Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh

Laparoscopic Repair of Large Incisional Hernias

Incisional hernias after abdominal operations are a significant cause of long-term morbidity and have been reported to occur in 3 to 20 per cent of laparotomy incisions. Traditional primary suture closure repair is plagued with up to a 50 per cent recurrence rate. With the introduction of prosthetic mesh repair recurrence decreased, but complications with mesh placement emerged ushering in the development of laparoscopic incisional herniorrhaphy. The records of patients who underwent laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001 were reviewed. Patient demographics, hernia defect size, recurrence, operative time, and procedure-related complications were evaluated. Fifty patients (22 male and 28 female, mean age 57 years with range of 24–83) were scheduled for laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001. The average patient was obese with a mean body mass index of 35.8 kg/m2 (range 16–57 kg/m2). Two patients (4%) had primary ventral hernias. Forty-eight patients (96%) had incisional hernias with 22 (46%) of these previously repaired with prosthetic mesh. Mean defect size was 206.1 cm2 (range 48–594 cm2). The average mesh size was 510.2 cm2 (range 224–1050 cm2). Gore-Tex® DualMesh and Bard® Composite Mesh were used in 84 and 16 per cent of the repairs, respectively. Mean operating time was 97 minutes. There were no deaths. Complications were seen in 12 per cent patients (six occurrences) and included two small bowel enterotomies, a symptomatic seroma requiring aspirate, a mesh reaction requiring a short course of intravenous antibiotics, and trocar site pain (two patients). There were no recurrences during a mean follow-up of 41 months (range 3–74 months). We conclude that laparoscopic incisional herniorrhaphy offers a safe and effective repair for large primary and recurrent ventral hernia with low morbidity.

Surgical treatment of incisional hernia

BACKGROUND

Incisional hernia is a common complication of abdominal surgery and an important source of morbidity. It may be repaired using open suture, open mesh or laparoscopic mesh techniques. This review examines the results of these methods of repair.

METHODS

A Medline literature search was performed to identify articles relating to 'incisional hernia', 'ventral hernia' and 'wound failure'. Relevant papers from the reference lists of these articles were also sought.

RESULTS

The recurrence rate after open suture repair may be as high as 31-49 per cent; for open mesh repair it is between 0 and 10 per cent. Comparative studies show that recurrence is significantly more frequent after open suture repair than after open mesh repair; complication rates are similar for both procedures. Recurrence rates after laparoscopic mesh repair vary from 0 to 9 per cent. Comparative studies show that laparoscopic mesh repair is at least as safe and effective as open mesh repair.

CONCLUSION

Open suture repair for incisional hernia carries an unacceptably high recurrence rate. The results of open mesh and laparoscopic mesh techniques are encouraging. There is scope for a large multicentre randomized clinical trial to compare laparoscopic and open mesh repair.

Laparoscopic incisional hernia repair in liver transplant and other immunosuppressed patients

We report the early results of laparoscopic incisional hernia repair in a small group of immunosuppressed patients and compare these results with a cohort of patients with open repair. We describe a modification used to secure the cephalad portion of the Gore-Tex mesh in high epigastric incisional hernias often encountered after liver transplantation. Data were gathered retrospectively for all incisional hernia repairs by our group from March 1996 to January 2001. Twelve of 13 attempted patients had successful completion of their laparoscopic hernia repairs with no reported recurrences to date. Two of these procedures were performed for recurrent hernias. We completed nine of nine attempted laparoscopic hernia repairs in liver transplant patients with epigastric incisional hernias. We repaired two of three attempted lower midline incisional hernias in renal disease patients. One of these patients was soon able to reuse his peritoneal dialysis catheter. A total of 15 patients, 12 with liver transplants, underwent open repair of their incisional hernias. These patients had seven recurrences and/or serious mesh infections with five patients electing repeated operations. In our initial series, laparoscopic mesh repair of incisional hernias is practical and safe in the abdominal organ transplant population with a low incidence of early recurrence and serious infections.

Laparoscopic repair of ventral incisional hernia

BACKGROUND

Laparoscopic repair of ventral incisional hernias was first reported in 1993. Since then, there have been sporadic case reports and small series published about this procedure, but it has not been widely adopted. Newer types of composite prosthetic mesh may reduce the potential problem of bowel adhesion.

METHODS

Thirty cases of laparoscopic ventral incisional hernia repairs (carried out by two surgeons or their senior registrars) have been retrospectively reviewed and reported in this article. The data were obtained from patient records and subsequent phone surveys.

RESULTS

Thirty patients between 29 and 82 years (mean: 58 years) underwent this procedure. There were 14 men and 16 women. The average weight of the patients was 81 kg. The hernias were up to 6 or 7 cm in diameter. Mesh was used in 28 cases (polypropylene in 25 cases, expanded polytetrafluoroethylene in two cases and composite mesh in one case). Most meshes were laid intraperitoneally and fixed into position with laparoscopic spiral tacks. Twenty-nine cases were completed laparoscopically. One operation (3.3%) was converted to an open procedure because of severe bowel adherence to the hernia sac. The mean operating time was 52 min for laparoscopic ventral incisional hernia repairs only. All but two patients tolerated an oral diet within 24 h. The postoperative hospital stay ranged from 0 to 11 days, with 17 patients (57%) staying overnight and eight patients (27%) staying another day. Over 80% of the patients returned to house duties within a week. There was no mortality, and minor complications occurred in four patients (14%). One patient had a small bowel obstruction treated successfully by repeat laparoscopy with division of fibrinous adhesions to polypropylene mesh on day four. Follow up ranged from 1 to 69 months (mean: 12 months). One patient did not attend follow-up appointments. There were three cases of hernia recurrence (10%).

CONCLUSION

The results suggest that laparoscopic repair of ventral incisional hernias is a safe, effective and technically feasible operation for small- to medium-sized hernias allowing shorter hospital stay, early recovery and resumption of normal activities. However, recurrence rates are comparable to open mesh hernioplasty especially for larger hernias.

Laparoscopic Ventral Hernia Repair Reduces Wound Complications

Postoperative wound complications can be a source of significant morbidity after open ventral hernia repair. By using smaller incisions a laparoscopic approach may decrease this complication. To determine the rate of wound complications after laparoscopic ventral hernia repair prospectively collected data on morbidity in 54 consecutive patients undergoing ventral hernia repair were analyzed. Wound complications were classified as major if there was an open wound or treatment with intravenous antibiotics was required. Minor wound complications consisted of wound erythema or drainage that was treated on an outpatient basis. Eighteen patients underwent open ventral hernia repair. Thirty-six patients underwent attempted laparoscopic repair; five required conversion to an open procedure. Wound complications occurred in 28 and 16 per cent of patients undergoing open and successful laparoscopic repairs, respectively. However, only 3 per cent of patients undergoing laparoscopic repair had a major wound complication as compared with 22 per cent of patients undergoing open herniorrhaphy. Two-thirds of the major wound complications in the attempted laparoscopic group occurred in patients requiring conversion to an open procedure. Laparoscopic ventral hernia repair is a safe and effective alternative to conventional open ventral hernia repair. The main advantage of this minimally invasive approach is a decrease in the rate of major wound complications.

Laparoscopic incisional and ventral herniorrhaphy in 100 patients

BACKGROUND

Laparoscopic incisional and ventral herniorrhaphy, a procedure first described 7 years ago, continues to gain acceptance. A series of about 100 patients who underwent the operation is described. Follow-up in this series was longer (mean 51 months) than that in previously reported series.

METHODS

A retrospective review was conducted of operative and follow-up records of a series of patients scheduled to undergo laparoscopic incisional or ventral herniorrhaphy between 1992 and 1997.

RESULTS

Laparoscopic repair was completed in 96 of 100 patients. The complication rate was 14%, with seromas accounting for half of the postoperative problems. Mean hospital stay was 1 day. The late recurrence rate was 9%, with 4 of the 9 recurrences developing >2 years postoperatively.

CONCLUSIONS

Laparoscopic incisional and ventral herniorrhaphy is safe and effective. Most patients require hospitalization for </=24 hours. Use of an adequately sized prosthesis secured with more than one method is essential. Patients should be observed >/=3 years.

Ventral hernia repair by the laparoscopic approach

An analysis of these results indicates that laparoscopic hernia repair can be performed safely by experienced laparoscopic surgeons, and with lower perioperative complication rates than for open hernia repair. Although the follow-up period for the laparoscopic repair is only 2 or 3 years, the recurrence rate is likely lower than with open repair. Most patients with ventral hernias are candidates for this laparoscopic repair if safe access and trocar placement can be obtained. The choice of mesh often provokes a debate among surgeons, but little practical difference in the results seems to exist between the two types of mesh available. Although the ePTFE mesh has a good theoretic basis for promoting tissue ingrowth on the parietal side of the mesh and minimizing adhesions to the bowel side of the mesh, data indicate that no difference in outcome exists related to adhesions or fistula formation (Tables 1 and 2), so surgeon preference and cost of the prosthesis should be the deciding variables. Fistulas are of concern because of the experience with mesh in the trauma patient and in the treatment of severe abdominal wall infections, when abdominal wall reconstruction often is performed in contaminated wounds in the acute phases and leaves the mesh exposed without soft tissue coverage. These conditions do not apply for most cases of elective hernia repair. Laparoscopic ventral hernia repair offers advantages over the conventional open mesh repair and may decrease the hernia recurrence rate to 10% to 15%. When properly performed, the laparoscopic approach does not and should not compromise the principles for successful mesh repair of ventral hernias.