The percentage distribution of technical aspects of mesh placement for the reported cases. Onlay — the mesh is positioned above the abdominal wall muscles and fascia, behind the subcutaneous fat, Sublay — retromuscular position of the mesh; IPOM — intraperitoneal onlay mesh, TAPP — transabdominal preperitoneal repair, TEP — totally extraperitoneal repair; Inlay — the mesh is positioned in the hernia defect, without overlap, and fixed to the margins of the defect, Ramirez — component separation technique the Ramirez operation.
In the open surgery group, the Sublay technique was most frequent. When choosing the laparoscopic approach, intraperitoneal on-lay mesh IPOM was the method of choice. In addition, the necessity of the component separation method was stressed in cases 3, 4 and 5. The diversity of the implant sizes used by the surgeons in each case was noteworthy. The majority of the respondents emphasised having a wide overlap of the mesh covering the defect. The suggested lower limit of the overlap was 5 cm. When considering the fixation method, we again found great heterogeneity among surgeons.
In all the cases in which the experts recommended the open method, they responded that they would either fix the mesh by non-absorbable sutures or leave the implant unsecured. There was no pattern in the preferred suture placement. In contrast, when describing laparoscopic operations, the main focus was on the mesh fixation technique. Tackers and sutures were most popular. Only two surgeons opted for fixation reinforcement with the addition of glue one in case 2 and one in cases 6 and 7.
Table III presents the distribution of fixation methods in each specific case. In small umbilical hernia repair, it is worth mentioning that 4 surgeons would use local anaesthesia. Furthermore, two surgeons stressed the fact that IPOM operation would be indicated in the obese patients. Of note are the cases in which there was a problem of implant fixation to the bony structures. In cases 7 and 8, there was great variety in the mesh fixation technique in the subcostal area. The respondents were unanimous in terms of taking necessary precautions when fixing the mesh above the rib line.
One respondent supported the use of glue in that area, and one would use running sutures. In cases of incisional hernias in the lower abdomen 4, 6, 9 , when considering a laparoscopic approach below the pubic bone and cooper ligament, the modification of the IPOM technique with mesh peritonealisation was the most popular.
Interestingly, one of the respondents did not consider muscle weakness after open appendectomy as pathology and was against surgical treatment. Another expert suggested open suture application with non-absorbable sutures. The majority would perform an open procedure with mesh in the Sublay position and muscular defect repair.
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Many different techniques are currently used for ventral and incisional hernia repair. The need for a consensus is a leading issue for both practicing surgeons and the surgeons in training. A consensus would make possible a platform for the discussion about algorithms of ventral hernia management as well as improve and unify the education of young surgeons and residents. Furthermore, our patients could obtain the best possible surgical care regardless of the hospital choice.
The indications for performing laparoscopic procedures were not identified in this study. Nevertheless, we noticed that experts were more willing to choose laparoscopic means of operation in cases of medium-sized incisional hernias, such as case 3, where it was important to assess not only the gap but also the remaining part of the wound closure, and in cases 2, 6 and 7, where the access and implant positioning were more difficult to perform openly.
The meta-analyses [ 2 , 5 — 7 ] have shown that the short-term outcomes of laparoscopic repair are promising, but we still lack a long-term follow-up meta-analysis that would state the numbers of recurrences and hence also the efficacy of this method. Moreover, we have to keep in mind the drawbacks of laparoscopic ventral hernia repairs LVHRs , such as increased risk of adhesions, bowel injuries and enterotomies during subsequent operations, as well as increased hospital costs.
In our study, experts were generally positive about laparoscopic surgery. When comparing Onlay and Sublay mesh placement, the recurrence rates in the literature do not differ significantly [ 8 ]. In a Cochrane review from , there was not sufficient evidence about which position of the mesh is superior [ 9 ]. There was also insufficient evidence to advocate the use of the component separation technique. In our survey, when comparing Onlay vs. Sublay, the retromuscular prosthetic repair Rives-Stoppa techniques using non-resorbable polypropylene or polyester mesh was chosen more frequently.
Similar opinions can be found in the literature and among hernia surgeons [ 8 , 9 ]. The heterogeneity on the topic of the type and size of mesh as well as the fixation methods, especially when considering laparoscopic approach, reflects the current trends in hernia repair. There are many new products on the market and few studies about the outcomes of their use in patients [ 10 ]. Even more in favour of the double crown technique are the results of the WoW randomised control trial, in which Muysoms et al.
However, the authors state several limitations of their study, such as inclusion of patients only with hernias at a distance from the bony borders of the abdomen and non-standardised mesh types. Furthermore, we should investigate the structure of the abdominal wall so we can know how to correctly place tackers, especially in the difficult cases. We also need to focus on unifying technical aspects of each procedure. The authors propose software that supports decision making in performing IPOM surgery.
After loading data on hernia dimension and localisation, the HAL program gives the surgeon information about where to place the mesh, how large the overlap should be, how many tackers or sutures should be used and where to place them. However, this software still needs clinical evaluation and further development.
This was another milestone towards more reliable and standardised studies with good reporting standards and statistical methodology. Multicentre randomised trials are considered the most valuable, but observational studies, such as comparative retrospective studies or noncomparative cohort studies, when conducted properly, can be very useful, especially for the evaluation of abdominal hernia repair.go site
Clinical Review: Abdominal wall hernias
Moreover, those authors mention that registries are a source of important information for health care, as they generate scientific hypotheses and allow researchers to consider safety questions. Another important publication from Italy was one of the first evidence-based guidelines for laparoscopic ventral incisional hernia repair [ 15 ]. The Naples group tried to answer the most concerning questions about the safety and feasibility of the laparoscopic approach in ventral hernia repair. Unfortunately, based on the available literature, the grade of recommendation did not reach A level in any of the chapters presented.
Nevertheless, the group managed to raise a number of important issues, such as the establishment of indications for a laparoscopic approach and the preferred preoperative work-up and selection of patients. Recently published in Surgical Endoscopy were the guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias International Endohernia Society IEHS [ 16 ]. The Bittner's group have taken into consideration the most important aspects of laparoscopic ventral hernia repair. The work was based on a massive quantity of data derived from the most important publications.
Therefore the article has been divided into separate parts and each part into sections with meticulously discussed questions on laparoscopic treatment of incisional and ventral hernia. Nevertheless when faced with common clinical cases as presented in our work it might be difficult to find an answer on how to perform the operation and select the patients.
The data available are not precise, still we have too few randomized control trails on specific subjects and results derived from National Databases are not considered as a high quality in the Oxfords EBM hierarchy. In the end the most fundamental questions such as indications for surgery were graded D, which states that there are no recommendation at all. Again we are informed that it is safe and feasible to do laparoscopy and how to precede if we chose this method of operation, but it is not and should not be our only choice.
In the group of our experts there were surgeons also involved in the IEHS guidelines creation, their unanimity reaffirms the lack of consensus. The variance of opinion in both studies was mostly in the technical aspects, and not in well-established principles such as the hernia mesh repair. We have to keep in mind that there is a difference between EBM, guidelines and everyday clinical practice.
Management of Abdominal Hernias
Many surgeons simply choose operating methods that suit their skills better. The reasons for that are lack of knowledge and reluctance toward changes. In addition, it is extremely difficult and tedious for every practicing surgeon to search medical databases and do a critical appraisal of each method. Still, in most surgical departments, training is based on the principle of master and his follower.
- Hernias of the Abdominal Wall?
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- The Invention of the White Race, Volume 2: The Origin of Racial Oppression in Anglo-America.
- The Customs of the Kingdoms of India (Penguin Great Journeys).
This type of teaching has many benefits, but in our opinion, it has one very important drawback: the successor will perpetuate the mistakes of his master. The modern way of training is based on multicentre internships. It gives trainees the opportunity to see many experienced surgeons at work and to learn from them. This allows them to obtain knowledge about various surgical techniques and gain the ability to think multidimensionally [ 17 — 20 ]. The results of our survey clearly show that even among experts, standardised procedures such as IPOM are performed in various ways.
For surgeons willing to adapt new procedures and surgeons in the process of training, information such as the variability of the procedure, depending on the anatomical location of the defect, the type of mesh and the fixation methods are the most essential. Therefore, there is a need for international hernia surgery education programmes, which will improve the quality of professional education in herniology and raise the level of medical service throughout the unified programme of teaching worldwide. Experts have not reached a consensus on the management of abdominal wall hernias.
Our survey results indicate the need for further research and the inclusion of large patient cohorts in the dedicated registries to evaluate the results of different surgical methods. To date, much effort has been expended to create a common language when describing ventral and incisional hernias, as well as foundations for large projects aimed at establishing recommendations.
However, much work remains before we can present definitive algorithms and educational models for hernia surgeons, which makes the discussion among surgeons more important. National Center for Biotechnology Information , U. Wideochir Inne Tech Maloinwazyjne. Published online Feb Author information Article notes Copyright and License information Disclaimer. Corresponding author.
Management of abdominal wall hernias in the bariatric patient — Mayo Clinic
This article has been cited by other articles in PMC. Abstract Introduction Laparoscopic repair is becoming an increasingly popular alternative in the treatment of abdominal wall hernias. Aim To assess whether there is a consensus on the management of the most common ventral abdominal wall hernias among recognised experts. Material and methods Fourteen specialists representing the boards of European surgical societies were surveyed to determine their choice of surgical technique for nine typical primary ventral and incisional hernias.
Results In none of the cases presented was a consensus of experts obtained. Conclusions Recognised experts have not reached a consensus on the management of abdominal wall hernias. Keywords: abdominal wall hernia, laparoscopic ventral hernia repair, consensus, experts opinion.