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Algorithm for management of ventral hernia in obese. Abbreviations: IPOM = intraperitoneal onlay meshplasty, AWR- abdominal wall reconstruction, RS = Rives-Stoppa
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Introduction
Management of ventral hernia in obese is a complex problem. The methods of weight loss, alternatives if the patient cannot undergo bariatric surgery, timing, and type of hernia surgery lacks clarity and are dependent on resources and expertise. There is a need for algorithms based on local population and expertise. In this paper, we pr...
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Inguinal hernia repair is one of the most common operations performed in general surgery worldwide. It may contain either the omentum or small bowel as its contents. However, during hernia surgery, there may be surprises due to encounter of rare or unexpected contents in the hernial sac. Among these are Meckel's diverticulum, Amyand's hernia, Rhict...
Citations
... Several studies have reported the use of machine learning for abdominal wall surgery [8][9][10][11][12][13][14][15][16][17][18][19][20][21]. This systematic review aims to evaluate the use of machine learning and artificial intelligence in hernia surgery. ...
Introduction
This systematic review aims to evaluate the use of machine learning and artificial intelligence in hernia surgery.
Methods
The PRISMA guidelines were followed throughout this systematic review. The ROBINS—I and Rob 2 tools were used to perform qualitative assessment of all studies included in this review. Recommendations were then summarized for the following pre-defined key items: protocol, research question, search strategy, study eligibility, data extraction, study design, risk of bias, publication bias, and statistical analysis.
Results
A total of 13 articles were ultimately included for this review, describing the use of machine learning and deep learning for hernia surgery. All studies were published from 2020 to 2023. Articles varied regarding the population studied, type of machine learning or Deep Learning Model (DLM) used, and hernia type. Of the thirteen included studies, all included either inguinal, ventral, or incisional hernias. Four studies evaluated recognition of surgical steps during inguinal hernia repair videos. Two studies predicted outcomes using image-based DMLs. Seven studies developed and validated deep learning algorithms to predict outcomes and identify factors associated with postoperative complications.
Conclusion
The use of ML for abdominal wall reconstruction has been shown to be a promising tool for predicting outcomes and identifying factors that could lead to postoperative complications.
... However, this study did not factor in the BMI of patients, it only factored in the size of the defect [60]. Baig et al. [61] published their work on patients with a BMI of 30 kg/m 2 . The study factored in the BMI and the size of the defect accordingly. ...
... Algorithm for the selection of procedures for VH based on hernia defect size (Table 2) Dr. Igor Belyansky invented and popularized new techniques and nomenclatures including Extended Totally Extraperitoneal Rives-Stoppa (eTEP-RS) and Extended Totally Extraperitoneal Transversus Abdominis Release (eTEP-TAR), which involved posterior component separation with limited access. Baig et al. [61] and Baig et al. [64] developed an algorithm based on the data from the literature and attempted to include these treatments into their hernia surgery. Hernia width was a key factor in their procedure selection [61,64]. ...
... Baig et al. [61] and Baig et al. [64] developed an algorithm based on the data from the literature and attempted to include these treatments into their hernia surgery. Hernia width was a key factor in their procedure selection [61,64]. ...
Purpose
While research on inguinal hernias is well-documented, ventral/incisional hernias still require investigation. In India, opinions on laparoscopic ventral hernia repair (LVHR) techniques are contested. The current consensus aims to standardize LVHR practice and identify gaps and unfulfilled demands that compromise patient safety and therapeutic outcomes.
Methods
Using the modified Delphi technique, panel of 14 experts (general surgeons) came to a consensus. Two rounds of consensus were conducted online. An advisory board meeting was held for the third round, wherein survey results were discussed and the final statements were decided with supporting clinical evidence.
Results
Experts recommended intraperitoneal onlay mesh (IPOM) plus/trans-abdominal retromuscular/extended totally extraperitoneal/mini- or less-open sublay operation/transabdominal preperitoneal/trans-abdominal partial extra-peritoneal/subcutaneous onlay laparoscopic approach/laparoscopic intracorporeal rectus aponeuroplasty as valid minimal access surgery (MAS) options for ventral hernia (VH). Intraperitoneal repair technique is the preferred MAS procedure for primary umbilical hernia < 4 cm without diastasis; incisional hernia in the presence of a vertical single midline incision; symptomatic hernia, BMI > 40 kg/m², and defect up to 4 cm; and for MAS VH surgery with grade 3/4 American Society of Anaesthesiologists. IPOM plus is the preferred MAS procedure for midline incisional hernia of width < 4 cm in patients with a previous laparotomy. Extraperitoneal repair technique is the preferred MAS procedure for L3 hernia < 4 cm; midline hernias < 4 cm with diastasis; and M5 hernia.
Conclusion
The consensus statements will help standardize LVHR practices, improve decision-making, and provide guidance on MAS in VHR in the Indian scenario.
... The impact of obesity on the natural evolution of a hernia and its consequences on the surgical procedure and complications are known, but are still being studied and precise recommendations are missing [11][12][13][14][15][16]. Moreover, all these studies are methodically limited, with low patient numbers and frequent loss to follow-up. ...
Purpose
Obesity is a known risk factor of recurrence after hernia surgery, but available data often concern pooled cases of primary and incisional hernia, with short follow-up. We aimed to analyze the impact of severe obesity (BMI ≥ 35 kg/m²) on the results of midline primary ventral hernia repair (mPVHR), in comparison with non-severely obese patients.
Methods
Data were extracted from a multicentric registry, in which patients’ data are consecutively and anonymously collected. We conducted a retrospective comparative study on patients with severe obesity (sOb) versus non-severely obese patients (non-sOb), who underwent surgery, with a minimal 2-year follow-up after their mPVHR.
Results
Among 2307 patients, 267 sOb and 2040 non-sOb matched inclusion criteria. Compared with non-sOb, sOb group gathered all the worse conditions and risk factors: more ASA3-4 (39.3% vs. 10.2%; p < 0.001), symptomatic hernia (15.7% vs. 6.8%; p < 0.001), defect > 4 cm in diameter (24.3% vs. 8.8%; p < 0.001), emergency surgery (6.1% vs. 2.5%; p = 0.003), and Altemeir class > 1 (9.4% vs. 2.9%; p < 0.001). Laparoscopic IPOM was used more often in sOb patients (40% vs. 32%; p = 0.016), but with smaller Hauters’ ratio (46 vs. 73; p < 0.001). Compared with the non-sOb, the rate of day-case surgery was lower (48% vs. 68%; p < 0.001), the surgical site occurrences were significantly more frequent (6.4 %vs. 2.5%; p < 0.001). The main outcome, 2-year recurrence, was 5.9% in the sOb vs. 2.1% (p = 0.008), and 2-year reoperations was 3% vs. 0.3% (p = 0.006). In the adjusted analysis, severe obesity was an independent risk factor for recurrence [OR = 2.82, (95%CI, 1.45; 5.22); p = 0.003].
Conclusion
In patients with severe obesity, mPVHR is technically challenging and recurrence rate is three times higher than that of non-severely obese patients.
Background
Mesh infection is one of the most devastating complications after ventral hernia repair. To date, no clear consensus exists on the optimal timing of definitive abdominal wall reconstruction (AWR) after excision of infected mesh. We evaluated outcomes of immediate multistaged AWR in patients with mesh infection.
Methods
We performed a retrospective review of patients with mesh infection who underwent immediate, multistaged AWR, which consisted of exploratory laparotomy with debridement and mesh explantation, followed by definitive AWR during the same admission. Primary outcomes included hernia recurrence and surgical site occurrences, defined as wound dehiscence, surgical site infection, hematoma, and seroma.
Results
Forty-seven patients with infected mesh were identified. At mean follow-up of 9.5 months, 5 patients (10.6%) experienced hernia recurrence. Higher body mass index ( P = 0.006), bridge repair ( P = 0.035), and postoperative surgical site infection ( P = 0.005) were associated with hernia recurrence.
Conclusion
Immediate multistaged AWR is an effective surgical approach in patients with infected mesh.
The review is devoted to the treatment of ventral hernias in patients with morbid obesity. This issue is important due to significant number of such patients and no unambiguous clinical recommendations. The advantages of simultaneous surgery (with bariatric intervention) are obvious, i.e. lower risk of postoperative hernia incarceration and no need for re-hospitalization with another intervention. High risk of bariatric population makes it necessary to minimize surgery time and surgical trauma. A staged approach with reducing body weight surgically or conservatively before hernia repair is often chosen. Hernia repair should be performed using laparoscopic or robotic techniques with obligatory use of mesh implants. Panniculectomy or abdominoplasty as the main surgery is a valid option. Currently, it is necessary to develop clear criteria for selecting patients with morbid obesity for staged and simultaneous treatment of ventral hernias.
Background:
Prior work has linked body mass index (BMI) with postoperative outcomes of ventral hernia repair (VHR), though recent data characterizing this association are limited. This study used a contemporary national cohort to investigate the association between BMI and VHR outcomes.
Methods:
Adults ≥ 18 years undergoing isolated, elective, primary VHR were identified using the 2016-2020 American College of Surgeons National Surgical Quality Improvement Program database. Patients were stratified by BMI. Restricted cubic splines were utilized to ascertain the BMI threshold for significantly increased morbidity. Multivariable models were developed to evaluate the association of BMI with outcomes of interest.
Results:
Of ~89,924 patients, 0.5 % were considered Underweight, 12.9 % Normal Weight, 29.5 % Overweight, 29.1 % Class I, 16.6 % Class II, 9.7 % Class III, and 1.7 % Superobese. After risk adjustment, class I (Adjusted Odds Ratio [AOR] 1.22, 95 % Confidence Interval [95%CI]: 1.06-1.41), class II (AOR 1.42, 95%CI: 1.21-1.66), class III obesity (AOR 1.76, 95%CI: 1.49-2.09) and superobesity (AOR 2.25, 95 % CI: 1.71-2.95) remained associated with increased odds of overall morbidity relative to normal BMI following open, but not laparoscopic, VHR. A BMI of 32 was identified as the threshold for the most significant increase in predicted rate of morbidity. Increasing BMI was linked to a stepwise rise in operative time and postoperative length of stay.
Conclusion:
BMI ≥ 32 is associated with greater morbidity following open, but not laparoscopic VHR. The relevance of BMI may be more pronounced in open VHR and must be considered for stratifying risk, improving outcomes, and optimizing care.
Key message:
Body mass index (BMI) continues to be a relevant factor in morbidity and resource use for elective open ventral hernia repair (VHR). A BMI of 32 serves as the threshold for significant increase in overall complications following open VHR, though this association is not observed in operations performed laparoscopically.
