 %, postoperative wound suppuration – from6,5% to 0%, inflammatory infiltrate – from 4,6% to 0%, chronic postoperative pain –from 6,4% to 2,6%, hernia recurrence – from 6,4% up to 0%.The optimal method of allohernioplasty for large IVH and diastasis of the rectusabdominis muscles from 5 to 10 cm is the open «sublay» technique in comparison withthe open «onlay» technique, reduces the incidence of seroma from 23,8% to 6,3%,postoperative wound suppuration – from 4,8% to 1,6%, chronic postoperative pain –from 4,8% to 1,6%, hernia recurrence – from 7,9% to 3,1%.In case of gigantic IVH, contracture of the rectus abdominis muscles and diastasisof more than 10 cm the anterior component separation technique of the anatomicalcomponents of the abdominal wall in combination with intra-abdominal alloplasty isoptimal in comparison with the use of an anterior component separation techniqueof an abdominal wall combined with «onlay» significant improvement in treatmentoutcomes, namely, reduction of seroma frequency from 25,6% to 7,3%, postoperativewound suppuration – from 4,9% to 2,4%, postoperative wound infiltrate – from 13,4%to 2,4 %, chronic postoperative pain – from 8,1% to 1,6%, recurrence of IVH – from6,5% to 1,6%.Conclusion. Optimization of the choice of laparoscopic and open allohernioplastyenables to increase significantly ventral hernias and to decrease the quantity of thepost-operative complications.

The principles of complex abdominal hernia repair

Large, complex abdominal hernias can be repaired with the component separation technique, which creates sliding bipedicled flaps of the rectus abdominis to allow autogenous repair of midline, ventral hernias. This technique involves longitudinal release of the external oblique aponeurosis just lateral to the linea semilunaris, and developing the plane between the external and internal oblique muscles to allow the rectus abdominis muscle and sheath to slide medially. Modifications of the original technique include the addition of mesh reinforcement, release of the deeper elements of the abdominal wall, and sparing of the peri-umbilical perforators to the skin from the deep inferior epigastric artery. Component separation technique is an effective technique to repair large ventral hernias but carries a significant risk of wound complications and a risk of cardiorespiratory compromise.

SHOULD QUALITY OF LIFE BE A CONSIDERATION TO OPERATE LARGE VENTRAL HERNIAS: A PROSPECTIVE STUDY

Context: Advances in Abdominal Wall Reconstruction including abdominal component separation techniques have enabled repair of complex ventral hernias whereas patients may have been denied surgery earlier. Traditionally the reason to operate ventral hernias has been the risk of strangulation. Something that is under studied is the effect of complex ventral hernias on Quality of Life (QoL) and how does it change after surgery.Whether techniques that require division of abdominal wall components impair abdominal wall function and consequently affect QoL is not determined. Aim:To assess the change in QOL at three months after surgery and compare it to the QOL immediately before surgery. Apart from the primary outcome of change in QOL, short term complications were also studied.A subgroup analysis of change in QOL after component separation technique was also done Settings and Design:A prospective analysis was carried out on consecutive patients undergoing open complex ventral hernia surgery over two-year period at our institution,a tertiary care hospital. Methods and Material:Patients with complex ventral hernias including those with hernia defect diameter more than 6 cm, recurrent hernia, multiple Swiss cheese defects, or patients requiring abdominal component separation were studied. Patients requiring emergency surgery and laparoscopic surgeries were excluded from study. The “HerniaRelated Quality-of-Life Survey”(HerQLes) which is a validated instrument was used. Statistical analysis used: After sample size estimation by a statistician forty-five consecutive patients meeting the study criteria between April 2017 and March 2019 were included in the study.Statistical analyses were done using SPSS version 24 software. Results:Of the 45 patients enrolled in the study,19 (42.2%) required abdominal component separation.The mean size of 2 the defect was 130 cm in component separation (CS) group and 39.0 cm2 in non-component separation (NCS) group. The mean preoperative QoL score in CS group was 53.9±11.2, while in the NCS group it was 45.7±13.6. QoL score postoperatively in CS group was 16.4±4, while in NCS group it was 13.8±1.5. There was a statistically significant improvement in QoL three months after surgery in both the groups (p-0.0001). Conclusion: In our study we found complex ventral hernias to be associated with a poor Quality of Life.The Quality of Life was seen to improve significantly within three months after surgery.Use of a component separation technique does not seem to impair the Quality of life.

Giant Inguinoscrotal Hernia: Single-Stage Repair Using Posterior Component Separation Technique and Transversus Abdominis Release

Giant inguinal hernia is one of the most unusual and significantly challenging in terms of surgical management. It is defined as an inguinal hernia that extends below the midpoint of inner thigh when the patient is in standing position. The physiological changes associated with the loss of domain can pose a risk for increased complications during surgery and the post-operative period. There is no standard surgical procedure for the treatment of this unusual and challenging type of groin hernia. Various surgical techniques have been reported in previous publications. We present a case of a giant right inguinoscrotal hernia; after CT examination, spirometry, blood gas analysis, echocardiography and anesthetic evaluation was treated with a single-stage repair using posterior component separation technique and transversus abdominis release. Keywords: Component separation; Giant Inguinal hernia; Inguinoscrotal hernia; Transversus Abdominis Release

A PROSPECTIVE STUDY OF COMPONENT SEPARATION IN VENTRAL HERNIA

Background: Abdominal wall hernias are a familiar surgical problem. Millions of patients are affected each year, presenting most commonly with primary ventral, incisional, and inguinal hernias. In this study we have done a prospective study of 25 cases of patients with ventral hernia in whom component separation technique is used to close the midline defect with the use of prosthetic mesh. Methods: This prospective randomized comparative study was conducted on 25 patients in each group of ventral hernia in the department of surgery, Sir T Hospital and medical college, Bhavnagar. It is a prospective study of component separation in ventral hernia repair in view of surgical site pain, recurrence rate post op complication, post op hospital stay. Results: It was found that average age was 50.8 years. That showed ventral hernia was more common in 5th and 6th decade of life. Out of 25 subjects 13(52%) were male and 12 (48%) were female. The component separation is mainly done in large ventral hernias, these included: Incisional hernia 20 patients (80%), Umbilical hernia 3 patients (12%), Paraumbilical hernia 2 patients (8%). It was seen that diabetes and COPD was found in major of the cases with ventral hernia. Patients with diabetes as comorbidity had more incidence of surgical site infection leading to high incidence of flap necrosis. Due to high, uncontrolled blood sugar during emergency operation, there were more incidence of both infection and flap necrosis. Conclusion: It was seen that component separation technique resulted in better mesh integration as the vascularity was preserved, significant reduction in morbidity, low incidence of wound discharge, gaping and flap necrosis, resulting in early discharge of patient. Keywords: Ventral hernia, Incisional hernia, Umbilical hernia, Para umbilical hernia, Component separation technique.

Prospective study of midline abdominal incisional hernia repair by component separation technique augmented with prosthetic mesh

Background: In our tertiary care hospital, we receive a large number of acute abdomen cases. Raised intra-abdominal pressure (IAP) makes laparostomy mandatory initially and abdominal wall approximation cannot be completed due to compromised state in most cases. Large incisional hernias were seen on complete healing and this study was done to see the feasibility of component separation technique (CST) with mesh augmentation.Methods: 30 patients were subjected to CST with mesh augmentation. Preoperative defect size mapping, Pre- and post-operative monitoring of IAP were done. Pain scoring by visual analogue scale (VAS), early and late complications was noted. Patients were followed up for 60 months.Results: CST with mesh augmentation was found to be feasible with 96.77% success rate as no recurrence was noted in follow up. Preoperative average Basal metabolic index was 26.09. Size of defect varied from 17-20×9-16 cm2 (length X width). Seroma seen in 50% of patients was managed without any intervention. Skin necrosis in 6.6% and wound dehiscence in 3.33%, managed with minimal debridement & local wound care respectively. Respiratory compromise and hematoma were not seen and no patient required any active ICU care. Average length of hospital stay was 5.22 days. Close monitoring of IAP in immediate post-operative period was found to be significant.Conclusion: Physical acceptance of stable abdominal wall gives a psychological boost to patients with early recovery in form of ambulation and early return to work.