Dite de Jong

As said above, complex abdominal wall repair (CAWR) aims to enhance quality of life (QoL). However, current studies often rely on complication and recurrence rates, neglecting patients’ subjective experiences or outcome concerning QoL. A multi-database systematic search on patients treated for complex hernias was performed, including studies evaluating outcome in terms of QoL at least three months postoperatively. Seven studies were included, encompassing 729 patients, all of whom underwent an open repair. Various QoL instruments were used, such as Short Form 36 and Carolinas Comfort Scale. A standardized mean difference of 0.70 when comparing pre- to postoperative values was found, highlighting the moderate to large effect of open CAWR on QoL outcomes (Chapter 2).

Current multimodal approaches of optimization prior to CAWH treatment mainly focus on prehabilitation of physical conditions like smoking, obesity or physical performance. However, enhancing mental health prior to surgery could mitigate stress reactions. (Chapter 3). To gain insight into the prevalence of psychological risk factors, we expanded our multidisciplinary approach by conducting a prospective study using multiple preoperative screening questionnaires. Postoperative data such as opioid use, length of stay, and complications were collected. We found that psychological comorbidities are highly prevalent among patients undergoing CAWR, with substantial proportions screening positive for anxiety, depression, PTSD, and low perceived control. Even though sample size was small, these findings underscore the psychological vulnerability of this patient population, which may be linked to longstanding functional impairment, repeated surgical interventions, and chronic lifestyle disruption. The need to recognize and address psychological risk factors as a part of routine preoperative assessment was emphasized by these findings (Chapter 4).

A critical function of the MDT is to find modifiable risk factors and to assess whether prehabilitation can successfully downstage patients, making them eligible for surgery. In our center, this MDT is thoroughly prepared: each involved specialist- including the pulmonologist, intensivist, anesthesiologist, cardiologist, physiotherapist and surgeon- has assessed the patient in an outpatient setting when relevant, with the surgeon, physiotherapist and anesthesiologist evaluating every patient as a standard part of the pathway. This structured, pre-assessed approach allows for a well-informed discussion on further optimization and surgical eligibility. Evaluating this process provides insight into its effectiveness in enhancing surgical outcomes.

A retrospective cohort study evaluated the impact of preoperative optimization on outcomes in complex hernia patients with modifiable risk factors undergoing CAWR. All 418 patients were discussed within an MDT framework and classified by risk: green (no risk factors), orange (modifiable risk factors, eligible after optimization), or red (ineligible due to unmodifiable risks). Among the orange group, 55% completed a preconditioning program, which normalized preoperative differences in BMI, HbA1c, smoking rates or improved physical performance. Postoperative complication rates were similar between green and orange groups, suggesting prehabilitation can downstage patients and refine outcomes (Chapter 5).

Another aspect discussed in an MDT is the need for postoperative ICU admission in complex hernia cases. A retrospective review of 379 cases (232 surgeries) assessed the accuracy of this multidisciplinary decision-making process. The recommendation was ICU admission in 38% of cases, with a positive predictive value of 55%, negative predictive value of 90%, and area under the curve of 0.763. Intraoperative events led to changes in decision in 15% of cases, with ICU overestimation of 45% and underestimation in 10%. These findings emphasize the role of MDTs in risk stratification and their potential value in hernia care pathways (Chapter 6).

Refining surgical outcomes in CAWH repair extends beyond perioperative planning. Midline fascial closure in CAWH reconstruction is challenging, with myofascial techniques presenting high morbidity. Technical advancements such as Botulinum Toxin A (BTA) prehabilitation may enhance feasibility of primary fascial closure by lengthening the lateral abdominal wall muscles (LAWM). We conducted a study involving 13 patients who received BTA before CAWR, compared to 26 propensity-matched controls. BTA prehabilitation resulted in a 27% absolute risk reduction in the need for component separation techniques (CST) and significantly increased LAWM length and mass. Overall, BTA exhibited favorable effects, preventing CST in 50% of cases, supporting its role in improving abdominal wall reconstruction (Chapter 7).

Postoperative outcome could also be decreased by less dissection using endoscopic approach. We reviewed 36 patients who underwent an endoscopic CST (eCST) procedure. Postoperative complications included seroma in the dissection plane between external and internal rectus muscle in 22%, hematoma in 8%, and 3% had a wound dehiscence. Three patients experienced recurrence in an average follow-up length of 24 months. Reconstruction in CAWR is tailored surgery and demands skills of several techniques; the choice of which techniques should be performed depends on hernia and patient characteristics (Chapter 8).

Transversus abdominis release (TAR) was introduced in 2012 as an alternative to anterior CST, providing enhanced overlap for large defects and hernias next to bony structures. A retrospective analysis of TAR outcomes in a specialized center showed a 35% textbook outcome (TO) rate, with results improving over time. Among 69 patients, systemic complications were seen in 48%, wound complications in 41%, and recurrences in 4%. Analysis of three successive cohorts (20 TARs each) showed significant improvement in TO and surgical site events with increasing experience, highlighting the ongoing learning curve of this complex technique (Chapter 9).

Combining synthetic mesh with tissue flaps for perineal hernias after abdominoperineal resection (APR) shows lower recurrence rates than mesh-only repairs. A retrospective analysis of a multicenter database examined patients who underwent perineal hernia repair with synthetic mesh or mesh combined with tissue flaps. Over a follow-up period of 54 months, hernias recurred in 42% of mesh-only repairs and 14% of mesh with flap repairs. This indicates that combining mesh with tissue flap repair approach significantly lowers recurrence rates compared to mesh-only repairs (Chapter 10).

Beyond surgical techniques, healthcare system constraints—such as delays in elective surgeries—may also change patient outcomes. A multicenter study examined elective and emergency hernia repair volumes before, during, and after the pandemic within a region. During the pandemic, hernia surgeries decreased by 15%, with a slight increase in urgent cases of 0.8%. Post-pandemic, volumes rebounded by 16%, yet urgency rates remained elevated. These findings show that delays in elective repairs may lead to more emergency interventions, stressing the need for careful prioritization during healthcare crises (Chapter 11).