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Both mesh and suture repair are used for the treatment of umbilical hernias, but for smaller umbilical hernias (diameter 1–4 cm) there is little evidence whether mesh repair would be beneficial. In this study we aimed to investigate whether use of a mesh was better in reducing recurrence compared with suture repair for smaller umbilical hernias. We did a randomised, double-blind, controlled multicentre trial in 12 hospitals (nine in the Netherlands, two in Germany, and one in Italy). Eligible participants were adults aged at least 18 years with a primary umbilical hernia of diameter 1–4 cm, and were randomly assigned (1:1) intraoperatively to either suture repair or mesh repair. In the first 3 years of the inclusion period, blocked randomisation (of non-specified size) was achieved by an envelope randomisation system; after this time computer-generated randomisation was introduced. Patients, investigators, and analysts were masked to the allocated treatment, and participants were stratified by hernia size (1–2 cm and >2–4 cm). At study initiation, all surgeons were invited to training sessions to ensure they used the same standardised techniques for suture repair or mesh repair. Patients underwent physical examinations at 2 weeks, and 3, 12, and 24–30 months after the operation. The primary outcome was the rate of recurrences of the umbilical hernia after 24 months assessed in the modified intention-to-treat population by physical examination and, in case of any doubt, abdominal ultrasound. This trial is registered with ClinicalTrials.gov, number NCT00789230. Between June 21, 2006, and April 16, 2014, we randomly assigned 300 patients, 150 to mesh repair and 150 to suture repair. The median follow-up was 25·1 months (IQR 15·5–33·4). After a maximum follow-up of 30 months, there were fewer recurrences in the mesh group than in the suture group (six [4%] in 146 patients vs 17 [12%] in 138 patients; 2-year actuarial estimates of recurrence 3·6% [95% CI 1·4–9·4] vs 11·4% (6·8–18·9); p=0·01, hazard ratio 0·31, 95% CI 0·12–0·80, corresponding to a number needed to treat of 12·8). The most common postoperative complications were seroma (one [<1%] in the suture group vs five [3%] in the mesh group), haematoma (two [1%] vs three [2%]), and wound infection (one [<1%] vs three [2%]). There were no anaesthetic complications or postoperative deaths. This is the first study showing high level evidence for mesh repair in patients with small hernias of diameter 1–4 cm. Hence we suggest mesh repair should be used for operations on all patients with an umbilical hernia of this size. Department of Surgery, Erasmus University Medical Center, Rotterdam, Netherlands.

Introduction and hypothesisOur aim was to evaluate clinically relevant long-term outcomes of transvaginal mesh or native tissue repair in women with recurrent pelvic organ prolapse (POP).MethodsWe performed a 7-year follow-up of a randomized controlled trial on trocar-guided mesh placement or native tissue repair in women with recurrent POP. Primary outcome was composite success, defined as absence of POP beyond the hymen, absence of bulge symptoms, and absence of retreatment for POP. Secondary outcomes were adverse events, pain, and dyspareunia. Multiple imputation was used for missing data of composite success and pain; estimates are presented with 95% confidence intervals (CI).ResultsBetween August 2006 and July 2008, 194 women were randomized; 190 underwent surgery. At 7 years, 142 (75%) were available for analysis, of whom, the primary outcome could be calculated in 127. Composite success was 53% (95% CI 41, 66) for mesh and 54% (95% CI 42, 65) for native tissue. Repeat surgery for POP was 25% for mesh and 16% for native tissue (difference 9%; 95% CI −5, 23) and occurred in untreated compartments in the mesh group and treated compartments in the native tissue group. Mesh exposure rate was 42%; pain with mesh 39% and native tissue 50% (difference − 11%, 95% CI −27, 6); dyspareunia with mesh 20% and native tissue 17% (difference 3%, 95% CI −9, 17).ConclusionsSeven-year composite success rates appeared similar for mesh and native tissue. Mesh did not reduce long-term repeat surgery rates due to de novo POP in nonmesh-treated vaginal compartments. Mesh exposure rates were high, though significant differences in pain and dyspareunia were not detected.Clinical trial registration. ClinicalTrials.gov, NCT00372190.

Introduction and Hypothesis The objective was to assess long-term mesh complications following total hysterectomy and sacrocolpopexy. Methods In this second extension study, women from a multicenter randomized trial were followed for more than 36 months after surgery. Owing to COVID-19, participants were assessed through either in-person visits or telephone questionnaires. The primary outcome was the incidence of permanent suture or mesh exposure. Secondary outcomes included surgical success and late adverse outcomes. Results Out of the 200 initially enrolled participants, 82 women took part in this second extension study. Among them, 46 were in the permanent suture group, and 36 in the delayed absorbable group. The mean follow-up duration was 5.3 years, with the cumulative mesh or suture exposure of 9.9%, involving 18 cases, of which 4 were incident cases. Surgical success after more than 5 years stood at 95%, with few experiencing bothersome bulge symptoms or requiring retreatment. No serious adverse events occurred, including mesh erosion into the bladder or bowel. The most common adverse events were vaginal pain, bleeding, dyspareunia, and stress urinary incontinence, with no significant differences between suture types. Conclusion The study found that mesh exposure risk gradually increased over time, reaching nearly 10% after more than 5 years post-surgery, regardless of suture type. However, surgical success remained high, and no delayed serious adverse events were reported.

Aim The aim of this paper was to provide a narrative review of surgical site infection after hernia surgery and the influence of perioperative preventative interventions. Methods The review was based on current national and international guidelines and a literature search. Results Mesh infection is a highly morbid complication after hernia surgery, and is associated with hospital re-admission, increased health care costs, re-operation, hernia recurrence, impaired quality of life and plaintiff litigation. The American College of Surgeons National Surgical Quality Improvement Program is a particularly useful resource for the study and evidence-based practise of abdominal wall hernia repair. Discussion The three major modifiable patient comorbidities significantly associated with postoperative surgical site infection in hernia surgery are obesity, tobacco smoking and diabetes mellitus. Preoperative optimization includes weight loss, cessation of smoking, and control of diabetes. Intraoperative interventions relate, in particular, to the control of fomite mediated transmission in the operating theatre and prevention of mesh contamination with S. aureus CFUs. Risk management strategies should also target the niche ecological conditions which enable bacterial survival and subsequent biofilm formation on an implanted mesh. Outcomes of mesh infection after hernia surgery are closely related to mesh type and porosity, patient smoking status, presence of MRSA, bacterial adhesion and biofilm production. The use of suction drains and the timing of drain removal are controversial and discussed in detail. Finally, the utility of the ACS-NSQIP Surgical Risk Calculator in predicting complications and outcomes in individual patients and the importance of quality improvement initiatives in surgical units are emphasized.

Women undergoing surgery for vaginal prolapse are at risk for urinary incontinence. In this randomized trial, women who received a midurethral sling had lower rates of incontinence at 3 and 12 months but higher rates of adverse events than those who received sham incisions. One in five women will undergo surgery for pelvic-organ prolapse in her lifetime, 1 and urinary incontinence commonly occurs with pelvic-organ prolapse. In previously continent women with pelvic-organ prolapse, urinary incontinence develops in approximately a quarter of them after prolapse repair; this phenomenon is referred to as occult, latent, de novo, iatrogenic, or potential stress urinary incontinence. 2 In 2006, the Colpopexy and Urinary Reduction Efforts (CARE) trial 2 showed that adding a bladder-neck suspension at the time of abdominal prolapse surgery in women without preoperative stress incontinence significantly reduced the risk of postoperative stress urinary incontinence (23.8%, vs. 44.1% in the control . . .

PurposeThe use of mesh is a common practice in ventral hernia repair (VHR). Lack of consensus on which prosthetic material works better in different settings remains. This meta-analysis aims to summarize the available evidence on hernia recurrence and complications after repair with synthetic, biologic, or biosynthetic/bioabsorbable meshes in hernias grade 2–3 of the Ventral Hernia Working Group modified classification. MethodsA literature search was conducted in January 2021 using Web of Science (WoS), Scopus, and MEDLINE (via PubMed) databases. Randomized Controlled Trials (RCTs) and observational studies with adult patients undergoing VHR with either synthetic, biologic, or biosynthetic/bioabsorbable mesh were included. Outcomes were hernia recurrence, Surgical Site Occurrence (SSO), Surgical Site Infection (SSI), 30 days re-intervention, and infected mesh removal. Random-effects meta-analyses of pooled proportions were performed. Quality of the studies was assessed, and heterogeneity was explored through sensitivity analyses.Results25 articles were eligible for inclusion. Mean age ranged from 47 to 64 years and participants’ follow-up ranged from 1 to 36 months. Biosynthetic/bioabsorbable mesh reported a 9% (95% CI 2–19%) rate of hernia recurrence, lower than synthetic and biologic meshes. Biosynthetic/bioabsorbable mesh repair also showed a lower incidence of SSI, with a 14% (95% CI 6–24%) rate, and there was no evidence of infected mesh removal. Rates of seroma were similar for the different materials.ConclusionsThis meta-analysis did not show meaningful differences among materials. However, the best proportions towards lower recurrence and complication rates after grade 2–3 VHR were after using biosynthetic/slowly absorbable mesh reinforcement. These results should be taken with caution, as head-to-head comparative studies between biosynthetic and synthetic/biologic meshes are lacking. Although, biosynthetic/bioabsorbable materials could be considered an alternative to synthetic and biologic mesh reinforcement in these settings.

PurposeImmediate breast reconstruction (IBR) at the time of mastectomy is gaining popularity, as studies show no negative impact on recurrence or patient survival, but better aesthetic outcome, less psychological distress and lower treatment costs. Using the largest database available in Europe, the presented study compared outcomes and complications of IBR vs. delayed breast reconstruction (DBR).Methods3926 female patients underwent 4577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups according to the time of reconstruction: an IBR and a DBR group. Surgical complications were accounted for and the groups were then compared.ResultsOverall, the rate of partial-(1.0 versus 1.2 percent of cases; p = 0.706) and total flap loss (2.3 versus 1.9 percent of cases; p = 0.516) showed no significant difference between the groups. The rate of revision surgery was slightly, but significantly lower in the IBR group (7.7 versus 9.8 percent; p = 0.039). Postoperative mobilization was commenced significantly earlier in the IBR group (mobilization on postoperative day 1: 82.1 versus 68.7 percent; p < 0.001), and concordantly the mean length of hospital stay was significantly shorter (7.3 (SD3.7) versus 8.9 (SD13.0) days; p < 0.001).ConclusionIBR is feasible and cannot be considered a risk factor for complications or flap outcome. Our results support the current trend towards an increasing number of IBR. Especially in times of economic pressure in health care, the importance of a decrease of hospitalization cannot be overemphasized.

Background and Objectives: There are many well-described approaches to symptomatic ventral hernia management; however, there remains a significant patient population with limited options for a durable ventral hernia repair with a reasonable risk of infection and recurrence. Drawing from the orthopedic literature, we changed our approach to this clinical problem and developed a palliative ventral hernioplasty pathway. Materials and Methods: A retrospective review (2017–2019) of patients’ palliative ventral hernioplasty was performed. Results: In total, 43 patients included, with a female preponderance of 24 (58.6%) and a mean age 61.5 ± 11.5 years. The mean BMI was 38.1 kg/m2 (IQR: 25.4–62), and 28 patients (65.1%) had a history of prior wound/mesh infection. Urgent repair was performed in 14 patients. Overall polypropylene prosthetic was implanted in 26 patients, and bioprosthetic/absorbable mesh was used in the remaining. The mean surface area of the implanted mesh was 561 cm2. The most common wound complications identified were skin separation (30.2%) and seroma formation (48.8%). Hernia recurrence occurred in four (9.3%) patients, with a mean follow-up of 24.1 months (9–37). Three patients had central lightweight mesh rupture and one had a recurrence (bioprosthetic mesh); all were subsequently repaired. Conclusions: Despite the small number of patients, our palliative ventral hernia repair pathway offers durable repair with an acceptable risk of recurrence and mesh infection in patients who would otherwise be considered nonoperative.

Background There has been a slow uptake of wound bundles and prophylactic mesh augmentation (PMA) strategies despite evidence supporting their role in reducing burst abdomens and incisional hernias (IH). This study evaluates outcomes of resorbable synthetic prophylactic mesh augmentation in reducing these rates and assesses the complication profile in emergency abdominal surgery. Methods A retrospective ethically approved observational study of all patients who underwent emergency open abdominal surgery using supplemental prophylactic onlay TIGR ® Mesh at Letterkenny University Hospital between September 2017 and April 2024 was undertaken to assess safety, complication profiles and outcomes. Comprehensive wound bundles and subcutaneous space closure were used. Results Of the 49 patients included, the mean age was 64 years (± 16.4, 31–86), 33/49 (67%) were female, and the mean body mass index (BMI) was 27 (± 7.4,17.3–45). 20% of patients had previous abdominal surgery. 19/49 (38%) patients experienced postoperative complications, of these 8 (42%) were Clavien-Dindo Grade I-II, and 11 (58%) were Grade III-IV. There were 7 in-hospital post-operative deaths (Grade V). 8 patients had open abdomens. Thirteen surgical site occurrences (SSO) were identified in 9 (18%) patients. There were no burst abdomens. Four of the superficial SSIs responded to antibiotics while one required opening and wound NPWT. Three patients (6%) developed an incisional hernia, which was detected at a mean follow-up of 353 days. Conclusion A comprehensive, evidence-based wound bundle using onlay PMA with a synthetic resorbable mesh, achieves efficacious, safe abdominal wall closure in high-risk, emergency laparotomy patients, including those who require delayed abdominal wall closure.

Introduction and hypothesis The objective of this study was to evaluate long-term outcomes of laparoscopic sacrocolpopexy (LSC) versus abdominal sacrocolpopexy (ASC) for vaginal vault prolapse (VVP). Methods Long-term follow-up of a multicenter randomized controlled trial (SALTO trial). A total of 74 women were randomly assigned to LSC ( n =37) or ASC ( n =37). Primary outcome was disease-specific quality of life, measured with validated questionnaires. Secondary outcomes included anatomical outcome, composite outcome of success, complications, and retreatment. Results We analyzed 22 patients in the LSC group and 19 patients in the ASC group for long-term follow-up, with a median follow-up of 109 months (9.1 years). Disease-specific quality of life did not differ after long-term follow-up with median scores of 0.0 (LSC: IQR 0–17; ASC: IQR 0–0) on the “genital prolapse” domain of the Urogenital Distress Inventory in both groups ( p = 0.175). Anatomical outcomes were the same for both groups on all points of the POP-Q. The composite outcome of success for the apical compartment is 78.6% ( n = 11) in the LSC group and 84.6% ( n  = 11) in the ASC group ( p = 0.686). Mesh exposures occurred in 2 patients (12.5%) in the LSC group and 1 patient (7.7%) in the ASC group. There were 5 surgical reinterventions in both groups (LSC: 22.7%; ASC: 26.3%, p = 0.729). Conclusions At long-term follow-up no substantial differences in quality of life, anatomical results, complications, or reinterventions between LSC and ASC were observed. Therefore, the laparoscopic approach is preferable, considering the short-term advantages. Trial registration Dutch Trial Register NTR6330, 18 January 2017, https://www.trialregister.nl/trial/5964