Small umbilical hernias and mesh repair: a big challenge René H.Fortelny Allgemein-, Viszeral- und Tumorchirurgie Wilhelminenspital, Wien, Österreich
Speakers Bureau: Bard Baxter B.Braun Johnson&Johnson Medtronic Disclosures No conflict of interest regarding this presentation
Questions to be answered: Definition of small umbilical hernia: 2 cm or 3cm Repair: Suture vs Mesh Mesh-position: Onlay vs Sublay vs intraperitoneal Complications: Infection, Pain, Shrinkage, Recurrence Risk-factors: Gender, BMI...
Complications of mesh devices for intraperitoneal umbilical hernia repair: a word of caution. Muysoms FE, Bontinck J, Pletinckx P. Hernia. 2011 Aug;15(4):463-8.
Retrospective analysis of umbilical, epigastric, and small incisional hernia repair using the Ventralex hernia patch. Tollens T, Den Hondt M, Devroe K, Terry C, Speybroeck S, Aelvoet C, Vanrykel JP. Hernia. 2011 Oct;15(5):531-40. MATERIALS AND METHODS: 176 patients abdominal wall hernia repair using Ventralex patch RESULTS: 135 patients mean follow-up 49 months Hernia recurrences 8.9% (12) Postoperative (1-month) complications: seroma 4%, superficial surgical site infections 3%, abscess 1.5% Long-term complications: infection 1.5%, subobstruction 1.5% Risk factor for hernia recurrence: female gender (unadjusted odds ratio 0.19, 95% CI 0.05-0.72, P = 0.02 CONCLUSIONS:...attention should be paid to follow the correct implantation technique, proper deployment technology should be used, and a lightweight version would be welcome.
A multicenter prospective study of patients undergoing open ventral hernia repair with intraperitoneal positioning using the monofilament polyester composite ventral patch: interim results of the PANACEA study. Berrevoet F et al Med Devices (Auckl). 2017 May 12;10:81-88. Single-arm, multicenter prospective study 126 patients open ventral hernia repair with the PCO-VP umbilical (87.3%) or epigastric hernia (12.7%) Mean hernia diameter 1.8 (± 0.8) cm. Cumulative hernia recurrence rate at 1 year 2.8% (3/106). Numeric Rating Scale (NRS) pain scores: from 2.1 ± 2.0 at preoperative baseline to 0.5 ± 0.7 at 1 month postop.(p < 0.001) low pain level was maintained at 12 months postop.(p < 0.001) CONCLUSION: recurrence rate is low, but, as laparoscopic evaluation shows a need for patch repositioning in some cases, an accurate surgical technique remains of utmost importance.
Long-term follow-up results after open small umbilical hernia repairs. Malý O, Sotona O. Rozhl Chir. 2014 Apr;93(4):208-11. Czech. PubMed PMID: 24881477. retrospective study primary elective umbilical hernia and the abdominal wall defect up to 3 cm f.u.at least 3 years 127 patients no mesh Recurrence rate: 13.4% CONCLUSION:...it is recommended to use the mesh more widely during primary surgery, especially in obese patients with BMI over 30 and the wall defect size exceeding 3 cm. The question remains whether to use the mesh in all overweight patients and with wall defect smaller than 3 cm.
Suture vs Mesh - Evidence Stabilini C et al. Mesh versus direct suture for the repair of umbilical and epigastric hernias. Ten-year experience. Ann Ital Chir. 2009 May-Jun;80(3):183-7. 98 patients umbilical (69 cases) or epigastric 29 cases hernias. 34 PS vs 64 PP mesh mean aponeurotic defect diameter 2.5 cm Complications mesh group: 3 seromas, 1 hematoma, 1mesh infection Recurrence rate: Mesh 3.1% vs Suture 14.7% (p 0.0475) f.u.5 years
Lower reoperation rate for recurrence after mesh versus sutured elective repair in small umbilical and epigastric hernias. A nationwide register study. Christoffersen MW, Helgstrand F, Rosenberg J, Kehlet H, Bisgaard T. World J Surg. 2013 Nov;37(11):2548-52. prospective cohort study based on intraoperative registrations from the Danish Ventral Hernia Database (DVHD) elective open mesh and sutured repair for small ( 2 cm) umbilical and epigastric hernias. In total, 4,786 enrolled Follow up 21 months ( 0-47) The cumulated reoperation rates for recurrence: 2.2 % for mesh reinforcement and 5.6 % for sutured repair (P = 0.001)
Suture vs Mesh - Evidence Long-term recurrence and chronic pain after repair for small umbilical or epigastric hernias: a regional cohort study. Christoffersen MW et al. T. Am J Surg. 2015 Apr;209(4):725-32. 1313 patients: 928 suture 385 mesh f.u. median 43 months Total cumulated recurrence rate: 10% for mesh vs 21% sutured repair (P =.001) Incidence of chronic pain: 6% after mesh vs 5% after sutured repair (P =.711)
Subgroup analyses: different suture materials: Nonabsorbable vs slowly absorbable vs fast absorbable suture no significant differences in cumulated recurrence rates (21% vs 18% vs 25%) mesh positions: inlay/plug vs sublay vs onlay vs intraperitoneal, (9% vs 10% vs 5% vs 8%; P 0.952) no significant differences hernia defect size in relation to recurrence: cumulated recurrence rates (mesh repair versus sutured repair) in hernia defects: > 0 to 1 cm: 12% vs 21% (P 0.033) and > 1 to 2 cm: 8% vs 17% (P 0.036) CONCLUSIONS: Mesh repair halved long-term risk of recurrence after repair for small ventral hernias without increased risk of chronic pain.
Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial. Kaufmann R, Halm JA, Eker HH, Klitsie PJ, Nieuwenhuizen J, van Geldere D, Simons MP, van der Harst E, van 't Riet M, van der Holt B, Kleinrensink GJ, Jeekel J, Lange JF. Lancet. 2018 Feb 16. Methods RCT 12 hospitals (9 Netherlands, 2 Germany, 1in Italy). 18 years with a primary umbilical hernia of diameter 1 4 cm, randomly assigned (1:1) intraop. to either suture repair or mesh repair. physical examinations at 2 weeks, and 3, 12, and 24 30 months primary outcome was the rate of recurrences
Results: Total 300 pts. enrolled 150 mesh vs 150 suture Median follow up : 25.1 month Complications: Seroma: 3% vs 1% Haematoma: 2% vs 1% Wound infection: 2% vs 1% Recurrence: 4% mesh (6/146) vs 12% suture (17/138) 2 year actuarial estimates: 3.6% vs 11.4% (NNT 12.8) Pain (VAS) and QoL (SF38, EQ) no significant difference Subgroup-Analysis - Recurrence: Umbilical hernia 1-2 cm: 2% vs 8% (2 vs 9) Umbilical hernia 2-4 cm: 9% vs 22% (4 vs 8)
Results Postop.Complications
Umbilical Hernia and Rectus Diastasis Sutured repair of primary small umbilical and epigastric hernias: concomitant rectus diastasis is a significant risk factor for recurrence. Köhler G, Luketina RR, Emmanuel K. World J Surg. 2015 Jan;39(1):121-6; retrospective analysis of 231 patients elective suture-based repair of small (< 2 cm) primary umbilical or epigastric hernias Results: Patients with and without rectus diastasis: hernia recurrence: 31% vs. 8% p < 0.001
Small umbilical hernia AND rectus diastasis Endoscopic Mini Open Sublay Repair (emilos) W.Reinpold Endoscopic assisted Linea alba reconstruction (ELAR) F.Köckerling Endoscopic Rives Stoppa by Stapler T.N.Costa
How I do it Small umbilical hernia (< 2cm): Strong fascia: running suture in small bites technique by monofile, permanent suture material (Polypropylene) Weak fascia: running suture in small bites technique by monofile, permanent suture material (Polypropylene) AND mesh enforcement in PUMP-technique using flat, macro-porous mesh Small umbilical hernia (< 2cm) AND rectus-diastasis: Endoscopic Mini Open Sublay Repair (emilos) with reconstruction of the posterior sheath by running barbered suture and flat mesh without fixation
Take home Definition of small umbilical hernia: 2 cm or 3cm Repair: Suture vs Mesh Mesh: Onlay vs Sublay vs intraperitoneal No significant differences Complications: Infection, Pain, Shrinkage, Recurrence Seroma, infection increased in mesh repair Shrinkage 3D-Meshes (Ventral-patch..) Recurrence and Reoperation-rate: mesh repair significant less Risk-factors: Gender, BMI, Rectus-diastasis...
Guidelines im Spiegel der Registerdaten Endoskopische extraperitoneale Netzversorgung komplexer Bauchwandhernien Trend oder Paradigmenwechsel? www.hernien.at www.hernie-kompakt.at www.hernien.at
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