Current status of laparoscopic ventral hernia repair

Study of the outcome of modified shoelace repair for midline incisional hernia

AIMS AND OBJECTIVES

To study the efficacy and short-term sequelae of modified shoelace repair for midline incisional hernias.

MATERIALS AND METHODS

A prospective non-randomized study of 30 cases of midline incisional hernias was carried out at a public hospital from May 2009 to Oct 2012. Patients underwent modified shoelace repair which comprises reconstruction of linea alba along with the use of polypropylene mesh to reinforce the facial layer. A proforma was maintained for each patient documenting patient details, nature of previous surgery and complications if any, postoperative course, and complications postincisional hernia repair.

RESULTS AND DISCUSSION

Thirty patients underwent this repair with no complications and no recurrence for minimum follow-up period of 12 months. Our technique is a simple extra-peritoneal procedure with no extensive tissue dissection and avoids the potential complications of bowel injury and adhesions with the mesh. The principle involved is that during straining, the recti shorten by tonic contraction and approximate toward the midline. An incisional hernia weakens the midline and causes the recti to move laterally with contraction as medial pull is lost. By reforming a strong new linea alba, there is restoration of medial pull on recti. This is further buttressed by the mesh.

CONCLUSION

Modified shoelace repair is a simple and safe extra-peritoneal procedure and can be used for all midline incisional hernias.

Predictors of recurrence after laparoscopic ventral hernia repair

Laparoscopic ventral hernia repair (LVHR) is widely used to manage ventral hernias, but predictors of hernia recurrence have been poorly investigated. This retrospective study investigated the influence of common risk factors on hernia recurrence. Data from 146 consecutive, unselected patients who underwent LVHR between 2000 and 2006 were collected. Demographic, clinical, and perioperative parameters were analyzed to identify predictable risk factors for hernia recurrence. Both univariate and multivariate Cox's regression analysis were employed. The overall recurrence rate was 8% (12 patients) after an average follow-up of 45 months. On univariate analysis, smoking (P=0.01) and earlier repair (P<0.00) were significantly different in recurred patients. However, only earlier repair was an independent predictor of multivariate Cox's regression analysis (hazard ratio 0.085, 95% confidence interval: 0.020-0.355; P=0.001). LVHR is a safe technique to repair ventral hernias. However, smokers with earlier failed repair attempts have a higher risk of recurrence.

Laparoscopic repair of incarcerated ventral abdominal wall hernias

BACKGROUND

The role of laparoscopy in the management of incarcerated (irreducible) ventral hernia remains to be elucidated. We present our experience of the laparoscopic repair of incarcerated primary ventral and incisional hernias over an 8-year period.

METHODS

A retrospective review of the records of 112 patients undergoing laparoscopic repair for incarcerated primary ventral and incisional hernias from January 1998 to February 2006 was performed. The patient demographics, perioperative data, and postoperative complications were assessed.

RESULTS

The procedure was completed entirely laparoscopically in 103 patients (91.9%) with the placement of intraperitoneal mesh. A sutured tissue repair (without mesh) was performed in seven patients and hernia repair was abandoned after laparoscopy in two patients. Five patients required limited conversion by a targeted skin incision for the resection of nonviable bowel (three patients) and to complete adhesiolysis within multiloculated hernial sacs (two patients). The contents of the hernial sacs were incarcerated omentum (42 patients), small bowel (28 patients), large bowel (six patients), and omentum and small bowel (34 patients). Of these, seven patients presented with signs of acute small-bowel obstruction. The mean size of the largest defect through which incarceration occurred was 3.5 +/- 1.6 cm (range 1.5-7.5 cm) and the mean size of the mesh used was 379 +/- 210 cm2 (range 225-780 cm2). The mean operative time was 96 +/- 40.8 min (range 50-170 min). Inadvertent enterotomy occurred in four patients during bowel reduction and adhesiolysis. In two patients, the enterotomy was repaired by total laparoscopy followed by mesh placement, and two patients required conversion to formal laparotomy due to long-segment tears and peritoneal contamination. The average postoperative hospital stay was 2.8 +/- 1.5 days (range 1-6.5 days). Postoperative complications occurred in 20.5% patients. There was no mortality. Hernia recurred in three patients at a mean follow-up of 48 +/- 28.3 months (range 1-84 months).

CONCLUSION

Laparoscopic ventral abdominal wall hernia repair can be safely performed with a low complication rate, even in incarcerated hernias. Careful bowel reduction with adhesiolysis and mesh repair in an uncontaminated abdomen with a 5-cm mesh overlap remain key factors for a successful outcome.

Outcomes following laparoscopic versus open repair of incisional hernia

AIM

The purpose of this study was to compare short- and long-term outcomes for patients undergoing laparoscopic or open surgery for incisional hernia repair using meta-analytical techniques.

METHODS

A literature search was performed to identify comparative studies reporting outcomes on laparoscopic versus open surgery for incisional hernia repair. A random-effect meta-analytical model was used and subgroup analysis performed on high-quality studies, those reporting on more than 30 patients, and those published since 2000.

RESULTS

Five studies, with a total of 351 patients, satisfied the inclusion criteria. Laparoscopic surgery was attempted in 148 (42.2%) patients. Overall, in the laparoscopic group, operative time was significantly longer--by 12.0 minutes (P = 0.03) and length of stay reduced by 3.3 days (P < 0.003) although this finding was associated with significant heterogeneity between studies (P < 0.001). There was no difference in the short-term adverse events between the groups, but there were fewer wound infections for laparoscopic patients in high-quality studies [odds ratio (OR) = 0.22, 95% confidence interval (CI): 0.05, 0.85, P = 0.03] and those reporting on more than 30 patients (OR = 0.19, 95% CI: 0.04, 0.84, P = 0.03). No difference in hernia recurrence was shown in the overall or subgroup analysis.

CONCLUSIONS

Laparoscopic incisional hernia repair was associated with a reduced length of stay and lower wound infection rate. The impact on post-operative quality of life and financial implications needs further prospective, validated evaluation.

Assessment of usefulness exhibited by different tacks in laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic ventral hernia repair is becoming a popular technique with good results and fast postoperative recovery. The mesh is placed directly under the peritoneum and anchored with transabdominal sutures and tacks. However, the ideal size of the mesh covering the hernia orifice is know, nor the ideal type or amount of tacks has to be described.

METHODS

To assess the forces acting on a single tack, a mathematical model of the ventral hernia was created. The force was described in reference to the surface of the hernia orifice and the pressure in the abdominal cavity. The following different types of mesh were examined in vitro: Proceed (knitted mesh), Dual Mesh (expanded polytetrafluoroethylene [ePTFE] flat mesh), and Shelhigh (biologic flat mesh). The following different tacks also were examined: Protac, Anchor, and EMS. A pig model was used to measure the forces needed to destroy the connection between mesh and tissue and to describe the place of destruction (mesh, tissue, or tack) and the force needed.

RESULTS

The force acting on a single tack proportionally depends on the surface of the hernia orifice and the pressure in the abdominal cavity. The force needed to disconnect the tissue and mesh reached 8.97 +/- 0.11 N for ProTac, 2.67 +/- 0.22 N for Anchor, and 6.67 +/- 1.32 N for EMS. These values do not allow the mesh to be held in the right position when the orifice exceeds 10 cm for Protac and EMS. The disconnection of the EMS and Protac junction damages the tissue. Anchor tacks are insufficient to hold the mesh and stay in the tissue

CONCLUSIONS

In the case of small hernias (diameter<10 cm) EMS or ProTac used alone are not enough to hold the mesh. Anchor is not recommended alone in any hernia.

Laparoscopic repair of low abdominal wall hernias by tack fixation to the cooper ligament

Laparoscopic repair of low abdominal wall hernias present a challenge in mesh fixation, especially in the obese patient. Few reports have suggested repair by tack fixation to the Cooper ligament. Thirteen women, mean age 54.7 years, range 27 to 93 years, presented with 14 low abdominal wall hernias. Body mass index averaged 31.5, range 21 to 50.6. Twelve hernias were diagnosed clinically. Twelve hernias were incisional (7 midline, 5 lateral); 1 recurrent spegelian; and 1 primary midline. All hernias were repaired using laparoscopic transabdominal preperitoneal dissection, mesh fixation to an exposed Cooper ligament using the Protack, inferior edge or total mesh coverage by peritoneal-bladder flap elevation and fixation. Five small midline and lateral hernias were repaired transabdominal preperitoneally with polypropylene mesh. Nine large lower abdominal wall hernias (6 midline, 3 lateral) were repaired with Bard Composix E/X mesh. Follow-up averaged 17.5 months (range 5 to 30 mo). No hernias recurred. In conclusion, although suture versus tack fixation of mesh with laparoscopic repair of ventral hernias remains controversial, tack fixation of mesh to an exposed Cooper ligament in midline and lateral low ventral hernias has proven to be a successful repair. This technique is also efficacious in the obese patient.

Laparoscopic incisional hernia repair. A new mesh fixation method without stapling

BACKGROUND

Recent advances in laparoscopic surgery have made various abdominal surgeries possible. To avoid wound infection, mesh repair of abdominal incisional hernias is performed laparoscopically. Here we present a new procedure to fix mesh to the abdominal wall.

SURGICAL TECHNIQUE

Four anchoring sutures are made using a suture-grasping device; the additional transabdominal sutures are then made with a modified double-needle device. Additional circumferential fixation with tacks is not necessary.

CONCLUSIONS

This new mesh fixation method involves simple suturing techniques and is less time consuming than the conventional procedure.

Laparoscopic ventral hernia repair using expanded polytetrafluoroethylene-polyester mesh compound

BACKGROUND

Many biomaterials and composites have been used in clinical and experimental laparoscopic ventral hernia repair. The ideal prosthesis should allow firm binding to the abdominal wall without adhesion to the bowel.

METHODS

A compound prosthesis was made by circumferentially suturing a Gore-Tex mesh as visceral interface to a smaller polyester mesh as parietal interface, and it was used in 46 laparoscopic ventral hernia repairs between January 2000 and December 2004.

RESULTS

Average operative time was 65 min, with no intraoperative complications. Mean hospital stay was 2.2 days. Postoperative complications were five seromas, two hematomas, and one recurrence after a mean follow-up of 32.2 months.

CONCLUSION

The prosthesis used was made of two biomaterials that have been tested and tried over the years. The polyester layer is known to induce sufficient tissue ingrowth, whereas Gore-Tex minimizes adhesion formation. The memory of the compound was high enough to allow easy laparoscopic unrolling and handling.

Safety of laparoscopic ventral hernia repair in older adults

The published recurrence rate after laparoscopic ventral hernia repair is much less than the rate of recurrence via the open approach. Studies have demonstrated the safety and efficacy of this procedure but have had relatively young patient populations. We present our experience in a significantly older population. A retrospective chart review of all patients undergoing a laparoscopic ventral hernia repair at our institution from May 2000 to September 2004 was performed. Data extracted from charts included demographics, number and type of previous abdominal operations, number of previous hernia repairs, defect and mesh size, postoperative complications, and follow-up. Ninety-seven patients underwent laparoscopic ventral hernia repair (50 men and 47 women). The mean age was 68.5 years (37-85 years) with 78% of patients over the age of 60. Patients had undergone a mean of 2.1 prior abdominal operations. Thirty-five (36%) patients had undergone a mean of 1.8 previous open hernia repairs; 54% with mesh. The mean length of stay was 3.4 days (0-31 days). Thirty-three minor complications occurred in 27 patients. Six major complications occurred in five patients. Three patients required reoperation. Thirty-one percent of patients complained of pain at a transabdominal suture site 6 weeks after surgery. Nine percent of patients had seromas lasting longer than 6 weeks. Two recurrences occurred during follow-up and two patients required mesh removal. There were no deaths. Laparoscopic ventral hernia repair can be performed safely in patients regardless of age. Length of stay and overall complications are not affected by age. Long-term follow-up is necessary to evaluate the effectiveness of LVHR in this patient population.

Deepithelialization of a complex ventral hernia for completely extraperitoneal Rives-Stoppa herniorrhaphy

Peritoneal incisions made during abdominal surgery are associated with numerous postoperative complications. Laparoscopic procedures are extraperitoneal, but they do not always provide adequate exposure of the defect nor room for manipulation. We suggest a de-epithelialization approach prior to mesh placement for the repair of large ventral hernias as a means of achieving a completely extraperitoneal ventral herniorrhaphy.

Laparoscopic incisional and ventral hernia repair: complications-how to avoid and handle

Complications will occur with any operative procedure. The possibility of this must be considered for laparoscopic incisional and ventral hernia repair (LIVH) as well. The most commonly reported of these include: intraoperative intestinal injury (1-3.5%), infection involving the prosthetic biomaterial (0.7-1.4%), (2.6-100%), postoperative ileus seromas (1-8%), and persistent postoperative pain (1-2%). The incidence of enterotomy can be reduced by careful dissection and judicious use of any energy source. Infection can be minimized by the use of perioperative antibiotics, an antimicrobially impregnated biomaterial, and careful manipulation of the prosthesis during the procedure. Seromas are so common that they should be expected but can be decreased by the use of a postoperative abdominal binder. Aspiration will be necessary in a few instances. Similarly, ileus is expected when there is significant bowel dissection and bleeding. Early ambulation and standard use of postoperative bowel care will aid in the treatment of this problem. Persistent pain will generally occur at the site of a transfascial suture. It cannot be predicted or prevented with certainty. When it occurs, local injection with bupivacaine, steroids, or non-steroidal agents will help, but occasionally, removal of the offending suture(s) will be required. The average recurrence rate for LIVH is approximately 5.6% in the literature. Rates as high as 15.7%, however, have been reported. Recurrence will be increased by inadequate prosthetic overlap of the fascial defect, infection that involves the biomaterial, which then requires its removal, and lack of the use of transfascial sutures. To prevent these risks, the surgeon must assure that there is at least a 3-cm overlap of all portions of the hernia defect and insist that sutures are used at 5-cm intervals to fix the biomaterial. Infection that requires explantation of the patch will generally result in recurrence, as this must be repaired primarily. Alternatively, the use of a collagen prosthesis may allow immediate repair, but this is associated with a high failure rate. A staged repair will be necessary in the future in most patients.

Computed tomography scanning and recurrence after laparoscopic ventral hernia repair

Laparoscopic ventral hernia repair is an advancing surgical method. It seems to have fewer recurrences than open surgery. However, with patients suspected of recurrence after laparoscopic hernia repair, it can be very difficult to determine whether or not there is recurrence by clinical examination alone. The purpose of this article is to show that computed tomography is a valuable diagnostic tool in excluding recurrence after laparoscopic ventral hernia repair. A total of 35 patients were included in a prospective study. They underwent laparoscopic ventral hernia repair, and all patients suspected of recurrence were computed tomography scanned. Four patients were suspected of recurrence. They all presented symptoms of swelling or pain or both. The computed tomography scanning did not show the presence of recurrence in any of the 4 cases. Computed tomography scanning can provide exact information about the content of swelling and whether there is recurrence or not. We conclude that computed tomography scanning is suitable as a valid imaging method in doubtful cases considering ventral hernia recurrence after laparoscopic ventral hernia repair.

Learning curve for laparoscopic ventral hernia repair

PURPOSE

To test if there was any difference in the indications and early outcomes of laparoscopic ventral hernia repair (LVHR) during a 36-month period at a single institution.

METHODS

From August 1999 to August 2002, 64 consecutive, unselected patients underwent attempted LVHR. The patients were retrospectively divided into two groups: group 1 included the first 32 patients, and group 2 included the second 32 patients. Data regarding patient demographics, results, and postoperative follow-up were compared between the groups.

RESULTS

Demographic characteristics, types of hernia, preoperative records, and hernia defects were well matched between the groups. Four patients in group 1 required conversion to laparotomy for bowel injuries, whereas no conversion was required in group 2 (12% vs 0%, P = 0.11 [NS]). The operative times and complication rates were similar, but bowel injuries were significantly more common in group 1 (19% vs 0%, P = 0.02), including the patients who were converted. The analgesic requirement was small and the hospital stay short in both groups; the differences were not significant. Three recurrences were noted in group 1 and none were noted in group 2, although follow-up was not comparable in the second group.

CONCLUSIONS

A learning curve is needed to decrease conversions and bowel injuries during LVHR. The improved experience could permit the treatment of larger defects laparoscopically.

Complications of laparoscopic incisional-ventral hernia repair: the experience of a single institution

BACKGROUND

Laparoscopic incisional-ventral hernia repair (LIVH) is used with increasing frequency for the morbidly obese and for complex and recurrent hernias. The experience of a single institution with this technique is reviewed and the findings and complications are presented.

METHODS

Data were collected retrospectively for a single surgeon's series of patients undergoing LIVH at the institution described in this report.

RESULTS

The review showed a complication rate of 15.2%, a recurrence rate of 2%, and a prosthetic infection rate of 2%. Patients with a body mass index greater than 30 cm/m2 accounted for 73% of the complications and made up 62.2% of the patients.

CONCLUSIONS

The LIVH procedure may be safely performed with low complication and recurrence rates even for the obese, allowing ventral hernia repair to be performed safely with good results. The LIVH technique should be considered for the repair of all incisional and ventral hernias requiring repair with a mesh prosthesis.

Incisional hernia repair

Incisional ventral hernias are a common problem encountered by surgeons, with over 100,000 repairs being performed annually in the United States. Although many predisposing factors for incisional ventral hernia are patient-related, some factors such as type of primary closure and materials used may reduce the overall incidence of incisional ventral hernia. With the advent of prosthetic meshes being used for incisional ventral hernia repair, the recurrence rate has dropped to approximately 10%. More recently, with the development of prosthetic mesh that is now safe to place intraperitoneally, the recurrence rate has dropped to under 5%. The current controversies that exist for incisional ventral hernia repair are which approach to use (open versus laparoscopic) and what type of fixation (partial- versus full-thickness abdominal muscular/fascial wall) is necessary to stabilize the position of the mesh while tissue ingrowth occurs. During the next decade the answers to these controversies should be available in the surgical literature.

Robot-assisted laparoscopic repair of ventral hernia with intracorporeal suturing

BACKGROUND

This study presents a novel technique for laparoscopic ventral hernia repair using the da Vinci Robot and intracorporeal suturing. Thus, it offers an alternative to transabdominal sutures and tackers.

METHODS

A ventral hernia model was created in six pigs. The mesh was fixed to the circumference of the fascia using interrupted sutures. The outer border of the mesh was then fixed to the posterior fascia using running sutures.

RESULTS

There were no complications. The depth and location of the interrupted and running sutures were confirmed postmortem.

CONCLUSIONS

The transabdominal sutures and tackers used in laparoscopic ventral hernia repair can be the focus for postoperative pain and adhesions. As an alternative, the da Vinci Robot can be used to facilitate intracorporeal suturing of the mesh directly to the fascial edge and to secure the circumference of the mesh to the posterior fascia. The preliminary results are promising and represent a safe method that can be implemented in humans.

Ventral hernia repair: a study of current practice

Ventral wall hernias are common; despite this, there are no guidelines on the best surgical management. The aim of this study was to examine the types of repair in use for abdominal wall hernias in the West of Scotland over a 3-month period. Data were gathered on 120 patients. There were 60 incisional, 32 umbilical, and 28 epigastric hernias. The main indication for repair was pain (78%), while 12 patients (10%), presented acutely with incarceration or strangulation. The most common method of repair was sutured (55%), followed by mesh (29%) and Mayo repair (16%). There was no correlation between use of mesh and hernia size or whether repair was for a recurrent hernia. Surgical practice varies widely in the repair of ventral wall hernias. Clinical trials are required to establish the best method of repair for this common condition.