Igor Belyansky

Prospective, Long-Term Comparison of Quality of Life in Laparoscopic Versus Open Ventral Hernia Repair

Objectives:To compare laparoscopic ventral hernia repair (LVHR) versus open ventral hernia repair (OVHR) for quality of life (QOL), complications, and recurrence in a large, prospective, multinational study. Introduction:As recurrence rates have decreased for LVHR and OVHR, QOL has become an extremely important differentiating outcomes measure. Methods:A prospective, international database was queried from September 2007 to July 2011 for LVHR and OVHR. Carolinas Comfort Scale (CCS) was utilized to quantify QOL (pain, movement limitation, and mesh sensation) preoperatively and at 1, 6, and 12 months postoperatively. Results:A total of 710 repairs included 402 OVHR and 308 LVHR. Demographics were mean age 57.1 ± 13.3 years, 49.6% male, 21.7% recurrent hernias, mean body mass index of 30.3 ± 6.6, and mean defect size of 89.4 ± 130.8. Preoperatively, 56.9% had pain, and 53.2% experienced movement limitation. At 1-month follow-up, 587 (82.7%) patients were provided CCS scores; more LVHR patients experienced pain (P < 0.001) and movement limitations (P < 0.001). At 6 and 12 months, there were no differences in QOL with 466 (65.6%) and 478 (67.3%) patients responding, respectively. After controlling for confounding variables, LVHR was independently associated with more frequent discomfort [odds ratio (OR) = 1.9, confidence interval (CI): 1.2–3.1], movement limitation (OR = 1.6, CI: 1.0–2.7), and overall symptoms (OR = 1.6, CI: 1.0–2.6) at 1 month. LVHR resulted in a shorter length of stay (LOS) (P < 0.001) and fewer infections (P = 0.004), but overall complication rates were equal. Recurrence rates were also equal (P = 0.66). Conclusion:In the largest, prospective QOL study comparing LVHR and OVHR, LVHR is associated with a decrease in QOL in the short term. LOS and infection rates are decreased in LVHR, but overall complication and recurrence rates are equal.

Prospective, comparative study of postoperative quality of life in TEP, TAPP, and modified Lichtenstein repairs.

Introduction:The purpose of this study was to compare postoperative quality of life (QOL) in patients undergoing laparoscopic totally extraperitoneal (TEP), transabdominal preperitoneal (TAPP), or modified Lichtenstein (ML) hernia repairs. Methods:The International Hernia Mesh Registry (2007–2010) was interrogated. 2086 patients who underwent 2499 inguinal hernia repairs were identified. A Carolinas Comfort Score was self-reported at 1-, 6-, 12-months and results were compared. Subgroups analysis and logistic regression were used to identify confounders and to control for significant variables. Results:One hundred seventy-two patients met the exclusion criteria. The distribution of unilateral procedures was TEP (n = 217), TAPP (n = 331), and ML (n = 953). Average follow-up was 12 months. Use of >10 tacks, lack of prostate pathology, recurrent hernia repairs, and bilateral hernia repairs were significant predictors of postoperative pain. One month after surgery 8.9%, 16.6%, and 16.5% were symptomatic for TEP (P = 0.038 vs. ML), TAPP and ML, respectively. At 6 months and 1 year no differences were observed. The number of tacks used varied significantly, with 18.1% of TAPP and 2.3% of TEP with >10 tacks (P = 0.005). The incidence of hernia recurrences were equivalent: TEP (0.42%), TAPP (1.34%), and ML (1.27%). The number or type of tacks utilized did not impact recurrence rates. Conclusion:Use of >10 tacks doubles the incidence of early postoperative pain while having no effect on rates of recurrence. There was no difference in chronic postoperative pain comparing ML, TEP, and TAPP including when controlled for tack use.

Comparative analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs.

BACKGROUNDnContaminated operative fields pose significant challenges for surgeons performing ventral hernia repair. Although biologic meshes have been utilized increasingly in these fields, recent evidence suggests that synthetic meshes represent a viable option. We analyzed the outcomes of biologic and synthetic mesh utilized in patients undergoing major ventral hernia repair in clean-contaminated/contaminated fields.nnnMETHODSnWe conducted a multicenter, retrospective review of patients undergoing open ventral hernia repair in clean-contaminated/contaminated fields using biologic or synthetic mesh. Patient and hernia details were characterized. Primary outcomes included 90-day surgical site event, surgical site infection, and hernia recurrence.nnnRESULTSnA total of 126 patients undergoing major ventral hernia repair in clean-contaminated/contaminated fields (69 biologic and 57 synthetic meshes) were analyzed. Groups were similar in both patient and hernia characteristics. There were 13 (22.8%) surgical site events in the synthetic cohort compared to 29 (42.0%) in the biologic cohort, Pxa0=xa0.024. Similarly, surgical site infections were less frequent in the synthetic group, with 7 (12.3%) vs 22 (31.9%), Pxa0=xa0.01. With a mean follow-up of 20xa0months, there were more recurrences in the biologic group: 15 (26.3%) vs 4 (8.9%) in the synthetic group, Pxa0=xa0.039.nnnCONCLUSIONnThe choice of mesh for clean-contaminated/contaminated ventral hernia repair remains debatable. We demonstrated that using synthetic sublay mesh resulted in a significantly lower wound morbidity and more durable outcomes versus a similar cohort of biologic repairs. This is likely secondary to improved bacterial clearance and faster integration of macroporous synthetics. Overall, our findings not only support suitability of synthetic mesh in contaminated settings but also challenge the purported advantage of biologics in clean-contaminated/contaminated ventral hernia repairs.

Laparoscopic Transversus Abdominis Release, a Novel Minimally Invasive Approach to Complex Abdominal Wall Reconstruction.

Background. Open abdominal wall reconstruction is used to repair complex abdominal wall hernias with contour abnormalities. We present a novel minimally invasive approach to address these types of defects, completed entirely laparoscopically. Methods. Three patients underwent laparoscopic abdominal wall reconstruction for complex hernias in August and September of 2015. Operative approach consisted of laparoscopic transversus abdominis components separation, defect closure, and wide mesh implantation in the retromuscular space. Results. Two males and one female with mean age and body mass index of 70 and 30.1, respectively, underwent a mean operation room time of 329 minutes. Estimated blood loss and length of stay were 91.7 cc and 4.7 days, respectively. No subcutaneous flaps were raised avoiding the need for subcutaneous drains. There were no perioperative complications. All of the subfascial drains were removed prior to patient discharge. On initial follow-up visit at 3 weeks, there was no evidence of wound complications, bulging, or hernia recurrences. Conclusion. Laparoscopic abdominal wall reconstruction with transversus abdominis release is a unique and feasible approach to complex abdominal wall defects with the potential to reduce pain, facilitate recovery, and decrease length of hospital stay for patients.

Outcomes of Retromuscular Porcine Biologic Mesh Repairs Using Transversus Abdominis Release Reconstruction

BACKGROUNDnOptimal mesh reinforcement and operative technique for major abdominal wall reconstructions (AWR) remain debatable. Posterior component separation via transversus abdominis release (TAR) allows for wide sublay mesh reinforcement with durable reconstruction, and has been gaining popularity in recent years. Although biologic mesh has been associated with mixed results, outcomes of AWR with bioprosthetics have not been well elucidated to date. We evaluated our outcomes of TAR reconstructions with retromuscular porcine biologic mesh reinforcement.nnnSTUDY DESIGNnConsecutive patients undergoing AWR using TAR with biologic mesh sublay reinforcement were identified in our prospective databases and analyzed. We characterized patient demographics and perioperative details. Main outcomes measures included wound complications and hernia recurrence.nnnRESULTSnBetween 2007 and 2014, seventy-seven patients (mean age 56 years, mean BMI 35 kg/m(2)) underwent AWR using TAR with biologic mesh. Mean hernia size was 306 ± 128 cm(2) with mean width of 14.3 ± 3.3 cm. The vast majority of patients had grade 3 hernias (92%) and more than half had a history of wound infection (55%). There were 22 (28.6%) surgical site infections consisting of 14 deep, 7 superficial, and 1 organ-space surgical site infections. There were no incidences of chronic mesh infection or explantation. In patients with at least 12 months follow-up (mean duration 28.2 months), there were 8 (12.5%) recurrences.nnnCONCLUSIONSnComplex hernias repaired with TAR and retromuscular porcine biologic mesh reinforcement are associated with a low rate of serious perioperative wound/mesh complications. Additionally, our approach resulted in a fairly low rate of hernia recurrences in this complex cohort of patients. We believe that the TAR approach and retromuscular mesh placement can be beneficial when biologic mesh reinforcement is chosen during complex and/or contaminatedxa0abdominal wall reconstructions.

Comparative analysis of perioperative outcomes of robotic versus open transversus abdominis release

BackgroundTransversus abdominis release (TAR) has evolved as an effective approach to complex abdominal wall reconstructions. Although the role of robotics in hernia surgery is rapidly expanding, the benefits of a robotic approach for abdominal wall reconstruction have not been established well. We aimed to compare the impact of the application of robotics to the TAR procedure on the perioperative outcomes when compared to the open TAR repairs.MethodsCase-matched comparison of patients undergoing robotic TAR (R-TAR) at two specialized hernia centers to a matched historic cohort of open TAR (O-TAR) patients was performed. Outcome measures included patient demographics, operative details, postoperative complications, and length of hospitalization.Results38 consecutive patients undergoing R-TAR were compared to 76 matched O-TAR. Patient demographics were similar between the groups, but ASA III status was more prevalent in the O-TAR group. The average operative time was significantly longer in the R-TAR group (299xa0±xa095 vs.. 211xa0±xa063xa0min, pxa0<xa00.001) and blood loss was significantly lower for the R-TAR group (49xa0±xa060 vs. 139xa0±xa0149xa0mL, pxa0<xa00.001). Wound morbidity was minimal in the R-TAR, but the rate of surgical site events and surgical site infection was not different between groups. Systemic complications were significantly less frequent in the R-TAR group (0 vs. 17.1%, pxa0=xa00.026). The length of hospitalization was significantly reduced in the R-TAR group (1.3xa0±xa01.3 vs. 6.0xa0±xa03.4xa0days, p <xa00.001).ConclusionsIn our early experience, robotic TAR was associated with longer operative times. However, we found that the use of robotics was associated with decreased intraoperative blood loss, fewer systemic complications, shorter hospitalizations, and eliminated readmissions. While long-term outcomes and patient selection criteria for robotic TAR repair are under investigations, we advocate selective use of robotics for TAR reconstructions in patients undergoing AWR.

Carolinas Comfort Scale as a Measure of Hernia Repair Quality of Life: A Reappraisal Utilizing 3788 International Patients.

Objective: The goal of the present study was to reaffirm the psychometric properties of the CCS using an expansive, multinational cohort. Background: The Carolinas Comfort Scale (CCS) is a validated, disease-specific, quality of life (QOL) questionnaire developed for patients undergoing hernia repair. Methods: The data were obtained from the International Hernia Mesh Registry, an American, European, and Australian prospective, hernia repair database designed to capture information delineating patient demographics, surgical findings, and QOL using the CCS at 1, 6, 12, and 24 months postoperatively. Results: A total of 3788 patients performed 11,060 postoperative surveys. Patient response rates exceeded 80% at 1 year postoperatively. Acceptability was demonstrated by an average of less than 2 missing items per survey. The formal test of reliability revealed a global Cronbachs alpha exceeding 0.95 for all hernia types. Test-retest validity was supported by the correlation found between 2 different administrations of the CCS using the kappa coefficient. Principal component analysis identified 2 components with a good distribution of variance, with the first component explaining approximately 60% of the variance, regardless of hernia type. Discriminant validity was assessed by comparing survey responses and use of pain medication at 1 month postoperatively and analysis revealed that symptomatic patients demonstrated significantly higher odds of requiring pain medication in all activity domains and for all hernia types. Conclusions: The present study confirms that the CCS questionnaire is a validated, sensitive, and robust instrument for assessing QOL after hernia repair, which has become a predominant outcome measure in this discipline of surgery.

A novel approach using the enhanced-view totally extraperitoneal (eTEP) technique for laparoscopic retromuscular hernia repair

BackgroundThe enhanced-view totally extraperitoneal (eTEP) technique has been previously described for Laparoscopic Inguinal Hernia Repair. We present a novel application of the eTEP access technique for the repair of ventral and incisional hernias.MethodsRetrospective review of consecutive laparoscopic retromuscular hernia repair cases utilizing the eTEP access approach from five hernia centers between August 2015 and October 2016 was conducted. Patient demographics, hernia characteristics, operative details, perioperative complications, and quality of life outcomes utilizing the Carolina’s Comfort Scale (CCS) were included in our data analysis.ResultsSeventy-nine patients with mean age of 54.9xa0years, mean BMI of 31.1xa0kg/m2, and median ASA of 2.0 were included in this analysis. Thirty-four percent of patients had a prior ventral or incisional hernia repair. Average mesh area of 634.4xa0cm2 was used for an average defect area of 132.1xa0cm2. Mean operative time, blood loss, and length of hospital stay were 218.9xa0min, 52.6xa0mL, and 1.8xa0days, respectively. There was one conversion to intraperitoneal mesh placement and one conversion to open retromuscular mesh placement. Postoperative complications consisted of seroma (nxa0=xa02) and trocar site dehiscence (nxa0=xa01). Comparison of mean pre- and postoperative CCS scores found significant improvements in pain (68%, pxa0<xa00.007) and movement limitations (87%, pxa0<xa00.004) at 6-month follow-up. There were no readmissions within 30xa0days and one hernia recurrence at mean follow-up of 332xa0±xa0122xa0days.ConclusionsOur initial multicenter evaluation of the eTEP access technique for ventral and incisional hernias has found the approach feasible and effective. This novel approach offers flexible port set-up optimal for laparoscopic closure of defects, along with wide mesh coverage in the retromuscular space with minimal transfascial fixation.

A prospective randomized double-blinded controlled trial evaluating indocyanine green fluorescence angiography on reducing wound complications in complex abdominal wall reconstruction

BACKGROUNDnThe purpose of this prospective, randomized, double-blinded controlled trial was to investigate the utility of indocyanine green fluorescence angiography (ICG-FA) in reducing wound complications in complex abdominal wall reconstruction.nnnMATERIALS AND METHODSnAll consented patients underwent ICG-FA with SPY Elite after hernia repair and before flap closure. They were randomized into the control group, in which the surgical team was blinded to ICG-FA images and performed surgery as they normally would, or the experimental group, in which the surgery team viewed the images and could modify tissue flaps according to their findings. Patient variables and wound complications were compared with standard statistical methods.nnnRESULTSnAmong 95 patients, nxa0=xa049 control versus nxa0=xa046 experimental, preoperative characteristics were similar including age (58.3 versus 56.7xa0y; Pxa0=xa00.4), body mass index (34.9 versus 33.6xa0kg/m(2); Pxa0=xa00.8), tobacco use (8.2% versus 8.7%; Pxa0=xa00.9), diabetes (30.6% versus 37.0%; Pxa0=xa00.5), and previous hernia repair (71.4% versus 60.9%; Pxa0=xa00.3). Operative characteristics were also similar, including rate of panniculectomy (69.4% versus 58.7%; Pxa0=xa00.3) and component separation (73.5% versus 69.6%; Pxa0=xa00.6). The experimental group more often had advancement flaps modified (37% versus 4.1%, Pxa0<xa00.0001). There was no difference between groups in rates of skin necrosis (6.1% versus 2.2%; Pxa0=xa00.3), fat necrosis (10.2% versus 13.0%, Pxa0=xa00.7), reoperation (14.3% versus 26.1%, Pxa0=xa00.7), wound infection (10.2% versus 21.7%; Pxa0=xa00.12), or overall wound-related complications (32.7% versus 37.0%, Pxa0=xa00.7). Skin/subcutaneous hypoperfusion on ICG-FA was associated with higher rates of wound infection (28% versus 9.4%, Pxa0<xa00.02), but flap modification after viewing images did not prevent wound-related complications (15.6% versus 12.5%, Pxa0=xa00.99).nnnCONCLUSIONSnThis is the first randomized, double-blinded, controlled trial to evaluate ICG-FA in abdominal wall reconstruction. Although ICG-FA guidance and intraoperative modification of flaps did not prevent wound-related complications or reoperation, it did identify at risk patients.

Impact of the Establishment of a Specialty Hernia Referral Center

Background. Creating a surgical specialty referral center requires a strong interest, expertise, and a market demand in that particular field, as well as some form of promotion. In 2004, we established a tertiary hernia referral center. Our goal in this study was to examine its impact on institutional volume and economics. Materials and methods. The database of all hernia repairs (2004-2011) was reviewed comparing hernia repair type and volume and center financial performance. The ventral hernia repair (VHR) patient subset was further analyzed with particular attention paid to previous repairs, comorbidities, referral patterns, and the concomitant involvement of plastic surgery. Results. From 2004 to 2011, 4927 hernia repairs were performed: 39.3% inguinal, 35.5% ventral or incisional, 16.2% umbilical, 5.8% diaphragmatic, 1.6% femoral, and 1.5% other. Annual billing increased yearly from 7% to 85% and averaged 37% per year. Comparing 2004 with 2011, procedural volume increased 234%, and billing increased 713%. During that period, there was a 2.5-fold increase in open VHRs, and plastic surgeon involvement increased almost 8-fold, (P = .004). In 2005, 51 VHR patients had a previous repair, 27.0% with mesh, versus 114 previous VHR in 2011, 58.3% with mesh (P < .0001). For VHR, in-state referrals from 2004 to 2011 increased 340% while out-of-state referrals jumped 580%. In 2011, 21% of all patients had more than 4 comorbidities, significantly increased from 2004 (P = .02). Conclusion. The establishment of a tertiary, regional referral center for hernia repair has led to a substantial increase in surgical volume, complexity, referral geography, and financial benefit to the institution.