Update of Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B
Abstract
In 2014 the International Endohernia Society (IEHS) published the first international “Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias”. Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. Methods: For the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. Results: Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago hernia-related publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques—minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. Conclusion: Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before.
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Vol.:(0123456789) 1 3 Surgical Endoscopy (2019) 33:3511–3549 https://doi.org/10.1007/s00464-019-06908-6 GUIDELINES Update ofGuidelines forlaparoscopic treatment ofventral andincisional abdominal wall hernias (International Endohernia Society (IEHS)): Part B R.Bittner1,2· K.Bain3· V.K.Bansal4· F.Berrevoet5· J.Bingener‑Casey6· D.Chen7· J.Chen8· P.Chowbey9· U.A.Dietz10· A.deBeaux11· G.Ferzli3· R.Fortelny12· H.Hoffmann13· M.Iskander14· Z.Ji15· L.N.Jorgensen16 · R.Khullar9· P.Kirchhoff13· F.Köckerling17· J.Kukleta18· K.LeBlanc19· J.Li20· D.Lomanto21· F.Mayer22· V.Meytes3· M.Misra23· S.Morales‑Conde24· H.Niebuhr25· D.Radvinsky26· B.Ramshaw27· D.Ranev28· W.Reinpold29· A.Sharma9· R.Schrittwieser30· B.Stechemesser31· B.Sutedja32· J.Tang33· J.Warren34· D.Weyhe35· A.Wiegering36· G.Woeste37· Q.Yao38 Received: 5 June 2019 / Accepted: 7 June 2019 / Published online: 10 July 2019 © The Author(s) 2019 Abstract In 2014 the International Endohernia Society (IEHS) published the first international “Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias”. Guidelines reflect the currently best available evidence in diagnostics and therapy and give recommendations to help surgeons to standardize their techniques and to improve their results. However, science is a dynamic field which is continuously developing. Therefore, guidelines require regular updates to keep pace with the evolving literature. Methods For the development of the original guidelines all relevant literature published up to year 2012 was analyzed using the ranking of the Oxford Centre for Evidence-Based-Medicine. For the present update all of the previous authors were asked to evaluate the literature published during the recent years from 2012 to 2017 and revise their statements and recommendations given in the initial guidelines accordingly. In two Consensus Conferences (October 2017 Beijing, March 2018 Cologne) the updates were presented, discussed, and confirmed. To avoid redundancy, only new statements or recommendations are included in this paper. Therefore, for full understanding both of the guidelines, the original and the current, must be read. In addition, the new developments in repair of abdominal wall hernias like surgical techniques within the abdominal wall, release operations (transversus muscle release, component separation), Botox application, and robot-assisted repair methods were included. Results Due to an increase of the number of patients and further development of surgical techniques, repair of primary and secondary abdominal wall hernias attracts increasing interests of many surgeons. Whereas up to three decades ago herniarelated publications did not exceed 20 per year, currently this number is about 10-fold higher. Recent years are characterized by the advent of new techniques—minimal invasive techniques using robotics and laparoscopy, totally extraperitoneal repairs, novel myofascial release techniques for optimal closure of large defects, and Botox for relaxing the abdominal wall. Furthermore, a concomitant rectus diastasis was recognized as a significant risk factor for recurrence. Despite still insufficient evidence with respect to these new techniques it seemed to us necessary to include them in the update to stimulate surgeons to do research in these fields. Conclusion Guidelines are recommendations based on best available evidence intended to help the surgeon to improve the quality of his daily work. However, science is a continuously evolving process, and as such guidelines should be updated about every 3 years. For a comprehensive reference, however, it is suggested to read both the initially guidelines published in 2014 together with the update. Moreover, the presented update includes also techniques which were not known 3 years before. Keywords Update Guidelines· Abdominal wall hernia· Ventral hernia repair· Primary ventral hernias· Secondary ventral hernias· Open sublay repair· Endoscopic sublay· Laparoscopic repair· IPOM· Rectus diastasis· Milos· Emilos· eTEP and Other Interventional Te chniques Part A of theseGuidelines is available at DOI https ://doi. org/10.1007/s0046 4-019-06907 -7. Extended author information available on the last page of the article
3512 Surgical Endoscopy (2019) 33:3511–3549 1 3 Content Part B Chapter1 How can the new techniques for minimal invasive extraperitoneal mesh repair of abdominal wall hernias and rectus diastasis be defined? Chapter2 Is there an indication for operative treatment of diastasis recti without hernia formation? Chapter3 Component separation techniques. Chapter4 In which patient group is a transversus abdominis release (TAR) indicated? Chapter5 The role of preoperative adjunct interventions in ventral hernia repair Chapter6 Robotic ventral/incisional hernia repair Chapter7 Treatment of lateral primary or incisional hernias: Which technique should be preferred? Chapter8 Education and Training in Laparoscopic Ventral Hernia Repair. Introduction Treatment of abdominal wall hernias is a rapidly evolving field of surgery. Correspondingly there is a dramatic increase of publications. There are many reasons for this development: rise of the number of laparotomies and the number of major surgeries being performed, progress in anesthesiology, increase of older patients with weak connective tissue, increase of patients with risk factors for hernias, and significant increase of patients managed with an open abdomen in a damage-control situation. Worldwide as many as two million patients are operated on every year. A variety of new repair techniques came up, recently even robot-assisted operations. The surgical approach may be open, laparoscopic, endoscopically within the abdominal wall, or hybrid approaches combining these modalities. The volume of literature, often with low levels of evidence and conflicting results, can be difficult to interpret in a meaningful way to assist the surgeon in appropriate management of the hernia patient. Therefore, there is a need for evidence-based guidelines to help the surgeon in his daily decision making process. “Guidelines are the bridge between science and clinical practice (Eccles M, Mason J.Health Technol Assess. 2001; 5(16):1–69. Review.). In 2014 this same group (IEHS) published the first international “Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias” [1, 2, 3]. It is generally accepted that guidelines require an update every 3 years to reflect the rapid evolution of techniques, materials and data available. The current update follows the same methodology as described in the original guidelines. The authors were encouraged to avoid redundancy and concentrate on the new studies showing a level of evidence 1, 2 and 3, and which were published between 2012 and 2017. Statements and recommendations which are still valid are not repeated. As such, this update should be read in the context and in conjunction with the initially published guidelines. New topics included in this update are: In which patient group is a component separation indicated? Should the component separation be done open or endoscopically? Is an anterior component separation better than the posterior one? Is preliminary treatment with Botox indicated in patients in whom a component separation is planned? Should TAR be done open or endoscopically? In patients presenting with a ventral hernia in combination with a rectus diastasis which is the best treatment option? Does robotassisted surgery have a future in repair of primary and secondary ventral hernias? What is the optimal treatment of lateral primary or incisional hernias? We are well aware that with respect to these innovations the evidence is not yet strong enough to give valuable statements or recommendations, however, the guidelines should inform the surgical community and stimulate further studies to gain more knowledge in the coming years. References 1. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli GS, Fortelny RH, Köckerling F, Kukleta J, Leblanc K, Lomanto D, Misra MC, Bansal VK, Morales-Conde S, Ramshaw B, Reinpold W, Rim S, Rohr M, Schrittwieser R, Simon T, Smietanski M, Stechemesser B, Timoney M, Chowbey P; International Endohernia Society (IEHS) (2014) Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)-part 1. Surg Endosc Jan; 28(1):2–29. https ://doi.org/10.1007/s0046 4-013- 3170-6. Epub 2013 Oct 11 2. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli GS, Fortelny RH, Köckerling F, Kukleta J, Leblanc K, Lomanto D, Misra MC, Bansal VK, Morales-Conde S, Ramshaw B, Reinpold W, Rim S, Rohr M, Schrittwieser R, Simon T, Smietanski M, Stechemesser B, Timoney M, Chowbey P; International Endohernia Society (IEHS) (2014) Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)-part 2. Surg Endosc Feb;28(2):353–79. 3. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli GS, Fortelny RH, Köckerling F, Kukleta J, Leblanc K, Lomanto D, Misra MC, Bansal VK, Morales-Conde S, Ramshaw B, Reinpold W, Rim S, Rohr M, Schrittwieser R, Simon T, Smietanski M, Stechemesser B, Timoney M, Chowbey P; International Endohernia
3513Surgical Endoscopy (2019) 33:3511–3549 1 3 Society (IEHS) (2014) Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)-part 3. Surg Endosc Feb;28(2):380–404. https ://doi.org/10.1007/ s0046 4-013-3172-4. Epub 2013 Sep 17 Chapter1. Key question: howcan thenew techniques forminimal invasive extraperitoneal mesh repair ofabdominal wall hernias andrectus diastasis be defined? David Chen, Wolfgang Reinpold, Reinhard Bittner, Ferdinand Koeckerling Methodology Search of MEDLINE, Embase, PubMed, PubMed Central, The Cochrane central registry of controlled trials (CENTRAL), Google Scholar, and Springer Link Search terms “incisional hernia”, “abdominal wall hernia”, “laparoscopic sublay repair”, endoscopic sublay mesh repair”, “endoscopic preperitoneal mesh repair”, “laparoscopic preperitoneal mesh repair”, “laparoscopic extraperitoneal mesh repair”, “sublay mesh repair”, “preperitoneal mesh repair”, “retromuscular mesh repair”, “endoscopic retromuscular mesh repair”, “laparoscopic retromuscular “ventral hernia”, “laparoscopic ventral hernia”, “endoscopic ventral hernia”, “laparoscopic umbilical hernia”, “ELAR”, “MILOS”, “EMILOS”, “eTEP”, “rTAPP ventral hernia”, “rRives hernia”, “TAR”, “rTAR”, “Stapler Abdominoplasty”, “stapled closure”, “Robotic”, “midline augmentation”, “midline reconstruction”, “Rectus diastasis”, “minimal invasive ventral hernia”, “minimal invasive incisional hernia”, “minimal invasive abdominal wall hernia”. Included publications Covering the period from 2003 to February 2018, using the search terms “abdominal wall hernia”, “ventral hernia”, and “incisional hernia” identified 12,507, 9971, and 3806 articles, respectively. One hundred and forty-three articles were identified for “rectus diastasis”. These were refined to 89 studies. In total, 30 studies were found to be relevant. Twenty-three were included in formulating these guidelines while 7 were excluded for language (2), open technique (2), or low quality (3). Table1 Classification of new techniques for minimal invasive extraperitoneal mesh repair of abdominal wall ventral hernias
3514 Surgical Endoscopy (2019) 33:3511–3549 1 3 Access: • Laparoscopic transabdominal preperitoneal (ventral TAPP) • Laparoscopic transabdominal retromuscular (ventral TARM)/ Laparoscopic retromuscular ventral hernia repair (RMVH) • Total extraperitoneal preperitoneal / retromuscular (ventral TEP) • Enhanced view total extraperitoneal preperitoneal / retromuscular (ventral eTEP) • Roboc Enhanced view total extraperitoneal preperitoneal / retromuscular (ventral reTEP) • Roboc Transabdominal preperitoneal (ventral rTAPP) • Roboc Transabdominal retromuscular (ventral rTARM)/ Roboc retromuscular ventral hernia repair (rRMVH) • Transhernial total extraperitoneal/ preperitoneal / retromuscular Mini or Less-Open Sublay repair (MILOS) or endoscopic variant (EMILOS) Locaon of mesh: • preperitoneal • retrorectus (between rectus abdominis muscle and posterior rectus sheath) • retromuscular (posterior to rectus abdominis or oblique muscles and peritoneum • onlay Modality of defect closure: • Suture • Tack • Linear stapler • None Reconstrucon of the abdominal wall: closure of hernia defect, posterior rectus sheath, and rectus diastasis • No closure • Only closure of hernia defect • Only closure of posterior rectus sheath • Closure of hernia defect and posterior rectus sheath • Closure of hernia defect and rectus diastasis • Closure of hernia defect, posterior rectus sheath and rectus diastasis Simultaneous Minimally invasive posterior component separaon (TAR) possible: • Laparoscopic ventral TAPP, TARM, RMVH, TEP, eTEP: yes • Roboc TAPP, roboc eTEP: yes • MILOS, EMILOS: yes • ELAR, Onlay: no
3515Surgical Endoscopy (2019) 33:3511–3549 1 3 Evidence of new minimal invasive extraperitoneal mesh repair techniques Statements: Level 3 Total Extraperitoneal Preperitoneal (TEP) ventral hernia repair may be used to correct small and medium size ventral hernias. Level 4 Endoscopic-assisted Linea Alba Reconstrucon (ELAR) with mesh augmentaon may be used to correct ventral hernias and coexising diastasis with wide extraperitoneal mesh augmentaon and favorable outcomes regarding recurrence, complicaons, and pain. Level 4 Laparoscopic transabdominal preperitoneal and retromuscular ventral hernia repair (ventral TAPP and TARM = RMVH) may be used to correct small and medium size ventral hernias and coexising diastasis with wide extraperitoneal mesh augmentaon, minimal fixaon, and favorable outcomes regarding recurrence, infecon, and pain. With large ventral hernias, ventral TAPP and RMVH operaons can be combined with posterior component separaon (TAR). Level 4 Enhanced-view Total Extraperitoneal Preperitoneal (eTEP) ventral hernia repair may be used to correct ventral hernias and coexisng diastasis with wide extraperitoneal mesh augmentaon, minimal fixaon, and favorable early outcomes regarding recurrence, infecon, and pain. With large ventral hernias, eTEP operaons can be combined with posterior component separaon (TAR). Level 2B Minimally invasive Less Open Sublay (MILOS) and its endoscopic variants (EMILOS) effecvely repair ventral hernias and coexising diastasis with wide extraperitoneal mesh augmentaon, minimal fixaon, and favorable outcomes regarding recurrence, infecon, and pain. With large ventral hernias, MILOS and EMILOS operaons can be combined with posterior component separaon (TAR). Level 3 Roboc Retromuscular Hernia Repair (RRVHR) may be used to repair ventral hernias and coexising diastasis with wide extraperitoneal mesh augmentaon, minimal fixaon, and favorable outcomes regarding fascial closure, recurrence, and length of stay but greater seroma rates and ulizaon of myofascial release. With large ventral hernias, RRVHR operaons can be combined with posterior component separaon (TAR). Level 4 Linear cung staplers may simplify and speed the creaon of the retromuscular pocket and plicate a coexisng diastasis during extraperitoneal hernia and rectus diastasis repairs (MILOS, EMILOS, eTEP, TAPP).
3516 Surgical Endoscopy (2019) 33:3511–3549 1 3 Recommendaon: Grade C Several minimally invasive laparoendoscopic and roboc opons for extraperitoneal mesh repair of ventral hernia with favorable short term outcomes can be offered. Ongoing evaluaon regarding long term outcomes, operave me, cost, and clinical benefit are needed. The new techniques should only be adopted aer adequate training. Key question In patients presenting with a ventral hernia in combination with a rectus diastasis, which is the best treatment option- IPOM plus, ELAR, MILOS, EMILOS, LIRA, eTEP, Stapler Abdominoplasty? Statements: Level 2A With regards to isolated Rectus Diastasis, no clear disncon in recurrence rate, postoperave complicaons, or paent reported outcomes can be made regarding plicaon as compared to hernia repair methods. Level 3 Coexisng Rectus diastasis significantly increases hernia recurrence rate (31 vs 8%) while closure with non-absorbable sutures and mesh repair decrease recurrence. Level 3 Mesh reinforcement is safe and durable for repair of large rectus diastases and those with concomitant hernia. Level 2B Plicaon of the Linea Alba during concurrent hernia and rectus diastasis repair reduces the average distance between the rectus muscles and may provide a funconal and aesthec benefits. Level 2A Laparoscopic IPOM ventral hernia and rectus diastasis repair with midline mesh augmentaon and defect closure (IPOM plus) results in less recurrence, seroma and bulging. Level 3 Laparoscopic intracorporeal rectus aponeuroplasty (LIRA) with mesh augmentaon may be used to correct ventral hernias with coexising diastasis with favorable outcomes regarding recurrence and pain. Level 3 Novel extraperitoneal ventral hernia repair techniques with mesh augmentaon (MILOS, eMILOS, eTEP, ventral TAPP, roboc eTEP, roboc TAPP, roboc RRVHR) may be ulized to repair ventral hernias with coexisng rectus diastasis.
3517Surgical Endoscopy (2019) 33:3511–3549 1 3 Recommendaons: Grade B Mesh reinforcement of ventral hernia repairs with a concomitant rectus diastasis is recommended. Grade B In laparoscopic IPOM repair of ventral hernia and concurrent rectus diastasis, reconstrucon of the linea alba with mesh augmentaon should be performed when possible. Grade C Several novel minimally invasive endoscopic, laparoscopic, and roboc opons for extraperitoneal mesh repair of ventral hernia with concomitant rectus diastasis can be offered. Ongoing evaluaon regarding long term outcomes, operave me, cost, and clinical benefit are needed. Introduction Laparoscopic intraperitoneal onlay mesh (IPOM) repair and open sublay mesh repair are currently the most common techniques for the treatment of primary and recurrent abdominal wall hernias worldwide [1–3]. A systematic review and two recently published meta-analyses concluded that laparoscopic IPOM and open abdominal wall hernia repairs are safe procedures with comparable short and longterm outcomes [1–3]. Although the open techniques are burdened with higher infection rates, laparoscopic IPOM repairs carry an increased risk of intraoperative bowel injury, adhesions, and bowel obstruction (1–4). Despite progress in mesh technology and the development of coated meshes designed to lower the risk of adhesion formation, the potential risks associated with an intraperitoneal foreign body have not yet been eliminated [1–4]. Traumatic mesh fixation increases the risk of adhesions, visceral damage, nerve injury, and acute and chronic pain. Reduction of the hernia sac with closure of the hernia defect is difficult with laparoscopic IPOM, and is often omitted leading to higher recurrence rates, eventrations (pseudorecurrences), and seroma formation [5–8]. In larger hernias with a diameter of more than 15cm, the laparoscopic IPOM repair can be very difficult [1–7]. To address the limitations of traditional laparoscopic and open ventral hernia repair, several minimally invasive endoscopic, laparoscopic, and robotic extraperitoneal techniques have developed with the goal of combining the benefits of traditional open sublay repair removing prosthetics out of the visceral compartment with those of minimally invasive surgery. The new minimal invasive extraperitoneal techniques can be classified according to access, mesh location, modality of defect closure, and anatomic reconstruction of the abdominal wall. In all of these novel procedures, standard uncoated permanent synthetic meshes (Polypropylene, PVDF, Polyester) may be used. Analogous to the differentiation in laparoscopic inguinal hernia repair, laparoscopic transabdominal techniques (ventral preperitoneal TAPP, ventral transabdominal retromuscular TARM/RMVH) can be differentiated from endoscopic total extraperitoneal procedures (ventral TEP, eTEP, MILOS, EMILOS). Most of these novel extraperitoneal operations can be combined with posterior component separation (transversus abdominis release—TAR) as needed to address larger defects or accommodate larger prostheses. The first article on minimal invasive extraperitoneal mesh repair of ventral hernias was published by Miserez etal. [8]. Subsequent development of transabdominal, total extraperitoneal, transhernial, and onlay techniques perfomed in mini-open, laparoscopic, and robotic fashion have expanded the minimally invasive extraperitoneal options for repair of ventral hernias and coexisting rectus diastasis. Classification details for these novel extraperitoneal repairs are shown in Table1. Patients with symptomatic umbilical, ventral, and incisional hernias and concomitant rectus abdominis diastasis represent a growing clinical problem and, as with isolated hernias, the ideal operative management of this complex hernia situation has not been defined. With regards to isolated rectus diastasis, defined as a thinning and widening of the linea alba, combined with laxity of the ventral abdominal wall musculature, controversy remains as to whether this pathology is cosmetic or functional due to the variation in severity, symptomatology, and the absence of strangulation risk found with hernias [9]. While physiotherapy can achieve a limited benefit with regards to size and symptoms with isolated mild rectus diastasis, surgery significantly improves abdominal wall function and pain regardless of operative technique employed and should be considered with diastasis wider than 3cm [10]. Currently, both plication and hernia repair methods are used to repair isolated rectus abdominis diastasis with no clear distinction in recurrence rate, postoperative complications, or patient reported outcomes found in the literature [9, 10]. The presence of rectus abdominis diastasis and coexisting hernia presents a greater challenge as the weakened linea alba and ventral abdominal musculature increase the risk of hernia formation, compromise the integrity of the midline,
3518 Surgical Endoscopy (2019) 33:3511–3549 1 3 and complicate the repair of ventral hernias. Köhler etal. demonstrated that a coexisting rectus diastasis significantly increases hernia recurrence rate with primary sutured closure (31 vs. 8%) [11]. As such, well established principles from ventral hernia repair including primary closure with non-absorbable sutures and mesh repair should be utilized to decrease hernia and diastasis recurrence [11]. Mesh repair of ventral hernias is well established as safe reducing the recurrence rate significantly compared to suture repair. Based on the volume of Level 1 studies studying ventral hernia, mesh reinforcement of ventral hernia repairs with a concomitant rectus diastasis is recommended while studies specifically evaluating ventral hernia and rectus diastasis corroborate these findings [12]. While the role of defect closure with isolated ventral hernia is likely beneficial but still unestablished, mesh reinforcement with ventral hernia in the setting of a concurrent rectus diastasis is more clear [11]. Multiple studies utilizing several different operative repair techniques demonstrate that restoration of the linea alba during concurrent hernia and rectus diastasis repair is feasible and reduces the average distance between the rectus muscles with potential functional and esthetic benefits [13–26]. These studies include traditional laparoscopic intraperitoneal (IPOM) repair with defect closure, subcutaneous closure of the anterior sheath, endoscopic subaponeurotic closure of the anterior sheath, laparoscopic sutured linea alba closure, laparoscopic posterior sheath closure, and linear stapled closure techniques to address the separation of the linea alba prior to mesh hernia repair. Restoration of the midline with correction of the diastasis at the time of ventral hernia repair when possible may provide additional benefit with regards to abdominal wall function, pain, and cosmesis [5, 10, 13, 17, 22, 25]. With regard to specific technique, several of the new minimally invasive mini-open, endoscopic, laparoscopic, and robotic extraperitoneal ventral hernia repairs may simultaneously address a coexisting rectus diastasis. There is a paucity of data in the literature for many of these novel techniques and an absence of comparative data to establish superiority of any given technique. The current literature summarized in these guidelines support that these reported techniques are safe, feasible, and effective in shorter term studies but ongoing and future studies are need to establish a “best treatment option”. Laparoscopic intraperitoneal onlay mesh (IPOM) repair is the best and longest studied minimally invasive ventral hernia repair technique. Palanivelu etal. described their “Venetian blind” technique in 2009 to address the cosmetic and functional implications of a coexisting rectus diastasis or bridged hernia defect demonstrating the feasibility and efficacy of closing the defect at the time of IPOM repair [13]. Multiple primary studies, meta-analyses, and systematic reviews have subsequently been performed demonstrating the benefits of defect closure with midline mesh augmentation during IPOM repair with regards to recurrence, seroma, and “pseudorecurrence” or bulging [5–7]. Extrapolating the data from these consistent level 2A studies to concurrent rectus diastasis and ventral hernia repair, reconstruction of linea alba with mesh augmentation, is recommended and should be performed when feasible. The minimally invasive Mini or Less Open Sublay Repair (MILOS) and its endoscopic variant (EMILOS) developed by Reinpold and colleagues utilize progressively smaller “mini (≤ 5cm) or less open (6–12cm)” incisions and laparoendoscopic transhernial approaches to replicate the traditional open Rives-Stoppa retrorectus or retromuscular sublay reconstruction for ventral hernia repair [14–16]. This approach simultaneously addresses the midline linea alba correcting coexisting diastasis with wide midline mesh augmentation and minimal fixation. Reinpold etal. performed a prospective, propensity score matched study within the German Hernia Registry (Herniamed) comparing 615 MILOS incisional hernia operations to laparoscopic IPOM incisional hernia repair and open sublay repair [14]. MILOS repair was associated with significantly fewer postoperative surgical complications, general complications, recurrences, and less chronic pain versus IPOM repair. Significantly fewer postoperative complications, reoperations, infections, general complications, recurrences, and less chronic pain were found compared to open sublay repair. The MILOS technique reproduces the functional and physiologic aspect of an open retromuscular repair with the benefits of minimally invasive techniques. Schwarz etal. and Bittner etal. demonstrated that this technique can be endoscopically modified (EMILOS) with similar feasibility, efficacy, and favorable outcomes for ventral hernia and rectus diastasis repair [15, 16]. In large defects, the MILOS technique can be combined with a posterior component separation (TAR). The Enhanced or Extended-view Total Extraperitoneal Preperitoneal (eTEP) approach developed by Daes has been used to perform midline and off midline ventral hernia repair augmenting the traditional preperitoneal space utilized in inguinal hernia repair to access almost any portion of the abdominal wall. With regards to ventral hernia with a coexisting rectus diastasis, this technique allows for midline closure of the linea alba and any diastasis with wide extraperitoneal mesh augmentation, minimal fixation, and may be combined with posterior component separation with release of the transversus abdominus muscle to access to the entire retromuscular plane. Belayansky etal. performed a retrospective multicenter review of 79 patients utilizing the eTEP approach demonstrating low complication rates, significantly improved pain and functionality scores using the Carolinas Comfort Scale, and low complication, infection, and recurrence rates [17]. While the operative approach may differ slightly, the eTEP technique is anatomically and
3519Surgical Endoscopy (2019) 33:3511–3549 1 3 physiologically similar to the eMILOS technique demonstrating similar benefits and efficacy. The Endoscopic-assisted Linea Alba Reconstruction (ELAR) with mesh augmentation developed by Koeckerling is based on the principles of the MILOS technique and utilizes an endoscopic subcutaneous approach with subsequent mesh augmentation and reinforcement to address ventral hernia defects with concurrent rectus diastasis [20]. This hybrid technique exposes the anterior layer of the rectus sheath from the xiphoid process to the subumbilical area, the medial segments of the anterior layer of both rectus sheaths are sutured to reconstruct the linea alba, and the resultant defect in the anterior layer of the rectus sheath is repaired by suturing a mesh to the anterior sheaths bilaterally to reconstruct the anterior abdominal wall. Koeckerling etal. reported low complication and reoperation rates (1.4%, 2 cases due to bleeding) with favorable early results regarding pain and recurrence in their series of 140 patients [18–20]. Laparoscopic intracorporeal rectus aponeuroplasty (LIRA) with mesh augmentation described by Gómez-Men- chero etal. was designed to address some of the challenges and limitations of closing the defect with the IPOM plus technique which may increase pain, recurrence, or require component separation to counteract the tension created by midline fascial reapproximation [21]. The posterior rectus aponeurosis is laparoscopically opened lengthwise around the hernia defect to create two flaps. The flaps are then sutured closed and the repair reinforced with an IPOM mesh. In their series of 12 patients followed to 1year, this novel technique achieves a reproducible, feasible, “tension-free” repair of ventral hernias with coexisting rectus diastasis with a low rate of postoperative pain and no reported recurrence, or bulging [21]. Despite its benefits, minimally invasive laparoscopic ventral hernia repair can be technically challenging especially with complex procedures such as component separation, transversus abdominis release, and suturing of the ventral midline. The need for high technical skill, dexterity, and proficiency may lead to variability with regards to clinical outcomes, complication rates, and adoption. The use of the robotic platform for ventral hernia has progressively increased due to the benefits of improved optics and visualization, superior ergonomics, and improved degrees of freedom and range of motion needed to perform precise suturing, adhesiolysis, dissection, and mesh positioning and fixation necessary for abdominal wall reconstruction. With regards to ventral hernias and coexisting rectus diastasis, the Robotic Retromuscular Hernia Repair (RRVHR) utilizes the same operative plane as the open Rives-Stoppa, MILOS, eMILOS, and eTEP ventral hernia repairs. Warren etal. compared their robotic retromuscular repair (53 patients) to traditional laparoscopic ventral hernia repair (103 patients) utilizing registry data from the American Hernias Society Quality Collaborative. Robotic retromuscular repair facilitated facial closure and extraperitoneal mesh placement in the vast majority of cases (96.2 vs. 50.5%; p < 0.001). Hernia size was similar but robotic operations were longer and myofascial release was performed in 43% of robotic operations. Direct hospital costs were similar between both groups while length of stay was significantly shorter after RRVHR (23). Robotic retromuscular ventral hernia repair enables a true abdominal wall reconstruction and allows for simultaneous correction of coexisting rectus diastasis with wide extraperitoneal mesh augmentation, minimal fixation, and favorable outcomes regarding fascial closure and recurrence [23]. The term “Stapler abdominoplasty” represents a technical modification of several extraperitoneal operative techniques for ventral hernia and rectus diastasis repair rather than a unique operative approach. Linear cutting staplers may be used to develop the retromuscular space and plicate a coexisting diastasis during extraperitoneal hernia and rectus diastasis repairs. Costa etal. introduced this technique using a laparoscopic transabdominal preperitoneal approach in 15 postbariatic patients with hernia and rectus diastasis demonstrating feasibility, simplicity, and low complication rates [7]. Stapled plication of the anterior rectus sheath and division of the linea alba into an anterior and posterior component may be used in conjunction with open Rives-Stoppa, MILOS, EMILOS, eTEP, and laparoscopic retromuscular repairs [24–26]. In general, the indication for repair of diastasis recti of the abdominal muscles is based upon cosmetic or functional impairment, as there is no risk of strangulation. However, the negative implication of a rectus diastasis on ventral hernias with regards to recurrence and complications warrants consideration of the optimal approach to address both disease processes simultaneously. In these cases, the morbidity and risk of larger, more complicated operations for typically smaller coexisting hernias must be considered. Currently, there are several novel minimally invasive endoscopic, laparoscopic, and robotic procedures to address ventral hernia with coexisting rectus diastasis that are feasible, safe, and effective. Future studies with long-term outcomes and comparative data will help to define optimal techniques for these coexisting pathologies. References (in parentheses the level of evidence) 1. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M (2011) Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane Database Syst Rev 16(3):CD007781. (2) 2. Al Chalabi H, Larkin J, Mehigan B, McCormick P (2015) A systematic review of laparoscopic versus open abdominal incisional hernia repair, with meta-
3526 Surgical Endoscopy (2019) 33:3511–3549 1 3 Engeland MI, Bleichrodt RP (2003) “Components separation technique” for the repair of large abdominal wall hernias. J Am Coll Surg 196(1):32–37 (3). 11. Hodgkinson JD, Maeda Y, Leo CA, Warusavitarne J, Vaizey CJ (2017) Complex abdominal wall reconstruction in the setting of active infection and contamination: a systematic review of hernia and fistula recurrence rates. Colorectal Dis 19(4):319–330. https ://doi. org/10.1111/codi.13609 (1A). 12. de Vries Reilingh TS, van Goor H, Charbon JA, Rosman C, Hesselink EJ, van der Wilt GJ, Bleichrodt RP (2007) Repair of giant midline abdominal wall hernias: “components separation technique” versus prosthetic repair: interim analysis of a randomized controlled trial. World J Surg 31(4):756–763 (3). 13. Harth KC, Rosen MJ (2010) Endoscopic versus open component separation in complex abdominal wall reconstruction. Am J Surg 199:342–347. https ://doi. org/10.1016/j.amjsu rg. 2009.09.015 (3). 14. Rasilainen SK, Mentula PJ, Leppäniemi AK (2016) Components separation technique is feasible for assisting delayed primary fascial closure of open abdomen. Scand J Surg 105(1):17–21 (4). 15. Sriussadaporn S, Sriussadaporn S, Pak-Art R, Kritayakirana K, Prichayudh S, Samorn P (2013) Management of difficult abdominal wall problems by components separation methods: a preliminary study in Thailand. J Med Assoc Thai 96(11):1449–1462 (4). 1. Key question Which type of anterior CST is preferred? Search terms The following search terms were used: ((component* separation) OR (separation of components) OR (myofascial release)) AND (hernia OR (abdominal wall) OR (”Hernia, Ventral”[Mesh])) AND (indication OR use). Search machines PubMed, Medline, and the Cochrane Library as well as Google scholar were searched for relevant studies. Abstracts of resulted articles were reviewed for their relevance to the different component separation techniques. From the total of 475 papers extracted, 7 reviews [1–7] and 12 case–control studies [8–19] were applicable to the key question. Statements: Level 3 Compared to open anterior component separaon (OaCS), endoscopic (EaCS) or open minimally invasive perforator-sparing anterior component separaon (MIaCS) result in a lower incidence of wound morbidity. Level 3 OaCS, EaCS and MIaCS are associated with comparable rates of fascial closure. Level 3 OaCS, EaCS and MIaCS are associated with comparable hernia recurrence rates. Level 3 Total costs are not increased by EaCS or MIaCS. Level 3 Indicaons for EaCS as compared to MIaCS remain to be defined. Recommendaons: Grade B For fascial closure of large midline hernias, surgeons should consider EaCS or MIaCS, as an alternave to OaCS, in order to reduce postoperave wound morbidity .
3527Surgical Endoscopy (2019) 33:3511–3549 1 3 Various systematic reviews and meta-analyses have recently been reported to compare the different techniques of CST. The minimal invasive and endoscopic component separation have been suggested to reduce the postoperative wound morbidity as large subcutaneous dissection and skin flaps might be avoided achieving the same outcomes in terms of fascial closure rate. In 2014 Feretis etal. reported 13 studies in their metaanalysis including 220 patients [3]. Overall they analyzed a wound complication rate of 17.5% versus 28% for endoscopic CST and Minimally Invasive CST respectively, resulting in a overall rate of 19.2%. However, when they only analyzed comparative studies, only 2 out of 5 studies [10, 12] showed a significantly lower incidence of wound morbidity in endoscopic and minimally invasive CST compared to open techniques, and the trend was clear in all studies [11, 13, 15]. This was confirmed by the systematic review of Switzer etal. who studied 63 studies including over 3000 patients with a wound complication rate of 34.6% for open versus 20.6% for endoscopic or minimally invasive techniques [2]. Jensen etal., in their review, only looked at studies that used the endoscopic CST as described by Rosen in 2007 [20] comparing it with the classical open Ramirez’ technique [21]. In total 5 retrospective cohort studies were observed with 163 patients, but again 43% versus 18% of wound morbidity was seen, in favor of the endoscopic CST [1]. Cornette etal., although analyzing the various anterior CST versus the posterior CST (TAR), found 13 studies for laparoscopic/endoscopic CST, only 5 on minimally invasive perforator sparing techniques and 22 on open CST. Considering wound morbidity, a slight trend in favor of perforator sparing techniques was found, versus open and laparoscopic techniques (16% vs. 21.4% and 20.3% respectively). However, as this trend is consistent throughout all the available data, despite their moderate to low quality, surgeons should consider endoscopic or minimally invasive (perforator sparing) CST, as an alternative to open CST, in order to reduce postoperative wound morbidity. Regarding recurrence rates after these various modalities, no differences are observed in the current medical literature. Furthermore, it is difficult to draw any conclusions regarding this parameter, as many variables influence recurrence rate in these large hernias. References (in parentheses the level of evidence) 1. Jensen KK, Henriksen NA, Jorgensen LN (2014) Endoscopic component separation for ventral hernia causes fewer wound complications compared to open components separation: a systematic review and metaanalysis. Surg Endosc 28:3046–3052 (1A). 2. Switzer NJ, Dykstra MA, Gill RS, Lim S, Lester E, de Gara C, Shi X, Birch DW, Karmali S (2015) Endoscopic versus open component separation: systematic review and meta-analysis. Surg Endosc 29:787–795 (1A). 3. Feretis M, Orchard P (2015) Minimally invasive component separation techniques in complex ventral abdominal hernia repair: a systematic review of the literature. Surg Laparosc Endosc Percutan Tech 25:100–105 (1A). 4. Holihan JL, Askenasy EP, Greenberg JA, Keith JN, Martindale RG, Roth JS, Mo J, Ko TC, Kao LS, Liang MK (2016) Ventral Hernia Outcome Collaboration Writing Group. Component separation vs. bridged repair for large ventral hernias: a multi-institutional risk-adjusted comparison, systematic review, and metaanalysis. Surg Infect (Larchmt) 17:17–26 (1A). 5. Cornette B, De Bacquer D, Berrevoet F (2018) Component separation technique for giant incisional hernia: a systematic review. Am J Surg 215(4):719–726. https ://doi.org/10.1016/j.amjsu rg.2017.07.032. Epub 2017 Aug 10 (1A). 6. Scheuerlein H, Thiessen A, Schug-Pass C, Köckerling F (2018) What do we know about component separation techniques for abdominal wall hernia repair? Front Surg. 2018 (5). 7. Muse TO, Zwischenberger BA, Miller MT, Borman DA, Davenport DL, Roth JS. Outcomes after ventral hernia repair using the Rives-stoppa, endoscopic, and open component separation techniques. Am Surg. 2018 84(3):433–437 (3). 8. Albright E, Diaz D, Davenport D, Roth JS (2011) The component separation technique for hernia repair: a comparison of open and endoscopic techniques. Am Surg 77:839–43 (3). 9. Azoury SC etal. (2014) A single institutional comparison of endoscopic and open abdominal component separation. Surg Endosc 28:3349–58 (3). 10. Fox M, Cannon RM, Egger M, Spate K, Kehdy FJ (2013) Laparoscopic component separation reduces postoperative wound complications but does not alter recurrence rates in complex hernia repairs. Am J Surg 206:869–874 (3). 11. Giurgius M, Bendure L, Davenport DL, Roth JS (2012) The endoscopic component separation technique for hernia repair results in reduced morbidity compared to the open component separation technique. Hernia 16:47–51 (3). 12. Harth KC, Rosen MJ (2010) Endoscopic versus open component separation in complex abdominal wall reconstruction. Am J Surg 199:342–346 (3). 13. Lowe JB, Garza JR, Bowman JL, Rohrich RJ, Strodel WE (2000) Endoscopically assisted “components separation” for closure of abdominal wall defects. Plast Reconstr Surg 105:720–729 (4).
3528 Surgical Endoscopy (2019) 33:3511–3549 1 3 14. Parker M, Bray JM, Pfluke JM, Asbun HJ, Smith CD, Bowers SP (2011) Preliminary experience and development of an algorithm for the optimal use of the laparoscopic component separation technique for myofascial advancement during ventral incisional hernia repair. J Laparoendosc Adv Surg Tech A 21:405–410 (4). 15. Ghali S, Turza KC, Baumann DP, Butler CE (2012) Minimally invasive component separation results in fewer wound-healing complications than open component separation for large ventral hernia repairs. J Am Coll Surg 214:981–989 (3). 16. Saulis AS, Dumanian GA (2002) Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plastic Reconstr Surg 109:2275–2280 (4). 17. Patel KM, Nahabedian MY, Gatti M, Bhanot P (2012) Indications and outcomes following complex abdominal reconstruction with component separation combined with porcine acellular dermal matrix reinforcement. Ann Plastic Surg 69:394–398 (4). 18. Clarke JM (2010) Incisional hernia repair by fascial component separation: results in 128 cases and evolution of technique. Am J Surg 200:2–8 (4). 19. Butler CE, Campbell KT (2011) Minimally invasive component separation with inlay bioprosthetic mesh (MICSIB) for complex abdominal wall reconstruction. Plastic Reconstr Surg 128:698–709 (4). 20. Rosen MJ, Jin J, McGee MF, Williams C, Marks J, Ponsky JL (2007) Laparoscopic component separation in the single-stage treatment of infected abdominal wall prosthetic removal. Hernia 11:435–440 (4). 21. Ramirez OM, Ruas E, Dellon AL (1990) ‘‘Components separation’’ method for closure of abdominalwall defects: an anatomic and clinical study. Plast Reconstr Surg 86:519–526 (4). 2. Key question Is a Transversus Abdominis Release (TAR) preferred over an anterior component separation technique? Search terms The following search terms were used: ((component* separation) OR (separation of components) OR (myofascial release)) AND (hernia OR (abdominal wall) OR (”Hernia, Ventral”[Mesh])) AND (anterior OR posterior). Search machines PubMed, Medline, and the Cochrane Library as well as Google scholar were searched for relevant studies. Abstracts of resulted articles were reviewed for their relevance to the different component separation techniques. From the total of 106 papers extracted, 3 reviews [1–3] and 3 case–control studies [4–5] were applicable to the key question. Statements: Level 3 EaCS and MIaCS result in a similar wound morbidity rate as a posterior Transversus Abdominis Release. Level 3 EaCS and MIaCS result in a comparable recurrence rate as a posterior Transversus Abdominis Release. Recommendaons: Grade B For intermediate to large defects, surgeons should consider EaCS, MIaCS or TAR as an alternave to OaCS in order to reduce postoperave wound morbidity. Grade C For lateral defects in need of a large mesh overlap, TAR should be preferred over anterior component separaon techniques.
3529Surgical Endoscopy (2019) 33:3511–3549 1 3 As a retromuscular mesh position in incisional hernia is still preferred over an onlay or intraperitoneal mesh repair, larger defects might be difficult to treat using this technique as the mesh overlap is limited by the lateral borders of the rectus sheet. Since the introduction of the posterior component separation technique using a transverses abdominis release (TAR), described by Novitsky etal., there is no need for large subcutaneous dissection to perform CST, and an extended wide overlap can be achieved for large defects and defects located lateral to the rectus muscles. Most of the literature involves retrospective observational cohort studies and not much comparative data are available. Recently, Hodgkinson etal. investigated the outcomes of posterior component separation and TAR with the open anterior CST. They report on 7 studies describing 281 cases of TAR for midline incisional hernia using a retromuscular mesh placement and compared those to 6 comparable studies describing 285 cases of open anterior CST and retromuscular mesh placement. Comparative analysis demonstrated no significant difference between hernia recurrence rate (p = 0.23) and no significant difference was found in wound complication rates between TAR and the open CST (p = 0.53). This finding was reported earlier already by Cornette etal. [2] and again confirmed recently by Scheuerlein etal. [3]. Therefore, surgeons are recommended to consider endoscopic, minimally invasive, or TAR as an alternative to OaCS in order to reduce postoperative wound morbidity. For lateral defects which may need a large mesh overlap, TAR should be preferred over anterior component separation techniques. References (in parentheses the level of evidence) 1. Hodgkinson JD, Leo CA, Maeda Y, Bassett P, Oke SM, Vaizey CJ, Warusavitarne J (2018) A meta-anal- ysis comparing open anterior component separation with posterior component separation and transversus abdominis release in the repair of midline ventral hernias. Hernia 22(4):617–626. https ://doi.org/10.1007/ s1002 9-018-1757-5. Epub 2018 Mar 7 (1A). 2. Cornette B, De Bacquer D, Berrevoet F (2018) Component separation technique for giant incisional hernia: A systematic review. Am J Surg 15(4):719–726. https :// doi.org/10.1016/j.amjsu rg.2017.07.032. Epub 2017 Aug 10 (1A). 3. Scheuerlein H, Thiessen A, Schug-Pass C, Köckerling F (2018) What Do We Know About Component Separation Techniques for Abdominal Wall Hernia Repair? Front Surg 27;5:24. https ://doi.org/10.3389/fsurg .2018.00024 (5). 4. Parent B, Horn D, Jacobson L, Petersen RP, Hinojosa M, Yates R, Wright AS, Louie O (2017) Wound morbidity in minimally invasive anterior component separation compared to transversus abdominis release. Plast Reconstr Surg 139:472–479. https ://doi.org/10.1097/prs.00000 00000 00295 7 (3). 5. Krpata DM, Blatnik JA, Novitsky YW, Rosen MJ (2012) Posterior and open anterior components separations: a comparative analysis. Am J Surg 203:318–322. https ://doi. org/10.1016/j.amjsu rg. 2011.10.009. Epub 2012 Jan 12 (3). Chapter4. Key question: In which patient group isatransversus abdominis release (TAR) indicated? G Woeste, Ade Beaux The main goal of ventral hernia repair is reconstruction of the midline and bringing the rectus muscle together. The recurrence rate has shown to be significantly lower when a bridging of the gap with the used mesh can be avoided [1]. A restoration of the midline is beneficial both in terms of functional results and recurrence rate. Whenever it is not possible to close the linea alba in midline ventral hernia repair, a component separation technique (CST) is indicated. The TAR technique can be used to achieve midline closure in most of the cases. With an advancement of 8 to 12cm per side Novitsky etal. have reported a closure rate of 97.2% [2]. When a recurrent hernia occurs after an anterior component separation (aCS) has been performed TAR has been shown to be an option for abdominal wall reconstruction in these complex cases [3]. However, it is an import rule that aCS and TAR should never be performed simultaneously at the same side. Apart from midline incisional hernias TAR can be used for the repair of lateral hernias (L1–4). A case series of hernias after kidney transplantation has been published with low morbidity and low recurrence rate [4]. Also a cohort of parastomal hernias has been successfully treated by stoma relocation and closure of the lateral hernia using TAR (5). Statements: Level 4 TAR is effective in reconstruction of the abdominal wall in wide midline hernias (M1-5, W3) as well as in lateral hernias (L1-4).
3530 Surgical Endoscopy (2019) 33:3511–3549 1 3 Recommendations: Grade C TAR can be applied for abdominal wall reconstruction to achieve restoration of the midline in complex ventral hernias (M1-5, W3) Grade C TAR can be used for recurrent hernias following previous anterior component separation. Grade C TAR can be used for lateral hernia repair (L1-4) References (in parentheses the level of evidence) 1. Holihan JL, Nguyen DH, Nguyen MT, Mo J, Kao LS, Liang MK (2016) Mesh location in open ventral hernia repair: A systematic review and network Meta-analysis. World J Surg 40:89–99. (1) 2. Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein SB (2016) Outcomes of posterior component separation with transversus abdominis muscle release and synthetic mesh sublay reinforcement. Ann Surg 264:226–232. (3) 3. Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ (2015) Posterior component separation with transversus abdominis release successfully addresses recurrent ventral hernias following anterior component separation. Hernia 19:285–291. (l4) 4. Petro CC, Orenstein SB, Criss CN, Sanchez EQ, Rosen MJ, Woodside KJ, Novitsky YW (2015) Transversus abdominis muscle release for repair of complex incisional hernias in kidney transplant recipients. Am J Surg 210:334–339. (4) 5. Raigani S, Criss CN, Petro CC, Prabhu AS, Novitsky YW, Rosen MJ (2014) Single-center experience with Parastomal hernia repair using retromuscular mesh placement. J Gastrointest Surg 18:1673–1677. (4) Should the TAR be done open or endoscopically? The open TAR technique has first been described by Novitsky in 42 patients with complex hernias with a mean defect size of 366cm2 [1]. The largest series of open TAR (O-TAR) is published by the same author [2]. In this retrospective series of 428 patients the incidence of surgical site events was 18.7% with 9.1% SSI and no mesh removal. The recurrence rate after 1year was only 3.7%. Winder etal. described similar results in their retrospective review of 37 patients with 5.4% SSI and 2.7% recurrences at 2years only in patients where a midline closure could not have been achieved [3]. The laparoscopic technique of TAR has been published in 2016 with a cohort of 3 patients showing no complications [4]. Also a robotic (rTAR) approach has been described [5]. The published results of rTAR are very limited. A nationwide series of 6 patients in Brazil has been described [6]. The authors conclude that this technique is feasible with two postoperative complications requiring reoperation. No randomized-controlled trials comparing open and laparoscopic or robotic TAR are published so far. Two retrospective studies compare the results of O-TAR and rTAR. The Cleveland group compared 38 patients who underwent rTAR with a matched historic cohort of 76 O-TAR cases [7]. Comparing the patient characteristics, more ASA III patients were found in the O-TAR group. The robotic approach showed significant longer OR time (299 ± 95 vs. 211 ± 63, p < 0.001). The incidence of wound morbidity did not show any significant difference between the two techniques for both SSE and SSI. The rTAR group showed lower blood loss (49 ± 60ml vs. 139 ± 149ml, p < 0.001), less systemic complications (0 vs. 17.1%, p = 0.026), and a shorter hospital stay (1.3 ± 1.3days vs. 6.0 ± 3.4days, p < 0.001). A retrospective review of 102 patients, 26 rTAR and 76 O-TAR, were compared by Bittner etal. [8]. Comparing the comorbidities, diabetes was more common in the O-TAR group (22.3% vs 0%, p = 0.01). The defect size was comparable (260 ± 209cm2 vs. 235 ± 107cm2, p = 0.55). In this cohort the OR time was significantly longer with rTAR (287 ± 121 vs. 365 ± 78min, p < 0.01). The surgical site events were the same in both groups (6.6% vs. 7.7%, p = 1.0). There was no significant difference in morbidity. The length of hospital stay was shorter after rTAR (3 vs. 6days). Level 3 Both open and minimally invasive TAR are safe procedures. Level 3 rTAR is associated with longer operative time compared to O-TAR. Level 3 rTAR can reduce postoperative length of hospital stay compared to O-TAR. Level 3 O-TAR and rTAR show the same incidence of postoperative wound morbidity. Grade C TAR can be performed open, laparoscopic and robotic
3531Surgical Endoscopy (2019) 33:3511–3549 1 3 References (in parentheses the level of evidence) 1. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ (2012) Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg 204:709–716. (4) 2. Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein SB (2016) Outcomes of posterior component separation with transversus abdominis muscle release and synthetic mesh sublay reinforcement. Ann Surg 264:226–232. (3) 3. Winder JS, Behar BJ, Juza RM, Potochny J, Pauli EM (2016) Transversus abdominis release for abdominal wall reconstruction: early experience with a novel technique. J Am Coll Surg 223:271–278. (4) 4. Belyansky I, Zahiri HR, Park A (2016) Laparoscopic transversus abdominis release, a novel minimally invasive approach to complex abdominal wall reconstruction. Surg Innov 23: 134–141. (5) 5. Ballecer C, Parra-Davila E (2016) Robotic ventral hernia repair. In: Novitsky YW (ed) Hernia surgery, Springer, New York, pp 273–286. (5) 6. Amaral MVFD, Guimaraes JR, Volpe P, Oliveira FMM, Domene CE, Roll S, Cavazzola LT (2017) Robotic transversus abdominis release (TAR): is it possible to offer minimally invasive surgery for abdominal wall complex defects? Rev Col Bras Cir 44:216–219. (5) 7. Martin del Campo LA, Weltz AS, Belyansky I, Novitsky YW (2018) Comparative analysis of perioperative outcomes of robotic versus open transversus abdominis release. Surg Endosc 32:840–845. (4) 8. Bittner JG 4th, Alrefai S, Mabe M, Del Prado PAR, Clingempeel NL (2018) Comparative analysis of open and robotic transversus abdominis release for ventral hernia repair. Surg Endosc 32:727–734. (4) Chapter5. Key Question: The role ofpreoperative adjunct interventions inventral hernia repair H. Hoffmann, P. Kirchhoff, J. Kukleta, W. Reinpold Search items “Botox AND Hernia”, “Botulinum Toxin A AND Hernia”, “Component Separation AND Botulinum Toxin A”, Component Separation” AND “Hernia”, Progressive Pneumoperitoneum AND Hernia” A systematic search of the available literature was performed in September 2017 of Medline, PubMed, Cochrane Library, and relevant journals and reference lists using the above-listed search terms. The search found 38 articles; however, only 26 studies were suitable for this review in terms of content.
3532 Surgical Endoscopy (2019) 33:3511–3549 1 3 Level 3 BTA administraon prior to VHR is associated with significantly less opioid analgesia use and significantly less pain. Level 4 Botulinum toxin A (BTA) prior to ventral hernia repair (VHR) facilitates a decrease in transverse hernia diameter, a significant reducon of lateral abdominal wall muscle thickness, and a significant elongaon of lateral abdominal wall muscles. In majority of paents with large ventral hernias BTA administraon alone enables direct fascial closure without addional component separaon techniques. BTA has shown to be effect when administered under ultrasound guidance between four to six weeks prior to VHR in either three or five injecon sites on each side. Despite BTA related side effect such as abdominal wall distension, impaired coughing and sneezing, BTA has been demonstrated to be safely administered prior to VHR without BTA related complicaons and adverse events. Before BTA administraon naonal medicaon regulaons should carefully be considered. Progressive pneumoperitoneum can increase the volume of the abdominal cavity by increasing the lateral abdominal wall muscle length, with the potenal of tension free primary fascial closure. However, PPP related complicaons must be considered. Tissue expander have a potenal as an adjunct in abdominal wall reconstrucon, but device related complicaons must be considered. Statements Recommendaons Due to the low evidence of available data, no recommendaons regarding the use of Botulinum Toxin A, progressive pneumoperitoneum and ssue expanders as adjunct intervenons in ventral hernia repair in can be made. Introduction Techniques such as progressive pneumoperitoneum (PPP), tissue expander (TE), and—most recently—Botulinum Toxin A (BTA) have gained some interest as an adjunct in the surgical approach of large incisional hernias, to gain primary fascial closure (PFC). Botulinum Toxin A Botulinum Toxin A (BTA) is a neurotoxic protein produced by clostridium botulinum. The paralyzing effect reaches a maximum 2weeks after topical administration and declines gradually after 2–3months [1–3]. Several clinical studies investigated the effect of BTA on abdominal wall muscle parameters using CT scans. Ibarra-Hurtado etal. [4]
3533Surgical Endoscopy (2019) 33:3511–3549 1 3 demonstrated a significant reduction of the transverse hernia defect in 12 patients. PFC was gained in six patients with BTA alone and with additional component separation (CS) in further six patients. In a subsequent study of 17 patients they demonstrated a significant reduction of lateral abdominal wall muscle thickness and the transverse hernia diameter, and a significant elongation of lateral abdominal wall muscles after BTA application [5]. PFC was possible in all patients, of which nine needed additional CS. Farooque etal. reported a significant increase in mean length of the lateral abdominal muscles post-BTA in a case series of 8 patients achieving PFC in all cases [6]. Also, Elstner etal. reported a significant increase in mean length of the lateral abdominal wall muscles in 27 patients, achieving PFC in all patients, with additional CS in six patients. Another study evaluated BTA administration in 56 consecutive patients undergoing VHR [7], of which 18 patients additionally underwent progressive pneumoperitoneum (PPP). They reported a significant increase in the lateral abdominal wall length. PFC was achieved in all patients, in 16% with additional CS. Another study from Elstner etal. investigated BTA and PPP administration in 16 patients with loss of domain undergoing VHR[8], achieving PFC in all patients without additional surgical dissection. Bueno-Lledó etal. performed a prospective observational study using BTA and PPP in 45 patients with loss of domain. They found a significant reduction of the VIH/VAC (volumes of the incisional hernia/volume of abdominal cavity) ratio by 14%. PFC was achieved in all patients with CS. There are seven clinical studies reporting the effect of BTA administration alone regarding avoidance of additional CS techniques [4–7, 9–11]. In total 150 patients were enrolled in these studies, achieving PFC with BTA alone in 78% (n = 117). Considering that BTA reaches its maximum paralyzing effect after 2weeks [1–3], timing of BTA application seems of somewhat importance. The available clinical studies follow different timing concepts ranging from the day of surgery up to 6weeks prior to surgery [4–12]. Regarding supportive imaging guidance during BTA administration, majority of available studies report the use of ultrasound [5, 6, 8–12]. Only on study used musculature electromyography [4]. The injection volume, units, and concentration of BTA administration in VHR shows heterogeneity amongst available clinical studies. Three studies used 500 units of BTA in total [4, 5, 12]. Six studies used a total dose of 300 units BTA [6–11]. Regarding concentration and administered volume of BTA authors reported BTA concentration of 100 units/ml in 5ml 0.9% saline solution [5], 10units/ ml in 50ml in 0.9% saline solution [12] or 2 units/ml in 150ml 0.9% saline solution [6–11]. Regarding injections sites, authors either perform three [6–11] or five [4, 5, 12] injections per side. Only one study investigated the effect of BTA administration on postoperative pain in a prospective cohort of 22 patients with BTA administration prior to VHR compared with a historic matched control group (n = 66). Patients with BTA administration had significantly less pain when compared to controls [10]. Since BTA is neurotoxic, potential complications or adverse events (AE) related to BTA application need to be addressed before injection. Only one study reported side effects of BTA administration such as abdominal wall distension, impaired coughing, and sneezing [11], while the majority of available clinical studies reported no BTA related adverse events or complications [5–12]. There are three reviews investigating the effect of BTA in incisional hernia repair including 15 studies with 259 patients [13], 6 studies with 133 patients [14] and 3 studies with 56 patients [15], respectively. The reviews reported PFC rates of 100% [13] and 84% [14] and decreases in the ventral hernia defect size [15]. Due to the small sample sizes and heterogeneity of included studies and the lack of standardization of BTA administration the level of evidence remained low (3a). Progressive pneumoperitoneum The concept of progressive pneumoperitoneum (PPP) was first described 1947 by Goni Moreno [16] and has been modified by other groups ever since. It consists of repeatedly inflating air into the abdominal cavity using sterile catheters over a few days, gaining an enlargement of the abdominal cavity to obtain hernia reduction and tension-free closure of large abdominal wall hernias. Since then a view case series and cohort studies with low number of patients have been published [13, 17–25]. All studies differ in terms of used gas for insufflation, patient population, timing, frequency, and volume of PPP insufflation. Investigated indications for PPP were giant incisional hernias [17–19, 23], large inguinal hernias [19] or patients with loss of domain [20–22, 24]. The timing of PPP insufflation showed differences among the available studies, starting at means between 5 and 15days prior to surgery. PPP insufflation was repeated every day in some studies [19, 22, 23], other studies had longer insufflation intervals of 2days or more [17, 18, 20, 21, 24]. The totally applied PPP volume ranged at means from 12 to 23l with insufflation volumes of 1000-4000ml per session. Adverse events (AE) were reported in most studies. Most frequent AE was shoulder pain in up to 24% [17, 18], limiting the amount of insufflated air. Bleeding complications [17, 18], catheter misplacement [17–19, 22], emphysema [19–21, 23], and catheter infection [22] have also been reported. However, PPP has been demonstrated to increase the volume of the abdominal cavity [17, 21, 24] by increasing the lateral abdominal wall muscle length [23]. As highlighted in a recent review [13], tension-free PFC after PPP in large ventral hernias was achieved in 84% of cases with a reported recurrence rate of 7.2%.
3534 Surgical Endoscopy (2019) 33:3511–3549 1 3 Tissue expanders The purpose of tissue expanders (TE) is to stretch skin or the underlying fascia allowing PFC in larger hernias. TE can be positioned subcutaneously in cases of skin loss, intermuscular between the external and internal oblique muscles in cases of large ventral hernias and intra-abdominal in cases of congenital abdominal wall defects [26]. There is no consensus regarding indications, optimal technique, and TE associated risks. Recent reviews with large heterogeneity regarding study design, study population, number of patients, indication, and position of TE [13, 26] demonstrated PFC rates of 93% using TE. References (in parentheses the level of evidence) 1. Nigam PK, Nigam A (2010) Botulinum toxin. Ind J Dermatol 55:8–14. 2. Truong D (Daniel D., Dressler D, Hallett M (2009) Manual of botulinum toxin therapy. Cambridge University Press 3. Hughes AJ (1994) Botulinum Toxin in Clinical Practice. Drugs 48:888–893. 4. Ibarra-Hurtado TR, Nuño-Guzmán CM, Echeagaray- Herrera JE, Robles-Vélez E, de Jesús González-Jaime J (2009) Use of Botulinum Toxin Type A Before Abdominal Wall Hernia Reconstruction. World J Surg 33:2553–2556. (4) 5. Ibarra-Hurtado TR, Nuno-Guzmán CM, Miranda-Diaz AG, Troyo-Sanromán R, Navarro-Ibarra R, Bravo- Cuellar L (2014) Effect of botulinum toxin type A in lateral abdominal wall muscles thickness and length of patients with midline incisional hernia secondary to open abdomen management. Hernia 18:647–652. (4) 6. Farooque F, Jacombs ASW, Roussos E, Read JW, Dardano AN, Edye M, Ibrahim N (2016) Preoperative abdominal muscle elongation with botulinum toxin A for complex incisional ventral hernia repair. ANZ J Surg 86:79–83. (4) 7. Rodriguez-Acevedo O, Elstner KE, Jacombs ASW, Read JW, Martins RT, Arduini F, Wehrhahm M, Craft C, Cosman PH, Dardano AN, Ibrahim N (2017) Preoperative Botulinum toxin A enabling defect closure and laparoscopic repair of complex ventral hernia. Surg Endosc 32:831–839. (4) 8. Elstner KE, Read JW, Rodriguez-Acevedo O, Ho-Shon K, Magnussen J, Ibrahim N (2017) Preoperative progressive pneumoperitoneum complementing chemical component relaxation in complex ventral hernia repair. Surg Endosc 31:1914–1922. (4) 9. Zielinski MD, Goussous N, Schiller HJ, Jenkins D, Ibarra-Hurtado TR, Nuño-Guzmán CM (2013) Chemical components separation with botulinum toxin A: A novel technique to improve primary fascial closure rates of the open abdomen. Hernia 17:101–107. (4) 10. Zendejas B, Khasawneh MA, Srvantstyan B, Jenkins DH, Schiller HJ, Zielinski MD (2013) Outcomes of Chemical Component Paralysis Using Botulinum Toxin for Incisional Hernia Repairs. World J Surg 37:2830–2837. (3b) 11. Elstner KE, Read JW, Rodriguez-Acevedo O, Cosman PH, Dardano AN, Jacombs ASW, Edye M, Zea A, Boesel T, Mikami DJ, Ibrahim N (2016) Preoperative chemical component relaxation using Botulinum toxin A: enabling laparoscopic repair of complex ventral hernia. Surg Endosc 31:1–8. (4) 12. Bueno-Lledó J, Torregrosa A, Ballester N, Carreño O, Carbonell F, Pastor PG, Pamies J, CortésV, Bonafé S, Iserte J (2017) Preoperative progressive pneumoperitoneum and botulinum toxin type A in patients with large incisional hernia. Hernia 21:233–243. (4) 13. Alam NN, Narang SK, Pathak S, Daniels IR, Smart NJ (2016) Methods of abdominal wall expansion for repair of incisional herniae: a systematic review. Hernia 20:191–199. (3a) 14. Soltanizadeh S, Helgstrand F, Jorgensen LN (2017) Botulinum Toxin A as an Adjunct to Abdominal Wall Reconstruction for Incisional Hernia. Plast Reconstr Surg Glob Open 5:e1358. (3a) 15. Weissler JM, Lanni MA, Tecce MG, Carney MJ, Shubinets V, Fischer JP (2017) Chemical component separation: a systematic review and meta-analysis of botulinum toxin for management of ventral hernia. J Plast Surg Hand Surg 1–9. (3a) 16. Moreno IG (1947) Chronic eventrations and large hernias; preoperative treatment by progressive pneumoperitomeum; original procedure. Surgery 22:945–53. (4) 17. Caldironi MW, Romano M, Bozza F, Pluchinotta AM, Pelizzo MR, Toniato A, Ranzato R (1990) Progressive pneumoperitoneum in the management of giant incisional hernias: A study of 41 patients. Br J Surg 77:306–307. (4) 18. Toniato A, Pagetta C, Bernante P, Piotto A, Pelizzo MR (2002) Incisional hernia treatment with progressive pneumoperitoneum and retromuscular prosthetic hernioplasty. Langenbeck Arch Surg 387:246–248. (4) 19. Mayagoitia JC, Suárez D, Arenas JC, Díaz de León V (2006) Preoperative progressive pneumoperitoneum in patients with abdominal-wall hernias. Hernia 10:213– 217. (4) 20. Sabbagh C, Dumont F, Robert B, Badaoui R, Verhaeghe P, Regimbeau JM (2011) Peritoneal volume is predictive of tension-free fascia closure of large incisional hernias with loss of domain: A prospective study. Hernia 15:559–565. (4) 21. Sabbagh C, Dumont F, Fuks D, Yzet T, Verhaeghe P, Regimbeau JM (2012) Progressive preoperative pneu-
3535Surgical Endoscopy (2019) 33:3511–3549 1 3 moperitoneum preparation (the Goni Moreno protocol) prior to large incisional hernia surgery: Volumetric, respiratory and clinical impacts. A prospective study. Hernia 16:33–40. (4) 22. Alyami M, Passot G, Voiglio E, Lundberg PW, Valette PJ, Muller A, Caillot JL (2015) Feasibility of Catheter Placement under Ultrasound Guidance for Progressive Preoperative Pneumoperitoneum for Large Incisional Hernia with Loss of Domain. World J Surg 39:2878– 2884. (4) 23. Dumont F, Fuks D, Verhaeghe P, Brehant O, Sabbagh C, Riboulot M, Yzet T, Regimbeau JM (2009) Progressive pneumoperitoneum increases the length of abdominal muscles. Hernia 13:183–187. (4) 24. Renard Y, Lardière-Deguelte S, de Mestier L, Appere F, Colosio A, Kianmanesh R, Palot JP (2016) Management of large incisional hernias with loss of domain: A prospective series of patients prepared by progressive preoperative pneumoperitoneum. Surgery 160:426– 435. (4) 25. Cuminal L, Rousset P, Passot G, Caillot JL, Valette PJ, Muller A (2017) Image-guided preoperative progressive pneumoperitoneum for large incisional hernia repair. Diagn Interv Imaging 98:507–509. (4) 26. Wooten KE, Ozturk CN, Ozturk C, Laub P, Aronoff N, Gurunluoglu R (2017) Role of tissue expansion in abdominal wall reconstruction: A systematic evidencebased review. J Plast Reconstr Aesthet Surg 70:741– 751. (3a) Chapter6. Robotic ventral/incisional hernia repair Jeremy AWarren, Alfredo M Carbonell, Davide Lomanto, R. Fortelny, Hrishekesh P Salgaonkar, Kevin Bain, Vadim Meytes, George Ferzli Key question 1. What are the differences between Robotic Intraperitoneal Onlay of Mesh (rIPOM) and standard IPOM? The following search terms were used to identify the relevant literature on robotic ventral hernia repair in July 2018. Abstracts of resulted articles were reviewed for their relevance to robotic ventral hernia repair. “Robotic ventral hernia” search identified 60 articles, 26 of which were relevant after review of the abstract. “Robotic incisional hernia” resulted in a total of 59 articles, with 3 additional relevant studies identified. Six additional articles were found using “robotic TAR,” 2 of which were relevant and included. Search for “robotic transversus abdominis release” revealed no additional articles, nor did search for “robotic component separation.” Finally, “robotic abdominal wall reconstruction” identified 1 additional relevant publication included in this review. Introduction Though first described in 2003 [1], there has been relatively little interest in robotic surgery for hernia repair until the last several years. Of 32 relevant articles in the published literature, 19 have been published in 2017–2018 alone. Technological interest, surgeon ergonomics, improved 3-dimensional visualization, and articulating instruments that greatly facilitate intracorporeal suturing and dissection are among the leading reasons for the exponential growth in robotic hernia repair. Disadvantages of the robotic platform are the loss of tactile feedback, relying entirely on visual cues, and intimate knowledge of tissue handling [2]. Additionally, cost can be significant barrier to utilization and allocation of health care resources [2–4]. Durability of various robotic repair techniques remains an unanswered clinical outcome. No studies to date have significantly long enough follow-up to determine hernia recurrence rates or other potential long-term complications. Several techniques have been described using the robot, including standard intraperitoneal onlay of mesh (rIPOM) similar to that of standard laparoscopic ventral hernia repair with intraperitoneal mesh (LVHR), transabdominal preperitoneal repair (rTAPP), retromuscular repair with or without transversus abdominis release (rRVHR or rTAR), and most recently a retromuscular repair using an extended totally extraperitoneal (eTEP) approach.
3542 Surgical Endoscopy (2019) 33:3511–3549 1 3 38. Abdalla RZ, Garcia RB, Costa R, Luca CR, Abdalla BM. (2012) Procedimento de Rives/Stoppa modificado robô-assistido para correção de hérnias ventrais da linha média. Arq Bras Cir Dig 25(2):129–132 (4) 39. Carbonell AM, Warren JA, Prabhu AS, Ballecer CD, Janczyk RJ, Herrera J, Huang LC, Phillips S, Rosen MJ, Poulose BK (2018) Reducing Length of Stay Using a Robotic-assisted Approach for Retromuscular Ventral Hernia Repair: A Comparative Analysis From the Americas Hernia Society Quality Collaborative. Ann Surg 267:210–217 (2c) 40. Bittner JG, Alrefai S, Vy M, Mabe M, Del Prado PAR, Clingempeel NL (2017) Comparative analysis of open and robotic transversus abdominis release for ventral hernia repair. Surg Endosc 16:179–188 (3) 41. Patel SV, Yu D, Elsolh B, Goldacre BM, Nash GM (2018) Assessment of conflicts of interest in robotic surgical studies: validating author’s declarations with the open payments database. Ann Surg 268:86–92 (2B) 42. Gonzalez AM, Romero RJ, Seetharamaiah R, Gallas M, Lamoureux J, Rabaza JR (2015) Laparoscopic ventral hernia repair with primary closure versus no primary closure of the defect: potential benefits of the robotic technology. Int J Med Robot 11:120–125 (3) 43. Sugiyama G, Chivukula S, Chung PJ, Alfonso A (2015) Robot-Assisted Transabdominal Preperitoneal Ventral Hernia Repair. JSLS. 19(4):1–3 (4) 44. Martin-del-Campo LA, Weltz AS, Belyansky I, Novitsky YW3. (2017) Comparative analysis of perioperative outcomes of robotic versus open transversus abdominis release. Surg Endosc 204:709–716 (3) 45. Halka JT, Vasyluk A, DeMare AM, Janczyk RJ, Iacco AA (2018) Robotic and hybrid robotic transversus abdominis release may be performed with low length of stay and wound morbidity. Am J Surg 215:462–465 (3) 46. Belyansky I, Reza Zahiri H, Sanford Z, Weltz AS, Park A (2018) Early operative outcomes of endoscopic (eTEP access) robotic-assisted retromuscular abdominal wall hernia repair. Hernia 22(5):837–847. https ://doi. org/10.1007/s1002 9-018-1795-z. Epub 2018 Jul 4 (4) Chapter7. Key question: treatment oflateral primary orincisional hernias: Which technique should be preferred? W. Reinpold, B. Sutedja Search terms Lateral abdominal wall hernia, lateral eventration, iliac hernia, subcostal hernia, flank hernia repair, flank hernia repair with mesh, lumbar hernia repair, lumbar hernia repair with mesh, unusual hernias of the abdominal wall, spigelian hernia, spigelian hernia repair, lateral incisional hernia, traumatic lumbar hernia, Grynfelt OR Grynfelt’s hernia, Petit OR Petit’s hernia; the above AND laparoscopy, lumbar hernia AND lumbar muscles AND paralysis, lumbar hernia AND lumbar muscles AND paralysis AND bulge, lumbar hernia AND lumbar muscles AND paralysis AND nephrectomy, lumbar hernia AND nephrectomy. Searching machines PubMed, Embase, and Medline (2000–2018) were searched. For the study of the old guidelines read the original publication in “Surg Endosc (2014) 28: page 399-401”. New Statements: Level 2B Laparoscopic repair of lateral abdominal wall hernias (with mesh) is associated with less surgical site infecons, less surgical site occurences, more intraoperave visceral lesions and an equal rate of recurrences and chronic pain compared to open mesh repair. Level 4 Laparoscopic repair of large lateral abdominal wall hernias (defect diameter > 15cm) is burdened with higher recurrence rates. New Recommendaons: Grade C Open and laparoscopic mesh techniques can be recommended for the treatment of primary and incisional hernias of the lateral abdominal wall Grade D Large lateral abdominal wall hernias (defect diameter > 15cm) should be treated by an open approach
3543Surgical Endoscopy (2019) 33:3511–3549 1 3 Introduction Lateral abdominal wall hernias comprise primary and secondary defects of the lumbar, subcostal, flank, and iliac region (EHS classification). Compared to midline hernias (hernias of the rectus compartment) primary and incisional lateral abdominal wall hernias are rare. Consequently, the evidence guiding the surgical treatment of lateral abdominal wall hernias is scant. The lumbar region is divided into the superior and inferior lumbar space. Primary lumbar hernias of the superior space are denominated Grynfeltt hernia and those of the lower space Petit hernia. The boundaries of the inferior lumbar hernia are the latissimus dorsi muscle posteriorly, the external oblique muscle anteriorly, and the iliac crest inferiorly. The boundaries of the superior lumbar hernia are the 12th rib superiorly, the internal oblique muscle anteriorly, and the erector spinae muscle posteriorly. Lateral hernias often are located in more than one region of the lateral compartment. The first IEHS guidelines included 12 papers, 11 case series with more than five patients and one small RCT which included 16 patients and compared open with laparoscopic repair. In total 123 patients were evaluated. The new literature search (2012–2018) revealed 10 case series (8 retrospective) which included 439 patients on open operations of lateral abdominal wall hernias [1–10] and 4 retrospective case series with 188 patients on laparoscopic repairs ([11–14]; Table1 + 2). The level of evidence of all trials was 4 and there were no reports on suture repair. The infection rate after open repair varied between 0 and 25% while no infections were reported after laparoscopic operations. The rate of intraoperative visceral damage was 0 to 4% in open and 0 to 15% in laparoscopic repair, respectively. One retrospective case series of 73 patients with laparoscopic repair of lateral incisional hernias with a medium follow-up of 62months reported a total recurrence rate of 8% and 25% in the subgroup of subcostal incisional hernias [11]. The authors concluded that a defect size of > 15cm was a risk factor of recurrence. Only four case series reported on chronic pain [5, 7, 8, 10]. However, according to a systematic review [15] chronic pain rates after open and laparoscopic lateral abdominal wall hernia repair seem to be comparable. Table1: Publications on open lateral abdominal wall hernia repair 2012 to 2018 [1–10] Author Type of trial Type of hernia Type of repair Number (n) Complications (%) Recurrence (%) Chronic pain (%) Mean Follow-up months Miscell. Moreno-Egea (2015) Retrospective case series Complex lateral hernias Double prosthetic repair 53 25 0 NR NR Mean defect diameter 18cm Phillips (2012) Retrospective case series Flank hernias Retromuscular 16 25 (Infections n = 3, Ureter lesion n = 1) 0 NR 17 9 incarcerated hernias Veyrie (2013) Retrospective case series Lateral incisional hernias Retromuscular with poyester mesh 61 Subcostal 14 Flank 12 Iliac 35 18 (n = 4 reoperations) 6.6 NR 47 Mean defect size 56 cm2 Luc (2014) Prospective comparative trial Lateral incisional hernias Open retromuscular or IPOM 112 61 after renal transplantation 24 (24.5 after renal transplant. versus 23.5) 10 versus 10 NR Incisional hernias after renal Tx or no renal Tx Peres (2014) Retrospective case series Subcos-tal incisional hernias open 25 33 (n = 8) 4 4 Blair (2015) Prospective case series Lateral incisional hernias Sublay/underlay with acell dermal matrix 20 (lumbar 10, suprapub. 7, iliac 3) 15 0 NR 24 Mean defect size 270 cm2 Pezeshk (2015) Retrospective case series Lateral incisional hernias Sublay/underlay with acell dermal matrix 29 31 3 10 21
3544 Surgical Endoscopy (2019) 33:3511–3549 1 3 Author Type of trial Type of hernia Type of repair Number (n) Complications (%) Recurrence (%) Chronic pain (%) Mean Follow-up months Miscell. Purnell (2016) Retrospective case series Flank hernias Open IPOM = 19 Open Interpar- Ietal = 12 31 0 infections 3 3 27 Patel (2016) Retrospective case series Lateral Incisional hernias Open retromus 50%, preperit 41%, IPOM 7% Onlay 2% 61 Subcostal 14 Flank 33 iliac 11 Lumbar 3 SSO 49% SSI 13% 12 NR 15 Mean defect size 79 cm2 Renard (2017) Retrospective case series Lumbar Incisional hernia Large Retromus Mesh with large overlap 31 32 7 10 Post Nephrectomy N = 20 Total articles (N = 10) 439 Table2: Publications on laparoscopic lateral abdominal wall hernia repair 2012 to 2018 [11–14] Author Type of trial Type of hernia Type of repair Number (n) Complications (%) Recurrence (%) Chronic pain (%) Mean Follow-up months Miscell. Moreno-Egea (2012) Retrospective case series Lateral Incisional Hernias (subcostal, Iliac, lumbar) Laparosopic IPOM 73 8 subcostal 25 62 Predictor for recurrence defect diameter >15cm Lal (2014) Retrospective case series Lateral Incisional hernias Laparo- Sopic IPOM 25 lumbar 5, suprapub 7, iliac 10, subsostal 3 Intraoperative lesions 15%, total 25% 4 (n = 1, iliac) Farrarese (2016) Retrospective case series Lateral Incisional Hernias (subcostal, flank, Iliac, lumbar) Laparosopic IPOM 76 Novitsky (2017) Retrospective case series Traumatic Flank hernias Laparosopic IPOM 14 0 0 35 N = 11 chronic incarcerated Total articles N = 4 188
3545Surgical Endoscopy (2019) 33:3511–3549 1 3 Spieghelian hernias New Statements: Level 2B Laparoendoscopic repair of Spieghelian hernias is superior to open repair because of reduced morbidity rates and length of hospital stay Level 4 Comparable results are achieved with laparoscopic IPOM and laparoendoscopic preperitoneal techniques New Recommendaons: Grade B For the treatment of Spieghelian hernias laparoendoscopic mesh repair should be preferred because of lower postoperave morbidity and reduced length of hospital stay. The Spiegelian hernia first escribed anatomically by Adriaan van den Spieghel (1578–1625) is located at the level of the semicircular line where the fascias of the oblique and transversus muscles begin to split into separate layers of the abdominal musculature. Spiegelian hernias (SH) account for 1% to 2% of abdominal wall hernias. Since the advent of minimally invasive surgery laparoscopic methods have become increasingly popular with various techniques being described in the literature. Since 2012 thirtytwo case series with 5 or more patients were included in this review. No randomized-controlled trials on the treatment of SH were identified. One systematic review was published in 2016 [4] which included 237 SHs that were repaired by various techniques. Intraperitoneal onlay mesh technique was the most popular repair method with minimal complications and recurrences reported in all techniques. Conclusions There are a number of laparoscopic techniques available to the surgeon repairing a SH. Overall, laparoscopic repair of the SH is a safe and acceptable method. References (in parentheses the level of evidence) 1. Moreno-Egea A (2015) Double Prosthetic Repair for Complex Incisional Hernia Repair: Long-term Results and Evolution of the Technique. Am Surg 81(11):1138–1143. (4) 2. Phillips MS, Krpata DM, Blatnik JA, Rosen MJ. (2012) Retromuscular preperitoneal repair of flank hernias J Gastrointest Surg. 16(8):1548–1553. (4) 3. Veyrie N, Poghosyan T, Corigliano N, Canard G, Servajean S, Bouillot JL. (2013) Lateral incisional hernia repair by the retromuscular approach with polyester standard mesh: topographic considerations and long-term follow-up of 61 consecutive patients. World J Surg 37(3):538–544. (4) 4. Luc G, David A, Couzi L, Midy D, Collet D, Dubuisson V. (2014) Lateral incisional hernia after renal transplantation: a comparative study. World J Surg 38(11):2791–2796. (4) 5. Peres MA, Aguiar HR, Andreollo NA (2014) Surgical treatment of subcostal incisional hernia with polypropylene mesh-analysis of late results. [Article in English, Portuguese] Rev Col Bras Cir. 41(2):82–86. (4) 6. Blair LJ, Cox TC, Huntington CR, Ross SW, Kneisl JS, Augenstein VA, Heniford BT. (2015) Bone Anchor Fixation in Abdominal Wall Reconstruction: A Useful Adjunct in Suprapubic and Para-iliac Hernia Repair. Am Surg 81(7):693–697. (4) 7. Pezeshk RA, Pulikkottil BJ, Bailey SH, Schaffer NE, Reece EM, Thornton NJ, Gupta AR, Hoxworth RE. (2015) An Evidence-Based Model for the Successful Treatment of Flank and Lateral Abdominal Wall Hernias. Plast Reconstr Surg 36(2):377–385. (4) 8. Purnell CA, Park E, Turin SY, Dumanian GA. (2016) Postoperative Flank Defects, Hernias, and Bulges: A Reliable Method for Repair. Plast Reconstr Surg 137(3):994–1001 (4) 9. Patel P, Warren JA, Mansour R, Cobb WS 4th (2016) A Large Single-Center Experience of Open Lateral Abdominal Wall Hernia Repairs. Am Surg 82(7):608– 612. (4) 10. Renard Y, de Mestier L, Cagniet A, Demichel N, Marchand C, Meffert JL, Kianmanesh R, Palot JP (2017) Open retromuscular large mesh reconstruction
3546 Surgical Endoscopy (2019) 33:3511–3549 1 3 of lumbar incisional hernias including the atrophic muscular area. Hernia 21(3):341–349. (4) 11. Moreno-Egea A, Carrillo-Alcaraz A. (2012) Management of non-midline incisional hernia by the laparoscopic approach: results of a long-term follow-up prospective study. Surg Endosc 26(4):1069–78. (4) 12. Lal R, Sharma D, Hazrah P, Kumar P, Borgharia S, Agarwal A. (2014) Laparoscopic management of nonmidline ventral hernia. J Laparoendosc Adv Surg Tech A 24(7):445–450. (4) 13. Farrarese A, Enrico S, Solej M, Surace A, Nardi MJ, Millo P, Allieta R, Feleppa C, D’Ambra L, Berti S, Gelarda E, Borghi F, Pozzo G, Marino B, Marchigiano E, Cumbo P, Bellomo MP, Filippa C, Depaolis P, Nano M, Martino V (2016) Laparoscopic management of non-midline incisional hernia: A multicentric study. Int J Surg 33 Suppl 1:S108–S113. (4) 14. Novitsky YW (2018) Laparoscopic repair of traumatic flank hernias. Hernia 22(2):363–369. https ://doi. org/10.1007/s1002 9-017-1707-7. Epub 2017 Dec 15. (4) 15. Zhou DJ, Carlson MA (2018) Incidence, etiology, management, and outcomes of flank hernia: review of published data. Hernia 22(2):353–361. https ://doi. org/10.1007/s1002 9-018-1740-1. Epub 2018 Jan 27 (2B) 16. Barnes TG, McWhinnie DL (2016) Laparoscopic Spigelian Hernia Repair: A Systematic Review. Surg Laparosc Endosc Percutan Tech. 26(4):265-70. (2B) Chapter8. Education andtraining inlaparoscopic ventral hernia repair D. Lomanto, Hrishikesh P. Salgaonkar Search terms Hernia/abdominal surgery/Ventral hernia, Umbilical, Incisional hernia, learning curve, Education/Laparoscopy, General surgery/education, Surgical procedures/operative education, Surgical procedures/operative psychology, Teaching/methods, Internship/residency, Competency-based education, Computer assisted instruction. Searching machines PubMed, Embase, Medline and Cochrane Library (2003–2017) were searched for studies for potential inclusion. For the study of the original guidelines read the publication in “Surg Endosc (2014) 28:401–403”. New publications In addition to studies included in the published guidelines, total of 5 new studies were found and included in the update. One Level 1 study, one level 2 study, and three Level 3 studies are supplementing the knowledge of Education and training in laparoscopic ventral or incisional hernia repair. New Statement: identical to previous except statement below: New Statement: idencal to previous except statement below: Level 3 Residents/trainees show moderate skills decay in difficult tasks, technical surgical skills and knowledge of procedure steps in LVHR and hence dedicated connuous simulaon-based assessment and training may help in maintaining skills and performance. Level 3 Residents and young surgeons benefit from a comprehensive, dynamic and flexible educational program employing mulple medium to enhance surgical skills and patent care in hernia. Recommendaons: No new recommendaons. Comments: We identified one new study defining learning curve in Laparoscopic ventral hernia repair (LVHR) [1]. In this study, results of LVHR performed by three experienced surgeons in a single center were retrospectively analyzed. They found that after 20 cases the overall performance plateaued, most notably in intra and postoperative complications. The operative time stabilized after 12 cases. The SAGES Hernia task force conducted a study using interviews and online surveys amongst the task force
3547Surgical Endoscopy (2019) 33:3511–3549 1 3 members, chief residents, fellows, and surgical residents [2]. They commented that the traditional “see one, do one, teach one” method and prevalent methods of training is inadequate for learning hernia repair. In addition to supervised surgery, most trainees prefer new learning methods such as simulation, web-based training, hands on laboratory, and master videos. The consensus was that educational programs should be comprehensive, dynamic, and flexible to employ various media to address the deficits in hernia surgery training and patient care. D’Angelo etal., in their multi-center study, tried to evaluate effect of time away from clinical work on clinical skills during dedicated research rotations in surgical residency [3]. Simulation-based training in LVHR, along with others procedures was used to assess improvements in perception of skill decay. They concluded that most residents during their research postings expect moderate skills decay in LVHR, and hence suggested to incorporate simulation-based training in the curriculum during dedicated research time or research fellowships to maintain trainees’ surgical skills. Sonnadara etal. similarly suggested that competency-based training rather than time spent in training should be used to assess a surgeon’s skill level [4]. A Cochrane systemic review suggested that virtual reality training when compared to no training or box-trainer training reduces operating time and improves operative performance of surgical trainees with limited laparoscopic experience [5]. In today’s day and age, it is necessary for residency and fellowship training programs to incorporate simulationbased training and virtual reality training in the curriculum along with surgical training under supervision. Specific simulation training for ventral and incisional hernia repair will benefit the trainee to gain hernia specific skills and also prevent skill decay. References (in parentheses graduation of evidence) 1. Al-Harazi A, Goel R, Tan CT, Cheah WK, Lomanto D (2014) Laparoscopic ventral hernia repair: defining the learning curve. Surg Laparosc Endosc Percutan Tech 24(6):475–477. PMID: 24743667 (3) 2. Zahiri HR, Park AE, Pugh CM, Vassiliou M, Voeller G (2015) “See one, do one, teach one”: inadequacies of current methods to train surgeons in hernia repair. Surg Endosc 29(10):2867–2872. Epub 2015 Jul 22. PMID: 26198155. (3) 3. D’Angelo A-LD, Ray RD, Jenewein CG, Jones GF, Pugh CM (2015) Residents’ Perception of Skill Decay during Dedicated Research Time. J Surg Res 199(1):23–31. Epub 2015 Jun 23. PMID: 26197949 (2b) 4. Sonnadara RR, Mui C, McQueen S, Mironova P, Nousiainen M, Safir O, Kraemer W, Ferguson P, Alman B, Reznick R (2014) Reflections on competency-based education and training for surgical residents. J Surg Educ 71(1):151–158. Epub 2013 Sep 14. PMID: 24411437. (3) 5. Nagendran M, Gurusamy KS, Aggarwal R, Loizidou M, Davidson BR (2013) Virtual reality training for surgical trainees in laparoscopic surgery. Cochrane Database of Systematic Reviews Issue 8. Art. No.: CD006575. https ://doi.org/10.1002/14651 858.cd006 575.pub3. (1a) Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Affiliations R.Bittner1,2· K.Bain3· V.K.Bansal4· F.Berrevoet5· J.Bingener‑Casey6· D.Chen7· J.Chen8· P.Chowbey9· U.A.Dietz10· A.deBeaux11· G.Ferzli3· R.Fortelny12· H.Hoffmann13· M.Iskander14· Z.Ji15· L.N.Jorgensen16 · R.Khullar9· P.Kirchhoff13· F.Köckerling17· J.Kukleta18· K.LeBlanc19· J.Li20· D.Lomanto21· F.Mayer22· V.Meytes3· M.Misra23· S.Morales‑Conde24· H.Niebuhr25· D.Radvinsky26· B.Ramshaw27· D.Ranev28· W.Reinpold29· A.Sharma9· R.Schrittwieser30· B.Stechemesser31· B.Sutedja32· J.Tang33· J.Warren34· D.Weyhe35· A.Wiegering36· G.Woeste37· Q.Yao38 * R. Bittner [email protected] K. Bain [email protected] V. K. Bansal dr[email protected] F. Berrevoet [email protected] J. Bingener-Casey [email protected] D. Chen [email protected]
3548 Surgical Endoscopy (2019) 33:3511–3549 1 3 J. Chen [email protected] P. Chowbey pradeepcho[email protected] U. A. Dietz [email protected] A. de Beaux [email protected] G. Ferzli [email protected] R. Fortelny dr.forteln[email protected] H. Hoffmann [email protected] M. Iskander Iskandar[email protected] Z. Ji [email protected]; [email protected] L. N. Jorgensen LarsNJorg[email protected] R. Khullar [email protected] P. Kirchhoff [email protected] F. Köckerling [email protected] J. Kukleta [email protected]h; jfk[email protected] K. LeBlanc [email protected] J. Li [email protected] D. Lomanto da[email protected]; [email protected] F. Mayer f.mayer.chir[email protected] V. Meytes v[email protected] M. Misra inf[email protected]g S. Morales-Conde [email protected] H. Niebuhr [email protected] D. Radvinsky [email protected] B. Ramshaw bruceramsha[email protected] D. Ranev [email protected] W. Reinpold [email protected] A. Sharma Anil.Shar[email protected] R. Schrittwieser schrr[email protected] B. Stechemesser [email protected] B. Sutedja dr[email protected] J. Tang [email protected] J. Warren JWar[email protected]g D. Weyhe dirk.w[email protected] A. Wiegering [email protected] G. Woeste Woes[email protected] Q. Yao steven[email protected] 1 I.M. Sechenov First Moscow State Medical University oftheMinistry ofHealth oftheRussian Federation (Sechenov University), Trubetskaya str., 8, b. 2, Moscow, Russia119992 2 Emeritus Director, Marienhospital Stuttgart, Supperstr. 19, 70565Stuttgart, Germany 3 Department ofSurgery, New York University, NewYork, USA 4 Department ofSurgical Disciplines, All India Institute ofMedical Sciences, Room No. 5026A, 5th Floor, Teaching Block, Ansari Nagar, NewDelhi110029, India 5 Universitair Ziekenhuis Gent, C. Heymanslaan 10, 9000Ghent, Belgium 6 Division ofBreast, Endocrine, Metabolic & Gastrointestinal Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN55905, USA 7 Lichtenstein Amid Hernia Clinic atUCLA, Section ofMinimally Invasive Surgery, UCLA Division ofGeneral Surgery, LosAngeles, USA 8 Department ofHernia andAbdominal Surgery, Beijing Chao-Yang Hospital, Capital Medical University, Fengtai, China 9 Max Super Speciality Hospital, 2 Press Enclave Road, Saket, NewDelhi110017, India 10 Klinik für Viszeral-, Gefäss- und Thoraxchirurgie, Kantonsspital Olten, Baslerstrasse 150, 4600Olten, Switzerland 11 Royal Infirmary ofEdinburgh, EdinburghEH164SA, UK 12 Allgemein-, Viszeral- und Tumorchirurgie, Wilhelminenspital, 1160Vienna, Austria 13 ZweiChirurgen GmbH, Zentrum für Hernienchirurgie und Proktologie, St. Johanns-Vorstadt 44, 4056Basel, Switzerland
3549Surgical Endoscopy (2019) 33:3511–3549 1 3 14 Department ofSurgery, Mount Sinai Hospital, 1010 5th Avenue, NewYork, NY10028, USA 15 Department ofSurgery, Southeast University School ofMedicine, Main Add. 87 Ding Jia Qiao, Nanjing210009, Jiangsu, China 16 Digestive Disease Center, Bispebjerg Hospital, University ofCopenhagen, 2400CopenhagenNV, Denmark 17 Visceral- und Gefäßchirurgie, Zentrum für Minimal Invasive Chirurgie, Vivantes Klinikum Spandau, Neue Bergstraße 6, 13585Berlin, Germany 18 Klinik Im Park, Grossmuensterplatz 9, 8001Zurich, Switzerland 19 Our Lady oftheLake Physician Group, 7777 Hennessy Blvd., Suite 612, BatonRouge, LA70808, USA 20 Department ofGeneral Surgery, Ruijin Hospital, Shanghai Jiao Tong University School ofMedicine, Shanghai200025, China 21 Department ofSurgery, YLL School ofMedicine, National University Hospital, Level 2, Kent Ridge Wing 2, 5 Lower Kent Ridge Road, Singapore119074, Singapore 22 Paracelsus Medizinische Universität Salzburg (PMU), Universitätsklinik für Chirurgie, Salzburg, Austria 23 Mahatma Gandhi University ofMedical Sciences & Technology, RIICO Institutional Area, Tonk Road, Sitapura, Jaipur, Rajasthan302022, India 24 Centro de Cirugía Mayor Ambulatoria Ave María, Avda. de la Palmera, 53, 41013Seville, Spain 25 HANSECHIRURGIE, Niebuhr Marleschki & Partner, Alte Holstenstr. 16, 21031Hamburg, Germany 26 SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY11203, USA 27 Department ofSurgery, University Surgeons Associates, 1930 Alcoa Highway, Bldg A, Ste 285, Knoxville, TN37920, USA 28 Lenox Hill Hospital-Northwell Health, NewYork, USA 29 Abteilung für Chirurgie, Wilhelmsburger Krankenhaus, Groß-Sand 3, 21107Hamburg, Germany 30 Abteilung für Chirurgie, LKH Hochsteiermark, Standort Bruck an der Mur Tragösser Str. 1, 8600BruckanderMur, Austria 31 Hernienzentrum Köln, Zeppelinstraße 1, 50667Cologne, Germany 32 Gading Pluit Hospital, Jl. Boulevard Timur Raya Kelapa Gading, Jakarta14250, Indonesia 33 Department ofGeneral Surgery, Huadong Hospital, Fudan University, Shanghai, China 34 Minimally Invasive Surgery, Greenville Health System, Department ofSurgery, University ofSouth Carolina School ofMedicine, Greenville, USA 35 Pius-Hospital Oldenburg, Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinik für Viszeralchirurgie, Georgstraße 12, 26121Oldenburg, Germany 36 Department ofGeneral, Visceral, Vascular andPaediatric Surgery, University Hospital ofWuerzburg, Oberduerrbacher Strasse 6, 97080Würzburg, Germany 37 AGAPLESION ELISABETHENSTIFT gemeinnützige GmbH, Akademisches Lehrkrankenhaus, Landgraf-Georg-Strasse 100, 64287Darmstadt, Germany 38 Department ofHernia andAbdominal Surgery, Huashan Hospital, Fudan University, Shanghai, China