Aim: Hernia registries report that guidelines are not always implemented by general surgeons and suggest that the success rate of this procedure is higher in hernia specialty centers. There are many definitions of hernia centers, but their objectives consist of improving healthcare by homogenizing the clinical practice. We performed a systematic review and meta-analysis to analyze hernia centers\' definitions and compare hernia centers with non-specialized centers. Material and Methods: Cochrane Central, Scopus, Scielo, and PubMed were systematically searched for studies defining a hernia center or comparing hernia centers and non-specialized centers. Outcomes assessed were recurrence, surgical site events, hospital length of stay (LOS), and operative time. We performed subgroup analyses of hernia type. Statistical analysis was performed with R Studio. Results: 3,260 studies were screened and 88 were thoroughly reviewed. Thirteen studies were included. Five studies defined a hernia center and eight studies, comprising 141,366 patients, compared a hernia center with a non-specialized center. Generally, the definitions were similar in decision-making and educational requirements but differed in structural aspects and the steps required for the certification. We found lower recurrence rates for hernia centers for both inguinal (1.08% versus 5.11%; RR 0.21; 95% CI 0.19 to 0.23; p < 0.001) and ventral hernia (3.2% vs. 8.9%; RR 0.425; 95% CI 0.28 to 0.64; p < 0.001). Hernia centers also presented lower surgical site infection for both ventral (4.3% vs. 11.9%; RR 0.435; 95% CI 0.21 to 0.90; p = 0.026) and inguinal (0.1% vs. 0.52%; RR 0.15; 95% CI 0.02 to 0.99; p = 0.49) repair. Conclusion: Our systematic review and meta-analysis support that a hernia center establishment improves postoperative outcomes data. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024522263, PROSPERO CRD42024522263.

Background: Diastasis recti (DR) is a common condition, especially in women after pregnancy, often associated with concomitant hernia defects and defined as a rupture of the midline and a separation of the rectus muscle more than 2 cm. Symptoms related to this are low back pain, urinary incontinence and pelvic prolapse, as well as abdominal bulging and core instability. We analyzed clinical and functional outcomes after treatment of DR alone or associated with midline hernias in 219 patients who underwent a midline reconstruction using miSAR® technique (minimally invasive stapled abdominal wall reconstruction). Methods: Between April 2019 and April 2022, 219 patients were treated with miSAR®. All patients were requested to quantify preoperative and postoperative functional symptoms (urinary incontinence, low back pain, abdominal swelling, and respiratory distress). Results: Twenty-seven men and 192 women underwent the miSAR® technique. The mean body mass index was 23.9 kg/m2. We performed the miSAR® technique in patients affected by incisional midline hernia and umbilical hernia alone or associated with DR. Composite mesh was used in 91.8% of cases. The average operating time was 90 minutes. Seven percent of the patients had postoperative complications, including two retromuscular hematomas, two retromuscular seromas, and one postoperative bleeding event. Two patients were readmitted for bowel obstruction. After surgery, there was symptomatic improvement in urinary incontinence, low back pain, respiratory symptoms, and abdominal swelling; this improvement was confirmed at 6 months and at 1- and 2-year follow-up. At the 1-year follow-up, the overall recurrence rate was 2.83%. Conclusion: miSAR® is a feasible and effective technique and shows promising results in the treatment of DR and ventral hernia. Possible enhancements include use of preoperative Botox to treat defects larger than 6 cm. Multicentric analysis is needed to validate the technique, and longer follow-up is required to assess the recurrence rate.

BACKGROUND: Surgical trauma causes immune impairment, but it is largely unknown whether surgery for cancer and benign diseases instigate comparable levels of immune inhibition. Here, we compared the impact of laparoscopic surgery on immunological biomarkers in patients with colorectal cancer (CRC) and ventral hernia (VH).
METHODS: Natural Killer cell activity (NKA), leukocyte subsets, and soluble programmed death ligand 1 (sPD-L1) were measured in blood samples collected from CRC (n = 29) and VH (n = 9) patients preoperatively (PREOP) and on postoperative day (POD) 1, 3-6, 2 weeks and 3 months. NKA was evaluated by the NK Vue assay that uses the level of IFNγ as a surrogate marker of NKA. Normal NKA was defined as IFNγ > 250 pg/mL and low NKA was defined as IFNγ < 250 pg/mL.
RESULTS: The CRC cohort was classified into either PREOPLOW having preoperative low NKA or PREOPHIGH having preoperative normal NKA. The median NKA of the PREOPLOW subset was only in the normal range in the POD3 months sample, whereas median NKA of the PREOPHIGH subset and the VH cohort were only low in the POD1 sample. While PREOPLOW differed from VH in the PREOP-, POD1-, and POD3-6 samples (P =.0006, P = .0181, and P = .0021), NKA in PREOPHIGH and VH differed in the POD1 samples (P = .0226). There were no apparent differences in the distribution of leukocyte subsets in the perioperative period between the cohorts.
CONCLUSIONS: CRC patients with preoperative normal NKA and VH patients showed the same pattern of recovery in NKA, while the CRC subset with preoperative low NKA seemed to experience prolonged NK cell impairment. As low NKA is associated with recurrence, preoperative level of NKA may identify patients who will benefit from immune-enhancing therapy in the perioperative period.

OBJECTIVE: Individual studies indicate poorer outcomes for smokers after hernia repair. Previous meta-analyses have examined the impact of smoking on specific outcomes such as recurrence and surgical site infection, but there has been a lack of comprehensive consensus or systematic review on this subject. Addressing this gap, our study undertakes a systematic review and meta-analysis to assess the impact of smoking on the outcomes of ventral hernia repair (VHR) and inguinal hernia repair.
METHODS: A thorough search of Cochrane Central, Scopus, SciELO, and PubMed/MEDLINE, focusing on studies that examined the effect of smoking on inguinal and VHR outcomes was conducted. Key outcomes evaluated included recurrence, reoperation, surgical site occurrences (SSO), surgical site infection (SSI), and seroma.
RESULTS: Out of 3296 screened studies, 42 met the inclusion criteria. These comprised 25 studies (69,295 patients) on VHR and 17 studies (204,337 patients) on inguinal hernia repair. The analysis revealed that smokers had significantly higher rates of recurrence (10.4% vs. 9.1%; RR 1.48; 95% CI [1.15; 1.90]; P < 0.01), SSO (13.6% vs. 12.7%; RR 1.44; 95% CI [1.12; 1.86]; P < 0.01) and SSI (6.6% vs. 4.2%; RR 1.64; 95% CI [1.38; 1.94]; P < 0.01) following VHR. Additionally, smokers undergoing inguinal hernia repair showed higher recurrence (9% vs. 8.7%; RR 1.91; 95% CI [1.21; 3.01]; P < 0.01), SSI (0.6% vs. 0.3%; RR 1.6; 95% CI [1.21; 2.0]; P < 0.001), and chronic pain (9.9% vs. 10%; RR 1.24; 95% CI [1.06; 1.45]; P < 0.01) rates. No significant differences were observed in seroma (RR 2.63; 95% CI [0.88; 7.91]; P = 0.084) and reoperation rates (RR 1.48; 95% CI [0.77; 2.85]; P = 0.236) for VHR, and in reoperation rates (RR 0.99; 95% CI [0.51; 1.91]; P = 0.978) for inguinal hernias between smokers and non-smokers. Analysis using funnel plots and Egger\'s test showed the absence of publication bias in the study outcomes.
CONCLUSIONS: This comprehensive meta-analysis found statistically significant increases in recurrence rates, and immediate postoperative complications, such as SSO and SSI following inguinal and VHR. Also, our subgroup analysis suggests that the MIS approach seems to be protective of adverse outcomes in the smokers group. However, our findings suggest that these findings are not of clinical relevance, so our data do not support the necessity of smoking cessation before hernia surgery. More studies are needed to elucidate the specific consequences of smoking in both inguinal and ventral hernia repair.
UNASSIGNED: ID CRD42024517640.

BACKGROUND: We investigate the effect of antiplatelet and anticoagulant medications on bleeding complications in patients undergoing ventral hernia repair.
METHODS: The Abdominal Core Health Quality Collaborative registry was queried from 2013 to 2022 for patients who underwent ventral hernia repair, evaluating the association between antiplatelet or anticoagulant use and bleeding complications.
RESULTS: 37,973 patients underwent ventral hernia repair: 11.5 ​% on antiplatelet therapy alone and 5.8 ​% on anticoagulation alone. Despite being held, an adjusted regression analysis showed that anticoagulation was associated with an increased risk for postoperative bleeding requiring transfusion (OR 2.4 [1.7-3.4], p ​< ​0.0001), reoperation for postoperative bleeding (OR 6.3 [3.9-10.0], p ​< ​0.0001), and readmission for bleeding complications (OR 4.9 [2.9-8.2], p ​< ​0.0001). Antiplatelet use was not a risk factor for any postoperative bleeding complication.
CONCLUSIONS: Despite being held preoperatively, patients on anticoagulants are at an increased risk for postoperative hemorrhagic complications. Antiplatelet therapy does not pose the same risk.

OBJECTIVE: To present a novel technique of preperitoneal cross-over for eTEP VHR.
METHODS: Patients who underwent robotic eTEP with mesh utilizing a preperitoneal cross over technique were identified using a single-institution hernia database. This novel technique involves minimally invasive access to the retro-rectus space on one side with midline cross over into the preperitoneal space on the contralateral side. Baseline demographics of the patients were obtained, and intra-operative and post-operative outcomes were reported.
RESULTS: Nine VHR patients underwent robotic eTEP with mesh using a preperitoneal crossover technique. Five patients were male, mean age was 53 ± 18.4 years, and mean BMI was 32.5 ± 4.2 kg/m2. Two patients were diabetic and 2 were previous smokers. Two of the hernias were recurrent. The average hernia defect was 96.9 ± 45.5 cm2 and the average mesh size was 593.3 ± 168.2 cm2. Four patients underwent a unilateral TAR, while five patients did not require any component separation. All cases were CDC Class 1 wounds. All patients met discharge criteria on post-operative day 1. There was one post-operative wound occurrence which was a seroma. There were no infectious complications and no hernia recurrences. The average follow up was 1.4 ± 1.2 months.
CONCLUSIONS: Preperitoneal cross-over during eTEP ventral hernia technique is a safe technique that allows placement of a large extra-peritoneal mesh. Early patient outcomes are favorable. Larger sample size and follow-up are needed to truly assess postoperative outcomes.

Objective Ventral hernia repair is a widely practiced surgical procedure worldwide. The objective of this paper is to evaluate and analyze the results of a hybrid approach for treating ventral hernias. Methods All patients with clinically and radiologically proven ventral hernia underwent hybrid laparoscopic ventral hernia repair at Princess Royal University Hospital, London, United Kingdom using a retrospective approach with the same surgical team. Large defects >10 cm, inguinal hernia, para-stomal hernia, incarcerated patients, and spigelian hernia were excluded. We utilized the laparoscopic approach for the dissection and isolation of the sac and used the port site for the delivery of mesh into the abdominal cavity. Results Our study comprises 67 patients, with 39 males (58.2%) and 28 females (41.8%). The median age in our study group was 41 years (range: 18-65 years). The median BMI was 38 kg/m2 (range: 24-52 kg/m2). The majority of the cases were umbilical or paraumbilical hernias (n = 46). The median defect size in our study was 5.4 cm (range: 2-10 cm). The median operative time was 67 minutes. We have not encountered any recurrences in this group. Conclusion This hybrid approach combines the advantages of both the open and laparoscopic approaches.

BACKGROUND: The surgical management of midline ventral hernias complicated by concomitant diastasis recti presents a significant clinical challenge. The Endoscopic Onlay Repair (ENDOR) offers a minimally invasive solution, effectively addressing both conditions. This study focuses on describing the adaptation of ENDOR to a robotic platform, termed R-ENDOR, aiming to report initial outcomes along with other established robotic surgical approaches.
METHODS: This retrospective case series study included consecutive adult patients who underwent R-ENDOR approach from October 2018 to April 2023, performed by a single surgeon. A comprehensive description of the surgical technique is included. Patient demographics, operative, and hernia-specific characteristics, as well as clinical outcomes are described.
RESULTS: A total of 15 patients undergoing R-ENDOR for ventral hernia repair with diastasis recti plication were included. The median age was 59 years (IQR 42-63), with 60% (n = 9) female patients. The majority (86%, n = 13) had an ASA score of ≤ 2, and the median BMI was 24 kg/m2, with 20% (n = 3) classified as obese. Median hernia size was 2 cm (IQR 2-2.25), with a median diastasis length of 19 cm (IQR 15-21.5) and width of 4 cm (IQR 3-6). The median operative time was 129 min (IQR 113-166). Most repairs (93%, n = 14) were reinforced with mesh, predominantly self-fixating (73.3%, n = 11). Eighty percent of patients (n = 12) were discharged on the same day, with a median follow-up of 153 days (IQR 55-309). Notable complications included clinically significant seromas in 20% of patients (n = 3), long-term hypoesthesia in 40% (n = 6), and readmission in one patient (6.6%) for surgical site infection (SSI) requiring IV antibiotic therapy.
CONCLUSIONS: Midline ventral hernias associated to diastasis recti can be managed robotically by ENDOR with safe and consistent 90-day outcomes in a carefully selected group of patients.

BACKGROUND: Preoperative application of botulinum toxin type A has demonstrated to be safe and effective in the closure of complex ventral hernias in adults. However, its use in pediatrics has been little documented.
METHODS: We present the case of a 22-month-old girl with a complex abdominal wall ventral hernia secondary to multiple neonatal laparotomies. In a first procedure, botulinum toxin was administered using an intramuscular approach at six sites of the muscle layers surrounding the defect, under general anesthesia and ultrasound control. 4 weeks later, an open hernia repair was conducted, without complications.
CONCLUSIONS: Botulinum toxin at low doses could facilitate the surgical treatment of complex ventral incisional hernias in children. Even though it is important to adjust dosage and anatomical reference points according to hernia type and patient age and weight, further studies are required to optimize these variables.
BACKGROUND: La aplicación preoperatoria de toxina botulínica A ha demostrado ser segura y efectiva en el cierre de hernias ventrales complejas en adultos. Sin embargo, se ha documentado poco su uso en pediatría.
METHODS: Se presenta el caso de una niña de 22 meses con una hernia de pared abdominal ventral compleja secundaria a múltiples laparotomías neonatales. En una primera intervención se administró por vía intramuscular toxina botulínica en seis puntos de las capas musculares alrededor del defecto bajo anestesia general y control ecográfico. Cuatro semanas después, se realizó una reparación abierta de la hernia, sin complicaciones.
UNASSIGNED: La toxina botulínica a dosis bajas podría facilitar el tratamiento quirúrgico de hernias incisionales ventrales complejas en niños. Es importante ajustar la dosis y los puntos de referencia anatómicos según el tipo de hernia, la edad y el peso del paciente, aunque se requieren más estudios para optimizar estas variables.

BACKGROUND: Active smoking is related to wound and respiratory complications following abdominal wall reconstruction (AWR), but no AWR studies directly compare outcomes of abstinent-smokers (AS), fulfilling four-weeks of smoking cessation, to non-smokers (NS).
METHODS: Prospectively maintained institutional database was queried for all AWR between 2012 and 2019. AS and NS were included. Primary outcomes were wound and respiratory complications; secondary outcome was recurrence. Standard statistical analyses were performed.
RESULTS: Evaluation included 1088 patients, 305 AS and 783 NS. AS had a lower BMI (31.3 vs 32.7 ​kg/m2; P ​= ​0.004) but increased ASA Class III (51.5% vs 34.5 ​%, P ​= ​0.009), COPD (8.9% vs 4.0 ​%, P ​= ​0.001), comorbidities (6.3 vs 4.7, P < 0.001), and wound class (Class III/IV: 25.3% vs 15.8 ​%, P ​= ​0.003). AS had increased defect size (229 vs 209.1 ​cm2; P ​= ​0.023), use of component separation (CST) (52.5% vs 43.8 ​%; P ​= ​0.010) and hospital stay (6.6 vs 6.2 days, P ​= ​0.015). Postoperative wound, mesh, and pulmonary infection, respiratory failure, and recurrence were similar. On multivariable regression, wound class and complications predicted recurrence. BMI, panniculectomy and CST predicted wound complications. BMI, CST, and wound class predicted respiratory complications.
CONCLUSIONS: Despite greater patient and hernia complexity, smoking cessation appears to result in similar outcomes to never-smokers in this AWR population.