The results of surgical treatment of complex incisional hernia

Research objective to assess the surgical treatment outcomes of complex incisional hernias of moderate and major severity classes meeting the criteria established by Slater et al. in the early and long-term postoperative period. A total of 121 patients with complex incisional hernias (hernia ≥10 cm in width) following surgical treatment at the A.V. Vishnevsky National Medical Research Center of Surgery in the period from 2015 to 2022 were enrolled in the study. Hernias meeting the criteria established by N.J. Slater et al. (2014) were considered complex. In 71 (58.68 %) cases were used reconstructive repair (midline fascial approximation). In 50 (41.32 %) cases, due to the impossibility of bringing the edges of the hernial orifice together, were used bridged repair (mesh is placed as a bridge). Common general complications in the early postoperative period were observed in 48 (40.5 %) patients, including 38 (31.4 %) cases of seroma, 5 (4.13 %) cases of skin dehiscence, 3 (2.48 %) cases of wound suppuration, 2 (1.65 %) cases of skin necrosis, and 1 (0.83 %) case of bleeding from the mesh placement. The mean follow-up was 3.12±0.15 years (from 1 to 7 years) after the surgery. Hernia recurrence was recorded in 9 (7.44 %) patients, ligature fistula of the anterior abdominal wall – in 3 (2.48 %) patients, pseudocyst of the anterior abdominal wall – in 3 (2.48 %) cases. Reconstructive repair was superior to bridged repair in terms of lower rate of local wound complications (32.39 % versus 52.00 %, p = 0.048) and long-term complications (5.63 % versus 22.00 %, p = 0.016), the last included hernia recurrence (2.82 % vs. 14.00 %, p = 0.021). The “Sandwich” bridging technique demonstrated optimal outcomes in terms of hernia recurrence. Reconstructive repair for complex incisional hernias have shown better outcomes compared to bridged repair. The “Sandwich” bridging repair is recommended, if there is no opportunity to perform reconstructive repair.

1. Cobb WS, Warren JA, Ewing JA, et al. Open retromuscular mesh repair of complex incisional hernia: predictors of wound events and recurrence. Journal of the American Col-lege of Surgeons. 2015;220(4):606–613. https://doi.org/10.1016/j.jamcollsurg.2014.12.055

2. Hadad I, Small W, Dumanian GA. Repair of massive ventralhernias with the separation of parts technique: reversal ofthe 'lost domain'. The American surgeon. 2009;75(4):301–306.https://doi.org/10.1177/000313480907500407

3. Rosen MJ, Krpata DM, Ermlich B, Blatnik JA. A 5-year clini-cal experience with single-staged repairs of infected andcontaminated abdominal wall defects utilizing biologic mesh.Annals of surgery. 2013;257(6):991–996. https://doi.org/10.1097/SLA.0b013e3182849871

4. Slater NJ, Montgomery A, Berrevoet F, et al. Criteria for defini-tion of a complex abdominal wall hernia. Hernia: the journal ofhernias and abdominal wall surgery. 2014;18(1):7–17.https://doi.org/10.1007/s10029-013-1168-6

5. Muysoms FE, Miserez M, Berrevoet F, et al. Classification ofprimary and incisional abdominal wall hernias. Hernia: the journal of hernias and abdominal wall surgery. 2009;13(4):407–414.https://doi.org/10.1007/s10029-009-0518-x

6. Korik VE, Klyuiko DA, But-Gusaim GV, Bogdan VG. Abdominal compartment syndrome: a state of the art review of diagnosticand treatment. Military medicsina. 2016;40(3):127–133.

7. Malbrain M, Jones F. Intra-abdominal pressure measurement techniques. In. Abdominal Compartment Syndrome. 1st ed.CRC Press; 2006, pp. 19–68.

8. Morales-Conde S. A new classification for seroma after la-paroscopic ventral hernia repair. Hernia: the journal of hernias and abdominal wall surgery. 2012;16(3):261–267.https://doi.org/10.1007/s10029-012-0911-8

9. Halligan S, Parker SG, Plumb AA, Windsor ACJ. Imagingcomplex ventral hernias, their surgical repair, and their complications. European radiology. 2018;28(8):3560–3569.https://doi.org/10.1007/s00330-018-5328-z

10. Scheuerlein H, Settmacher U, Lenschow M, Rauchfuss F.Complex incisional hernias. Archives of Clinical Gastroen-terology. 2016;2(1):017–026. https://doi.org/10.17352/2455-2283.000014

11. Snyder CW, Graham LA, Gray SH, et al. Effect of mesh type and position on subsequent abdominal operations after incisional hernia repair. J Am Coll Surg. 2011;212(4):496–502 .https://doi.org/10.1016/j.jamcollsurg.2010.12.004

12. Timmermans L, de Goede B, van Dijk SM, et al. Meta-analysisof sublay versus onlay mesh repair in incisional hernia sur-gery. American journal of surgery. 2014;207(6):980–988.https://doi.org/10.1016/j.amjsurg.2013.08.030

13. Gogia BS, Chertova AD, Aljautdinov RR, et al. Abdominal wallpseudocyst after subcutaneous onlay endoscopic approach(SCOLA) mesh repair: a case report and literature review.Hernia: the journal of hernias and abdominal wall surgery.2024;28(1):269–274. https://doi.org/10.1007/s10029-023-02775-2

14. Pauli EM, Rosen MJ. Open ventral hernia repair with compo-nent separation. The Surgical clinics of North America.2013;93(5):1111–1133. https://doi.org/10.1016/j.suc.2013.06.010

15. Bernard C, Polliand C, Mutelica L, Champault G. Repair of giantincisional abdominal wall hernias using open intraperitoneal mesh. Hernia: the journal of hernias and abdominal wall surgery. 2007;11(4):315–320. https://doi.org/10.1007/s10029-007-0222-7

16. Deerenberg EB, Timmermans L, Hogerzeil DP, et al. A systematic review of the surgical treatment of large incisional hernia. Hernia: the journal of hernias and abdominal wall surgery.2015;19(1):89–101. https://doi.org/10.1007/s10029-014-1321-x

17. Eriksson A, Rosenberg J, Bisgaard T. Surgical treatment for giant incisional hernia: a qualitative systematic review. Hernia: the journal of hernias and abdominal wall surgery. 2014;18(1):31–38.https://doi.org/10.1007/s10029-013-1066-y

18. Liang MK, Holihan JL, Itani K, et al. Ventral hernia man-agement: expert consensus guided by systematic review.Annals of surgery. 2017;265(1):80–89. https://doi.org/10.1097/SLA.0000000000001701

19. Kriger AG, Akhtanin EA, Gogia BSh, et al. Surgical treatment of enterocutaneous fistulas in patients with ventral incisional hernia. Pirogov Russian Journal of Surgery. 2022;(9):21–26. (InRuss.) https://doi.org/10.17116/hirurgia202209121

20. Iannitti DA, Hope WW, Norton HJ, et al. Technique and outcomes of abdominal incisional hernia repair using a synthetic composite mesh: a report of 455 cases. Journal ofthe American College of Surgeons. 2008;206(1):83–88.https://doi.org/10.1016/j.jamcollsurg.2007.07.030

21. Booth JH, Garvey PB, Baumann DP, et al. Primary fascialclosure with mesh reinforcement is superior to bridgedmesh repair for abdominal wall reconstruction. Journal ofthe American College of Surgeons. 2013;217(6):999–1009.https://doi.org/10.1016/j.jamcollsurg.2013.08.015

22. Holihan JL, Askenasy EP, Greenberg JA, et al. Component separation vs. bridged repair for large ventral hernias: a multiinstitutional risk-adjusted comparison, systematic review,and metaanalysis. Surgical infections. 2016;17(1):17–26.https://doi.org/10.1089/sur.2015.124

23. Gogia BSh, Chertova AD, Aljautdinov RR, KarmazanovskyGG. Two-stage abdominal wall reconstruction in a patientwith a complex postoperative hernia. Journal of experimental and clinical surgery. 2022;15(4):333–341. (In Russ.)https://doi.org/10.18499/2070-478X-2022-15-4-333-341

24. Ramirez OM, Ruas E., Dellon AL Components separationmethod for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstruct Surg. 1990;86(3):519–526.

25. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversusabdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. American journal of surgery. 2012;204(5):709–716. https://doi.org/10.1016/j.amjsurg.2012.02.008

26. Lowe JB 3rd, Lowe JB, Baty JD, et al. Risks associated with “components separation” for closure of complex abdominalwall defects. Plast Reconstruct Surg. 2003;111:1276–1283.https://doi.org/10.3919/jjsa.79.1309

27. Pereira-Rodriguez JA, Bravo-Salva A, Montcusí-Ventura B, et al. EVEREG registry members. early outcomes of separation techniques: an analysis of the spanish registry of incisional hernia (EVEREG). Hernia. 2021;25(6):1573–1580.https://doi.org/10.1007/s10029-021-02449-x

28. de Vries Reilingh TS, van Goor H, Charbon JA, et al. Repair ofgiant midline abdominal wall hernias: “components separation technique” versus prosthetic repair: interim analysis of a ran-domized controlled trial. World journal of surgery.2007;31(4):756–763. https://doi.org/10.1007/s00268-006-0502-x

29. Wegdam JA, Thoolen JMM, Nienhuijs SW, et al. Systematic review of transversus abdominis release in complexabdominal wall reconstruction. Hernia: the journal of hernias and abdominal wall surgery. 2019;23(1):5–15.https://doi.org/10.1007/s10029-018-1870-5

30. Punjani R, Arora E, Mankeshwar R, Gala J. An early experiencewith transversus abdominis release for complex ventral hernias:a retrospective review of 100 cases. Hernia: the journal of hernias and abdominal wall surgery. 2021;25(2):353–364.https://doi.org/10.1007/s10029-020-02202-w

31. Martín-Cartes JA, Tamayo-López MJ, Bustos-Jiménez M.'Sandwich' technique in the treatment of large and complex incisional hernias. ANZ journal of surgery. 2016;86(5):343–347.https://doi.org/10.1111/ans.13285

32. Hadeed JG, Walsh MD, Pappas TN, et al. Complex abdominal wall hernias: a new classification system and approach to management based on review of 133 consecutive patients. Annals of plastic surgery. 2011;66(5):497–503.https://doi.org/10.1097/SAP.0b013e3182145387