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Original article
Comparative analysis of 2 surgical techniques in the treatment of subxiphoid incisional hernia. Observational study
Análisis comparativo de 2 técnicas quirúrgicas en el tratamiento de la hernia incisional subxifoidea. Estudio observacional
David Abelló
Corresponding author
davidabelloaudi@gmail.com

Corresponding author.
, Jesús Martínez-Hoed, Miriam Menéndez, Hanna Cholewa, Lourdes Avelino, Santiago Bonafé, Salvador Pous-Serrano, José Bueno-Lledo
Unidad de Cirugía de Corta Estancia y Pared, Hospital Politécnico y Universitario la Fe, València, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Subxiphoid incisional hernias &#40;SIH&#41;&#44; or M1 according to the European Hernia Society &#40;EHS&#41; classification<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#44; have an incidence of 1&#37;&#8211;4&#46;2&#37; in patients who have undergone sternotomy<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; Its global incidence varies according to the series&#44; which is due to the fact that SIH are small in size and go unnoticed by the patient and the medical professional&#46; It is also rare for SIH to cause symptoms or episodes of incarceration<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The only studies that analyze the incidence and risk factors for developing SIH are based on patients who have undergone sternotomies performed during surgeries- involving thoracic or cardiovascular surgeons<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a>&#46; The main risk factor described for developing SIH is the need for transfusion of packed red blood cells&#44; which can be considered an indirect marker of surgical complexity<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; Obesity and postoperative surgical wound infection are also predisposing factors<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and common variables in the development of any incisional hernia&#46; SIH can also occur after subcostal and supraumbilical laparotomies in patients with high comorbidity<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#44; such as&#44; for example&#44; liver transplant recipients or patients with immunosuppressive treatment<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The surgical solution for SIH is complex<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Primary closure of the defect has been reported to lead to hernia recurrence in up to 80&#37; of cases<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#44; and postoperative complications can appear in 50&#37; of patients<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#46; This difficulty is related to the anatomical region where it occurs &#40;inferior to the costal margin and the xiphoid process&#41;&#44; and the bone structures that can hinder fixation and adequate coverage of the mesh over the hernia defect&#44; which may lead to an aponeurotic closure with tension<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of our study was to retrospectively analyze the rate of recurrence and comorbidity in the surgical repair of SIH using a preperitoneal incisional hernia repair technique &#40;PT&#41; or the adjusted double-mesh technique &#40;ADMT&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">We have conducted an observational and retrospective study of SIH procedures performed at our Hospital from January 2011 to January 2019&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">All patients with SIH were evaluated in outpatient clinics and were studied preoperatively by computed tomography &#40;CT&#41; scan to classify the type of incisional hernia using the EHS classification<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46; The study inclusion criteria were&#58; patients who underwent elective SIH that included areas M1 or M1-M2&#46; SIH combined with defects also in M3&#44; M4 and M5&#44; as well as repairs performed in the emergency room&#44; were excluded from the study&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All patients were operated on by the same team of 5 specialists in abdominal wall surgery&#46; The main surgeon chose the surgical technique to be performed as well as the type of prosthesis to be used&#46; The surgical repairs performed to address SIH included the preperitoneal technique &#40;PT&#41; and ADMT&#44; as previously described by our group<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46; In general terms&#44; the surgeon leaned towards performing ADMT when the SIH presented a transverse hernia defect diameter 10&#160;&#8805;&#160;cm&#44; which seriously hindered suprafascial closure over the prosthesis&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patients were administered antibiotic prophylaxis one hour before the skin incision&#44; as well as thromboembolic prophylaxis with low-molecular-weight heparin&#44; which was initiated 6&#160;h after surgery&#46; The skin antiseptic used was alcoholic chlorhexidine or povidone iodine&#46; In PT&#44; the hernia sac was dissected up to its neck&#44; progressing in the dissection along the subxiphoid and substernal preperitoneal plane&#44; surpassing the defect by 5&#160;cm on all axes&#44; where we finally positioned the prosthetic mesh&#46; The most widely used type of mesh was wide-pore polypropylene &#40;PPL&#41;&#44; which was affixed with interrupted sutures of PPL or extra&#8211;long-term absorption monofilament sutures &#40;Monomax&#174;&#41;&#44; using AbsorbaTack&#174; at the ribs and sternum&#46; Subsequently&#44; the primary closure of the rectus aponeurosis was attempted above the prosthesis with continuous slow absorption monofilament suture &#40;Monomax loop&#174;&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Unlike the previous technique&#44; in ADMT&#44; once the PPL mesh was positioned in the preperitoneal position&#44; the rectus sheath was not closed&#44; but rather a second PPL inlay mesh was positioned and adjusted to the edge of the defect by means of a continuous PPL monofilament suture<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">For all patients&#44; we used wide preperitoneal overlap of the mesh prosthesis in the retroxiphoid area with fixation to the xiphoid and ribs&#46; In all cases&#44; redon drains were placed in the preperitoneal dissection area where the mesh was located&#46; These drains were removed when the daily discharge was less than 50 cc&#46; At the end of the procedure&#44; a compression bandage was applied&#44; and an abdominal girdle was placed in the hospital room&#44; which the patients used for the first 2 postoperative months&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The following epidemiological data were reviewed respectively&#58; age&#44; sex&#44; and comorbidities &#40;obesity&#44; smoking&#44; arterial hypertension&#44; diabetes mellitus&#44; bronchopathy&#44; use of anticoagulants&#44; and organ transplant recipient&#41;&#46; In addition&#44; we analyzed intraoperative variables &#40;surgical time&#44; surgical incidents&#44; concomitant surgeries&#44; etc&#46;&#41; and postoperative variables &#40;complications according to the Clavien&#8211;Dindo<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> classification&#44; length of hospital stay&#44; readmission rate&#44; recurrence rate&#41;&#46; Hernia recurrence was defined clinically by physical examination of the patient&#44; and we requested an abdominal computed tomography scan in Valsalva for confirmation&#46; Finally&#44; we carried out a comparative analysis of the 2 surgical techniques performed&#44; focusing on the rate of recurrence and perioperative complications&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patients were monitored in the outpatient clinical with postoperative follow-up visits at 15 days&#44; 30 days&#44; 6 months and 1&#160;year&#44; followed by annual appointments until completing a 3-year follow-up period&#44; which we tried to complete in most patients&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The statistical analysis was conducted with IBM SPSS&#174; Statistics version 25&#46;0 software &#40;IBM&#44; USA&#41;&#44; using the means with standard deviation as the main descriptive measures for the quantitative variables&#44; and frequencies with percentages for the qualitative variables&#46; The chi-squared test was used for the qualitative variables and the Student&#8217;s <span class="elsevierStyleItalic">t</span> test for the quantitative variables&#46; Differences were considered significant when the <span class="elsevierStyleItalic">P</span> value was less than &#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">We analyzed a total of 42 patients who underwent surgical repair of an SIH between January 2011 and January 2019&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the patient demographic variables and comorbidities as well as characteristics of the SIH according to the EHS classification&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Most of the patients were operated on with a SIH M1W2&#46; Subcostal laparotomy was the most frequent previously performed herniated incision in our series &#40;71&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; PT was the most frequent surgical option&#44; performed in 22 patients &#40;52&#46;4&#37;&#41;&#44; while ADMT was performed in 20 patients &#40;47&#46;6&#37;&#41;&#46; There were no significant differences between the 2 treatment groups in terms of comorbidity and SIH characteristics&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the perioperative results of both surgical techniques&#46; The surgical time required for the PT was lower than that of the ADMT &#40;77&#46;3&#160;&#177;&#160;17&#46;8&#160;min vs 98&#46;3&#160;&#177;&#160;12&#46;5&#160;min&#59; <span class="elsevierStyleItalic">P</span>&#160;&#60;&#160;&#46;001&#41;&#59; however&#44; there were no differences in terms of hospital stay &#40;3&#46;6&#160;&#177;&#160;1&#46;1 days vs 3&#46;6&#160;&#177;&#160;1&#46;1 days&#59; <span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;&#46;978&#41;&#46; In neither of the 2 techniques were intraoperative complications recorded&#46; All postoperative complications that were recorded &#40;seroma&#44; wound infection&#44; and pain&#41; were mild &#40;Clavien&#8211;Dindo grade I&#41; and resolved with conservative treatment&#46; ADMT presented better results than PT in terms of its appearance&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The mean postoperative follow-up was 25&#46;8&#160;&#177;&#160;15&#46;1 months&#44; finding a hernia recurrence rate of 2&#46;4&#37;&#46; Although there were no significant differences in terms of recurrence&#44; it should be noted that the only registered case is from the ADMT group&#46; This appeared one year after follow-up in a patient with multiple risk factors &#40;obesity&#44; smoking&#44; high blood pressure&#44; and liver transplantation&#41;&#46; The characteristics of the recurrence were a new symptomatic incisional hernia in the lower part of the prosthesis placed during the ADMT&#44; in M2-M3 position&#46; Anterior separation of components was selected for the repair&#44; with good results and with no new recurrence in the subsequent follow-up&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Several surgical techniques have been described in the scientific literature to treat SIH&#46; The first to be described was the primary closure of the defect associated with a supra-aponeurotic mesh&#44; which provided results that were less than acceptable<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;14</span></a>&#46; Subsequently&#44; the preperitoneal approaches &#40;PT and ADMT&#41; were described<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;15</span></a>&#44; and more recently&#44; the placement of intra-abdominal mesh via laparoscopy<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;16&#44;17</span></a>&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarizes the results of the most representative series published in the scientific literature to date&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Hernia recurrence after SIH repair is high<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10</span></a>&#46; Possible influencing factors include the location of the defect&#44; which contributes to the complexity of the repair as it is in an area of &#8203;&#8203;tension&#46; Furthermore&#44; there is little room for maneuverability during the fascia approximation and closure of the hernia defect&#46; The proximity of bone structures also influences mesh fixation&#44; making extensive retrosternal dissection necessary in order to achieve a large area of &#8203;&#8203;overlap under the bone to accommodate the prosthesis&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Holihan et al&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> published 2 meta-analyses where they demonstrated that positioning the mesh in a preperitoneal instead of a suprafascial position reduces the rates of recurrence and surgical site infection<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a>&#46; Even so&#44; the supra-aponeurotic position of the mesh is an approach that continues to be widely used in our country<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#46; An extensive plane of retrosternal preperitoneal dissection is essential for wide mesh coverage&#44; going several centimeters beyond the entire hernia defect&#46; Hence&#44; the technique of choice for SIH repair is the preperitoneal technique<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;21&#44;22</span></a>&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Raakow et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and Mackey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> are the only groups that have published the results of a comparative study on SIH repair techniques&#44; which found that hernia recurrence after repair is influenced by the positioning of the mesh&#46; Mackey observed a 43&#37; incidence of hernia recurrence at primary closure&#44; which decreased to 30&#37; when he used mesh&#46; Raakow showed that the recurrence rate can reach 0&#37; with the use of PT&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">However&#44; published data regarding the appearance of complications&#44; the surgical approach and the plane to position the mesh are very diverse<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">It is important to note that the choice of surgical technique is also influenced by the characteristics of the incisional hernia&#46; Our group tries to position the mesh in the preperitoneal plane&#44; widely surpassing the defect&#44; and subsequently performing a tension-free primary closure of the anterior defect of the rectus sheath&#46; In cases where this primary closure is not possible&#44; a second mesh is positioned following the double-mesh technique&#44; which&#44; by positioning a second inlay mesh&#44; allows for the edges of the anterior fascia to be connected without tension to protect the preperitoneal mesh&#46; Even so&#44; our results regarding hernia recurrence showed that there are no significant differences between the two options&#46; We found one case of recurrence in the ADMT group influenced by the lack of closure of the suprafascial defect with SIH and a transverse diameter greater than 10&#160;cm&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Postoperative complications associated with SIH repair are multiple and diverse&#46; The most frequent are those related to the surgical wound &#40;such as hematomas&#44; seromas or surgical site infections&#41; that can be resolved with conservative management<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;16&#44;23</span></a>&#46; However&#44; in the series by Raakow et al<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&#44; it is striking that the laparoscopic approach subgroup had a 25&#37; rate of surgical reoperations due to bleeding &#40;grade IIIb&#41;&#44; although the cause of this high incidence was not explained&#46; Despite negative factors&#44; such as the existence of immunosuppression or comorbidity associated with these patients&#44; the results of our series regarding postoperative morbidity seem correct to us&#46; All the postoperative complications recorded were mild &#40;grade I&#41;&#46; The incidence of these was more frequent in the PT group &#40;27&#46;3&#37;&#41; compared to the ADMT group &#40;5&#37;&#41;&#46; This was possibly due to the fact that patients with complications are part of a subgroup with abundant comorbidity &#40;HTN&#44; obesity&#44; bronchopathy&#44; diabetes&#44; etc&#46;&#41;&#46; Even so&#44; this complication rate is at the lower limit of what has been published in the literature<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;10&#44;11&#44;21</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Regarding the demographic characteristics and comorbidity of the patients&#44; there was a large volume of patients whose medical History included a transplantation &#40;59&#46;5&#37;&#41;&#46; This fact is partially explained by their being long and complex surgeries that often require the transfusion of blood products&#44; which are elements that can affect tissue quality<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&#46; In addition&#44; immunosuppressive medication&#44; especially steroids&#44; alter the healing process and predispose patients to the formation of hernias<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;26</span></a>&#46; Therefore&#44; it is interesting to consider the possibility of preventing SIH by placing a prophylactic mesh during subcostal laparotomy&#46; In patients undergoing bilateral subcostal laparotomy&#44; Blazquez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> have shown a reduction in the incidence of incisional hernia of 1&#46;7&#37; in the group with the prophylactic mesh placed in the suprafascial position compared to 17&#46;5&#37; in the group without mesh &#40;<span class="elsevierStyleItalic">P</span>&#160;&#61;&#160;&#46;0006&#41;&#46; Likewise&#44; in patients with midline laparotomy&#44; Borab et al&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> and Argudo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> also reported a reduction in the risk of incisional hernia of 85&#37; and 78&#37;&#44; respectively&#44; through the use of suprafascial mesh&#46; Lastly&#44; we should mention a multicenter clinical trial&#44; PRIMA&#44; which concludes that there is a significant reduction in the risk of incisional hernia with the positioning of a suprafascial mesh in midline laparotomies compared to the retromuscular position in high-risk patients<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46; Although it is not the objective for this study and along the same line as what was published by the previous groups&#44; in patients with high comorbidity and a high probability of developing SIH&#44; the placement of a prophylactic mesh could be useful&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Our study has limitations&#46; On the one hand&#44; the retrospective analysis of the series is limited by the information found in the clinical history of each patient as well as the bias of the observer&#46; Thus&#44; 42 cases could represent a small number of cases to draw conclusions&#44; but we must not forget that these numbers are similar to &#40;and even greater than&#41; the other series analyzed&#46; The most interesting part of this study may lie in the comparison of 2 SIH surgical techniques&#44; as well as the acceptable results when analyzing hernia complications and recurrence during a mean follow-up period of more than 25 months&#46; We hope that this article lays the foundation for being able to conduct a prospective multicenter study with a larger sample size that would allow us to reach more solid conclusions regarding the efficacy of surgical techniques to treat SIH&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">As conclusions&#44; and according to our results&#44; preperitoneal hernia repair is the ideal technique to repair subxiphoid incisional hernias&#46; The adjusted double-mesh technique may be an effective approach with a low complication rate&#44; but when the recurrence rates are analyzed globally&#44; fascial closure over the preperitoneal prosthetic mesh has a lesser impact&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46; This study has received no specific funding from public&#44; commercial or non-profit organizations&#46;</p></span></span>"
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            0 => "Subxiphoid incisional hernia"
            1 => "M1 incisional hernia"
            2 => "Preperitoneal hernia repair"
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            0 => "Hernia incisional subxifoidea"
            1 => "Eventraci&#243;n M1"
            2 => "Eventroplastia preperitoneal"
            3 => "T&#233;cnica de la doble malla ajustada"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears&#46; The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years&#44; especially postoperative complications and the recurrence rate&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">It is an observational&#44; retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit&#46; We analysed the comorbidities&#44; surgical techniques &#40;preperitoneal hernia repair or TP&#44; and adjusted double mesh technique&#41; and postoperative variable&#44; especially the hernia recurrence&#46; The postoperative complications were summarized flowing the Clavien-Dindo classification&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">42 patients were operated&#58; 22 &#40;52&#44;4&#37;&#41; TP and 20 &#40;47&#44;6&#37;&#41; adjusted double mesh technique&#46; All the complications registered were minor &#40;grade I&#41; and it appeared mostly in TP group &#40;P&#160;&#61;&#160;&#46;053&#41;&#46; The average follow up was 25&#46;8&#160;&#177;&#160;15&#46;1 months&#59; there were no statistically significant differences in hernia recurrence comparing two treatment groups &#40;P&#160;&#61;&#160;&#46;288&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">According to our results&#44; TP is the ideal technique to repair a subxiphoid incisional hernia&#46; Adjusted double mesh technique may represent an effective approach with a low complication rate&#44; although globally analyzing the recurrence rate&#44; aponeurosis closure over the preperitoneal mesh entails less impact on it&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La hernia incisional subxifoidea presenta complejidad en su soluci&#243;n quir&#250;rgica por las caracter&#237;sticas de la regi&#243;n anat&#243;mica donde aparece&#46; El objetivo de nuestro estudio fue el an&#225;lisis de los resultados obtenidos con las diferentes t&#233;cnicas realizadas en nuestro centro durante 9 a&#241;os&#44; incidiendo en las complicaciones postoperatorias y la tasa de recidiva&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">M&#233;todos</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional&#44; retrospectivo desde enero de 2011 hasta enero de 2019 de los pacientes intervenidos de hernia incisional subxifoidea en nuestra Unidad&#46; Se analizaron las comorbilidades&#44; t&#233;cnicas quir&#250;rgicas empleadas &#40;eventroplastia preperitoneal o TP&#44; y t&#233;cnica de doble malla ajustada&#41; y variables postoperatorias&#44; incidiendo en la recidiva herniaria&#46; Las complicaciones se recogieron seg&#250;n la clasificaci&#243;n de Clavien-Dindo&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Resultados</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Se intervinieron un total de 42 pacientes&#58; 22 &#40;52&#44;4&#37;&#41; mediante una TP&#44; y 20 &#40;47&#44;6&#37;&#41; mediante t&#233;cnica de doble malla ajustada&#46; Todas las complicaciones registradas fueron leves &#40;grado i&#41; y aparecieron mayoritariamente en el grupo de la TP &#40;p&#160;&#61;&#160;0&#44;053&#41;&#46; El seguimiento medio postoperatorio fue 25&#44;8 &#177;15&#44;1 meses&#59; no existieron diferencias estad&#237;sticamente significativas en cuanto a recidiva comparando los 2 grupos de tratamiento &#40;p&#160;&#61;&#160;0&#44;288&#41;&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusiones</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Seg&#250;n nuestros resultados&#44; la TP fue la t&#233;cnica ideal para reparar una hernia incisional subxifoidea&#46; La t&#233;cnica de doble malla ajustada puede representar un abordaje eficaz con un bajo &#237;ndice de complicaciones&#44; aunque analizando globalmente la tasa de recidiva&#44; el cierre fascial por encima de la pr&#243;tesis preperitoneal conlleva un menor impacto en la misma&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Grade I&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Grades II&#8211;V&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Author&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recurrence &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Follow-up &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cohen and Starling<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Onlay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marlex&#174;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Davidson and Bailey<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1987&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Primary closure<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bouillot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1997&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sublay</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mersilene&#174;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;hematomas&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#8722;60&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Landau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lap&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IPOM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gore-Tex&#174;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30 &#40;bowel obstruction&#44; fever and seroma&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#8722;42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mackey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">OpenLap&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Primary closureProsthesis<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>Prosthesis<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NRNR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;infection&#41;24 &#40;infection&#41;NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">433330&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eisenberg et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2008&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lap&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IPOM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Parietex&#174; and Gore dual&#174;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;paralytic ileus and pulmonary edema&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Carbonell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Preperitoneal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PPL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;4 &#40;seroma and wound infection&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#8722;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Shah et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lap&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IPOM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vennarecci et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sublay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Permacol&#174;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">De Mesquita et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Open&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Onlay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Marlex&#174;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;2 hematomas and 3 infections&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">7&#8722;33&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Raakow et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">OpenLap&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">SublayIPOM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ultrapro&#174; and Vypro&#174;Composite&#174;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20&#37; &#40;paralytic ileus and mild infection&#41;25&#37; reoperation due to bleeding&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">037&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">48&#46;8&#160;&#177;&#160;24&#46;332&#46;5&#160;&#177;&#160;24&#46;5&nbsp;\t\t\t\t\t\t\n
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                          "etal" => false
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