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102
U. A. Dietz et al.
needed to work with clinicians and to formulate
and test novel statistical algorithms. This,
together with risk adjustment, is one of the preconditions for the application of the data to
other populations. To produce results that are
readily applicable to multiple populations, the
statistical handling of missing individual data in
the registry must be transparent and published;
some registries practice the exclusion of incomplete data sets from their analyses, which can
represent a clear bias. Thus, for example, follow-up compliance declines sharply after only
6months. Further, statistical analysis of registry
data is not trivial if many patients and many
variables lead to many subgroup analyses. It
must be pointed out, however, that a registry
analysis does not involve a comparison between
procedures, but rather investigation of the
results obtained with the procedures in a given
population.
Without adequate risk adjustment, there can
be no benchmarking and no comparison
between two clinics. This is of special importance in a time when benchmarking is overrated. And nally, the general applicability of
results from registries must be reassessed.
Above all statements regarding the superiority
of one or another, surgical technique must be
examined closely in light of all the available
data and the risk adjustment, for the experience
of the surgeon also plays a role. Every act of
benchmarking that compares the “surgeon with
the mean value of his peers” is nonsense. For
benchmarks as they pertain to patients must
always aim at the best, never at the mediocrity
of a majority!
Conclusion
Perhaps the most important advantage of a
database is the awareness they raise regarding
the ndings they contain. This is the starting
point for lifelong learning and continuous
improvement of personal results. Surveillance
of medical products, benchmarking, and public health policy interests should not be
allowed to overburden and misuse the potential of databases.
References
1. Nilsson E, Haapaniemi S.Hernia registers and specialization. Surg Clin North Am. 1998;78:1141–55.
2. Binswanger M.Wenn Kennzahlen schaden. Harvard
Businessmanager. 2004;6:180–11.
3. Helgstrand F, Jorgensen LN.The Danish ventral hernia database—a valuable tool for quality assessment
and research. Clin Epidemiol. 2016;25:719–23.
4. Lawson EH, Zingmond DS, Hall BL, Louie R, Brook
RH, Ko CY.Comparison between clinical registry and
Medicare claims data on the classication of hospital
quality of surgical care. Ann Surg. 2015;261:290–6.
5. Kumar A, Yip YL, Smith B, Marwede D, Novotny
D. An ontology for carcinoma classication for
clinical bioinformatics. Stud Health Technol Inform.
2005;116:635–40.
6. Muysoms F, Campanelli G, Champault GG, et al.
EuraHS: the development of an international online
platform for registration and outcome measurement
of ventral abdominal wall hernia repair. Hernia.
2012;16:239–50.
7. Mathieu E, Barratt A, Carter SM, Jamtvedt G.Internet
trials: participant experiences and perspectives. BMC
Med Res Methodol. 2012;12:162.
8. Simonsohn U, Nelson LD, Simmons JP. P-curve:
a key to the le drawer. J Exp Psychol Gen.
2014;143:534–47.
9. Nuzzo R.Statistical errors. Nature. 2014;506:150–2.
Ventral Hernia Surgery inEurope:
Trends andActual Situation
S.G.Parker andA.C.J.Windsor
10
10.1 Background
European surgeons have been at the centre of hernia research for the past 150years. In the mid1800s, Billroth predicted the development of
prosthetic mesh by writing, “if we could articially produce tissues of the density and toughness of fascia and tendon, the secret of the ‘radical
cure’ for hernia would be discovered” [1]. Since
then the search for the perfect mesh implant has
been one of the main aims of hernia research.
Hernia research has also focused on improving the surgical technique for both inguinal hernia and ventral hernia surgery. Nuttall, from the
UK, described his technique of “rectus transplantation in the treatment of ventral hernias” in 1926,
and although this has not been adopted as a commonly used technique, this paved the way for
reconstructive surgeons to use more imaginative
and complex techniques to try and improve outcomes. In the same publication, Nuttall acknowledges that “the difculties of obtaining a ‘radical
cure’ in large ventral hernias are well known”
[2]. Over the last century, despite the discovery of
numerous innovative surgical techniques and the
synthesis of many complex surgical meshes, the
complication rates and hernia recurrence rates
after ventral hernia repair remain high, and the
“difculties” in nding a “radical cure” for ventral hernia disease still remain.
We will rst discuss the trends in ventral hernia surgery in Europe, focusing particularly on
the contributions made by European surgeons.
We will outline the trends in ventral hernia prevalence; we will discuss the risk factors involved in
ventral hernia recurrence, the methods used to
prevent ventral hernia occurrence, the evolution
of the mesh implant in ventral hernia repair, the
development of ventral hernia grading scales and
the emergence of day surgery and laparoscopic
surgery along with the associated reduction in
length of hospital stay. After this, we will discuss
the actual situation of European ventral hernia
surgery focusing on the innovative surgical techniques being used, ventral hernia sub-specialisation, multidisciplinary abdominal wall
reconstruction, surgical site infection prophylaxis and nally the emergence of national ventral hernia databases. Ventral hernia repair has
now become so complex that the term “abdominal wall reconstruction” is now commonly used.
10.2 Trends
10.2.1 Prevalence ofVentral Hernia
S. G. Parker · A. C. J. Windsor (*)
Department of Surgery, St Mark’s Hospital, North
London Hospitals NHS Trust,
Harrow, Middlesex, UK
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_10
Worldwide, studies have shown an increasing
prevalence of ventral hernia over the last 20years
[3, 4]. In Europe, smaller studies have also
reported an increasing prevalence in the ventral
103
104
S. G. Parker and A. C. J. Windsor
hernia repair [5, 6]. This increasing prevalence is
due to the increasing number of intra-abdominal
operations being performed and the high incisional hernia [7] and hernia recurrence rates,
which are reported at between 10 and 30% [8, 9].
A systematic review performed by Bosanquet
etal. from Cardiff University reported an overall
primary incisional hernia rate after midline laparotomy at 12.8% at 2years follow-up [10]. This
review also reported an increase in prevalence of
midline incisional hernia, with reported rates
averaging 8% in 1980 to 16% in 2012 [10] showing that incisional hernia rates have doubled in
the past 30years. There is, however, some doubt
as to whether the true ventral and incisional hernia recurrence rates (and therefore prevalence
rates) are ever reported. Results from the Danish
Ventral Hernia Database have demonstrated that
reoperation rates (frequently used to estimate
ventral hernia recurrence rates) underestimate
hernia recurrence by four- to vefold, [11] and a
publication from Spain in 2014 reported the true
umbilical trocar incisional hernia rate at 26%
after laparoscopic cholecystectomy at 47months
of follow-up. Previous estimates of umbilical trocar incisional hernia rates had been reported at
between 1 and 2% [12]. Consequently, it seems
that ventral hernia recurrence rates are likely to
be grossly underestimated due to loss to
follow-up.
10.2.2 Prevention ofVentral Hernia
European surgeons have led the research in incisional hernia prevention. In 1976, Jenkins published his landmark paper “The burst abdominal
wound: a mechanical approach” demonstrating
that a suture length to wound length ratio of 4:1
or greater signicantly reduced the rate of burst
abdomen when compared to a ratio of 2:1 [13].
Jenkins later published his results for incisional
hernia repair showing that his new technique for
mass closure reduced the rates of incisional hernia recurrence [14]. Consequently, the “Jenkins
Rule” which advised a suture length to wound
length ratio of 4:1 became common practice
amongst general surgeons. European academic
surgeons continued to analyse laparotomy closure technique and its associated wound complications and incisional hernia occurrence. Mayer
etal. showed that with high tension on a suture
line, there is a higher incidence of surgical site
infection (SSI) compared to low tension [15]; this
is probably due to compressed and devitalised
tissue. Suture closure with large bites was shown
to be associated with SSI, and again this is
thought to be because large bites compress and
cut through more tissues when compared to small
bites [16]. The Israelsson group, from Sweden,
published the rst level one evidence, in 2009,
which showed the “small bites” technique for
midline laparotomy closure signicantly reduced
the incidence of post laparotomy SSIs and incisional hernia. In the following year, the INLINE
systematic review, written in Germany, was published [17]. This conrmed that laparotomy closure should be performed using a continuous (vs.
interrupted), slowly absorbable (vs. rapidly
absorbable) suture to signicantly lower incisional hernia rates. To nally address the topic of
whether laparotomy closure should be with either
the continuous “small bites” (Israelsson technique) or the continuous “large bites” (Jenkin’s
rule) technique, a multicentre randomised controlled trial (RCT), the STITCH trial, was carried
out in the Netherlands between 2009 and 2012,
and the results were published in 2015. This
RCT, containing 560 patients, showed a signicant reduction in the rate of incisional hernia
using the “small bites” closure technique therefore recommending it’s standard use for laparotomy closure [18].
There are two other much-debated topics in
incisional hernia prevention. Firstly, whether or
not a midline or transverse incision should be
used, and secondly, whether or not a prosthetic
mesh (synthetic or biologic) should be inserted
at the time of laparotomy closure. Brown etal.,
from the UK, published a Cochrane review supporting the use of transverse abdominal incisions
as this signicantly reduces post-operative pain,
the risk of wound rupture and incisional hernia
and may quicken recovery. The review does recognise the limitations of transverse incisions in
terms of access to the abdominal cavity and
10 Ventral Hernia Surgery inEurope: Trends andActual Situation
105
recognises that the choice of incision remains
the preference of the surgeon [19]. Timmerlans
etal., from the Netherlands, published a metaanalysis of ve RCTs and showed a signicant
reduction in the rate of incisional hernia after
using polypropylene mesh at primary laparotomy closure when compared to suture closure.
There was no difference in wound infection or
seroma rate [20]. Currently, general surgeons do
not use the addition of synthetic mesh as a standard method of laparotomy closure despite this
supportive evidence to do so. This is because of
the added expense, the risk of mesh-related complications and the difculties in access if a
sequential intra-abdominal operation is required.
There is currently insufcient evidence to support the use of biological mesh for incisional
hernia prophylaxis [21].
This research into laparotomy closure resulted
in the publication of European Hernia Society
guidelines on the closure of abdominal incisions
in 2015 [22]. These guidelines include the use of
a non-midline incision where possible, a continuous slowly absorbable suture, the “small bites”
technique, the mesh augmentation in high-risk
patients and the closure of laparoscopic port sites
with a diameter of 10mm or greater.
10.2.3 Risk Factors forVentral Hernia
Recurrence
The prevalence of ventral hernia disease remains
high, and there is no evidence that recurrence
rates after repair are improving. To reduce recurrence rates, researchers have been working to
identify and control the risk factors associated
with recurrence. Observational studies and large
case series of ventral hernia repairs have been
published to analyse the variables that predispose
to wound complications and recurrence. In the
literature, high BMI [23], smoking [24], diabetes
[25], advanced age [26], steroid use [27], previous hernia repair [28], previous and post-operative wound infections [29], size of hernia defect
[26] and onlay mesh [30] have all been shown to
be associated with surgical site occurrences and
hernia recurrence. In Europe, Rios et al. pub-
lished a series of 261 open ventral hernia repairs
showing that age greater than 60, previously
attempted ventral hernia repair, hernia width
greater than 10 cm, and post-operative wound
infection all predisposed to hernia recurrence [9].
Bencini et al. published a series of 146 laparoscopic ventral hernia repairs in 2009 and showed
that smoking and previously failed ventral hernia
repair were signicant factors for recurrence
[31]. In 2013, the Danish Ventral Hernia Database
published its outcomes for 3258 incisional hernia
repairs and showed poor early outcomes for
patients with advanced age, open repair, a hernia
defect greater 7 cm in diameter, and a vertical
incision at the time of primary laparotomy.
Higher late complication rates were associated
with younger age, open repair, wider hernia
defects greater than 7cm, and onlay or intraperitoneal mesh [26]. Advanced age was an inverse
risk factor for long-term reoperation due to more
comorbidity, fewer cosmetic objections and
shorter life expectancy. Recently, Hauters etal.,
from Belgium, have shown that in laparoscopic
ventral hernia repairs with a bridging technique,
recurrence is associated with incisional ventral
hernia, BMI>35, defect width >4cm, defect area
>20cm
2
, mesh overlap <5cm and ratio of mesh
area to defect area of ≤12 [32]. This demonstrates
a worldwide emerging trend in ventral hernia
research that surgeons are increasingly looking at
preoperative CT scan dimensions as risk factors
for recurrence.
10.3 The Mesh Implant
The rst prosthetic mesh was made from silver
ligree and used by Goepel in Germany [33], and
during the rst half of the nineteenth century,
other metallic meshes were trialled, but their use
was not popularised due to their propensity to
cause sinus tracts and chronic pain. The rst use
of polypropylene mesh was in 1956 when Sir
Francis Usher used a at sheet of polypropylene
mesh (Marlex) to bridge a hernia defect [34].
Since then polypropylene has become the most
widely utilised material for ventral hernia repair.
Polyester and expanded polytetrauoroethylene
106
S. G. Parker and A. C. J. Windsor
(ePTFE) are two other plastics that have been
used to make synthetic mesh. In the 1980s, Rives
and Stoppa helped to popularised the mesh repair
with their independent publications describing
the placement of mesh in the retro-rectus plane
[35, 36]. During the 1990s, Luijendkil etal. conducted the rst multicentre randomised trial comparing suture and mesh repair in 181 elective
ventral hernias [37]. The 3-year hernia recurrence
rates were 46% for suture repair and 23% for
mesh repair. At 10years of follow-up, the authors
found a recurrence rate of 63% for suture repair
and 32% for mesh repair with no signicant difference in other complications [38]. This level
one evidence has led to surgeons abandoning primary suture repair and adopting mesh repair as
the technique of choice. As a result, researchers
have since focused on the properties of the mesh
prosthesis aiming to discover which mesh produces the best surgical outcomes.
Multiple mesh products have been developed.
For small ventral hernias, patch or plug systems
have been developed and are widely used across
Europe [39, 40]. The advent of laparoscopic ventral hernia repair has led to the invention of composite meshes, as synthetic polypropylene and
polyester meshes cause bowel adhesions when in
contact with the abdominal viscera [41].
Composite meshes have a biodegradable coating
that provides a barrier between the viscera and
the synthetic mesh allowing for the formation of
neoperitoneum before absorption. Many composite mesh products have emerged on the market (Parietex, Proceed, DualMesh, etc.). The fear
of mesh infection and subsequent mesh explantation after ventral hernia repair has led to the
development of both biologic and biosynthetic
mesh. Published guidelines recommend the use
of biologic mesh in a contaminated operative
eld due to the theoretical benets of tissue
ingrowth, revascularisation and infection resistance [42]. However, level one evidence comparing synthetic vs. biologic mesh in contaminated
ventral hernia repair is still lacking, and recent
retrospective trials give conicting results as the
real benets of a biologic mesh [43, 44]. Similar
to composite mesh, there are multiple biologic
(Strattice, Cellis, XenMatrix, Surgimend, etc.)
and biosynthetic (Gore Bio-A, Phasix, Tiger,
etc.) mesh products available.
Many other mesh products exist but to go into
all the available products, and their theoretical
advantages, disadvantages and indications is
beyond the scope of this chapter. Mesh products
differ in their pore size, weight, strength, absorption half-life, method of xation and cost. Today,
there is a highly competitive market in Europe,
and worldwide companies compete to produce
the best synthetic mesh.
10.4 Ventral Hernia Grading
Scales
At the second international meeting of herniologists in Suvretta, Austria, in 1998, Volker
Schumpelick called for a classication of incisional hernias, which would enable “multicentre
trials” and “comparison of the literature”.
Consequently, at the turn of the century, incisional
hernia classication systems began to be described
by European surgeons. In the following year,
Schumpelick published his own grading scale
[45], and at a similar time, Chevrel and Rath published their, better known, classication scale
[46]. A modication of the Chevrel classication
was published shortly afterwards, after a meeting
of ten international hernia experts [47]. In 2005,
Ammaturo and Bassi argued for the addition of
the “anterior abdominal wall to the hernia defect
ratio” to the Chevrel classication [48]. Later,
Dietz etal. described a highly complex incisional
hernia classication system [49]. However, none
of these grading systems have been validated or
adopted for clinical use. At the 29th Congress of
the European Hernia Society (EHS) in May 2007,
Andrew Kingsnorth, the society’s president,
stressed that a classication of ventral and incisional hernia was important as the literature was
comparing “apples and oranges”. This led to the
development of the EHS classication systems
for primary and incisional abdominal wall hernias
[50]. Both the primary and incisional classications categorise the hernias according to their
location and size, allowing for the comparison of
ventral hernias according to their morphology.
10 Ventral Hernia Surgery inEurope: Trends andActual Situation
107
These two EHS classication systems have been
widely adopted in the literature as they are simple
to use but detailed enough to describe a ventral
hernia’s physical characteristics. They are currently being used by both the European ventral
hernia database (EuraHS) and the American
Hernia Society Quality Collaborative (AHSQC)
database. To date, there is only one publication
that externally validates the EHS classication
system. This shows a signicant dependence of
surgical site occurrences according to the EHS
classication [51].
Worldwide, several other classication systems have been described, which stratify patients
according to their risk of either surgical site
infection or recurrence. Some have been externally validated showing differing degrees of
accuracy. Perhaps the most well-known of these
is the Ventral Hernia Working Group (VHWG)
grading scale [42], which uses comorbidity and
risk of wound contamination to stratify patients
into four tiers. Many European surgeons use this
scale whilst carrying out their own research and
when describing ventral hernias.
10.5 Reduction inHospital
Length ofStay
During the end of the twentieth century, the
length of hospital stay for the post-operative ventral hernia patient has reduced signicantly. This
came about because of the development of day
surgery and the invention of laparoscopic
surgery.
10.5.1 Day Surgery
Day surgery for hernia repair was a concept principally developed in the UK by Brendan Devlin.
His landmark paper, published in the Lancet in
1977, showed no difference in complication rates
after inguinal hernia repair for patients who were
discharged 8h after surgery compared to patients
who stayed in hospital for 5 or 6days after surgery [52]. In this paper, he also demonstrated that
day surgery resulted in signicant cost savings.
Over time day surgery units were developed
throughout Europe, with many hernia centres
reporting large case series of day-case ventral
hernia repairs by the early 2000s [53, 54].
10.5.2 Laparoscopic Ventral Hernia Surgery
Ever since the rst laparoscopic cholecystectomy
in 1985, laparoscopic surgery has been utilised
for a vast number of general surgery procedures.
The rst laparoscopic ventral hernia repair is
accredited to Leblanc in 1993 [55]. Soon afterwards case series of laparoscopic ventral hernia
repairs started to be published by European surgeons [56]. The rst RCT comparing laparoscopic and open ventral hernia repairs was
published in 1999 by a Spanish surgical group
[57]. This RCT demonstrated that laparoscopic
repair signicantly reduced not only post-operative complication rates but also length of hospital
stay, reoperation rate, hernia recurrence and
operation time. Since this publication other RCTs
haven’t shown such complimentary result for the
laparoscopic technique; however, there is little
doubt that laparoscopic repair does signicantly
reduce the length of hospital stay and the local
wound infection rates [58].
During the early twenty-rst century, laparoscopic ventral hernia repair has become a widely
accepted technique. Large case series have been
published from European hospitals, most notably
from Spain [59, 60]. To improve outcomes,
researchers have been trying to adjust and
improve the ner details of laparoscopic repair.
In Europe, Muysoms et al. carried out an RCT
comparing the “double crown”, “tackers only”
mesh xation technique with the “tackers and
sutures” mesh xation technique. This trial found
that the “double crown” xation was quicker and
less painful post-operatively and at 3 months
after hernia repair. There was no associated
increase in recurrence rate [61]. However, a published systematic review, also from Belgium,
reports “none of the currently available mesh
xation techniques used for LVHR is found to be
superior in preventing hernia recurrence as well
108
S. G. Parker and A. C. J. Windsor
as in reducing abdominal wall pain”, and the literature, in general, remains inconclusive about
the best mesh xation technique. Indeed, much
of the literature on laparoscopic ventral hernia
repair has been contradictory, and this led to the
publication of the evidence-based guidelines
from Italy in 2013 [62]. Of note, they recommend
a mesh to hernia defect overlap of 3 cm for
smaller defects (3–4cm) and a 5cm mesh overlap for larger defects (>4cm). Currently research
in laparoscopic ventral hernia repair in Europe is
focusing on mesh type, defect closure and mesh
xation with glue. Further studies are required to
evaluate the long-term outcomes of these many
different methods and techniques.
10.6 Actual Situation
10.6.1 Innovative Surgical Techniques
In recent years, there has been much pioneering
work investigating new ventral hernia repair
techniques. This innovation was, in part, led by
French surgeons, Rives and Stoppa, who both
published their case series of retro-rectus incisional hernia repairs in the 1980s [35, 36]. This
technique placed the synthetic mesh posterior to
the rectus abdominis muscles and anterior to the
posterior sheath and has reduced the local wound
complication rates and hernia recurrence in
patients receiving open surgery [26]. Shortly
afterwards, Ramirez published the anterior component separation technique, which is used by
most hernia surgeons to achieve primary abdominal closure with large ventral defects [63].
Preoperative pneumoperitoneum and botulinum
injections into the abdominal strap muscles are
two other techniques that have been invented by
surgeons to stretch the abdominal muscles before
ventral hernia repair. Several European surgeons
have published their series of ventral hernia
repairs with preoperative pneumoperitoneum
[64–68], over the last 30years. However, despite
these series show promising results, preoperative
pneumoperitoneum has not become a routine
practice in specialist hernia centres.
Today, innovative ventral hernia repair techniques are being investigated by many European
surgeons. Whilst the Rives-Stoppa repair and the
anterior component separation technique remain
standard techniques for open midline hernia
repair, many European institutions are now using
the open transversus abdominis release (TAR)
approach for the larger, more complex midline
hernias [69, 70] with one cohort study reporting a
lower wound infection rate with TAR when compared to anterior component separation [71]. This
is thought to be due to the use of subcutaneous
skin aps during anterior component separation,
which predispose to local wound complications.
Laparoscopic ventral hernia repair with intraperitoneal onlay mesh (IPOM) is also a commonly
used technique throughout Europe. To improve
this technique, specialist centres are now using
the “laparoscopic augmentation” repair, or the
“IPOM plus” repair, which combines closure of
the defect with intraperitoneal mesh placement.
Defect closure is achieved either via an intra-corporeal continuous suture or by extracorporeal
interrupted transfascial sutures. A recent large
case series of 1326 patients from Belgium using
the “IPOM plus” technique shows promising
results with a wound infection rate, a seroma formation rate and a recurrence rate of <1%, 2.6%
and 4.7%, respectively, at 78 months follow-up
[72]. In Denmark, Lars Jorgensen is performing
open ventral hernia repairs with assisted endoscopic component separation [73]. This technique preserves the blood supply to the midline
subcutaneous tissue, therefore aiming to reduce
local wound complication rates. At present, larger
studies are required to see if endoscopic component separation adds any signicant clinical benet. The use of preoperative pneumoperitoneum
may become “in vogue” again after a recent case
series published by Renard et al., from Reims,
which showed an 8% recurrence rate [74]. In
addition, another recent case series from Spain
used both preoperative pneumoperitoneum and
botulinum injections for preoperative abdominal
wall relaxation [75]. By using both techniques
simultaneously, they have reported an excellent
recurrence rate of 4.4% with a median follow-up
of 40.5 months. Other innovative techniques
10 Ventral Hernia Surgery inEurope: Trends andActual Situation
109
currently being investigated in Europe include
both robotic and laparoscopic retro-rectus ventral
hernia repair. The results of these two new techniques are yet to be reported in the literature.
1
10.6.2 Sub-Specialisation
Ventral hernia repair is becoming increasingly
complex. This is partly due to the rising prevalence of obesity, advancing age and the high
recurrence rate of ventral hernia (as each subsequent hernia repair becomes increasingly challenging). The presentation of obese, elderly
patients with multiple previous ventral hernia
repairs and a history of signicant abdominal surgery (either for cancer or not) are now not
unusual. These patients with multiple comorbidities and large, complex recurrent ventral hernias
are difcult to repair. As a result, most European
countries have started to introduce national centres for hernia surgery with varying degrees of
formality. In Germany, a three-tier system for
ventral hernia surgery, with formal surgeon training and certication, has been implemented [76],
and Denmark has ve nationally approved hernia
surgery centres [77]. In the UK, complex ventral
hernia patients have traditionally been referred to
our national intestinal failure units; however, we
plan to create hernia centres [78] and introduce a
national triage system for ventral hernia patients.
Specialist hernia centres must have the appropriate resources if they are to treat these complex
patients affectively. Multidisciplinary teams
including both general and plastic surgeons, bariatric surgeons, intensivists and radiologists are
required. If the centre also treats intestinal failure
with contaminated ventral hernias containing
entero-cutaneous stulas, medical nutritionists
are also required. This multidisciplinary approach
to complex ventral hernia repair is being performed in many centres across Europe [69–80].
1
Robotic ventral hernia repair is being carried out by Filip
Muysoms, Gent University Hospital, Belgium.
Laparoscopic retro-rectus ventral hernia repair is being
performed by Salvador Morales-Conde, Ave Maria
Surgical Centre, Seville, Spain.
10.6.3 Prevention ofSurgical Site
Infections
As previously stated in this chapter, studies have
reported an association between surgical site
infections (SSIs) and ventral hernia recurrence
[29, 81]. Consequently, in recent years there has
been much research into the prevention of postoperative wound infections. One technique that
has been instrumental in lowering SSIs is the
design of the negative wound pressure dressing.
Retrospective comparative studies [82, 83] of
post abdominal wall reconstruction have shown
negative pressure dressings to signicantly
reduce wound infections rates. These negative
pressure dressings are now being used in clinical
practice for SSI prophylaxis, particularly for
high-risk or contaminated patients.
10.6.4 National andInternational
Ventral Hernia Databases
Throughout surgery there has been an emergence of multicentre databases. Pooled data
from large population samples can be used by
academic surgeons to determine complications
rates, discover preoperative risk factors for operative failure and improve our knowledge about
the consequences of variations in surgical technique. In Europe, so far, three national and one
international databases have been implemented
in recent years: the Danish Ventral Hernia
Database (DVHD) [84], the German Ventral
Hernia Database, “HerniaMed”, the Spanish
incisional hernia database (EVEREG) [85] and
the European registry for abdominal wall hernias
(EuraHS) [86]. The Danish database was the rst
to be founded in 2007 and has already produced
many informative publications. These databases
will contribute much to the future literature and
to our understanding about ventral hernia disease. In particular, they should be used to externally validate the previously mentioned ventral
hernia grading scales as accurate grading scales
which predict ventral hernia repair success and
would be extremely useful in the clinical
setting.
110
S. G. Parker and A. C. J. Windsor
Conclusion
As ventral hernia recurrence rates and postoperative wound complications rates remain
high, the challenges involved in improving
ventral hernia repair outcomes are at the forefront of surgical science. As a result, there has
been a signicant increase in academic interest in this area of surgery. In Europe and
worldwide, this subspecialty is now rapidly
evolving with much innovation, which
requires accurate investigation and publication to further our understanding and to
improve operative outcomes.
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