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26 Robotic Ventral andIncisional Hernia Repair: Management ofAdverse Events
421
post- operative period while recovering in the hospital are taken, including pharmacologic prophylaxis with subcutaneous Heparin or low-molecular weight Heparin
(Lovenox), along with mechanical prophylaxis with sequential compression
devices and frequent ambulation. If the surgery is planned to be ambulatory, then
post-operative pharmacologic DVT prophylaxis is not indicated unless, again, if
the patient has a prior history of DVT and/or PE [18]. In fact, large studies have
already demonstrated that robotic ventral hernia repair is associated with shorter
length of stay and complication rates, where DVT and PE do not play a signicant
role [19].
Hospital-acquired pneumonia (HAP) has also been studied as a possible adverse
event following minimally invasive ventral or incisional hernia repair, including the
robotic approach. The literature results vary, but a recent study showed higher rates
of pneumonia in patients who underwent robotic ventral hernia repair compared to
those who had the procedure with laparoscopic techniques. However, after controlling for confounding variables, there was no signicant difference [20]. Part of the
reason may be that the patients who are selected to undergo a robotic repair tend to
be of more advanced age and with a higher American Society of Anesthesiologists
(ASA) classication, which puts them at a higher risk for pneumonia. Aspiration
precautions in this patient population are essential. On the other hand, the use of
incentive spirometry on robotic ventral or incisional hernia repair patients is part of
the fundamental principles of postoperative recovery, both in the hospital and at
home, to counteract the effects of atelectasis and prevent pneumonia.
Finally, the discussion of adverse events during or after robotic ventral or incisional hernia repair cannot be complete without an analysis of system malfunction.
This topic has been a very important one for the Food and Drug Administration
(FDA) for several years since the robotic platform was approved in the United
States. At least in the urology international literature, possible malfunction mechanisms during urologic robotic procedures have included the arm system, the optical
system, the power system with the connector, endoscopic instruments, and the software itself [21]. The most important lesson is the proper training of the surgical
team to manage the malfunction in a timely fashion and, if not possible, to convert
to a traditional laparoscopic approach if possible before considering conversion to
open. In either case, patient safety is at the forefront of any action taken in the operating room.
In the American literature, a very large retrospective series of 14years of data
has revealed some important lessons, as well, specically pertaining to the surgical
specialties that utilize the robot more often. These specialties, including gynecology, urology, and general surgery, exhibit lower rates of mortality, injuries, and
conversions to open compared to those specialties where the robotic platform is not
frequently used, such as cardiothoracic surgery and otolaryngology. System malfunction was also studied in terms of adverse events dealing with the components of
the platform, including burnt or broken pieces of instruments falling into the patient,
electrical arcing, unintended operation of instruments, system errors, and problems
with the visual system. The procedure was interrupted to restart the system sometimes, while other times the procedure was rescheduled when critical portions were
422
A. M. Gonzalez and R. J. Oviedo
not performed. Education is of paramount importance, both for the surgical team
and for the industry, so that adverse events are reported properly and dealt with as
soon as they occur [22].
To summarize, robotic ventral and incisional hernia repair has become one of the
most frequently performed minimally invasive procedures for general surgeons in
the last few years, with the development of advanced techniques for abdominal wall
reconstruction that go beyond a traditional laparoscopic intraperitoneal onlay mesh
(IPOM) repair. These advanced techniques expand to the realm of intracorporeal
primary closure of the hernia, preperitoneal or extraperitoneal mesh implantation,
with or without posterior component separation via the transversus abdominis
release (TAR) approach. Patients who were traditionally not considered for minimal
access surgery are being offered a robotic repair, with successful outcomes and low
rates of complications, including recurrence. Adverse events do and will continue to
occur, but their incidence can be lowered with the use of meticulous technique especially during adhesiolysis and enterolysis, the primary repair of the defect, the
implantation of the mesh in the selected plane, and the adherence to sound surgical
principles just as it is done during open surgery. Constant awareness and knowledge
of possible system malfunction scenarios and potential injuries to the patient must
always be mastered by the entire team to achieve the highest standards of quality
and patient safety.
References
1. Warren JA, Love M.Incisional hernia repair– minimally invasive approaches. Surg Clin N
Am. 2018;98:537–59. https://doi.org/10.1016/j.suc.2018.01008
2. Bensley RP, etal. Risk of late-onset adhesions and incisional hernia repairs after surgery. J Am
Coll Surg. 2013;216(6):1159–116812. https://doi.org/10.1016/j.jamcollsurg.2013.01.060.
3. Prabhu AS, etal. Laparoscopic vs robotic Intraperitoneal mesh repair for incisional hernia: an
Americas hernia society quality collaborative analysis. J Am Coll Surg. 2017;225(2):285–93.
4. Li J, Ji Z, Zhang W, Li L.The comparison of lightweight mesh and standard mesh in incisional
hernia repair with the open sublay technique: the results of a meta-analysis. Surg Laparosc
Endosc Percutan Tech. 2015;25:238–44.
5. Darehzereshki A, et al. Biologic versus nonbiologic mesh in ventral hernia repair: a sys-
tematic review and meta-analysis. World J Surg. 2014;38:40–50. https://doi.org/10.1007/
s00268-013-2232-1.
6. Kennedy M, etal. Robotic TAPP ventral hernia repair: early lessons learned at an inner city
safety net hospital. JSLS. 2018;22(1):e2017.00070. https://doi.org/10.4293/JSLS.2017.00070.
7. Sharma A, Chowbey P, Kantharla NS, Baijal M, Soni V, Khullar R.Previously implanted intra-
peritoneal mesh increases morbidity during re-laparoscopy: a retrospective, case-matched
cohort study. Hernia. 2018;22:343–51. https://doi.org/10.1007/s10029-017-1686-8
8. Haitian Z, et al. Totally extraperitoneal laparoscopic hernioplasty – the optimal surgical
approach. Surg Laparosc Endosc Percutan Tech. 2009;19(6):501–5.
9. Williams SB, Greenspon J, Young HA, Orkin BA. Small bowel obstruction: conserva-
tive vs surgical management. Dis Colon Rectum. 2005;48:1140–6. https://doi.org/10.1007/
s10350-004-0882-7.
10. Carbonell AM, et al. Reducing length of stay using a robotic-assisted approach for ret-
romuscular ventral hernia repair. Ann Surg. 2018;267(2):210–7. https://doi.org/10.1097/
SLA.0000000000002244.
26 Robotic Ventral andIncisional Hernia Repair: Management ofAdverse Events
11. Chou R, etal. Guidelines on the management of postoperative pain: a clinical practice perspec-
tive from the American pain society, the American Society of Regional Anesthesia and Pain
Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia,
Executive Committee, and Administrative Council. J Pain. 2016;17(2):131–57.
12. Boerboom SL, etal. Preperitoneal bupivacaine inltration reduces postoperative opioid con-
sumption, acute pain, and chronic postsurgical pain after bariatric surgery: a randomized controlled trial. Obes Surg. 2018;28(10):3102–10.
13. Tayar C, Karoui M, Cherqui D, Fagniez PL. Robot-assisted laparoscopic mesh repair
of incisional hernias with exclusive intracorporeal suturing: a pilot study. Surg Endosc.
2007;21:1786–9. https://doi.org/10.1007/s00464-007-9247-3.
14. Lindmark M, Strigard K, Lowenmark T, Dahlstrand U, Gunnarsson U.Risk factors for surgi-
cal complications in ventral hernia repair. World J Surg. 2018;42(11):3528–36.
15. Oviedo RJ, Robertson JC, Desai AS.Robotic ventral hernia repair and endoscopic component
separation: outcomes. JSLS. 2017;21(3):e2017.00055.
16. Oviedo RJ, Brownstein NC, Smith SL, Robertson JC, Nair-Collins S.First 200 robotic general
surgery cases in a community hospital: a retrospective cohort study. World J Surg Surgical Res.
2018;1:1034.
17. Gonzalez AM, Romero RJ, Seetharamaiah R, Gallas M, Lamoureux J, Rabaza JR.Laparoscopic
ventral hernia repair with primary closure versus no primary closure of the defect: potential
benets of the robotic technology. Int J Med Robot. 2015;11:120–5. https://doi.org/10.1002/
rcs.1605.
18. Gonzalez A, etal. Robotic-assisted ventral hernia repair: a multicenter evaluation of clinical
outcomes. Surg Endosc. 2017;31:1342–9. https://doi.org/10.1007/s00464-016-5118-0.
19. Beekman R, Crowther M, Farrokhyar F, Birch DW.Practice patterns for deep vein thrombosis
prophylaxis in minimal-access surgery. Can J Surg. 2006;49(3):197–202.
20. Altieri MS, Yang J, Xu J, Talamini M, Pryor A, Telem DA.Outcomes after robotic ventral
hernia repair: a study of 21,565 patients in the state of NewYork. Am Surg. 2018;84(6):902–8.
21. Coakley KM, etal. A nationwide evaluation of robotic ventral hernia surgery. Am J Surg.
2017;214:1158–63. https://doi.org/10.1016/j.amjsurg.2017.08.022.
22. Chen CC, etal. Malfunction of the da Vinci robotic system in urology. Int J Urol. 2012;19:736–
40. https://doi.org/10.1111/j.1442-2042.2012.03010.x.
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Incisional Hernia inOncologic Surgery
27
JohnM.Lyons III
The past 50years has seen major changes in the eld of cancer surgery. Where previously, radical surgery was thought to be a prerequisite for cure, modern cancer
surgeons understand that radicality can be superuous; and bigger procedures do
not always lead to better cancer outcomes. Today, preoperative surgical evaluation
considers technology, multimodal therapy, and minimally invasive techniques.
While great advances in multimodal cancer treatment have been realized, surgery
remains the mainstay of treatment for most solid organ intra-abdominal malignancies. Rather than replacing surgery as a treatment modality, systemic therapy has, in
many cases, enabled surgeons to expand their services to patients previously considered unresectable.
A good example is colorectal liver metastasis. Previously, very conservative criteria limited resectability only to those with unilobar, small volume, liver-only disease in whom a very wide margin could be achieved. However, liver surgery has
become safer in the past 30years [1]. This fact as well as advances in portal vein
embolization, ablation techniques, and multi stage hepatectomy has led to an
increase in the number of complex resections [2]. Moreover, pre-operative chemotherapy has the ability convert select patients with advanced disease to a resectable
status [3]. Preoperative “conversion therapy” is now discussed regularly in patients
with locally advanced pancreas cancer, gastric cancer, and several other solid organ
malignancies [4, 5]. A similar trend has been seen in the management of primary
and secondary peritoneal malignancies. Once thought to be a futile endeavor, now
select patients with good functional status and low volume peritoneal disease are
offered large cytoreductive surgeries with concomitant administration of intraoperative chemotherapy routinely.
J. M. Lyons III (*)
Our Lady of the Lake Physician Group, Baton Rouge, LA, USA
Louisiana State University Health Sciences Center, New Orleans, LA, USA
e-mail: John.lyons@fmolhs.org
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_27
425
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J. M. Lyons III
While our ability to support these patients through complex oncologic resections
has improved greatly, postoperative incisional hernia (IH) remains a source of major
morbidity. About 1/3 of patients with postoperative IH will have symptoms of pain/
discomfort, obstruction, or limitations of activity which can translate into worse
physical and social functioning, general health perception, and overall lower body
image [6, 7]. An estimated 17% of these patients present with incarceration or strangulation necessitating an urgent or emergent operation [8]. Moreover, the incidence
of these defects appears to be rising as does the cost of repairs with a recent estimate
of over $3 billion per year [9, 10].
Several technical and patient-related factors have been identied as predictive of
postoperative IH.These include obesity, poor glycemic control, smoking, loss of
domain, surgical site infection [11]. This chapter reviews several risk factors associated with the development of postoperative IH, focusing on those which have unique
signicance or prevalence in the cancer patient.
27.1 Size oftheIncision
The choice of incision in abdominal surgery depends on adequacy of exposure,
previous abdominal incisions, body habitus, the anticipated pathology, and surgeon
preference. Traditional (open) approaches to cancer surgery include midline, paramedian, transverse, and oblique incisions.
The midline incision is the most commonly used in abdominal surgery as it is the
simplest and provides adequate exposure to practically all four quadrants [12]. It is
rapid to open and close; it is usually bloodless; and no muscle bers are divided.
However, IH is a major problem following midline incision with rates ranging up to
20% [13].
The paramedian incision may be an alternative to the midline incision. It is usually made by incising the skin down to the anterior rectus sheath over its the middle
third. The rectus muscle is dissected free from its anterior and medial attachments
and mobilized laterally to expose the posterior sheath, which is then incised longitudinally. The rectus muscle is not divided and its blood supply and innervation is
maintained so that it bolsters the closure of the posterior and anterior sheaths at the
conclusion of the case [14]. One of the challenges in evaluating this incision is that
not all paramedian incisions are the same. Some groups using a medial paramedian
(closer to the midline) have shown rates of IH very similar to those of a midline
laparotomy [15, 16]. However, other groups using the lateral paramedian incision
have seen virtually no incisional hernias [17]. Cahalane etal. combined prospective
data from several series using the lateral paramedian incision and observed hernias
in only four of 1203 (0.33%) cases at 1year, without a single dehiscence [17]. Thus,
the closer the fascial incision is to the midline, the less effective the paramedian
incision is in the prevention of IH.In addition, the paramedian incision tends to be
more limiting and more time-consuming than the midline incision.
Transverse and/or oblique incisions are associated with fewer IH, and some have
suggested less respiratory compromise, less overall morbidity than midline
27 Incisional Hernia inOncologic Surgery
427
incisions [18, 19]. However, similar exposure constraints limit the utility of these
approaches to cases with a very narrow focus.
The eld of minimally invasive surgery has grown considerably since the report
of the rst laparoscopic appendectomy by Dr. Kurt Semm in the early 1980s [20].
Since that time, it has been applied to several types of oncologic resection; however
the most comprehensive and thorough analysis of minimally invasive oncologic
resection has been in the arena of colorectal surgery. The rst laparoscopic colectomies were performed in the early 1990s [21]. While these early cases demonstrated
technical feasibility, concerns regarding adequacy of lymph node staging, the effect
of abdominal insufation on tumor dissemination, and the risk of trocar site implants
made the oncologic merits of laparoscopy less certain. To address these oncologic
concerns, several randomized controlled trials were conducted comparing laparoscopic to open colon resections [22–25]. In general, laparoscopy was found to have
lower blood loss, less need for narcotics, quicker return of bowel function. Moreover,
they all demonstrated oncologic equivalency with regard to survival and recurrence
in long-term follow-up. The range of laparoscopic procedures has now expanded to
include resection for gastric cancer, esophageal cancer, gynecologic cancer, as well
as prostate and bladder cancer [26–29]. Minimally invasive pancreatic and liver
resection surgery is also being evaluated [30, 31].
Incisional hernia rates following laparoscopic and open surgery have been compared by many. A retrospective analysis of 1057 colectomies (289 laparoscopic, 768
open) performed in a single British training center focused exclusively on patients
with colorectal cancer [32]. The primary outcome was incidence of IH relative to
surgical approach. They found the overall incidence of IH was 14.8% and noted no
signicant difference between the open and laparoscopic technique (14.4% vs. 15.9%,
p=0.566). These ndings were corroborated by a larger British registry study looking
at IH incidence in colorectal cancer patients [33]. However, this is contrary to data
obtained from the Danish Colorectal Cancer Group and the Dutch National Patient
Registry which did show a difference in IH incidence favoring laparoscopy (5.3% vs.
7.3%, p<0.001) [34]. In general, the published rates of IH after laparoscopy vary
greatly in non-randomized studies likely reecting different methods of IH detection
(some using radiology, other using only clinical examination) and varying length of
follow up. Two of the randomized multicenter trials designed to assess oncological
outcome did not detect a decrease in IH after laparoscopic access, although a trend in
favor of laparoscopy was seen in follow-up of the CLASICC trial [35, 36].
Kossler-Ebs etal., performed a meta-analysis on 24 randomized controlled trials comparing IH rates after laparoscopic versus open surgery for all indications [37]. This
included analysis of 3490 patients. The authors found that IH was signicantly
reduced among patients whose surgery was completely laparoscopic (4.3% vs. 10.1%,
p=0.0002). However, this difference was not observed in the subgroup of patients
having “laparoscopic assisted” surgery with the hernia incidence at the extraction site
comparable to that of open surgical approaches (5.5% vs. 7.8%, p=0.31).
Proponents of robotic-assisted surgery have suggested that the rate of IH is lower
than that of typical laparoscopy because the robotic technique enables the use of
smaller port incision sites and wristed instruments which promote less direct tissue
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J. M. Lyons III
trauma [38]. To date, there are few series reporting IH rates following robotic
abdominal surgery; and most of these reports are small, single institutional series.
However, data that do exist suggest that the reduction in IH following robotic surgery is negligible. One single-institution retrospective review of 259 patients undergoing a robotic colorectal surgery from 2009 to 2014 found the overall IH rate to be
5.8% [39]—a rate similar to that reported by several laparoscopic series [40, 41]. A
relatively recent study from the Memorial Sloan Kettering Cancer Center compared
IH rates among patients who had undergone laparoscopic versus robotic right colectomy for colon cancer [42]. The clinical and demographic characteristics between
the two groups were similar except that patients in the laparoscopic group had more
advanced stage on average. Overall complication rates between the two groups were
similar as was the incidence of IH.The rate of IH development was 22% and 17%
(p=0.39) for the laparoscopic and robotic groups, respectively.
27.2 Obesity
Obesity is a critical world health problem. A 2005 pooled analysis indicated that
937 million adults are overweight, and 396 million are obese. Taken together this
means that approximately 1/3 of the world population is considered either overweight or obese; and if that trend continues, the incidence of overweight and obese
people worldwide is projected to reach approximately 58% by 2030 [43]. The physiologic relationship between obesity and oncogenesis is complex, but the biological
mechanisms that have received most attention include insulin, insulin-like growth
factors, sex hormones, and adipokines. Briey, in the obese patient, insulin resistance develops as a metabolic adaptation to increased levels of circulating free fatty
acids released from intra-abdominal adipose tissue. This is compensated by
increased pancreatic insulin secretion. This chronic hyperinsulinemia has been
linked to oncogenesis in several types of cancers [44].
The link between obesity and cancer has been demonstrated in numerous clinical
studies as well [45]. In 2002, the International Agency for Research on Cancer
(IARC) concluded that there is adequate evidence of an association between obesity
and several cancers including colon, postmenopausal breast, endometrial, kidney,
and esophageal [46]. In 2009, a collaborative analysis of 57 prospective studies was
reported evaluating the relationship between body mass index (BMI) and cause specic mortality evaluating over 900,000 patients [47]. These authors found that for
every increase in BMI by 5kg/m
Obesity is also a major risk factor for the development of incisional hernias. This
is likely because of the increased abdominal wall tension observed in obese patients.
According to Laplace’s law, abdominal wall tension is directly related to the radius
of the abdomen and intra-abdominal pressure, and studies have conrmed a direct
correlation between obesity and increased intra-abdominal pressure [48, 49]. In
consideration of these pathophysiological mechanisms, central obesity plays a very
strong role in IH development. Some have contended that rather than central obesity
or BMI, the degree of visceral adiposity is a better predictor of IH in cancer patients.
2
, all cancer mortality increased by 10%.
27 Incisional Hernia inOncologic Surgery
Using pre-operative CT scans, Aquina at el. assessed several radiographic measurements of abdominal fat volume in a series of patients undergoing surgery for
colorectal cancer. With very good interobserver reliability, they found that visceral
fat volume determined by preoperative imaging was more predictive of IH than
BMI alone (HR 2.04, 95% CI 1.07–3.91) [50]. In addition, visceral fat is metabolically active and is likely to alter the normal immune function [51]. This alteration
has been linked to an increased risk of surgical site infection after colon resection;
another independent risk factor for incisional hernia development [52].
429
27.3 Malnutrition
In order to promote healing, the surgical wound mediates the release of amino acids
from muscles, gluconeogenesis, and other metabolic responses through afferent
nerve bers that perceive pain, inammation, and changes in pH [53]. Successful
healing also requires vitamins C, A, and B6 for collagen synthesis and cross-linking
and essential fatty acids for cell synthesis. It is an anabolic process that occurs during a state of postoperative catabolism. Without these substances, wound healing is
impaired. Naturally, patients with inadequate nutrition possess a limited supply of
nutritional building blocks and not unexpectedly experience poor wound healing.
This association between poor nutritional parameters and IH development has been
demonstrated by many studies [54, 55]. One of the largest series to demonstrate this
comes from the National Surgery Quality Improvement Program (NSQIP). Data
from NSQIP (a large, multicenter, risk-adjusted, database) have consistently shown
low serum albumin to be a risk factor for IH formation [55].
While malnutrition is not a feature exclusive to cancer patients, cancer has a profound impact on patient metabolism [56]. Advanced cancer patients can experience
accelerated proteolysis, lipolysis, and diminished muscle protein synthesis [57]. Altered
carbohydrate metabolism leads to increased hepatic glucose production and decreased
insulin sensitivity. These alterations cause increased energy expenditure, loss of lean
body mass, and generalized wasting [58]. The link between cancer-related malnutrition
and IH has been noted in clinical studies as well. Researchers from the University of
Wisconsin studied 265 patients following cytoreductive surgery for gynecologic malignancy [59]. At 1-year follow up, they found that poor nutritional status (preoperative
albumin 3g/dL or less) was an independent risk factor for early onset IH development.
These nutritional considerations deserve special attention in cancer patients who are
undergoing surgery; and taken together, it may explain why several authors have found
that just harboring a cancer diagnosis is a risk factor for incisional hernia.
27.4 Immunosuppression
When cancer cells are encountered invivo, the immune system recognizes tumor
specic antigens on the surface of cancer cells in a manner similar to the recognition
of non-self-pathogens [60]. Innate immune cells, such as NK cells, recognize the
430
J. M. Lyons III
lack of MHC-I surface molecules on cancer cells, engage in active killing of these
cells, and then recruit other inammatory cells through their cytokine production.
Recruited monocytes phagocytose tumor cells and then present tumor-associated
antigens on their surface which activates a specic cytolytic T cell response that is
directed against the tumor. Then, like a pathogen induced immune response, these
specic effector T cells clonally expand and travel to the tumor to eradicate it from
the body. Over time, selective cancer cells develop the ability to evade the immune
system by decreasing their immunogenicity while at the same time promoting a
highly immunosuppressive microenvironment that continues to support their own
nutrition, angiogenesis and matrix remodeling.
Data from transplant recipients indicate that the immunosuppression is an important and potentially modiable risk factor for IH formation. Several studies have
found variable results but seem to implicate high dose steroids and sirolimus with
higher rates of hernia formation [61, 62]. One study from 2002 compared mycophenolate mofetil and sirolimus directly and found signicantly more wound complications with sirolimus, a nding supported by a similar study in heart transplant
patients [63, 64]. Conversely, another study noted that failure to initiate immunosuppression therapy following transplantation was associated with a higher risk of
hernia formation [65]. However, the decision to withhold immunosuppression following transplantation is likely representative of other clinical factors (i.e. delayed
graft failure or presence of postoperative infections) that could also likely be risk
factors for IH development.
Cytotoxic chemotherapy has long been known to affect the immune system.
Most cytotoxic agents work by indiscriminant interference with the proliferation of
rapidly dividing cells. This causes a major suppressive effect on the cellular mediators of both humoral and cell-mediated immunity during treatment. In addition,
some have demonstrated diminished levels of immune parameters persisting for up
to 12months following cessation of treatment suggesting a more extended immunological effect than has previously been considered [66]. The relationship between
chemotherapy and IH has been discussed in the literature. While some authors have
found postoperative chemotherapy to be a risk for IH formation, Nilson etal., and
others observed that preoperative, but not postoperative chemotherapy, was associated with IH [67–69]. They also noted that longer duration (>6cycles) of preoperative chemotherapy was predictive of IH formation, and that the greatest risk factor
observed was the administration of bevacizumab. This anti-VEGF agent has long
been associated with impaired healing and has been implicated by others in the
formation of postoperative IH [67].
27.5 Age
The median age of a new cancer diagnosis is in the United States is 66, and over
75% of patients with cancer are older than 55 [70]. Between 1982 and 2003, the
population older than 65 doubled, and the population older than 85 quadrupled [71].
As a result, seniors with cancer are more frequently referred to surgeons for
27 Incisional Hernia inOncologic Surgery
431
consideration of resection. Aging is associated with decline in functional reserve as
well as physiologic changes in major organs that may affect the ability to heal from
surgical procedures. Several authors have demonstrated age to be a signicant risk
for the development of postoperative IH [13, 72]. Itatsu etal., studied this in a prospective observation of over 4000 patients who underwent abdominal surgery from
November 2009 to February 2011 [69]. They noted an estimated incidence of IH to
be 10.3% at 2years. Moreover, in multivariable analysis, increasing age by 10year
interval (HR-1.3, 1.6 to 1.45) was found to be an independent risk factor for the
development of IH.
27.6 Special Considerations: Cytoreductive Surgery
Surgical cytoreduction with hyperthermic intraperitoneal chemotherapy (HIPEC) is
a strategy used to treat primary and secondary peritoneal malignancies. The rst
descriptions of cytoreductive surgery were in the 1930s when Dr. JV Meigs
described tumor debulking surgery for ovarian cancer theorizing that reducing macroscopic disease would improve symptoms [73]. Phase 1 trials were eventually conducted in the 1980s [74]; and through work conducted by Sugarbaker and others,
guidelines regarding patient selection, technical feasibility, in adequacy of cytoreduction have been assembled [75].
Current indications exist for gynecologic, colorectal, appendiceal, and primary
peritoneal neoplasms. The technique involves stripping disease from the peritoneum and visceral organs and leaving minimal residual tumor volume within the
abdomen. Following surgery, a heated chemotherapy perfusate is administered
intraoperatively into the abdomen to cover all peritoneal surfaces. Intraperitoneal
chemotherapy allows a high local concentration of cytotoxic drugs to target any
microscopic residual tumor volume [76]. Patients undergoing these procedures can
experience signicant morbidity and mortality, up to 52% and 5.8% in some series
[76]. More common sources of morbidity include stula formation, abscess, anastomotic leakage, and signicant abdominal wall complications as well. Valle etal.
reported an increased risk of abdominal wall infection in patients with colorectal
surgery undergoing HIPEC [77]. This was attributed to longer operative time, intraoperative contamination during enteric resections, and treatment-related immunosuppression. In 2017, Struller etal., described the abdominal wall morbidity of 271
patients undergoing HIPEC at a single European comprehensive cancer center [78].
They noted an abdominal wall rupture rate of 4% which they acknowledged as elevated, but they also noted an IH incidence of only 7%. They felt that this rate was
low secondary to shorter follow up. Risk factors for these complications included
age, cardiopulmonary comorbidities, and certain histiotypes including pseudomyxoma and mesothelioma.
Several reconstructive strategies have been undertaken to mitigate the degree of
abdominal wall morbidity that is experienced postoperatively. Scholer et al.
described their experience using a combination of biologic mesh, component separation, and rectus abdominis myocutaneous ap to reconstruct HIPEC patients