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Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature
Anil Sharma, Chaitanya Sinha, Manish Baijal, Vandana Soni, Rajesh Khullar, Pradeep Chowbey
Department of Minimal Access, Metabolic and Bariatric Surgery, Max Super Speciality Hospital, New Delhi, India
|Date of Submission||19-Jun-2019|
|Date of Decision||03-Oct-2019|
|Date of Acceptance||20-Jan-2020|
|Date of Web Publication||12-Sep-2020|
Institute of Minimal Access, Metabolic and Bariatric Surgery, 5th Floor, East Block, Max Super Speciality Hospital, Saket, New Delhi
Source of Support: None, Conflict of Interest: None
With increasing complexity of ventral incisional hernias being operated on, the treatment strategy has also evolved to obtain optimal results. Hybrid ventral hernia repair is a promising technique in management of complex/difficult ventral incisional hernias. The aim of this article is to review the literature and analyse the results of hybrid technique in management of ventral incisional hernia and determine its clinical status and ascertain its role. We reviewed the literature on hybrid technique for incisional ventral hernia repair on PubMed, Medline and Google Scholar database published between 2002 and 2019 and out of 218 articles screened, 10 studies were included in the review. Selection of articles was in accordance with the PRISMA guideline. Variables analysed were seroma, wound infection, chronic pain and recurrence. Qualitative analysis of the variables was carried out. In this systematic review, the incidence of complications associated within this procedure were seroma formation (5.47%), wound infections (6.53%) and chronic pain (4.49%). Recurrence was seen in 3.29% of patients. Hybrid ventral hernia repair represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. However, larger multi-centric prospective studies with long term follow up is required to standardise the technique and to establish it as a procedure of choice for this complex disease entity.
Keywords: Complex ventral hernia, enterotomies, hybrid technique, incisional ventral hernia
|How to cite this URL:|
Sharma A, Sinha C, Baijal M, Soni V, Khullar R, Chowbey P. Hybrid approach for ventral incisional hernias of the abdominal wall: A systematic review of the literature. J Min Access Surg [Epub ahead of print] [cited 2020 Oct 22]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=294953
| ¤ Introduction|| |
There are several laparoscopic techniques for repair of abdominal wall hernias. Laparoscopic intraperitoneal onlay mesh (IPOM) repair was accepted due to the advantages of decreased post-operative morbidity (mainly wound related) compared to the open approach., However, some common sequelae associated with laparoscopic IPOM include seroma formation, bulging and failure to restore abdominal wall function., In an effort to improve outcomes, laparoscopic IPOM in combination with defect closure (laparoscopic IPOM plus) was suggested for the management of ventral incisional hernias. Several authors have reported improved surgical outcomes.
As more and more complex ventral hernias are being operated on, the treatment strategy has also evolved to obtain the optimal results. Complex incisional hernias include hernias with large defects, dense adhesions requiring extensive adhesiolysis, previously implanted mesh and redundant abdominal wall skin and tissue requiring excision. These can be difficult to manage entirely laparoscopically due to increased risk of intraoperative complications, especially enterotomies. Hybrid approach, combining open and laparoscopic techniques, confers the advantages of both techniques. It has been suggested that hybrid approach is a feasible and safe approach for difficult post-operative ventral hernia. It has been shown to reduce patient morbidity due to targeted skin incision and at the same time retaining several advantages of minimal access approach, namely laparoscopic evaluation of the entire abdominal wall with the placement of large intraperitoneal prosthesis. Early conversion to the combined technique is associated with less technical difficulty, decreased operative time, lower enterotomy rates, shorter hospital stay and improved patient outcomes.
The objective of this study was to review and analyse the available literature on the hybrid technique of ventral incisional hernia repair and determine the clinical status and surgical outcomes of this technique in the management of complex ventral incisional hernia.
| ¤ Materials and Methods|| |
In this article, two independent authors reviewed the literature on the hybrid IPOM technique for the management of ventral incisional hernia repair. PubMed, Medline and Google Scholar electronic database search was performed using the following keywords, (ventral hernia OR incisional hernia AND hybrid technique AND repair AND surgery). Articles with a follow-up period of < 12 months were excluded from the study. Out of 964 articles identified through our database search, the abstracts of 218 publications were screened. Published between 2002 and 2019, for the present analysis, 10 publications were found to be of interest. A cross-reference search was also carried out from these articles, and relevant manuscripts were included in the study. Out of these, 9 were original articles.,,,,,,,, One article was a randomised controlled trial (RCT) study comparing laparoscopic and hybrid techniques of incisional hernia repair. Hybrid technique data were extracted and included in the study. Another study had included primary, recurrent and incisional ventral hernia in their article, and only incisional hernia data were extracted for the inclusion in this study.
Three articles were not in the English language and were excluded. One article using a biological mesh for hybrid repair was also excluded. Studies on hybrid technique repair of parastomal hernia were also excluded.
According to the PRISMA guidelines, a systematic presentation, and synthesis, of the characteristics and findings of the included studies has been made [Figure 1]. Patients' demographic, intra-operative and post-operative data were collected and analysed. Patient demographics included were age, gender, body mass index (BMI) and co-morbidities, including smoking was recorded [Table 1]. Intra-operative data included defect size and operative time [Table 2]. The post-operative variables studied were seroma formation, wound infections, chronic pain and recurrence rates [Table 2]. Two-hundred and thirty-two patients were analysed from 10 studies, and their results are summarised in [Table 1], [Table 2], [Table 3].
|Table 1: Characteristics of studies included in this study with patient demographics|
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Surgical technique of hybrid intraperitoneal onlay mesh
The reviewed literature describes two techniques of hybrid repair. In the first method of hybrid repair as described in the articles reviewed,,,, initial laparoscopy was converted to open adhesiolysis and repair with or without sac excision, followed by laparoscopic IPOM placement. In the second method of hybrid repair as described in the reviewed articles,,,,, involves exposure of the defect through an incision over previous scar, adhesiolysis performed with or without sac excision and defect closed, followed by laparoscopic IPOM placement to complete the repair.
All the studies have used synthetic mesh for hernia repair, with a minimum overlap of 3 cm (3–7 cm) on all sides. The fixation of the mesh was accomplished by a combination of tackers and transfascial sutures.
Outcomes of hybrid intraperitoneal onlay mesh
Altogether, 232 patients with incisional ventral hernias were included from the ten articles reviewed. Variables analysed were seroma formation, wound infection, chronic pain and recurrence rates [Table 2].
In this review, the pooled seroma rate was 5.47% (0%–14.3%). All the seroma reported in the studies were managed conservatively and resolved spontaneously, without the need for any intervention. One study in a prospective RCT found significantly less seroma formation at 1 month in the hybrid group compared to laparoscopic IPOM (45.3% vs. 67%, P = 0.004). However, this outcome had no impact on recurrence rates at 1-year of follow-up.
Seroma formation is the most common complication after laparoscopic IPOM, which apart from giving a poor aesthetic outcome, also causes discomfort, pain and presents a risk of infection. In open onlay repair with defect closure for incisional hernia, seroma formation has been reported in the range between 38.5 and 45.6%. In standard laparoscopic IPOM (sIPOM), the incidence of clinical seroma has been reported from 0.5% to 78%., In a multi-centre, registry-based, propensity score-matched comparison of 9907 patients comparing laparoscopic IPOM to open sublay technique for elective incisional hernia repair, a statistically significant difference was reported in seroma rates between the two groups (lap IPOM 1.94% vs. open sublay 5.12%; P < 0.001).
In a review of literature of IPOM-Plus, it has been reported that the closure of fascial defect reduces the incidence of seroma in patients (0%–11.43%). In another study, a meta-analysis of closure of the fascial defect during laparoscopic incisional and ventral hernia repair, closure of fascial defect demonstrated the lower rate of seroma as compared to non-closure of defect (2·5% vs. 12·2%, P < 0.001). IEHS guidelines have given a low-level recommendation (Grade D: No recommendation at all) to include hernia sac during fascial closure to prevent seroma formation.
The pooled wound infection rate in our study was 6.53% (0%–28.6%). One of the studies in the articles reviewed reported infection in two patients (28.6%), resulting in re-operations and mesh excision. One patient had a BMI of 62 with two prior periumbilical incisional hernias repair, and the other patients had undergone prior ventral hernia repairs with a recurrent large incisional hernia. Ozturk et al. reported wound infection in 18.75% patients; however, all of them were managed conservatively without necessitating mesh extraction in any of the patients.
In a systematic review and meta-analysis on open ventral hernia repair, ten studies reported surgical site infection in their results, and the pooled rates were 16.9% (0%–33%) for onlay, 31.3% (8.7%–37.1%) for inlay and 3.7% (0%–21%) for sublay placement of mesh.
In a multi-centre registry-based study of laparoscopic IPOM, deep wound infection rates reported were laparoscopic IPOM 0.30% vs. open sublay 1.34%; P < 0.001. In another study, the wound infection rate of 0.64% and mesh infection rate of 0.16% have been reported after laparoscopic ventral/incisional hernia repair.
The pooled chronic pain rate in our study was 4.49% (0%–15.3%). Chronic pain after laparoscopic repair of abdominal wall hernias is an under-reported outcome of the procedure. Six studies have analysed chronic pain as surgical complication after hybrid IPOM in 4.49% of patients.,,,,, The rest of the four articles did not report chronic pain as the outcome in their study.
Sharma et al. reported chronic pain in 15.3% of their patients. In a prospective, randomised, multicentre study by Ahonen-Siirtola et al., chronic pain was seen in 5% of patients. However, none of the authors have defined the criteria for diagnosing chronic pain.
Mesh fixation with transfascial sutures may cause ischaemic injuries to abdominal wall musculature or neuromuscular entrapment, resulting in post-operative chronic pain. Tackers used for fixation may also cause nerve entrapment., In a retrospective study of laparoscopic ventral/incisional hernia repair in 1242 patients, chronic pain occurred in 14.7% patients, with the highest incidence found in the group of patients where a combination of tackers and transfascial sutures were used for mesh fixation (16.4%); however, the association was not statistically significant (P = 0.078). All the articles included in our study have used a combination of tackers and transfascial sutures for mesh fixation.
Bedi et al. in a review of literature, including 34 original articles on laparoscopic ventral and incisional hernia repair reported chronic pain as complication in 2.75% of patients. In a meta-analysis of closure of the fascial defect during laparoscopic incisional and ventral hernia repair, when compared to non-closure of defect, no significant difference in pain scores was observed (mean 2 ⋅ 47 vs. 3 ⋅ 68). However, the definition and method of recording pain were different between different studies, making the comparison difficult.
The pooled recurrence rate in our study was 3.29% (0%–6.3%). One of the most important surgical outcome measures after any hernia repair is the recurrence rate. In our analysis, eight patients had recurrences. Sharma et al. had one recurrence in their study, with a mean follow-up period of 51 months. Eitan and Bickel et al. had no recurrences in their study, with a mean follow-up period of 36.4 months. Most studies reported no recurrences.
In open onlay technique in incisional hernia repair, recurrence rates reported ranges from 0 to 32%, with a mean value of 9.9%, and a comparison to literature data on the sublay operation showed more post-operative complications, in particular wound complications and seroma, with onlay technique. However, comparable recurrence rates were identified.
Another review of literature and meta-analysis for open ventral hernia repair has reported variable recurrence rates depending on the location of the mesh, the pooled recurrence rates being 16.5% (0%–36%) for onlay, 30.2% (0%–80%) for inlay, 7% (0%–48%) for sublay and 14.7% (0%–56%) for underlay. In open IPOM with a bridging situation, the recurrence rates have been reported in the range between 0% and 61%, with a mean value of 12.6%.
In a single-centre study of 1242 patients of laparoscopic ventral/incisional hernia repair with a mean follow-up of 11.6 months, the recurrence rate was reported to be 4.4%. There was also a significant correlation between the use of staplers alone and recurrences. In a review of literature of closure versus non-closure of fascial defects in laparoscopic ventral incisional hernias, the overall recurrence rate of IPOM-Plus was 0%–7.7%, with a median follow-up period of 10.5–50.4 months.
| ¤ Discussion|| |
Since the introduction of the laparoscopic approach by LeBlanc and Booth in 1993, minimal access technique has gained widespread popularity, primarily because of its advantages of less morbidity, short hospital stay, early return to activities and ability to identify additional or occult defects in the abdominal wall. Despite the advantages of laparoscopic approach, post-operative morbidity has been reported in 3%–18% of cases., With growing experience, it was realised that purely laparoscopic procedures were associated with higher failure rates in cases of complex abdominal hernias. Rather than matching the patient to a certain surgical technique, the technique should be tailored to the patients characteristic and the defect size. The recurrence rates in laparoscopic IPOM, contrary to expectations, still range between 4.4% and 29%, almost at par with the open technique.,, This was partly due to the widespread application of the laparoscopic IPOM technique to all ventral hernias, irrespective of its complexity and the understanding of the disease process. In our review, recurrence rates after the hybrid technique of incisional hernia repair ranged from 0 to 6.3%, which is less than what most literature has reported for open techniques of repair and comparable to laparoscopic IPOM and IPOM plus for the repair of ventral incisional hernias.,
Seroma formation is a common complication after ventral hernia repair. In open onlay repair, the seroma rate has been reported to range between 38.5% and 45.6%. Seroma rates for standard IPOM have been reported to range from 0.5% to 78%. In IPOM plus, seroma rates have been reported to range from 0% to 11.43%. Seroma formation in our review ranged from 0% to 14.3%, with a mean of 5.47%, which is lower than open onlay repair and standard IPOM technique and comparable to IPOM plus. However, only two studies in the articles reviewed have mentioned the excision of sac as part of the surgical technique.,
Wound infection rates have been reported to be 16.9% for open onlay repair, 31.3% for open inlay repair and 3.7% for open sublay repair. Wound infection rates in standard IPOM have been reported to range from 0.30% to 0.60%., In our review, the wound infection rate was 6.53%, which is less than what literature has reported for open onlay and open inlay repair and comparable to open sublay repair. However, wound infection rates were lower for standard IPOM technique.
Chronic pain after standard IPOM has been reported in the range of 2.75%–14.7%;, however, both the articles have included both primary and incisional ventral hernias in their study. In this review, the incidence of chronic pain was 4.49%. It should be noted that the criteria for diagnosing chronic pain have not been well described in our included studies.
Longer follow-up is essential to assess the true rate of recurrence, and at least a 3-year follow-up has been suggested to know the incidence of delayed recurrences. Most of the studies included in this review have reported a maximum follow-up period of 12 months, with only two studies having a mean follow-up period of more than 3 years. This highlights the need to have more studies with longer follow-up periods to know the recurrence rates after the hybrid IPOM technique. Another limitation in our review is the variation in defect size across different studies, with one study reporting an average defect size 5.94 cm2, which could have an impact on surgical outcomes.
| ¤ Conclusion|| |
In conclusion, this systematic review of the literature suggests that hybrid ventral hernia repair is a promising technique in the management of complex/difficult ventral incisional hernias and represents a natural evolution in advancement of hernia repair. The judicious use of hybrid repair in selected patients combines the safety of open surgery with several advantages of the laparoscopic approach with favourable surgical outcomes in terms of recurrence, seroma and incidence of chronic pain. It reduces the morbidity of large abdominal flaps of open repair while preserving the benefits of laparoscopic approach such as the placement of a large underlay mesh and fixation under vision and identification of occult hernias. It allows safe adhesiolysis and safe bowel handling and reduction in patients of incarcerated hernia with extensive adhesions, reducing the risks of inadvertent enterotomies. However, larger multi-centric prospective studies with longer follow-up periods are required to standardise the technique and to establish it as the procedure of choice for this complex disease entity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]