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Aim: Posterior component separation using transversus abdominis release (TAR) is well established as an option for repair of large hernia defects. TAR can be performed robotically (rTAR) or open (oTAR) with limited data to demonstrate benefit and guide decision making. We conducted a systematic review and meta-analysis comparing rTAR and oTAR approaches for ventral hernia repair (VHR). Material and Methods: We searched Pubmed, Embase, Cochrane, and Web of Science for studies comparing rTAR and oTAR for VHR. Hybrid rTAR was not included in our analysis. Our primary outcomes were overall postoperative and intraoperative complications, surgical site occurrences (SSO), SSO requiring surgical intervention (SSOPI), surgical site infection (SSI) superficial or deep, and fascial closure. Additional outcomes were operative time (OT), readmission, length of hospital stay (LOS). We performed sensitivity analysis to explore reasons for heterogeneity and outliers, and a proportional meta-analysis of conversion during rTAR. We performed a meta-regression exploring the relationship of BMI, hernia defect and mesh width rTAR/oTAR with the analyzed outcome within each study. Results: 503 studies were screened and seven studies were included in this analysis. Our sample totaled 780 patients, of which 298 (38.2%) underwent rTAR. Defect width ranged between 8.7 to 13.5 cm (cm) for rTAR and 10 to 13.5 cm for oTAR. Mean mesh area ranged from 66.9 to 980 cm2 and from 51.3 to 1344 cm2 for rTAR and oTAR respectively. We found lower overall complications (9% versus 24.6%; RR 0.43; 95% CI 0.26 to 0.73; P < 0.01) and intraoperative complication (5.9% versus 9.1%; RR 0.44; 95% CI 0.22 to 0.88; P = 0.02) rates for the rTAR group. There was no difference in fascial closure between the groups (99% versus 94.6%; RR 1.05; 95% CI 0.99 to 1.11; P = 0.11). rTAR presented lower SSI rates (2.5% versus 7.8%; RR 0.33; 95% CI 0.13 to 0.8; P = 0.01). No differences were found in SSO (16.3% versus 13.7%; RR 0.87; 95% CI 0.51 to 1.48; P = 0.6) or SSOPI (5.4% versus 8.9%%; RR 0.5; 95% CI 0.22 to 1.15; P = 0.1) rates. No statistically significant differences were found in superficial SSI (0.76% versus 3%; RR 0.36; 95% CI 0.07 to 1.75; P = 0.21) and deep SSI (0% versus 4.2%; RR 0.23; 95% CI 0.02 to 3.12; P = 0.27). Open surgery presented a lower OT (MD −67.7 min; P < 0.001), but robotic surgery showed a reduced LOS (−3.9 days; 95% CI −4.8 to −3.1; P < 0.001). No differences were found in readmission and 1 year recurrence rates. The proportional meta-analysis showed a conversion to open rate of 6.4 per 100 patients (95% CI 3.3 to 12 patients) during rTAR. Meta-regression presented no statistically significant influences of rTAR/oTAR mesh width and defect width relations and BMI, despite the analysis was limited by the low number of studies. Conclusion: Robotic TAR may be associated with lower intraoperative and postoperative complications, lower SSI, shorter LOS, and longer operative times when compared to oTAR. Given the limitations of the included studies, randomized trials are needed to better evaluate the impact of the robotic-assisted surgery for complex abdominal wall reconstruction. PROSPERO registration: CRD42024540991. [ABSTRACT FROM AUTHOR]

Purpose: The study aim was to assess the impact of clinically significant weight loss (CSWL; ≥5% weight reduction) on postoperative complications following abdominal wall reconstruction with the component separation technique (CST). Methods: A retrospective review of patients who underwent open ventral hernia repair (VHR) with CST from November 2008 to January 2022 was performed. Cohorts were stratified by presence of CSWL from baseline weight at preoperative consultation. Results: Of 180 total patients, 40 (22.2%) achieved CSWL prior to VHR. Mean age was 59.6 ± 11.2 years. Patients in the CSWL cohort represented a higher average body mass index (BMI) (33.6 vs. 31.7 kg/m2, p = 0.076), and were obese more frequently (80.0% vs. 56.4%, p = 0.007). The CSWL cohort had a higher proportion of patients in Ventral Hernia Working Group (VHWG) classification II (82.5% vs. 63.6%) while the non-CSWL cohort had more VHWG classification III/IV (20.0% vs. 10.0%, p = 0.078). Mean follow-up duration was 6.1 ± 13.4 months. Complications, including 30- and 90-day surgical site occurrence (SSO), return to operating room, readmission, and hernia recurrence (CSWL: 5.0% vs. non-CWL 1.4%, p = 0.179), were comparable between cohorts. BMI was an independent predictor of any complication (OR 1.07, p = 0.044) and 90-day SSO (OR 1.10, p = 0.043). Conclusion: Achievement of CSWL prior to open VHR utilizing CST results in similar post-reconstruction outcomes to patients who maintained a comparable BMI at baseline. Higher day-of-surgery BMI was more consequential to postoperative complications than percent weight loss. [ABSTRACT FROM AUTHOR]

Metabolic syndrome (MetS) is characterized by cardiometabolic abnormalities such as hypertension, obesity, diabetes, or dyslipidemia. This study aims to evaluate the association of MetS on the postoperative outcomes of ventral, umbilical, and epigastric hernia repair using component separation. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent ventral, umbilical, and epigastric hernia repair with component separation between 2015 and 2021. MetS status was defined as patients receiving medical treatment for diabetes mellitus and hypertension, with a body mass index greater than 30 kg/m2. Propensity matching was performed to generate two balanced cohorts with and without MetS. T -tests and Fisher's Exact tests assessed group differences. Logistic regression models evaluated complications between the groups. After propensity score matching, 3930 patients were included in the analysis, with 1965 in each group (MetS versus non-MetS). Significant differences were observed in the severity and clinical presentation of hernias between the groups. The MetS cohort had higher rates of incarcerated hernia (39.1% versus 33.2%; P < 0.001), and recurrent ventral hernia (42.7% versus 36.5%; P < 0.001) compared to the non-MetS cohort. The MetS group demonstrated significantly increased rates of renal insufficiency (P = 0.026), unplanned intubation (P = 0.003), cardiac arrest (P = 0.005), and reoperation rates (P = 0.002) than the non-MetS cohort. Logistic regression models demonstrated higher likelihood of postoperative complications in the MetS group, including mild systemic complications (OR 1.25; 95%CI 1.030-1.518; P = 0.024), severe systemic complications (OR 1.63; 95%CI 1.248-2.120; P < 0.001), and reoperation (OR 1.47; 95%CI 1.158-1.866; P = 0.002). There were no significant differences in the rates of 30-d wound complications between groups. The presence of metabolic derangement appears to be associated with adverse postoperative medical outcomes and increased reoperation rates after hernia repair with component separation. These findings highlight the importance of optimizing preoperative comorbidities as surgeons counsel patients with MetS. • Metabolic syndrome is a cluster of cardiometabolic abnormalities, including hypertension, obesity, diabetes, and dyslipidemia. • Higher rates of incarcerated hernia and recurrent ventral hernia present in patients with diagnosis of metabolic derangement. • Metabolic derangement can be associated with an increased risk of mild and severe systemic complications and reoperation in patients undergoing hernia repair with component separation. • Metabolic derangement was not associated with increased risk of wound complications following hernia repair with component separation. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study is to evaluate the safety and long-term outcomes of GORE Synecor™ in ventral hernia repair (VHR). Methods: This retrospective, single-center case review analyzed outcomes in patients who underwent VHR with Synecor from May 2016 to December 2022. Primary outcomes were hernia recurrence and mesh infection rates. Secondary outcomes were 30-day morbidity, 30-day mortality, 30-day readmission, re-operation, surgical-site infection (SSI) and occurrence (SSO) rates, and occurrences requiring intervention (SSOI). Results: 278 patients were identified. Mean follow-up was 24.1 (0.2–87.1) months. Mean hernia defect size was 63.4 (± 77.2) cm2. Overall hernia recurrence and mesh infection rates were 5.0% and 1.4% respectively. No mesh infections required full explantation. We report the following overall rates: 13.3% 30-day morbidity, 4.7% 30-day readmission, 2.9% re-operation, 7.2% SSI, 6.1% SSO, and 2.9% SSOI. 30-day morbidity was significantly higher in non-clean (42.1% vs 11.2%, p < 0.01), onlay (OL) mesh (37.0% vs preperitoneal (PP) 16.4%, p = 0.05 vs retrorectus (RR) 15.0%, p < 0.05 vs intraperitoneal (IP) 5.2%, p < 0.001), and open cases (23.5% vs 3.1% laparoscopic vs 4.4% robotic, p < 0.01). SSI rates were significantly higher in non-clean (31.6% vs 5.4%, p < 0.001), OL mesh (29.6% vs RR 11.3%, p < 0.05 vs PP 5.5%, p < 0.01 vs IP 0.0%, p < 0.001), and open cases (15.2% vs 0% laparoscopic vs 0% robotic, p < 0.05). Conclusion: Long-term performance of a novel hybrid mesh in VHR demonstrates a low recurrence rate and favorable safety profile in various defect sizes and mesh placement locations. [ABSTRACT FROM AUTHOR]

Abdominal wall reconstruction is a common and necessary surgery, two factors that drive innovation. This review article examines recent developments in ventral hernia repair including primary fascial closure, mesh selection between biologic, permanent synthetic, and biosynthetic meshes, component separation, and functional abdominal wall reconstruction from a plastic surgery perspective, exploring the full range of hernia repair's own reconstructive ladder. New materials and techniques are examined to explore the ever-increasing options available to surgeons who work within the sphere of ventral hernia repair and provide updates for evolving trends in the field. [ABSTRACT FROM AUTHOR]

The management of giant inguinoscrotal hernias remains a challenge as a result of the loss of the intra-abdominal domain from long-standing hernia contents within the scrotum. Multiple techniques have been described for abdominal wall relaxation and augmentation to allow the safe return of viscera from the scrotum to the intraperitoneal cavity without adversely affecting cardiorespiratory physiology. Preoperative progressive pneumoperitoneum, phrenectomy, and component separation are but a few common techniques previously described as adjuncts to the management of these massively large hernias. However, these strategies require an additional invasive stage, and reproducibility remains challenging. Botulinum toxin A (BTA) has been successfully used for the management of complex ventral hernias. Its use for these hernias has shown reproducibility and a low side effect profile. In the present report, we describe our institutional experience with BTA for giant inguinal hernias in two patients and present a review of the literature. In one case, a 77-year-old man with a substantial cardiac history presented with a giant left inguinal hernia that was interfering with his activities of daily living. He had BTA six weeks prior to inguinal hernia repair. Repair was performed via an inguinal incision with a favorable return of the viscera into the peritoneum. He was discharged on the same day of the operation. A second patient, 78 years of age, had a giant right inguinoscrotal hernia. He had a significant cardiac history and was treated with BTA six weeks prior to inguinal hernia repair via a groin incision. Neither patient had complaints nor recurrence at 7- and 3-month follow-ups. While the literature on this topic is scarce, we found 13 cases of inguinal hernias treated with BTA as an adjunct. BTA might be a promising adjunct for the management of giant inguinoscrotal hernias in addition to or in place of current strategies. [ABSTRACT FROM AUTHOR]

Introduction Abdominal wall dehiscence is one of the critical postoperative complications following abdominal surgeries. Emergency surgery highly contributes to the incidence of a burst abdomen due to a lack of proper preoperative preparation and the presence of intraabdominal sepsis. Anterior component separation was primarily evolved in abdominal wall reconstruction in the open abdomen and huge ventral hernia repair. Methods This prospective study included 50 patients operated by midline laparotomy for non-traumatic abdominal emergencies. Anterior component separation technique was randomly applied in 25 patients before laparotomy closure, the other 25 patients were closed using the traditional midline closure method. Preoperative patient's demographics, operative time, and different postoperative complications were reported. Incidence of burst abdomen in both groups was reported. Results Preoperative patient's demographic data showed no significant difference between both groups; the mean age of the patients was 53.69±7.34. Operative time was significantly longer in the Anterior Components Separation (ACS) group (P<0.001). The incidence of abdominal wall dehiscence after ACS technique (4.3%) was significantly less than after traditional technique (24%). Postoperative seroma and hematoma were the common postoperative complications after ACS however the incidence was not statistically significant. Incisional hernia was detected in (13.04%) in ACS group and in (32%) in traditional group. Conclusion Application of ACS technique during laparotomy closure in abdominal emergencies seems to lower the incidence of abdominal wall dehiscence with no increase in different postoperative complications. [ABSTRACT FROM AUTHOR]

Background: Several techniques have been described to repair giant omphaloceles. Component Separation Technique (CST) is a surgical technique first reported in adults to repair large abdominal wall defects. The purpose of this study is to describe our experience using this technique in repairing large ventral hernias secondary to giant omphaloceles in children. Methods: Nine patients with giant omphalocele were treated. The abdominal wall was reconstructed using CST, based on the enlargement of the abdominal wall by separate mobilization of the muscular layers. Patients were monitored for complications during admission, postoperative complications, and all patients were seen for follow-up. Results: Component separation technique was performed at a median age of 7.2 years. The median diameter of the hernia was 109.8 cm2. There was no mortality. Minor complications were seen (infection, skin necrosis, and hematoma). There were no recurrences after an average follow-up of 3.3 years (2 - 4 years). Conclusions: Component separation technique is a valuable method for repairing large ventral hernias as a consequence of giant omphaloceles in children. Our series supports the use of CST in children, in a wide age range, from newborns for primary closure to adolescence in cases of giant ventral hernias secondary to omphaloceles with multiple previous surgeries. Level of Evidence: II

Background Abdominal wall reconstruction is challenging for surgeons and may be life altering for patients. There are scant high-quality studies on patient-reported outcomes following abdominal wall reconstruction. We assess long-term surgical and patient-reported outcomes of perforator-preserving open anterior component separation (OPP-ACS) following large ventral hernia repair. Methods A retrospective review of patients with large ventral hernia defects who underwent OPP-ACS performed by the authors (B.A.S., M.J.T.) was conducted between 2015 and 2019. Demographics, surgical history, operative details, outcomes, and complications were extracted. A validated questionnaire, Carolinas Comfort Scale (CCS), was used to assess postoperative quality of life. Results Twenty-two patients (12 males and 10 females) with a mean age and BMI of 60.9 ± 10 years and 28.9 ± 4.8 kg/m 2 , respectively, were included. Mean follow-up was 28.5 ± 16.3 months. All had prior abdominal surgery; 15 (68%) for abdominopelvic malignancy, 3 (14%) for previous failed hernia repair, and 8 (36%) had history of abdominopelvic radiation. Overall, 16 (73%) hernias were in the midline, 4 (18%) in the right lower quadrant, 1 (4.5%) in the right upper quadrant, and 1 (4.5%) in the left lower quadrant. Mean hernia defect surface area was 145 ± 112 cm 2. A total of 9 patients (40.9%) underwent bilateral component separation, whereas 13 (59.1%) had unilateral. Bioprosthetic mesh was used in all patients as underlay. Mean mesh size and thickness were 545.6 ± 207.7 cm 2 and 3.4 ± 0.5 mm, respectively. One patient presented with a minor wound dehiscence, and two presented with seromas not requiring aspiration/evacuation. One patient had hernia recurrence 22 months after surgery. One patient was readmitted for partial small bowel obstruction and one required wound revision. A total of 14 (65%) patients responded to the CCS questionnaire. At 12 months, mean score for all 23 items was 0.29 ± 0.21 (0.08–0.62), which corresponds to absence or minimal symptoms. Conclusion The OPP-ACS is a safe surgical option for large, complex ventral hernias. Our cases showed minimal complication rate and hernia recurrence, and our patients reported significant improvement in life quality. [ABSTRACT FROM AUTHOR]

Purpose: Currently, there are no reliable preoperative methods for predicting component separation (CS) during incisional hernia repair. By quantitatively measuring preoperative computed tomography (CT) imaging, we aimed to assess the value of hernia defect size, abdominal wall muscle quality, and hernia volume in predicting CS. Methods: The data of 102 patients who underwent open Rives-Stoppa retro-muscular mesh repair for midline incisional hernia between January 2019 and March 2022 were retrospectively analyzed. The patients were divided into two groups: "CS group" patients who required CS to attempt fascial closure, and "non-CS" group patients who required only Rives-Stoppa retro-muscular release to achieve fascial closure. Hernia defect width, hernia defect angle, rectus width, abdominal wall muscle area and CT attenuation, hernia volume (HV), and abdominal cavity volume (ACV) were measured on CT images. The rectus width to defect width ratio (RDR), HV/ACV, and HV/peritoneal volume (PV; i.e., HV + ACV) were calculated. Differences between the indices of the two groups were compared. Logistic regression models were applied to analyze the relationships between the above CT parameters and CS. Receiver operator characteristic (ROC) curves were generated to evaluate the potential utility of CT parameters in predicting CS. Results: Of the102 patients, 69 were in the non-CS group and 33 were in the CS group. Compared with the non-CS group, hernia defect width (P < 0.001), hernia defect angle (P < 0.001), and hernia volume (P < 0.001) were larger in the CS group, while RDR (P < 0.001) was smaller. The abdominal wall muscle area in the CS group was slightly greater than that in the non-CS group (P = 0.046), and there was no significant difference in the CT attenuation of the abdominal wall muscle between the two groups (P = 0.089). Multivariate logistic regression identified hernia defect width (OR 1.815, 95% CI 1.428–2.308, P < 0.001), RDR (OR 0.018, 95% CI 0.003–0.106, P < 0.001), hernia defect angle (OR 1.077, 95% CI 1.042–1.114, P < 0.001), hernia volume (OR 1.002, 95% CI 1.001–1.003, P < 0.001), and CT attenuation of abdominal wall muscle (OR 0.962, 95% CI 0.927–0.998, P = 0.037) as independent predictors of CS. Hernia defect width was the best predictor for CS, with a cut-off point of 9.2 cm and an area under the curve (AUC) of 0.890. The AUCs of RDR, hernia defect angle, hernia volume, and abdominal wall muscle CT attenuation were 0.843, 0.812, 0.747, and 0.572, respectively. Conclusion: Quantitative CT measurements are of great value for preoperative prediction of CS. Hernia defect size, hernia volume, and the CT attenuation of abdominal wall muscle are all preoperative predictive indicators of CS. [ABSTRACT FROM AUTHOR]

Transversus abdominis release (TAR) is the newest approach that allows effective myofascial mobilization, creating a large retromuscular space and wide mesh overlap to repair complex and large incisional ventral hernias. This article narrates the technical details and results of the TAR technique performed in a single center. The present study is a retrospective analysis of a prospective dataset from 25 patients who underwent posterior component separation (PCS) with TAR procedure for large incisional ventral hernias between October 2017 and July 2021. The minimum follow-up period was ten months. Twenty-five patients (five male, 20 female) with a mean age of 61.2 years, a mean BMI of 32.2 kg/m2, and a median ASA score of 2.0 underwent the TAR procedure. Fifteen (60%) patients had a history of incisional hernia surgery. The mean surgical time was 248 minutes. The mean total defect and mesh areas were 187.4 (90-500) cm2 and 1141.8 (750-2250) cm2, respectively. The mean visual analog scale (VAS) pain score on the first postoperative day was 4.5 and the median hospital length of stay (LOS) was 5 days. There were three (12%) surgical site infections (SSIs), two of which were deep infections that needed debridement. During the follow-up period (median of 26 months), two (8%) recurrences were recorded. The TAR technique represents an effective and safe repair modality of large and complex incisional hernias. TAR is an essential addition to the repertoire of the surgical community. [Med-Science 2022; 11(4.000): 1487-93]

Background: The optimal material for reinforcement of complex abdominal ventral hernia repair (VHR) remains controversial. Biologic prostheses such as porcine and bovine acellular dermal matrix (PADM/BADM) have shown favorable results, but few head-to-head comparisons between the two types exist. We sought to provide such a comparison. Methods: We performed a retrospective cohort study comparing 40 consecutive patients who underwent open component separation (CS/VHR) with PADM reinforcement to 39 consecutive patients who underwent open CS/VHR with BADM reinforcement at our institution. Patient characteristics, outcomes, complications, reoperations, and hernia recurrences were obtained by chart review. Fisher's exact and t-test analyses compared patient characteristics and outcomes between the 2 cohorts. Statistical significance was set as P <.05. Results: Patient groups did not differ significantly in race (P=.36), age (P=.8), BMI (P=.34), sex (P=.09), steroid usage (p-1.00), COPD (P=.43), number of previous abdominal operations (P=.66), and duration of follow-up (P=.65). There were significantly more smokers in the PADM group (37.5% vs 12.8%, P=.01). Mean defect size was significantly greater in the PADM group (372.5 cm2 vs 292. cm2 in the BADM group, P=.001) as was the number of Ventral Hernia Working Group (VHWG) grade III/IV hernias (65.0% vs 38.4%, P=.02). Recurrence rates were lower in the BADM group, (12.5% vs 5.1%, P=.26), as was recurrence or complications requiring reoperation (17.5% vs 5.1%, P=.15). Postoperative wound events were also significantly lower in the BADM group (30.0% vs 2.6%, P=.001). Conclusions: In our series, CS/BADM was associated with significantly fewer wound complications. Recurrences and complications requiring reoperation were also fewer, which trended toward but did not reach statistical significance, presumably due to the small sample size. These findings indicating superiority of BADM over PADM are potentially confounded by the higher percentage of smokers, the larger mean defect size, and the higher number of VHWG III/IV patients in the PADM group. Further prospective study of these findings is warranted. [ABSTRACT FROM AUTHOR]

Purpose: Patient optimization and selecting the proper technique to repair large incisional hernias is a multifaceted challenge. Body mass index (BMI) is a modifiable variable that may infer higher intra-abdominal pressures and, thus, predict the need for component separation (CS) at the time of surgery, but no data exist to support this. This paper assesses if the ratio of anterior–posterior (AP): transverse (TRSV) abdominal diameter, from pre-operative CT imaging, indicates a larger proportion of intra-abdominal fat and correlates with a hernia defect requiring a component separation for successful tension-free closure. Methods: Ninety patients were identified who underwent either an open hernia repair with mesh by primary closure (N = 53) or who required a component separation at the time of surgery (N = 37). Pre-operative CT images were used to measure hernia defect width, AP abdominal diameter, and TRSV abdominal diameter. Quantitative data, nominal data, and logistic regression was used to determine predictors associated with surgical group categorization. Results: The average hernia defect widths for primary closure and CS were 7.7 ± 3.6 cm (mean ± SD) and 9.8 ± 4.5, respectively (p = 0.015). The average BMI for primary closure was 33.9 ± 7.2 and 33.8 ± 4.9 for those requiring CS (p = 0.924). The AP:TRSV diameter ratios for primary closure and CS were 0.41 ± 0.08 and 0.49 ± 0.10, respectively (p < 0.001). In a multivariate analysis including both defect width and AP:TRSV diameter ratio, only AP:TRSV diameter ratio predicted the need for a CS (p = 0.001) while BMI did not (p = 0.92). Conclusion: Intraabdominal fat distribution measured by AP:TRSV abdominal diameter ratio correlates with successful tension-free fascial closure during incisional hernia repair, while BMI does not. [ABSTRACT FROM AUTHOR]

Component separation (CS) techniques have evolved in recent years. How surgeons apply the various CS techniques, anterior component separation (aCS) versus posterior component separation (pCS), by patient and hernia-specific factors remain unknown in the general population. Improving the quality of ventral hernia repair (VHR) on a large scale requires an understanding of current practice variations and how these variations ultimately affect patient care. In this study, we examine the application of CS techniques and the associated short-term outcomes while taking into consideration patient and hernia-specific factors. We retrospectively reviewed a clinically rich statewide hernia registry, the Michigan Surgical Quality Collaborative Hernia Registry, of persons older than 18 y who underwent VHR between January 2020 and July 2021. The exposure of interest was the use of CS. Our primary outcome was a composite end point of 30-d adverse events including any complication, emergency department visit, readmission, and reoperation. Our secondary outcome was surgical site infection (SSI). Multivariable logistic regression examined the association of CS use, 30-d adverse events, and SSI with patient-, hernia-, and operative-specific variables. We performed a sensitivity analysis evaluating for differences in application and outcomes of the posterior and aCS techniques. A total of 1319 patients underwent VHR, with a median age (interquartile range) of 55 y (22), 641 (49%) female patients, and a median body mass index of 32 (9) kg/m2. CS was used in 138 (11%) patients, of which 101 (73%) were pCS and 37 (27%) were aCS. Compared to patients without CS, patients undergoing a CS had larger median hernia widths (2.5 cm (range 0.01-23 cm) versus 8 cm (1-30 cm), P < 0.001). Of the CS cases, 49 (36%) performed in hernias less than 6 cm in size. Following multivariate regression, factors independently associated with the use of a CS were diabetes (odds ratio [OR]: 2.00, 95% confidence interval [CI]: 1.19-3.36), previous hernia repair (OR: 1.88, 95% CI: 1.20-2.96), hernia width (OR: 1.28, 95% CI: 1.22-1.34), and an open approach (OR: 3.83, 95% CI: 2.24-6.53). Compared to patients not having a CS, use of a CS was associated with increased odds of 30-d adverse events (OR: 1.88 95% CI: 1.13-3.12) but was not associated with SSI (OR: 1.95, 95% CI: 0.74-4.63). Regression analysis demonstrated no differences in 30-d adverse events or SSI between the pCS and aCS techniques. This is the first population-level report of patients undergoing VHR with concurrent posterior or aCS. These data suggest wide variation in the application of CS in VHR and raises a concern for potential overutilization in smaller hernias. Continued analysis of CS application and the associated outcomes, specifically recurrence, is necessary and underway. [ABSTRACT FROM AUTHOR]

Background: Component separation techniques have recently gained popularity for the repair of complex ventral hernias. Anterior and posterior component separation techniques offer similar myofascial medialization, with a differing complication profile. The aim of this study is to compare the efficacy, patient morbidity and post-operative complications between anterior component separation (ACST) and transversus abdominis release (TAR) for large ventral hernias. Methods: Between December 2017 and September 2019, data was collected and analysed for patients undergoing ACST and TAR, in terms of demographics, peri-operative events, adverse events and hernia recurrence. Results: 25 patients each underwent ACST and TAR during our study period. Mean age was 53.5 and 52.8 years and mean BMI was 31.4 and 29.5 respectively. The mean defect area was 120.8 cm2 and 131.9 cm2, and average mesh size was 741.8 cm2 and 1429.04 cm2 respectively in the ACST and TAR groups. Four patients undergoing TAR had intra-operative complications with none in the ACST group. In the ACST group, 8 patients had an SSI, of which 5 patients needed operative intervention, while 3 patients in the TAR group had an SSI, all of whom were managed with bedside procedures. One patient in the ACST group had a recurrence. None of the patients in the TAR group had a recurrence. Conclusions: Component separation techniques are gaining popularity in treatment of large ventral hernias. While they have comparable outcomes with respect to recurrence, wound morbidity is more frequent and severe in the ACST group.

Transversus abdominis release (TAR) is the newest approach that allows effective myofascial mobilization, creating a large retromuscular space and wide mesh overlap to repair complex and large incisional ventral hernias. This article narrates the technical details and results of the TAR technique performed in a single center. The present study is a retrospective analysis of a prospective dataset from 25 patients who underwent posterior component separation (PCS) with TAR procedure for large incisional ventral hernias between October 2017 and July 2021. The minimum follow-up period was ten months. Twenty-five patients (five male, 20 female) with a mean age of 61.2 years, a mean BMI of 32.2 kg/m2, and a median ASA score of 2.0 underwent the TAR procedure. Fifteen (60%) patients had a history of incisional hernia surgery. The mean surgical time was 248 minutes. The mean total defect and mesh areas were 187.4 (90-500) cm2 and 1141.8 (750-2250) cm2, respectively. The mean visual analog scale (VAS) pain score on the first postoperative day was 4.5 and the median hospital length of stay (LOS) was 5 days. There were three (12%) surgical site infections (SSIs), two of which were deep infections that needed debridement. During the follow-up period (median of 26 months), two (8%) recurrences were recorded. The TAR technique represents an effective and safe repair modality of large and complex incisional hernias. TAR is an essential addition to the repertoire of the surgical community. [ABSTRACT FROM AUTHOR]

Background Component separation is the ideal management for large ventral abdominal hernia. There are different techniques of component separation used for repair. The most popular of them are posterior component separation with transversus abdominis release and anterior component separation (ACS). In this study, we aimed to compare between both techniques in the management of large midline ventral abdominal hernia. Patients and methods This is a prospective comparative study on 40 patients diagnosed as having large midline ventral abdominal hernia with a surface area defect between 300 and 600 cm2, with a defect width more than 10 cm, presented to Ain Shams University hospitals. Patients were divided into two groups, with 20 patients in each. Group A underwent hernial repair by ACS, and group B underwent hernial repair by using posterior component separation with transversus abdominis muscle release (PCS-TAR). Results We had no statistically significant difference in the preoperative demographic data between both groups. Regarding the operative data, the mean operative time in the PCS-TAR group was significantly higher than the ACS group (267.5 vs. 254.25 min, respectively). There was a nonsignificant difference in the blood loss between both groups. Regarding the postoperative data, the mean time of drain removal was significantly higher in the ACS group than the PCS-TAR group (14.9 vs. 13.6 days, respectively). The incidence of wound seroma and infection was significantly higher in the ACS group than the PCS-TAR group. After 12 months of follow-up, we had only one (5%) case with recurrence in the PCS-TAR group versus six (30%) patients in the ACS group, and this difference was statistically significant. Conclusion Posterior component separation with TAR is preferred over ACS in terms of wound complications and recurrence in large midline ventral hernia with defect surface area between 300 and 600 cm2 but with longer operative time. [ABSTRACT FROM AUTHOR]

Background: Repair of incisional hernias following orthotopic liver transplantation (OLT) is a surgical challenge due to concurrent midline and transverse abdominal wall defects in the context of lifelong immunosuppression. The peritoneal flap hernioplasty addresses this problem by using flaps of the hernial sac to bridge the fascial gap and isolate the mesh from both the intraperitoneal contents and the subcutaneous space, exploiting the retro-rectus space medially and the avascular plane between the internal and external oblique muscles laterally. We report our short and long-term results of 26 consecutive liver transplant cases with incisional hernias undergoing repair with the peritoneal flap technique. Methods: Post-OLT patients undergoing elective peritoneal flap hernioplasty for incisional hernias from Jan 1, 2010–Nov 1, 2017 were identified from the Lothian Surgical Audit system (LSA), a prospectively-maintained computer database of all surgical procedures in the Edinburgh region of south-east Scotland. Patient demographics and clinical data were obtained from the hospital case-notes. Follow-up data were obtained in Feb 2020. Results: A total of 517 liver transplantations were performed during the inclusion period. Twenty-six of these (18 males, 69%) developed an incisional hernia and underwent a peritoneal flap repair. Median mesh size (Optilene Elastic, 48 g/m2, BBraun) was 900 cm2 (range 225–1500 cm2). The median time to repair following OLT was 33 months (range 12–70 months). Median follow-up was 54 months (range 24–115 months) and median postoperative stay was 5 days (range 3–11 days). Altogether, three patients (12%) presented with postoperative complications: 1 with hematoma (4%) and two with chronic pain (8%). No episodes of infection or symptomatic seroma were recorded. No recurrence was recorded within the follow-up period. Conclusion: Repair of incisional hernias in patients following liver transplantation with the Peritoneal Flap Hernioplasty is a safe procedure associated with few complications and a very low recurrence rate. We propose this technique for the reconstruction of incisional hernias following liver transplantation. [ABSTRACT FROM AUTHOR]

Introduction: Abdominal compartment syndrome (ACS) is a serious complication of acute pancreatitis. Case report: We present the case of a 54-year-old obese woman, a smoker and with severe scoliosis, who underwent a scheduled intervention for incisional hernia with retraction of the wall. We performed anterior separation of components and placement of interfascial polypropylene mesh. During the postoperative period, she presented severe acute pancreatitis, which required urgent surgical decompression and laparostomy. Finally, the abdominal wall was successfully repaired with a biological replacement mesh to achieve a complete closure without tension. Conclusion: A high index of suspicion for the detection of complications, urgent surgical decompression leaving a laparostomy with a vaccum system, and defi nitive delayed closure are key points to keep in mind if we are facing an ACS after surgery on the abdominal wall. [ABSTRACT FROM AUTHOR]

Component separation techniques have recently gained popularity for the repair of complex ventral hernias. Anterior and posterior component separation techniques offer similar myofascial medialization, with a differing complication profile. The aim of this study is to compare the efficacy, patient morbidity and post-operative complications between anterior component separation (ACST) and transversus abdominis release (TAR) for large ventral hernias. Between December 2017 and September 2019, data was collected and analysed for patients undergoing ACST and TAR, in terms of demographics, peri-operative events, adverse events and hernia recurrence. 25 patients each underwent ACST and TAR during our study period. Mean age was 53.5 and 52.8 years and mean BMI was 31.4 and 29.5 respectively. The mean defect area was 120.8 cm2 and 131.9 cm2, and average mesh size was 741.8 cm2 and 1429.04 cm2 respectively in the ACST and TAR groups. Four patients undergoing TAR had intra-operative complications with none in the ACST group. In the ACST group, 8 patients had an SSI, of which 5 patients needed operative intervention, while 3 patients in the TAR group had an SSI, all of whom were managed with bedside procedures. One patient in the ACST group had a recurrence. None of the patients in the TAR group had a recurrence. Component separation techniques are gaining popularity in treatment of large ventral hernias. While they have comparable outcomes with respect to recurrence, wound morbidity is more frequent and severe in the ACST group. [ABSTRACT FROM AUTHOR]

Background: Transversus abdominis release (TAR) is increasingly used to address complex ventral hernias; consequently, associated complications are seen more frequently. Our hernia center has a growing experience with redo-transversus abdominis release (redo-TAR) to address large, complex hernia recurrences after failed TAR. Here, we describe our outcomes after abdominal wall reconstruction with redo-TAR. Study design: Adults undergoing elective open, redo-TAR at our institution from January 2015 to February 2021 were queried from a prospectively collected database in the Abdominal Core Health Quality Collaborative. The primary outcome was 30-day wound morbidity. Secondary outcomes were long-term composite hernia recurrence and patient-reported quality of life. Results: Sixty-five patients underwent redo-TAR. Median age was 60 years, 50.8% were female, and median BMI 31.8 kg/m2. Median recurrent hernias were 16 cm wide by 25 cm long. Frequent mechanisms of recurrence included linea semilunaris injury (27.7%), mesh fracture (18.5%), infection (16.9%), and posterior sheath disruption (15.4%). Wound complications occurred in 33.8% and 16.9% required procedural intervention. With median clinical and PRO follow-up of 12 and 19 months, respectively, the composite hernia recurrence rate was 22.5% and patients reported significantly improved quality of life (HerQLes: median + 36.7, PROMIS: median – 9.5). Conclusion: Redo-TAR may be performed as a salvage procedure to reconstruct complex defects after failed TAR, however, in our center, it is associated with increased wound morbidity and fairly high composite recurrence rates. Despite this, patients report improvements in quality of life and pain. Tracking outcomes after TAR will facilitate understanding how to manage its failures. [ABSTRACT FROM AUTHOR]

Background: Transversus abdominis release (TAR) is a relatively recent surgical technique for ventral hernia repair which allows placement of a large prosthesis in the retro-muscular plane with considerable myofascial medialization. A retrospective review of 100 cases who underwent TAR for complex ventral hernias was performed to evaluate the safety and efficacy of TAR in a series of large ventral hernias.Methods: Between March 2016 and May 2019, 100 consecutive patients who underwent open TAR were identified from our prospectively maintained database. A retrospective review was performed to analyze patient demographics, peri-operative events, adverse outcomes and recurrence.Results: 12 primary and 88 incisional hernia cases underwent TAR with prosthetic mesh repair during the study period. Mean age was 52.5 years, mean BMI was 30.87 kgs/m2, mean ASA class 1.95. In our series, 41% were diabetic, 11% had COPD. All patients underwent preoperative CT scans. The mean defect was 140.18 cm2. Average mesh area was 1344 cm2. Average blood loss was 245 mL. Defects were bridged in 19% cases despite bilateral component separation. Readmission rate at 1 month was 3%, for wound complications. We recorded 9 surgical site infections, 17 surgical site occurrences, 10 of which needed procedural interventions. We recorded no recurrences at a mean follow-up duration of 20.2 months.Conclusions: Our early results with TAR are encouraging. We have demonstrated that the repair allows anatomical reconstruction with a large sublay mesh while inflicting minimal morbidity. TAR can be a valuable tool in complex ventral hernia repair. [ABSTRACT FROM AUTHOR]

Over 350,000 surgeries are performed for ventral hernias (VHs) annually. Abdominal wall component separation has been more frequently used for the management of VHs. The goal of this study is to better understand factors associated with component separation complication rates. The National Inpatient Sample (2005-2014) was used to identify all patients with an International Classification of Diseases ninth Revision diagnosis of VHs who underwent open VH repair with a pedicleor graft advancement flap. All cases included in this study were elective and not associated with additional procedures. Demographic, clinical, and hospital characteristics were extracted. Independent predictors of complications and outcomes were determined by multivariable regression analysis. Component separation was performed in 4346 patients. Mean age was 56; majority were female (55%) and white (80%). Most patients (73%) underwent surgery in an urban teaching hospital; mesh was used in 80% of cases and 11% were smokers. Hypertension was the most common comorbidity (50%), followed by obesity (26%), diabetes mellitus (DM) (23%), coronary artery disease (11%), and chronic obstructive pulmonary disease (COPD) (8%). Half of the patients (50%) had private insurance, and 35% had Medicare. Patients were distributed equally over household income quartiles. The mortality rate was 0.5%; median length of stay was 5 d. Overall complication rate was 25% (wound 11%, intraoperative 5%, infectious 11%, and pulmonary 8%). Mesh was associated with a lower rate of wound complications (10% versus 15%, P = 0.001). On multivariable analysis, patients with COPD (odds ratio: 2.02; 95% confidence interval: 1.58-2.59), obesity (1.37; 1.16-1.63), DM (1.3; 1.09-1.55), and those in the lowest income quartile (1.44; 1.06-1.96) had higher overall complication rates. Consistent with other studies, patients with COPD, Obesity, DM, and lower income status were associated with increased complications after component separation. • One in four cases of component separation has post-operative complications. • Low socioeconomic status is associated with higher complication rates. • Obesity is an independent predictor for use of mesh. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Incisional ventral hernia occurs after almost every fourth laparotomy. Still, both simple suturing of the hernia defect and open mesh repair, lead to a high incidence of infections and recurrences. In recent years, we have observed a further evolution of operational techniques used in order to reduce the number of complications. The search for effective repair methods is currently going in two directions: on the one hand, techniques to reduce tissue tension in the suture line are being developed and disseminated (including modifications to the so-called Ramirez technique); on the other hand, minimally invasive techniques are introduced that allow placement of large synthetic meshes without the need for extensive tissue dissection using open repair. In the first group of presented techniques, emphasis is put on basics and access in the following repair method: original Ramirez technique, modified Ramirez technique, anterior component separation with periumbilical perforator-sparing, endoscopic anterior component separation and transversus abdominis release. In the second part of the manuscript, attention is drawn to the following hernia repair techniques: eTEP, reversed TEP, MILOS/eMILOS, stapler repair, TAPP, TARUP, TESLA, SCOLA, REPA, LIRA, IPOM, IPOM-plus. When choosing the optimal technique for a given patient, the surgeon should first of all be guided by technical feasibility, availability of materials, their own experience, as well as the characteristics of the patient and overall burdens. Nevertheless, surgeons undertaking reconstruction of the abdominal wall in the case of hernias should know different surgical accesses and individual spaces of the abdominal integument, in which a synthetic material may be placed. However, it should be emphasized that poor ergonomics of novel techniques, complex anatomy and complicated dissection of space, as well as the need for laparoscopic suturing in a difficult arrangement of tissue layers and in a narrow space, without a full triangulation of instruments, make these operations a challenge even for a surgeon experienced in minimally invasive surgeries. [ABSTRACT FROM AUTHOR]

Background: Component separation remains an integral step during ventral hernia repair. Although a multitude of techniques are described, anterior component separation (ACS) via external oblique release (EOR) and posterior component separation (PCS) via transversus abdominis muscle release (TAR) are commonly utilized. The extent of myofascial medialization after ACS or PCS has not been well elucidated. We conducted a comparative analysis of ACS versus PCS in an established cadaveric model.Methods: Fifteen cadavers underwent both ACS via EOR and PCS via TAR. Following midline laparotomy (MLL), baseline myofascial elasticity was measured. Steps for ACS included creation of subcutaneous flaps (SQF), external oblique release (EOR), and retrorectus dissection (RRD). For PCS, steps included retrorectus dissection (RRD), transversus abdominis muscle division (TAD), and retromuscular dissection (RMD). Maximal advancement of anterior rectus fascia (ARF) was measured following application of tension to the fascia as a whole, and separately at upper, middle, and lower segments. Statistical analysis was performed with Mann-Whitney U test. Values are represented as average myofascial medialization in centimeters.Results: Following MLL an average of 5.0 ± 0.9 cm (range 3.4-6.0 cm) of baseline medialization was obtained. Complete ACS provided 8.8 ± 1.2 cm (range 6.3-10.7 cm) of ARF advancement compared to 10.2 ± 1.7 cm (range 7.6-12.7 cm) with PCS, p = 0.046. In the upper and mid-abdomen, we noted increased ARF advancement with PCS versus ACS (8.1 ± 1.4 cm vs. 6.7 ± 1.2 cm and 11.4 ± 1.5 vs. 9.6 ± 1.4 cm, respectively, p = 0.01). Similar levels of ARF advancement were observed in the lower abdomen, 9.1 ± 1.7 cm versus 8.7 ± 1.8 cm, p = 0.535.Conclusions: Component separation via both anterior and posterior approaches provide substantial myofascial advancement. In our model, we noted statistically greater anterior fascial medialization after PCS versus ACS as a whole, and especially in the upper and mid-abdomen. We advocate PCS as a reliable and possibly superior alternative for linea alba restoration for reconstructive repairs, especially for large defects in the upper and mid-abdomen. [ABSTRACT FROM AUTHOR]

Introduction: BMI and hernia defect size are strongly associated with outcomes after open ventral hernia repair (OVHR). The impact of abdominal subcutaneous fat (SQV), intra-abdominal volume (IAV), hernia volume (HV), and ratio of HV to intra-abdominal volume (HV:IAV, representing visceral eventration) is less clearly elucidated. This study examines the interaction of multiple markers of adiposity and hernia size in OVHR.Methods: OVHR with preoperative CT scans were identified. 3D volumetric software measured HV, SQV, IAV, and HV:IAV was calculated. A principal component analysis was performed to create new component variables for collinear variables. Hernia PC was composed primarily of hernia dimensions, EAV (extra-abdominal volume PC) included SQV and BMI, and IAV PC included IAV.Results: A total of 1178 OVHR patients had a preoperative CT scan. Their demographics included a mean age of 58.5 ± 12.4 years, BMI of 34.2 ± 7.7 kg/m2, and 57.8% were female. The mean defect area was 150.8 ± 136.7 cm2, and 66.0% were recurrent, Patients had mean SQV of 6719.4 ± 3563.9 cm3, HV of 966.9 ± 1303.5 cm3, IAV of 4250.2 ± 2118.1 cm3, and a HV:IAV of 0.29 ± 0.46. In multivariate analysis, Hernia PC was associated with panniculectomy (OR 1.52, CI 1.37-1.69) and component separation (OR 1.34, CI 1.21-1.49) and was negatively associated with fascial closure (OR 0.78, CI 0.69-0.88). Hernia PC was also associated with reoperation, readmission, and development of wound complications (OR 1.18, CI 1.08-1.30; OR 1.15, CI 1.04-1.27; OR 1.28, CI 1.16-1.41, respectively). EAV PC was associated with performance of a panniculectomy (OR 1.33, CI 1.20-1.48), readmission (OR 1.18, CI 1.06-1.32), and wound complications (OR 1.41, CI 1.27-1.57). IAV PC was not associated with adverse outcomes.Conclusion: Values of hernia area, volume, IAV, HV:IAV, BMI, and SQV are collinear markers of patient obesity and hernia proportions. They are distinct enough to be represented by three principal component variables, indicating more nuanced discrete influences on variability of surgical outcomes other than BMI. [ABSTRACT FROM AUTHOR]

Background: Component Separation (CST) typically involves incision of one or more fascial planes to generate myofascial advancement flaps to assist with fascial closure in ventral hernia repair (VHR). The aim of this study was to compare peri-operative outcomes and quality of life (QOL) after CST versus patients without CST (No-CST) in large, preperitoneal VHR (PPVHR).Methods: A prospective, single institution hernia study examined all patients undergoing PPVHR with synthetic mesh. Emergency and contaminated operations were excluded. A case-control cohort was identified using propensity score matching for CST and No-CST. QOL was assessed using the Carolinas Comfort Scale.Results: The algorithm matched 113 CST cases to 113 No-CST cases. The groups (CST vs No-CST) were similar regarding age, BMI, diabetes, smoking, defect size, mesh size, and follow-up. In univariate analysis, there was no difference in recurrence between the CST and no-CST groups (0.9% vs 0.9%, p = 1.0) or mesh infection (0.9% vs 0.0%, p = 1.0). CST did have more wound complications (29.2% vs 16.1%, p = 0.019). When controlling for panniculectomy and diabetes with multivariate logistic regression, CST continued to have had an increased risk for wound complications (OR 2.27, CI 1.16-4.47). QOL was routinely assessed. The groups were similar pre-operatively with 76.3% of CST patients and 77.8% of No-CST patients having pain (p = 1.0). At 1, 6, 12, 24, and 36 months post-operatively, the groups had equal QOL.Conclusion: The use of CST versus No-CST in the repair of large VHs results in an increased risk of wound complications but does not increase the hernia recurrence rate. In the largest QOL comparative study to date, CST's generation of myofascial advancement flaps does not negatively impact patient QOL in the repair of large ventral hernias in the short or long term. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing abdominal wall reconstruction (AWR) are at an increased risk of developing respiratory complications. Previous studies have demonstrated that postoperative findings, such as an increase in plateau pressure greater than 6 cm H2O following fascial closure, creates an increased risk of postoperative respiratory complications. The purpose of this study is to determine if specific preoperative characteristics are an indicator for postoperative respiratory failure.Methods: The 2005-2013 ACS-NSQIP participant use data were reviewed to evaluate post-operative intubation status following AWR procedures for ventral hernias. Prolonged intubation, defined as intubation up to 48 h post-operatively, was evaluated. Multivariable logistic regression was used to control for patient demographics and comorbidities. Odds ratios and 95% confidence intervals were reported as appropriate using SPSS.Results: 4378 patients were identified. Majority (51%) of patients were female. 2.96% of patients experienced a prolonged intubation. Factors such as a history of severe COPD, ASA 3 or 4, current smoker within 1 year, and a BMI of 40 were all found to have a significant association with a prolonged intubation.Conclusions: Post-operative prolonged intubation is a known complication of AWR. We have demonstrated that pre-operative factors, such as a history of COPD, ASA 3 or 4, current smoker, and a BMI > 40 kg/m2 are factors associated with a prolonged intubation. Optimization of each may allow for a reduction in the risk of prolonged intubation in patients undergoing AWR. [ABSTRACT FROM AUTHOR]

Abdominal wall hernia repair is one of the most common operations done by general surgeons today. Patients with incisional hernias can be extremely challenging to manage due to a number of factors that include obesity, prior hernia repairs, previous mesh placement, loss of domain, and other variables. The approach to patients with incisional hernias has evolved considerably over the last 20 years due to both advances in mesh technology and surgical approaches. Key factors in a successful outcome include modification of risk factors prior to surgery such as smoking cessation and weight reduction, selection of mesh appropriate to the hernia type and planned location of the mesh, and broad overlap of mesh beyond the margins of the hernia defect. Newer techniques such as transabdominis release and component separation with retrorectus mesh placement and robotic approaches to abdominal wall hernia are being increasingly utilized in these patients. This article reviews these aspects of abdominal wall hernia repair with a discussion of recent results and the importance of quality improvement and monitoring of outcomes. [ABSTRACT FROM AUTHOR]

Background: Complex ventral incisional hernia repair represents a challenging clinical condition in which biologically derived graft reinforcement is often utilized, but little long-term data inform that decision. Urinary bladder matrix (UBM) has shown effectiveness in diverse clinical settings as durable reinforcement graft material, but it has not been studied over a long term in ventral incisional hernia repair. This study evaluates the clinical, radiographic, and histological outcome of complex incisional hernia repair using UBM reinforcement with 12-70 months of follow-up.Methods: A single-arm, retrospective observational study of all ventral incisional hernia repairs utilizing UBM reinforcement over a 6-year time frame by a single surgeon was performed. Patients were assessed in long-term follow-up clinically and with the Carolina Comfort Scale. A subset of patients was assessed with abdominal wall ultrasound or CT scan. Three patients had abdominal wall fascial biopsies years after the incisional hernia repair with UBM graft, and the histology is analyzed.Results: 64 patients underwent repair of complex incisional hernias with UBM graft reinforcement by a single surgeon. 42 patients had concomitant procedures including large or small bowel resection, excision of infected mesh, evacuation of abscess or hematoma, cholecystectomy, or panniculectomy with abdominoplasty. 16 patients had ostomies at the time of repair. Median follow-up time is 36 months, with a range of 12-70 months. Nine patients (14%) have required surgical repair of a recurrent hernia, and a tenth patient has a recurrence that is managed non-surgically, for a total recurrence rate of 15.6% over the entire time frame. Median time to recurrence was 32 months, and a Kaplan-Meier freedom from recurrence curve is depicted. 28 patients have undergone ultrasound or CT assessments of the abdominal wall which demonstrate radiographic fascial integrity 12-70 months after repair. Three patients have been re-explored for unrelated reasons in the years following ventral incisional hernia repair with UBM, and full thickness fascial biopsies demonstrate a robust remodeling response histologically similar to native myofascial tissue. No patients have developed graft infection, fistulization to the graft, or required graft explantation. Carolina Comfort Scale assessment of 45 patients 3 years after the repair averaged 16 out of a possible 115.Conclusion: In 64 patients undergoing complex ventral incisional hernia repair with UBM reinforcement, all have experienced successful resolution of complex clinical conditions and 15.6% of these repairs have recurred at a median follow-up of 3 years. Three full-thickness biopsies of the repaired fascia years later shed light on a promising remodeling response which may signal strength and durability comparable to native fascia. [ABSTRACT FROM AUTHOR]

Summary Background Postoperative complication following ventral hernia repair (VHR) is a major clinical and financial burden. Preoperative risk assessment is necessary to minimize adverse outcomes following VHR. This study examines the ability of an independent parameter to predict postoperative morbidity following VHR. Methods A retrospective analysis of 58 patients who underwent VHR by component separation between January 2009 and December 2013 was performed. Preoperative abdominal CT scans were analyzed to assess sarcopenia. Sarcopenia was determined using the Hounsfield unit average calculation (HUAC), a measure of psoas muscle size and density. Sarcopenia was defined as an HUAC score of less than 19.6 HU calculated using receiver operating characteristic (ROC) analysis and the Youden index. Multivariate analysis was performed to analyze the association of sarcopenia and postoperative complications. Results Preoperative sarcopenia was associated with an increased risk for postoperative complications (odds ratio [OR] = 5.3; p  = 0.04). Preexisting gastrointestinal conditions such as ulcerative colitis or colon cancer were associated with an increased risk for postoperative complications ( OR  = 5.7; p  = 0.05). A significantly higher rate of hernia recurrence (33.3% vs. 10.8% [ p  = 0.04]) and renal failure (19% vs. 2.7% [ p  = 0.03]) was noted in patients with sarcopenia when compared to patients without sarcopenia. Conclusions Sarcopenia is an independent risk factor for postoperative complications in patients who underwent VHR. Assessment of sarcopenia using the HUAC score provides an opportunity for the adjustment of perioperative care plans to minimize postoperative complication rates. [ABSTRACT FROM AUTHOR]

Due to the abundant and lax tissue of the abdominal wall, most ventral trunk defects are amenable to local soft tissue closure. However, when abdominal defects are accompanied by a lack of soft tissue, the surgeon faces a more complex subset of reconstructions. Three important principles guide the reconstruction of these wounds: timing of closure, careful assessment of the true extent of the wound, and the components of the defect. This article focuses on these three guiding principles and suggests the authors' preferred technique for these difficult defects. [ABSTRACT FROM AUTHOR]

Abdominal wall reconstruction has undergone substantial evolution over the last few decades. The optimal method of repair should be tailored to each patient's unique condition; however, a general approach that integrates four major factors can be applied as a conceptual framework to most clinical scenarios. Major factors to be considered include selection of mesh material, mesh inset position and technique, selective component separation, and management of soft tissue. These topics are inextricably intertwined in the sense that each can have specific implications, and in some cases, a determinative impact on the other decisions. When the relationship among these four factors is appreciated and applied to patient management, the reconstructive surgeon can achieve consistent outcomes that reflect skill, experience, and understanding. [ABSTRACT FROM AUTHOR]

Management of the abdominal catastrophe requires a multidisciplinary approach. The plastic surgeon is a key member of the surgical team assisting in the creation of a durable, functional anatomic abdominal wall reconstruction. Plastic surgeons must be familiar with the concepts and pathophysiology related to the open abdomen, techniques for temporary abdominal closure, and when such techniques are appropriate to implement. In this article, the authors provide a review of the open abdomen concept, which practicing plastic surgeons and trainees may find helpful if faced with this clinical scenario. [ABSTRACT FROM AUTHOR]

Background: Abdominal wall hernia is a significant cause for reoperation following laparotomy. Anterior component separation (ACS) is a widely used technique for closure of large abdominal wall defects. We propose that adding scoring of transversalis fascia to ACS can provide additional midline advancement of the anterior rectus sheath.Methods: Open ACS was performed in eight cadavers. The medial advancement of the anterior rectus sheath was recorded at three points bilaterally during application of constant load, and again following scoring of the transversalis fascia. This technique was then used on two patients with recurrent, complex ventral hernias which could not be closed with ACS alone.Results: In the cadaver model, transversalis fascia scoring provides additional 34.01, 27.12, and 25.05% advancement at each point compared to ACS. Results were significant. In both patients, primary fascial closure of defects over 20 cm width at midline was achieved.Conclusions: Adding transversalis fascia scoring in a controlled standard fashion to ACS may help surgeons achieve closure of abdominal wall defects when ACS alone is not sufficient.Level of Evidence: Level V, therapeutic study. [ABSTRACT FROM AUTHOR]