Francesca Ceci

Abdominal wall reconstruction (AWR): the need to identify the hospital units and referral centers entitled to perform it

Criteria to identify hospital units and referral centers in Italy entitled to perform major general surgery, such as esophageal, hepato-pancreatic and colo-rectal surgery were recently proposed [1]. The role of indicators of effectiveness and quality of care, and dramatic innovations in modern surgical subspecialty concur with this proposal [2]. Furthermore there is a robust evidence of improved outcomes of patients treated by specialist multidisciplinary teams. Abdominal wall reconstruction (AWR) for primary or incisional hernia remains a challenging problem for primary care physicians, surgeons, and patients. Cochrane collaboration places the number of AWRs performed in Europe at about 400,000/year and at 300,000/year in USA [3]. In USA this number is expected to increase of 11,000 procedures each year in the near future. Taking into account the number of repairs performed in 2006, the total estimated procedural cost for AWR was US

Comment to “Long-term outcomes (>5 year follow-up) with porcine acellular dermal matrix (Permacol™) in incisional hernias at risk for infection” by Abdelfatah MM, Rostambeigi N, Podgaetz E, Sarr MG (DOI 10.1007/s10029-013-1165-9)

3.2 billion [4]. We personally calculated that 40,000 AWRs (ICD-9 procedural code 53.51, 53.61, 53.59, 53.69) were performed in Italy in 2014 with an estimated cost of 200 million euro, without taking in account economic costs to society including time lost for work and chronic disability (associated with hernias). Approximately a quarter of all incisional hernia repairs needs a reoperation, even with the use of meshes, and the recurrence exponentially increases with subsequent repairs [5]. This could cause significant further rises in healthcare costs mainly if technologically advanced meshes or biologic implants are required [6]. In USA each 1% reduction in hernia recurrence would result in a US

Teaching Hernia Surgery: The Experience of the Italian School

32 million yearly savings in procedural cost alone. Moreover, other complications, such as surgical site occurrence (SSO), mainly the surgical site infection (SSI), length of hospital stay and quality of life should be taken in account. The cost for an outpatient AWR rises from US

Mesh Plug Repair

16,000 to 65,000 and 82,000, in cases of SSI and mesh infection, respectively [4, 7, 8]. Over the last 20 years a great number of innovations both in operative techniques and technologies have revolutionized surgical treatment. New reconstructive procedures, including component separation, gained popularity with the additional potential benefit of restoring functionality of the abdominal wall. Furthermore, laparoscopic ventral hernia repair (LVHR) improves patient-centered outcomes and represents a viable option in selected cases [9]. Mesh repair significantly reduces the number of recurrences but it needs a strong knowledge of the characteristics of devices, more and more largely proposed on the market [10–12]. Careful matching of patient characteristics and surgical techniques in the choice of prosthetics could minimize postoperative complications and readmissions [13]. In conclusion, it seems inevitable that surgeons are specializing in abdominal wall surgery to an increasing extent [5]. Are AWRs ‘‘complex’’ enough to warrant hospital units and referral centers entitled to perform them? Despite the development of prosthetic techniques, results following abdominal hernia repair are not so good as expected, in term of recurrence and wound complications. Numerous factors should be taken in account, including that in several cases of ventral hernia the best technique and the proper device have not been utilized [5]. This principally happens in case of complex abdominal wall hernias, when clear criteria of & Francesco Gossetti gossetti@tiscalinet.it

Chronic anemia due to transmural e-PTFE anti-adhesive barrier mesh migration in the small bowel after open incisional hernia repair: A case report

We read with great interest the article by Abdelfatah et al. titled ‘‘Long-term outcomes ([5 year follow-up) with porcine acellular dermal matrix (Permacol) in incisional hernia at risk for infection’’ [1]. This retrospective study included 65 consecutive patients, who underwent abdominal wall reconstruction (AWR) with porcine acellular dermal matrix (PADM) for repair of incisional hernias at high risk for surgical site infection (SSI). The surgical wound was clean in 49 %, clean-contaminated or contaminated in 45 % and infected in 6 % of cases. At the end of the study, authors concluded the use of Permacol PADM is far from ideal to unsatisfactory in the overall picture. Only in selected patients its use might prove to be useful. In fact, results from Abdelfatah et al. are discouraging and PADM as bioprosthesis for ventral hernia appears unreliable as definitive repair at this time. In Abdelfatah series, SSI occurred in 20 % within 30 postoperative days and in 37 % after this period (with 25 % of PADM infection). Infection required subtotal or total removal of PADM in 15 cases. Fifty-nine patients with a follow-up C5 years displayed overall recurrence in 66 %, documented at physical examination or objective findings (CT scan or reoperation). Why these bad results? authors have full knowledge of some limitations of their study, including the heterogeneous differing types of repair, onlay, inlays and sublays with bridging (patches) or reinforcement by the PADM. We absolutely agree with them and we believe that the explanation of such discouraging results actually must be sought in the surgical technique. Abdelfatah et al. report that a bridging patch repair was performed in 31/65 patients, an onlay or intraperitoneal reinforcement of an autogenous suture repair in 28/65 and an inlay repair in 6/65. PADM was never placed as a sublay in the retromuscular space, as described by Rives and Stoppa [2, 3]. Results from our experience are different. Between July 2005 and December 2013, 45 consecutive patients underwent abdominal wall reconstruction (AWR) with PADM (32 with Permacol, Covidien and 13 with CollaMend, Bard, Davol) for incisional hernias. Four patients needed more than one implant, due to concomitant hernias in other sites (parastomal or perineal), for a total number of 50 implants. All patients were at risk of infection, 87 % of them displaying grade III, according to mod.WVHG (Table 1) [4]. In 86 % of implants, PADM was used as augmentation repair while in 14 % of them sublay bridging repair was performed (Table 2). Sixty-eight percent of defects were treated with primary suture of the midline and retromuscular PADM reinforcement (Rives–Stoppa technique). When ventral rectus sheaths could not be reapproximated, techniques of posterior components separation were performed [5, 6]. All patients were collected in a database and examined every year. The presence or absence of recurrent hernias was documented by cross-sectional imaging (CT scan or MRI) with Valsalva manoeuvre. Our short-term SSI rate was quite similar to Abdelfatah et al. (26 vs. 20 %), despite the higher risk of infection in our patients (87 vs. 50 %). In our series, one patient died due to sepsis on 30th postoperative day. Long-term SSI was demonstrated in 2 cases (4 %), both belonging to the This comment refers to the article available at doi:10.1007/s10029013-1165-9.

Comment on: Biologic mesh in ventral hernia repair: Outcomes, recurrence, and charge analysis

Training hernia surgery has become more and more challenging today. The increasingly high number of inguinal and ventral/incisional repairs, new surgical approaches, innovative techniques, both open and laparoscopic, and a huge number of prosthetic materials and medical devices available to the market, together with the complexity of patient population, require in fact a specialized surgeon with a deep knowledge in hernia surgery. According to these concerns, the Italian School of Hernia and Abdominal Wall Surgery was created in 2008, first in Europe, to train surgery residents and surgeons interested to develop a special knowledge in hernia surgery.

Laparoscopically assisted treatment of entero-atmospheric fistula following abdominal wall repair of complex incisional hernia: Case report

Besides the Lichtenstein technique, the mesh plug repair (MPR) has demonstrated excellent results over the years, with recurrence, chronic pain, and quality of life rates comparable to Lichtenstein’s in most of the reported outcomes. MPR is a deep repair with the device laying in the pre-peritoneal space. The technique was originally proposed in the late 1980s by Gilbert and Trabucco and finally standardized by Rutkow, who introduced the first preformed plug (PerFix™). Since then, many 3D devices have been offered on the market, made with new materials and new profiles, to meet the current requirements of the hernia surgery and overcome criticisms addressed to this technique, such as the excessive use of foreign material and the risk of plug migration. In fact, choosing the proper plug besides paying attention to technical details can reduce migration that seems anyway very rare. Originally proposed for all groin hernias, MPR today should be indicated for the treatment of lateral, recurrent “internal,” and femoral hernias, according to a tailored management of inguinal hernia. MPR offers the fastest learning curve, the shortest operative time, and the lowest perceived difficulty among all the procedures for groin hernia repair. It should remain in the toolbox of all general surgeons.

Comment to: Development of a standardized curriculum concept for continuing training in hernia surgery: German Hernia School. Lorenz, R., Stechemesser, B., Reinpold, W. et al.

Highlights • Mesh related unusual complication.• Intraluminal mesh migration.• Mesh erosion.

Topic: Mesh and Prosthesis.

To the Editors: The article by Huntington et al is of great interest because it provides stimulating arguments concerning the use of biologic mesh in difficult abdominal wall reconstruction (AWR). Recently, we have commented on the article by Majumder et al, which was also published in Surgery and suggested that selection of the proper implant is crucial. Results of the Huntington et al study confirm this statement. In fact, in 223 AWRs performed with non–cross-linked biologic mesh, at a mean follow-up of 18.2 months, recurrence rate was significantly lower (P < .001) in the Strattice group (14.7%) when compared to another porcine acellular dermal matrix, such as Xenmatrix (59.1%), and to human acellular dermis Alloderm (35.0%), Allomax (34.8 %), and FlexHD (37.1%). Fascial bridging repair was performed in a minority of cases (8.8%) in the Strattice group when compared to the other groups (P < .0001). In our opinion, this could partially explain the better results of Strattice mesh because bridging technique with biologic mesh is unsatisfactory and should be avoided when possible. Nevertheless, we agree with the authors that Strattice performs better than the other non–cross-linked meshes. Our experience with biologics (49 AWRs) mainly concerns the use of porcine cross-linked acellular dermal matrix, Permacol and CollaMend, because these implants are both easily commercially available in Europe. From the beginning of our experience, we restricted the indications to the use of biologics to cleancontaminated or contaminated operative fields. The overall recurrence rate was actually 8.2%, with a median follow-up longer than 59.3 months. Our results were significantly better in the Permacol group than in the CollaMend group, with a recurrence rate of 2.8% and 23%, respectively. This confirms that not all biologics are equal also in the cross-linked subgroup. After all, could Strattice and Permacol be considered the “leaders” of biologic implants, in the non–crossand cross-linked groups, respectively? Could both be used in all AWRs at risk of infection, or rather would specific indications to the use of one or another be needed? Controlled randomized trials are necessary to answer this question. As a matter of fact, contrary to that reported by Huntington et al, no study has ever compared Strattice and Permacol. The repair of infected and contaminated hernias study, cited by Huntington, is a prospective trial of single-stage AWR with the use of biologic non–cross-linked porcine tissue matrix (Strattice). Only one retrospective study exists comparing Permacol versus Alloderm, with a recurrence rate that was significantly higher in the Alloderm group (47% and 32%, respectively). Different techniques were performed in this study with bridging repair in more than 50% of cases thus limiting results. In the search for the best mesh to be used in AWR, we believe that it is time to perform a controlled randomized trial comparing long-term outcomes of Strattice versus Permacol. As Huntington et al assert, a study like this would collect 60 patients in each mesh group to have a study 80% power at 5% level, and we agree with them. Furthermore, in our opinion, this study should use some selection criteria, such as patient demographic and comorbidity not significantly being different in the 2 groups, following the same indication for biologics (clean-contaminated or contaminated field), using the same technique of repair (retrorectus placement of the implant), and having a follow-up not shorter than 5 years. This study could be difficult to realize even at a dedicated hernia referral center. Could a multicenter collected study be helpful to overcome this criticism and get to a final clinical decision?

Topic: Experimental Surgery

Highlights • Laparoscopy is useful in approaching a complex abdominal cavity.• Multidisciplinary approach and well-planned surgery improved the EAF treatment.• Different forms of tube drainage inside or around the fistula are proposed.