To Örebro University

BACKGROUND: This study aimed to compare preperitoneal ventral mesh patch with barbed suture in ventral hernia repair, evaluating recurrence rates and complications, and to assess the safety of preperitoneal patch placement.

METHODS: In this randomized clinical trial, adult patients undergoing ventral hernia repair at Karlskoga Hospital between 2020 and 2023 were randomized 1 : 1 to either a ventral mesh patch repair group or a non-absorbable barbed suture repair group, blinded to patients and outcome assessors. The primary outcome was recurrence detected at clinical examination and CT verification 1 year after surgery. Pain (measured on a visual analogue scale and using the Ventral Hernia Pain Questionnaire), nausea, and surgical site events (including wound infection, haematoma and seroma) were assessed 4 h, 1 week, 1 month, and 4 years after operation.

RESULTS: Of 256 eligible patients, 209 were screened, and 205 were randomized to ventral mesh patch repair (103) or barbed suture repair (102). The hernia recurrence rate at 1 year was lower in the ventral patch repair group (1.9 versus 5.9%), although this was not statistically significant (P = 0.14). The surgical site infection rate at 1 month was significantly lower in the ventral patch group (0.9 versus 6.9%; P = 0.02). At 1 month, the ventral patch repair group had higher 'pain right now' scores on the Ventral Hernia Pain Questionnaire (P = 0.02), although this difference had disappeared by 1 year.

CONCLUSION: Preperitoneal ventral hernia patch repair is a safe and effective technique with a recurrence rate not statistically significant from that after barbed suture repair. Although postoperative pain scores at 1 month were higher after ventral patch repair, this difference had disappeared by 1 year.

Introduction: Aim: To compare preperitoneal ventral mesh patch with barbed suture in ventral hernia repair, evaluating recurrence rates and complications, and to assess the safety and efficacy of standardised preperitoneal patch placement.

Methods: In this randomised controlled trial, 205 adult patients undergoing ventral hernia repair were randomised 1:1 to either a ventral mesh patch repair group (n=103) or a 2.0 non-absorbable barbed suture repair group (n=102), blinded to patients and outcome assessors. Primary outcome was recurrence one year after surgery. Pain, nausea, and surgical site events were assessed on four occasions up to one year.

Results: 205 patients were randomised to ventral mesh patch repair (n=103) or barbed suture repair (n=102). Hernia recurrence at one year was lower in the ventral patch group (1.9% vs. 5.9%), though not statistically significant (p=0.14). Surgical site infection rate at one month was significantly less in the ventral patch group (0.9% vs. 6.9%; p=0.02). At one month, the ventral patch group had higher "Pain right now" scores on the VHPQ (p=0.02), this difference had disappeared by one year.

Discussion: Conclusion: Preperitoneal ventral hernia patch repair is a safe and effective technique that results in a lower recurrence rate (though not statistically significant) than barbed suture. While postoperative pain scores at one month were higher in the patch group, this difference had disappeared by one year.

Introduction: Rectus Abdominis Diastasis (RAD) is a common condition where separation of the rectus abdominis muscles results in a widening of the linea alba. This separation is often due to increased intra-abdominal pressure most notably during pregnancy. This study evaluates the impact of the minimal incision repair of rectus abdominis diastasis (MIRRAD) procedure on physical activity, muscle strength, quality of life, and overall satisfaction in women with postpartum rectus abdominis diastasis (PP-RAD).

Method: A cohort of 31 female patients, aged 20-50 years, diagnosed with PP-RAD unresponsive to conservative treatment, underwent the MIRRAD procedure. Assessments were conducted preoperatively and one year postoperatively, these included the Modified Abdominal Trunk Function Protocol (MATFP), Disability Rating Index (DRI), and Urinary Disability Index (UDI) questionnaires. Physical activity intensity was monitored using accelerometers.

Result: Significant improvements were observed in vigorous physical activities (Z = -2.352, p = .019), vector magnitude counts per minute (Z = -2.163, p = .031), and steps per minute (Z = -3.131, p = .002). DRI showed significant improvements in physical tasks like dressing, walking, and strenuous work (Z ranging from -2.705 to -4.603, p < .001). UDI indicated significant improvements in urinary symptoms, including reduced frequency (Z = -2.984, p = .003) and less urinary leakage (Z = -2.357, p = .018). MATFP demonstrated gains in back and abdominal muscle strength (Z = -4.321, p < .001) and trunk stability (Z = -3.991, p < .001).

Discussion: The MIRRAD procedure significantly improves physical strength, trunk stability, and urinary function, enhancing daily activities and overall physical health in women with PP-RAD. Further research is recommended to evaluate long-term outcomes.

PURPOSE: Postpartum rectus abdominis diastasis (PP-RAD) is a condition that may cause abdominal wall insufficiency, affecting daily life. When conservative treatments are unsuccessful, surgical intervention may be necessary. This study aimed to assess the safety and effectiveness of minimal incision repair of rectus abdominis diastasis (MIRRAD) as day-case surgery in women with PP-RAD.

METHODS: This study included 33 female patients aged 20-50 years with PP-RAD and an inter-rectus distance (IRD) of ≥ 3 cm. All patients had previously undergone conservative treatment without satisfactory outcomes. Each patient received the MIRRAD procedure as day-case surgery apart from one who stayed overnight due to nausea. Follow-up evaluations were conducted at 4 h, 1 week, 1 month, and 1 year after surgery.

RESULTS: The average inter-rectus distance (IRD) was 4.4 cm, with a mean diastasis length of 15 cm. Of the 33 patients included, 2 did not attend the 1 year follow-up leaving 31 for final analysis. Of these, 30 had one or more concomitant hernias. The mean operation time was 67 min. At the 1 year follow-up, 87% of patients were satisfied with the results, and 90% said they would undergo the procedure again if necessary. No surgical site infection was reported, and recovery was generally smooth. Thirty of the 31 patients were discharged within 4 to 6 h after surgery, while one patient stayed overnight.

CONCLUSION: MIRRAD appears to be a safe and effective surgical option for PP-RAD, particularly in cases without significant excess skin. Further studies with larger populations and longer follow-up are needed to confirm these findings and establish standard patient selection criteria.

Introduction: Hernia of the linea alba (ventral hernia) is a common surgical condition that affects both men and women. The association between pregnancy and risk of developing ventral hernias is unclear. This study aimed to assess the risk of developing a primary ventral hernia requiring repair, and whether increasing parity is associated with a greater risk of developing a ventral hernia.

Method: This nationwide cohort study included women born between 1950-1980 who were registered in the Swedish Medical Birth Register (MBR). Data on pregnancies and vaginal or caesarean sections were retrieved from the Birth Register. The cohort was cross-matched with the National Patient Register (NPR) to identify subsequent primary hernia repairs.

Result: This study included 1,630,754 women born between 1950 and 1980. Among these, 1,588,609 (97.4%) were registered in MBR. The incidence rates for Umbilical Hernia Repair (UHR) and Epigastric Hernia Repair (EHR) were 13.2/100,000 person-years and 5.4 per 100,000 person-years, respectively. When compared with women registered for one delivery, the incidence rate ratio for UHR was higher among those with two deliveries (1.3, 95% CI: 1.26-1.33) and among those registered with ≥3 deliveries (1.6, 95% CI: 1.58-1.68).

The incidence rate ratios were 1.29 (95% CI: 1.20-1.39) and 1.34 ( 95% CI: 1.24-1.45) for EHR among women with two and ≥3 registered deliveries, respectively.

Discussion: A history of more than one pregnancy is associated with an increased incidence of umbilical and epigastric hernias. The incidence rate of UHR and EHR was higher in women who underwent caesarean delivery than in those who underwent vaginal delivery.

INTRODUCTION: The association between pregnancy and the risk of developing ventral hernias is unclear. This study aimed to assess the risk of developing a primary ventral hernia requiring repair and whether increasing parity is associated with a greater risk of developing a ventral hernia.

MATERIALS AND METHODS: This nationwide cohort study included women born between 1950 and 1980 who were registered in the Swedish Medical Birth Register (MBR). Data on pregnancies and vaginal or cesarean sections were retrieved from the birth register. The cohort was cross-matched with the National Patient Register (NPR) to identify subsequent primary hernia repairs.

RESULTS: This study included 1,630,754 women born between 1950 and 1980. Among these, 1,588,609 (97.4%) were registered in the MBR. The incidence rates for umbilical hernia repair (UHR) and epigastric hernia repair (EHR) were 13.2/100,000 person-years and 5.4 per 100,000 person-years, respectively. When compared with women registered for one delivery, the incidence rate ratio for UHR was higher among those with two deliveries (1.18, 95% CI:1.12-1.24) and among those registered with >= 3 deliveries (1.48 95% CI: 1.41-1.56). The incidence rate ratios were 1.29 (95% CI: 1.20-1.39) and 1.34 (95% CI: 1.24-1.45) for EHR among women with two and >= 3 registered deliveries, respectively.

CONCLUSION: A history of more than one pregnancy is associated with an increased incidence of umbilical and epigastric hernias.

Background: Postpartum rectus abdominis diastasis (PP-RAD) and primary ventral hernias (PVH) are closely related in women. PP-RAD is caused by separation of the rectus abdominis muscles following pregnancy, leading to core instability and an increased risk of hernia formation. PP-RAD can significantly affect quality of life. The aim of this thesis was to evaluate the risk factors for ventral hernia formation and recurrence. The surgical interventions presented in the thesis aimed to reduce complication and recurrence rates and to improve the quality of life for female patients affected by PP-RAD.

Paper I aimed to evaluate reoperation rates due to recurrence in ventral hernia repairs across different genders, ages, and surgical methods. The study concluded that women and patients younger than 50 had significantly higher reoperation rates regardless of repair method.

Paper II evaluated the impact of parity and delivery method on risk of PVH. A register study on >1.5 million women. The study concluded that risk of hernia repair increased with number of pregnancies and cesarean sections were associated with higher rate of hernia repairs.

Paper III and IV are based on prospective studies evaluating a new Minimally Incision Repair method of Rectus Abdominis Diastasis (MIRRAD) as a day-case surgery. Paper III concluded that MIRRAD is a safe and effective method that can be performed on an outpatient basis, offering a less invasive option for repairing PPRAD.

Paper IV examined the impact of the MIRRAD procedure on patients' quality of life. The findings showed a significant improvement in the quality of life for women with PP-RAD.

Paper V is an RCT of 205 procedures comparing the safety and efficacy of placinga ventral hernia patch in the preperitoneal space with repairing with non-absorbable barbed sutures. The study concluded that preperitoneal ventral hernia patch is a safe and effective method with a lower recurrence rate compared to barbed suture repair.

AIM: This study evaluates the impact of the minimal incision repair of rectus abdominis diastasis (MIRRAD) procedure on physical activity, muscle strength, quality of life, and overall satisfaction in women with postpartum rectus abdominis diastasis (PP-RAD).

METHODS: A cohort of 31 female patients, aged 20-50 years, diagnosed with PP-RAD unresponsive to conservative treatment, underwent the MIRRAD procedure. Assessments were conducted preoperatively and 1 year postoperatively, these included the Modified Abdominal Trunk Function Protocol (MATFP), Disability Rating Index (DRI), and Urinary Disability Index (UDI) questionnaires. Physical activity intensity was monitored using accelerometers. RESULTS: Significant improvements were observed in vigorous physical activities (Z = -2.352, p = 0.019), vector magnitude counts per minute (Z = -2.163, p = 0.031), and steps per minute (Z = -3.131, p = 0.002). DRI showed significant improvements in physical tasks like dressing, walking, and strenuous work (Z ranging from -2.705 to -4.603, p < 0.001). UDI indicated significant improvements in urinary symptoms, including reduced frequency (Z = -2.984, p = 0.003) and less urinary leakage (Z = -2.357, p = 0.018). MATFP demonstrated gains in back and abdominal muscle strength (Z = -4.321, p < 0.001) and trunk stability (Z = -3.991, p < 0.001).

CONCLUSION: The MIRRAD procedure significantly improves physical strength, trunk stability, and urinary function, enhancing daily activities and overall physical health in women with PP-RAD. Further research is recommended to evaluate long-term outcomes.

Introduction: The influence of pregnancy on the risk of ventral hernia recurrence is not known. This study aims to assess whether the frequency of pregnancies is associated with an elevated risk of developing ventral hernias.

Method: This nationwide study cohort constitutes women borne 1950 – who were registered in the Swedish Birth Register (MBR). Data on pregnancies, distinguishing between vaginal and caesarian sections, were retrieved from the Birth Register. The cohort was cross-matched with the National Patient Register (NPR) to identify subsequent primary hernia repairs.

Results: A total of 1,630,754 women born between 1950 and 1980 were        included in the study. Among them, 1,588,609 (92.3%) were registered for at least one birth. The incidence rate for Umbilical Hernia Repair (UHR) and Epigastric Hernia Repair (EHR) was 13.21 per 100,000 person-years and 5.4 per 100,000 person-years, respectively. When compared with women registered for one delivery, the incidence rate ratio for UHR was 1.3 (95% CI: 1.26–1.33, P < 0.001) among thos eregistered for two deliveries and 1.6 (95% CI: 1.58–1.68, P < 0.001) among those registered for ≥3 deliveries.

The incidence rate ratios were 1.29 (95% CI: 1.20–1.39, P < 0.001) and 1.34 (95% CI: 1.24–1.45, P < 0.001) for EHR among women with two and ≥3 registered deliveries, respectively.

Conclusion: A history of more than one pregnancy is associated with an increased incidence of umbilical and epigastric hernias.

Aim: The aim of this study was to analyse the risk for reoperation following primary ventral hernia repair.

Methods: The study was based on umbilical hernia and epigastric hernia repairs registered in the population-based Swedish National Patient Register (NPR) 2010–2019. Reoperation was defined as repeat repair after primary repair.

Results: Altogether 30,253 umbilical hernia repairs and 7407 epigastric hernia repairs were identified. There were 624 reoperations registered following primary umbilical repair and 137 following primary epigastric repairs. In multivariable Cox proportional hazard analysis, the hazard ratio (HR) for reoperation was 0.284 (95% confidence interval (CI) 0.106–0.760) after open onlay mesh repair, 0.476 (CI 0.359–0.629) after open interstitial mesh repair, 0.368 (CI 0.230–0.590) afteropen sublay mesh repair, 0.446 (CI 0.167–1.194) after open intraperitoneal onlay mesh repair, 0.931 (CI 0.639–1.357) after laparoscopic repair, and 0.939 (CI 0.502–1.757) after other (unknown) techniques, when compared to open suture repair as reference method. Following umbilical hernia repair, the risk for reoperation was also significantly higher for patients aged ≤49 years (HR 1.669, CI 1.391–2.002), for women (HR 1.390, CI 1.178–1.641), and for patients with liver cirrhosis (HR 2.546, CI 1.050–6.174). For patients undergoing epigastric hernia repair, the only significant risk factor for reoperation was age ≤49 years (HR 2.079, CI 1.380–3.134).

Conclusions: All types of open mesh repair were associated with lower reoperation rates than open suture repair and laparoscopic repair. Female sex, young age and liver cirrhosis were risk factors for reoperation due to hernia recurrence, regardless of method.