Safety and durability of one-stage repair of abdominal wall defects with enteric fistulas

Item does not contain fulltextOBJECTIVE: To evaluate the safety and long-term durability of 1-stage repair of enteric fistulas in the presence of an abdominal wall defect. BACKGROUND: Patients with enteric fistulas and an abdominal wall defect present an extreme challenge to surgeons and have been associated with significant morbidity and mortality. Durability of repair is unknown as studies fail to report this or use limited follow-up periods. METHODS: Chart review was done of consecutive patients who underwent 1-stage repair. Short-term outcomes included morbidity (wound and medical) and mortality. Long-term durability of repair was determined by prospective outpatient follow-up at least 3 years after surgery. RESULTS: Thirty-nine patients were included with a mean age of 61.2 years, a mean BMI of 24.4 kg/m2, and a mean abdominal wall defect size of 247.9 cm2. Component separation technique was used in 34 (87.2%) and synthetic mesh in 13 (33.3%) patients. There was 1 (2.6%) postoperative death. Twenty-four wound complications developed in 18 (46.2%) patients, including surgical-site infection in 8 (20.5%) patients. Two (5.1%) enteric fistulas recurred and were treated conservatively resulting in closure. Medical complications were seen 36 times in 23 (59%) patients. Twelve of 33 (36.4%) living patients developed a recurrent hernia after a mean follow-up of 62.7 months (range: 36-130). CONCLUSIONS: One-stage abdominal wall reconstruction with enteric fistula takedown is feasible at the cost of considerable morbidity. Our treatment strategy including component separation technique with synthetic mesh on-demand results in a durable repair in 6 to 7 of 10 patients

The TREPP as alternative technique for recurrent inguinal hernia after Lichtenstein's repair: A consecutive case series

BACKGROUND: Recurrent inguinal hernias after initial repair with mesh are preferably treated via an alternative route (e.g. posterior after anterior). For recurrent inguinal hernias after an anterior repair such as Lichtenstein's, an endoscopic approach such as the total extraperitoneal or transabdominal preperitoneal technique (TEP or TAPP) is recommended if expertise is present. The TransREctus sheath PrePeritoneal (TREPP) technique is a promising open posterior technique and could be an alternative to endoscopic methods. This study aims to evaluate the results of the TREPP technique for recurrent inguinal hernia. MATERIALS AND METHODS: Consecutive patients who underwent a TREPP repair for recurrent hernia after initial operation according to Lichtenstein were included in a retrospective manner. A minimum of one year follow-up after the TREPP repair was maintained. Data retrieved from the patient files were combined with the findings at an outpatient department visit. RESULTS: Between January 2006 and December 2013 fifty-two patients were eligible for inclusion of which 38 patients were clinically evaluated. The mean follow-up of these thirty-eight patients was 65 months (range 17-108 months) in which 2 patients had developed a re-recurrence. One patient reported chronic postoperative inguinal pain (CPIP) since the TREPP and four patients experienced CPIP since the primary inguinal hernia repair. Peri-operative and <30 day complications were rare and no severe adverse events occurred. CONCLUSION: TREPP seems to be a feasible alternative for recurrent inguinal hernia repair after an initial operation according to Lichtenstein. It may yield extra advantages compared to endoscopic repairs, such as a short learning curve, spinal anesthesia and lower costs

Perioperative monitoring of inguinal hernia patients with a smartphone application

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Long-term results of the SOFTGRIP trial: TIPP versus ProGrip Lichtenstein's inguinal hernia repair.

PURPOSE: In preventing Chronic Postoperative Inguinal Pain (CPIP) after inguinal herniorrhaphy, mesh position and mesh fixation seem important factors. The SOFTGRIP trial compared the TransInguinal PrePeritoneal (TIPP) repair to Polysoft mesh, to the Open anterior repair (Lichtenstein) using the self-gripping ProGrip mesh. Since CPIP might resolve and recurrence rate increase, this study reports the SOFTGRIP trial's long-term results (with a minimal follow-up of 5 years). METHODS: All patients initially randomized in the SOFTGRIP trial were contacted if not deceased. Patients were invited for an interview and physical examination. The procedures and methodology of this randomized clinical trial have been published together with the short-term results. The main outcomes for this long-term follow-up study were chronic pain, recurrences, re-operations and numbness. RESULTS: A total of 193 patients (81.4% of the initially randomized patients) were included for long-term follow-up analyses, 96 after TIPP, 97 after ProGrip Lichtenstein. After a median follow-up of 74 months (range 60-80) there were no significant differences between the two groups. Overall, chronic pain drastically decreased. Fourteen patients reported CPIP at long-term follow-up (overall 7.3%, 7 after TIPP and 7 after ProGrip Lichtenstein, any form, frequency and intensity of pain included). Recurrence rate increased from 2.6% (n = 6) at one-year follow-up, to 8.3% (n = 16) at 5-year's follow-up. CONCLUSION: The SOFTGRIP trial´s long-term outcomes show that after both TIPP and ProGrip Lichtenstein, recurrence rate increases and CPIP mostly disappears. These findings aid in better informing patients on the benefits and harms of inguinal hernia repair. The findings of accumulating recurrences and fading of chronic pain, confirms the need for long-term follow-up studies. High-quality long-term data on TIPP, ProGrip Lichtenstein and other types of herniorrhaphy are scarce and complication rates vary widely. Further long-term studies are needed to reveal the true spectrum of benefits and harms of the different inguinal hernia repair techniques. TRIAL REGISTRATION: Registered on August 25, 2009 at the Dutch Trial Registry ( www.trialregister.nl ) NTR1853

Case series of recurrent inguinal hernia after primary TREPP repair: re-TREPP seems feasible and safe

Item does not contain fulltextINTRODUCTION: The Trans REctussheath PrePeritoneal (TREPP) mesh repair was introduced in 2006 to decrease the risk of postoperative inguinal pain in hernia surgery. For the repair of a recurrent inguinal hernia after a primary TREPP an alternative open anterior route (Lichtenstein) may seem the most logical option, but coincides with an increased risk of chronic postoperative inguinal pain. Therefore, this study aimed to evaluate the feasibility of a second TREPP procedure to repair a recurrent inguinal hernia after an initial TREPP repair. METHODS: Consecutive patients with a recurrent inguinal hernia after a primary TREPP, repaired by a re-TREPP were retrospectively included in the study. Data, retrieved from the electronic patient files, were combined with the clinical findings at the outpatient department where the patients were physically investigated according to a priorly written and registered protocol. RESULTS: Overall about 1800 TREPPs were performed between 2006 and 2013. Since the introduction of TREPP in 2006, 40 patients presented with a recurrence in our center. From this group 19 patients were re-operated with the TREPP technique. No intraoperative complications occurred. There was one conversion from re-TREPP to Lichtenstein and no re-recurrences occurred to date. Ten out of 19 patients could be clinically evaluated with a mean follow-up period of 37 months (range 11-95). None of these patients (n=10) complained of chronic postoperative inguinal pain. Two patients reported discomfort. One patient died non procedure related, three weeks after re-TREPP of sudden cardiac death. CONCLUSION: These first experiences with re-TREPP for secondary inguinal hernia repair are encouraging for the aspects of feasibility and safety, particularly in experienced surgical hands

Large Contaminated Ventral Hernia Repair Using Component Separation Technique with Synthetic Mesh

Item does not contain fulltextBACKGROUND: Large ventral hernia repair represents a major reconstructive surgical challenge, especially under contaminated conditions. Synthetic mesh is usually avoided in these circumstances because of fear of mesh infection, although evidence is outdated and does not regard new materials and techniques. The authors evaluated the safety of synthetic mesh in large contaminated ventral hernia repair. METHODS: All large ventral hernias repaired with the components separation technique and polypropylene mesh were included in analysis. Primary outcomes were wound and medical complications, with a focus on surgical-site infection and mesh removal. For risk analysis, patients were stratified by surgical wound class, Ventral Hernia Working Group grade, and modified Ventral Hernia Working Group grade. RESULTS: One hundred thirty-seven patients were included, with a mean age of 58.6 years, mean body mass index of 26.6 cm, and mean defect size of 235.6 cm. Surgical-site infection and total wound complication rates were 16.1 and 48.9 percent, respectively. The surgical wound class distribution of surgical-site infections was as follows: clean, five of 56 (9.1 percent); clean-contaminated, five of 34 (14.7 percent); contaminated, three of 19 (15.8 percent); and dirty/infected, nine of 28 (32.1 percent). Seven meshes (5.1 percent) needed removal, two after clean repairs, three after clean-contaminated repairs, and two after dirty/infected repairs. Surgical wound class (OR, 1.77; 95 percent CI, 1.20 to 2.61) and Ventral Hernia Working Group grade (OR, 2.31; 95 percent CI, 1.24 to 4.28) were predictors of surgical-site infection. CONCLUSION: Rate of surgical-site infection after large contaminated ventral hernia repair with synthetic mesh is considerable but with a low mesh removal rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV

Large Contaminated Ventral Hernia Repair Using Component Separation Technique with Synthetic Mesh

BACKGROUND: Large ventral hernia repair represents a major reconstructive surgical challenge, especially under contaminated conditions. Synthetic mesh is usually avoided in these circumstances because of fear of mesh infection, although evidence is outdated and does not regard new materials and techniques. The authors evaluated the safety of synthetic mesh in large contaminated ventral hernia repair. METHODS: All large ventral hernias repaired with the components separation technique and polypropylene mesh were included in analysis. Primary outcomes were wound and medical complications, with a focus on surgical-site infection and mesh removal. For risk analysis, patients were stratified by surgical wound class, Ventral Hernia Working Group grade, and modified Ventral Hernia Working Group grade. RESULTS: One hundred thirty-seven patients were included, with a mean age of 58.6 years, mean body mass index of 26.6 cm, and mean defect size of 235.6 cm. Surgical-site infection and total wound complication rates were 16.1 and 48.9 percent, respectively. The surgical wound class distribution of surgical-site infections was as follows: clean, five of 56 (9.1 percent); clean-contaminated, five of 34 (14.7 percent); contaminated, three of 19 (15.8 percent); and dirty/infected, nine of 28 (32.1 percent). Seven meshes (5.1 percent) needed removal, two after clean repairs, three after clean-contaminated repairs, and two after dirty/infected repairs. Surgical wound class (OR, 1.77; 95 percent CI, 1.20 to 2.61) and Ventral Hernia Working Group grade (OR, 2.31; 95 percent CI, 1.24 to 4.28) were predictors of surgical-site infection. CONCLUSION: Rate of surgical-site infection after large contaminated ventral hernia repair with synthetic mesh is considerable but with a low mesh removal rate. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV