Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 465 - файл

C. Horne, MD · A. Prabhu, MD (*) Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA e-mail: PRABHUA@ccf.org

Increased risk of complications is not limited to open repair exclusively, as patients with BMI >40 have a fourfold increased risk of recurrence when under­going laparoscopic hernia repair [20]. Bariatric surgery either prior to denitive recurrent repair or concurrent with laparoscopic hernia repair has been evaluated. Currently the data is limited to small, single institution retrospective analyses. There have been promising results in patients who underwent bariatric surgery prior to complex ventral hernia repair [21]. A study by Newcomb etal. showed no recurrence at 2–50 months postoperatively, and patients also had a signicant decrease in BMI from an average of 51kg/m hernia repair [21]. Although this study showed effective weight loss after bariatric surgery, patients undergoing concomitant bariatric surgery and ventral hernia repair are known to have increased 30-day unplanned reoperation, unplanned

readmission, and 30-day postoperative complications [22]. Although studies sug­gest that concomitant laparoscopic ventral hernia repair during bariatric surgery is safe, the authors prefer to avoid placement of intraperitoneal barrier coated mesh at the time of a clean-contaminated case as it has been suggested that barrier coat­ing may harbor infection and potentially result in wound complications [23]. Some patients with complex surgical histories and multiply recurrent hernias may not be candidates for a laparoscopic bariatric intervention. Additionally, adequate preoperative evaluation with a multidisciplinary team prior to bariatric surgery is essential, and patients with a recurrent ventral hernia and obstructive symptoms may not be able to complete the process prior to requiring surgical intervention for their hernia. Still, in patients that are candidates for bariatric surgery, it is rec­ommended that they undergo bariatric surgery prior to ventral hernia repair when possible.

the author’s practice, routine closure of the fascial defect is performed when techni­cally feasible.

One main limitation to laparoscopic hernia repair for recurrent hernias is defect size. Heniford et al. and Hauters et al. demonstrated that hernia defect size was associated with increased risk of recurrence after laparoscopic ventral hernia repair [20, 26]. Hauters etal. found that despite having more than 5cm overlap, when the mesh size to defect size ratio was less than 8, this was associated with a 70% risk of recurrence [26]. As defect size increases, laparoscopic bridge repair may result in mesh eventration, or pseudohernia occurrence, over time, which can be both dis­satisfying to patients and ineffective as a long-term repair. Although laparoscopic repair has been successful with defects that are larger, recurrence rates increase signicantly as the width of the hernia defect increases [26, 28]. While there is cur­rently no upper limit of defect size that can be approached laparoscopically, we currently recommend laparoscopic intraperitoneal onlay mesh repair for defects ≤7cm in greatest width.

As surgical site infections are a well-known factor associated with increased her­nia recurrence, it is likely that potential contamination will have to be managed when repairing a recurrent hernia [15, 20]. The type of reinforcement material utilized in these repairs must be carefully considered to minimize surgical site infection as well as repeat recurrence. Traditionally, biologic mesh was favored in contaminated situations due to the high incidence of postoperative wound morbid­ity. Recommendations from the Ventral Hernia Working Group suggest against synthetic mesh in both grade 3 (contamination of the wound or suspicion of con­tamination) or grade 4 (frankly infected wounds) as using biologic mesh in these situations does not require mesh resection even in the face of active infection [34]. Data in repair of grade 3 and 4 hernia repairs with biologic mesh demonstrates recurrence rates of approximately 12% and surgical site infection rates of 15–36% [46, 47]. There is data that supports the safety of using synthetic material in a contaminated eld. Lopez et al. evaluated placement of synthetic and biologic meshes in contaminated elds and saw no difference in surgical site infections (SSI) between the two groups but a 35% recurrence rate in situations when bio­logical cases were used compared to 8.3% when synthetic mesh was used [48]. Introduction of biosynthetic mesh provides another potential option in the repair of contaminated hernias. One example of biosynthetic mesh, Gore BioA, is com­posed of an absorbable copolymer that is gradually absorbed by the body in approximately 6–7months. A multicenter, prospective trial evaluated the use of this synthetic material in grade 2 and grade 3 [34] hernia repairs. Postoperative wound events occurred in 28% of patients, and recurrence occurred in 17% of repairs at 2years [49]. This represents a signicant decrease in surgical site occur­rence as well as hernia recurrence when compared to repair with non-cross-linked porcine dermis [ thetic mesh in contaminated elds, caution must be used in performing repairs with absorbable materials and should be saved for select circumstances. Additional biosynthetic meshes have subsequently been developed, however thus far there is insufcient literature available to comment on their performance in contaminated hernia repairs.