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

Is mesh fixation necessary in laparoendoscopic techniques for M3 inguinal defects? An experimental study

BACKGROUND

Although international guidelines recommend not fixing the mesh in almost all cases of laparoendoscopic repairs, in case of large direct hernias (M3) mesh fixation is recommended to reduce recurrence risk. Despite lack of high-quality evidence, the recommendation was upgraded to strong by expert panel. The authors conducted a research experiment to verify the hypothesis that it is possible to preserve the mesh in the operating field in large direct hernias (M3) without the need to use fixing materials.

METHOD

The authors conducted an experiment with scientists from Universities of Technology in a model that reflects the conditions in the groin area. By simulating conditions of the highest possible intra-abdominal pressure, they examined the mesh behavior within the groin and its ability to dislocate under the forces generated by this pressure. The experiment involved six spatial implants and one flat macroporous mesh.

RESULTS

Heavyweight spatial meshes and lightweight spatial-individualized meshes showed no tendency to dislocate or move directly to the orifice, which was considered a rapid hernia recurrence. Lightweight meshes, both spatial and flat, underwent significant migration and shifting toward the hernial orifices.

CONCLUSION

Based on the results, we believe that mesh fixation is not the only alternative to preventing recurrence in complex defects. Similar effects can be achieved using a larger, more rigid, and anatomically fitted implant. The type of implant (rather than its fixation) seems to be a key factor from the point of view of mechanics and biophysics. Clinical trials confirming the results in vivo will allow to supplement or amend the guidelines for the treatment of large inguinal hernias.

Laparoscopic closure of the vaginal rings in the standing horse using a tacked intraperitoneal slitted mesh (TISM) technique

BACKGROUND

Indirect inguinal herniation (IIH) is a potentially life-threatening condition in stallions. The ideal preventive measure for breeding stallions ensures a minimally invasive closure of the vaginal ring that avoids recurrence of IIH while preserving both testicles.

OBJECTIVES

To describe a minimally invasive laparoscopic tacked intra-peritoneal slitted mesh (TISM) technique in the standing horse to close the vaginal rings and to evaluate its efficacy in preventing recurrence of IIH in stallions.

STUDY DESIGN

Retrospective case series.

METHODS

Medical records of 17 stallions with a history of IIH were reviewed retrospectively. The surgical procedure was performed on the standing horse through a flank approach using four laparoscopic portals. The vaginal ring was covered with a commercial mesh. The mesh was partially cut to create a slitted mesh with two flaps: the dorsal flap was passed under the spermatic cord and ductus deferens and the ventral flap above. The mesh was secured in place with laparoscopic tacks. Long-term follow-up was obtained by a structured telephone interview of the owners.

RESULTS

A total of 32 laparoscopic vaginal rings closures were successfully performed in 17 horses. No major intra- or postoperative complications occurred. None of the horse suffered from re-occurrence. Nine of the 13 active breeding stallions were breeding again with similar semen quality as before treatment, 4/13 will resume their breeding activity during the next breeding season. None of the horses were castrated and none of the owners reported abnormal size or shape of the testicles. In three stallions, post-operative pain and activity limitations were noted that gradually resolved after 6 months.

MAIN LIMITATIONS

The lack of large numbers to compare the results of different mesh and tack combinations, the lack of follow-up veterinary examinations and the limited number of laparoscopic rechecks.

CONCLUSION

The TISM technique is an effective minimally invasive technique to surgically reduce the size of the vaginal ring and thereby prevent recurrence of IIH.

Hybrid technique for postoperative ventral hernias - own experience

INTRODUCTION

There are many techniques which may be involved in abdominal hernia repair, from classical to tension-free. Treatment of complicated hernias has undergone evolution. Many surgeons consider the laparoscopic method as a method of choice for incisional hernia repair. Sometimes miniinvasive repair of complicated hernia is not so easy to perform. We are convinced that selected patients may benefit from combined open and laparoscopic techniques.

AIM

To present the operating technique and early results of treatment of 15 patients operated on using the 3 hybrid technique.

MATERIAL AND METHODS

Fifteen patients suffering from recurrent incisional hernias underwent the hybrid technique for their repair between June 2012 and April 2015. The hybrid technique was performed using synthetic meshes in 14 cases and a biological implant in 1 case.

RESULTS

The early postoperative period was uncomplicated in all cases. Within a maximum follow-up period of 32 months, two deep wound infections were observed.

CONCLUSIONS

The hybrid technique may be used in patients with recurrent incisional hernias.

New minimally invasive technique of parastomal hernia repair - methods and review

INTRODUCTION

Parastomal hernia is described as the most common complication in patients with ostomy. It is reported that its incidence varies from 3% to 39% for colostomies and 0 to 6% for ileostomies. Surgical repair remains the treatment of choice. There are three types of surgical treatment - fascial repair, stoma relocation and repair using prosthetic mesh via a laparoscopic or open approach. Recently there have been several meta-analyses and systematic reviews aiming to compare the results of surgical treatment, and the authors agreed that the quality of evidence precludes firm conclusions.

AIM

To describe the novel concept of parastomal hernia repair - HyPER/SPHR technique (hybrid parastomal endoscopic re-do/Szczepkowski parastomal hernia repair) and its early results in 12 consecutive cases.

MATERIAL AND METHODS

Twelve consecutive patients were operated on due to parastomal hernia using the new HyPER hybrid technique between June 2013 and May 2014. The patients' condition was evaluated during the perioperative period, 6 weeks and then every 3 months after surgery.

RESULTS

After 6 weeks of follow-up we have not observed any mesh-related complications. All 12 patients were examined 3 months and 6 months after repair surgery for evaluation. No recurrence, stoma site infection or stoma-related problems were found. None of the patients complained of pain and none of them needed to be hospitalized again. Reported quality of life on a 0-10 scale after 6 weeks of follow-up was 8 (range: 7-10).

CONCLUSIONS

The HyPER procedure for treatment of parastomal hernias proposed by the authors is a safe and feasible surgical technique with a high patient satisfaction rate and a low number of complications. The hybrid procedure seems to be a promising method for parastomal hernia repair.

Physical and mathematical modelling of implant-fascia system in order to improve laparoscopic repair of ventral hernia

BACKGROUND

This paper describes an investigation of biomechanical behaviour of hernia repair, which is focused on the selection of safe linking of certain type of implant with fascia in laparoscopic operation. The strength of various fixations of the implant to the fascia is analysed.

METHODS

The research is based on experimental observations of operated hernia model behaviour during a dynamic impulse load corresponding to post-operative cough. Fifty seven different types of models of implanted mesh are considered. Five types of implants and five types of connectors are used. Mechanical properties of the implants as well as limit tearing forces of joints are identified in uni-axial tensile tests. Mathematical model of implanted mesh based on finite element method is proposed. The identified mechanical properties of the materials are applied and the model is calibrated using quantities measured during experiments.

FINDINGS

The presented results point at trans-abdominal sutures and ProTacks (connectors) and at DynaMesh (implant) as the most reliable materials used in ventral hernia operation, in the tested materials group. Desired properties of implants seem to be: elastic properties similar to the properties of tissues and high local strength, as fixation have a local character. The proposed mathematical model can be applied to simulate real behaviour of an implant with appropriate accuracy and to estimate the number of tacks for the implantation of hernia meshes.

INTERPRETATION

The presented results may help in the deeper understanding of the fascia-mesh system behaviour, and thus may lead to improve the fixation methods.

Assessment of adhesion formation after laparoscopic intraperitoneal implantation of Dynamesh IPOM mesh

INTRODUCTION

Formation of adhesions after laparoscopic hernia repair using the intra-peritoneal onlay mesh (IPOM) procedure can lead to intestinal obstruction or mesh erosion into intestinal lumen. The aims of this study included: measurement of adhesion formation with Dynamesh IPOM after laparoscopic intraperitoneal implantation, and assessment of the occurrence of isolated adhesions at the fastening sites of slowly absorbable sutures.

MATERIAL AND METHODS

Twelve healthy pigs underwent laparoscopic implantation of 2 Dynamesh IPOM mesh fragments each, one was fastened with PDSII, and the other with Maxon sutures. An assessment of adhesion formation was carried out after 6 weeks and included an evaluation of surface area, hardness according to the Zhulke scale, and index values. The occurrence of isolated adhesions at slowly absorbable suture fixation points was also analyzed.

RESULTS

Adhesions were noted in 83.3% of Dynamesh IPOM meshes. Adhesions covered on average 37.7% of the mesh surface with mean hardness 1.46 and index value 78.8. In groups fixed with PDS in comparison to Maxon sutures adhesions covered mean 31.6% vs. 42.5% (p = 0.62) of the mesh surface, mean hardness was 1.67 vs.1.25 (p = 0.34) and index 85.42 vs. 72.02 (p = 0.95).

CONCLUSIONS

The Dynamesh IPOM mesh, in spite of its anti-adhesive layer of PVDF, does not prevent the formation of adhesions. Adhesion hardness, surface area, and index values of the Dynamesh IPOM mesh are close to the mean values of these parameters for other commercially available 2-layer meshes. Slowly absorbable sutures used for fastening did not increase the risk of adhesion formation.

Ventral hernia mesh tack causes liver hemorrhage

INTRODUCTION

The laparoscopic approach is an increasingly popular option for ventral hernia repair. In the wake of this new technology, unexpected complications have been reported.

CASE PRESENTATION

We present the case of a patient who developed a liver laceration and hemorrhage after a mesh tacking device partially dislodged subsequent to ventral hernia repair. The patient underwent exploratory laparotomy, liver hemostasis and removal of the offending tack.

DISCUSSION

Our patient partially dislodged a mesh tacking device likely after violent coughing during a bout of pneumonia. The exposed blade caused a liver laceration and hemorrhage. Few other unexpected complications of the use of mesh tacking devices have been noted in the literature. Tackless hernia repair has also been described.

CONCLUSION

Laparoscopic ventral hernia repair with tacks may have unexpected complications of which the surgeon should be aware and advise patients. Our patient developed a liver laceration and symptomatic hemorrhage after partially dislodging a hernia mesh tack. Further research into tackless hernia repair may be beneficial. A low long-term recurrence rate would demonstrate if tackless hernia repair is a viable option.

Investigation of abdomen surface deformation due to life excitation: implications for implant selection and orientation in laparoscopic ventral hernia repair

BACKGROUND

Ventral hernia is a common medical problem. Statistically there are around 10% recurrences of the sickness. The authors' former investigation proved edges of the hernia orifice displacements to be one of the factors causing recurrence. Thus, experimental investigation of the abdomen surface deformation due to some normal activities of people is studied.

METHODS

Eight slim, healthy people were asked to extremely stretch their abdomens. Bending, stretching and expiration were considered. The deformations registration was made by two cameras located in front of the patient on both sides. Special calculation procedure was used in order to transform characteristic point displacements to strains of abdomen in different directions.

FINDINGS

The extreme strains, their localization and directions are identified. The study proves that the highest strains, bigger than 25% on average, appear in the upper part of the central vertical line of the abdomen and in lower sides in semi-vertical direction. The lowest strains, smaller than 7%, occur in a horizontal line situated low in the abdomen. For each patient similar zones of smaller or bigger strains are identified, however a wide discrepancy of the strain values obtained for different patients is stated. For example the strains in lower part in semi-vertical direction for one patient equals 9% and for another 134%!

INTERPRETATION

The acquired conclusions may be useful for surgeons in finding practical solutions to dilemmas concerning the choice of an implant (elastic or stiff) for a specific ventral hernia, its proper connection with fascia and orientation in the abdomen.

Biomechanics of the front abdominal wall as a potential factor leading to recurrence with laparoscopic ventral hernia repair

BACKGROUND

Intraabdominal pressure often is blamed as the cause of mesh-fascia junction failure after laparoscopic ventral hernia repair. Stretching of the mesh during a cough or defecation may lead to recurrence. Little is known about the movements of mesh in the abdominal cavity after this operation. This study investigated the front abdominal wall to describe its elasticity in vivo and searched for elongations that possibly stretched an implanted mesh, thereby causing fixation failure and subsequent recurrence.

METHODS

To measure front abdominal wall elongations, a model of fascia movements was created. Eight healthy volunteers were measured during exercise to determine the extent of elongations in their front abdominal wall. Videos were analyzed in three positions to create a mathematical shell structure. A computerized model based on the net movement of nodes was calculated to determine the axes and values for maximum elongations.

RESULTS

The largest average elongations were measured for the upper midline (32.08%) and the transverse line in the low lateral area (34.06%). The maximum values for these lines were larger than 100% for the middle line (133.78%) and exceeded 50% for the entire middle line. The values for the horizontal lines did not reach 10% at any level. According to these data, areas of both high and low elasticity were defined.

CONCLUSIONS

The presented experiment adds new parameters to the understanding of in vivo mesh behavior. Elongation of the front abdominal wall may stretch implanted mesh and could be a cause of recurrence in cases of insufficient fixation.

Long-Term Outcomes with Transfascial Sutures versus Tacks in Laparoscopic Ventral Hernia Repair: A Review

Although most surgeons report using both transfascial sutures and laparoscopically placed tacks to secure prostheses in laparoscopic ventral hernia repair, a significant minority have reported large series in which sutures were omitted. A systematic review of the available literature was conducted for large case series and controlled trials documenting long-term follow-up. Forty-three articles were identified, including 6015 patients whose prostheses were secured with transfascial sutures (with or without tacks), and 2450 patients receiving tacks or staples alone. The mean follow-up time reported was 30.1 months. No significant difference was found in rates of hernia recurrence, mesh removal, prolonged postoperative pain, patient body mass index, or hernia defect size between the two groups. The suture group did experience a significantly higher rate of surgical site infection. Although suture tensile strength is greater than that of tacks, and despite numerous anecdotal reports of hernia recurrence secondary to suture failure or omission, the existing literature does not show superiority of one mesh fixation technique over the other for recurrence, whereas infection rates increase when transfascial suture is used.

Seroma formation and method of mesh fixation in laparoscopic ventral hernia repair--highlights of a case series

INTRODUCTION

Laparoscopic ventral hernia repair (LVHR) is gaining popularity amongst minimally invasive surgeons, promising shorter lengths of hospital stay and decreased morbidity compared to conventional open repair. We aim to report our experience of LVHR performed at a single institution and analyse morbidity to improve outcome.

METHODS

A retrospective analysis using a prospectively collected database and patient re-cords was performed on all patients that underwent LVHR. Patient demographics, morbidity and mortality were recorded. Patients with recurrences underwent further analysis.

RESULTS

There were a total of 55 laparoscopic ventral hernia operations performed on 50 patients. 24 (48%) were male, and the median BMI was 31 (range 20-41). The median operating time was 50 mins (range 30-120), the median length of stay (LOS) was one day (range 1-14) and the median follow-up period was 14 months (range 3-31). Operative complications occurred in two (3.6%) patients. Minor morbidity occurred in 12 (21.8%) patients. Eight (14.5%) patients developed seromas within the residual hernia sac post-operatively. There were six recurrences following LVHR in five patients. At re-operation, all recurrences appeared to be due to mesh detachment.

CONCLUSION

LVHR is safe and the results are comparable to published series. We are encouraged by a shorter LOS and operative time compared to most published data. Post-operative se-roma formation is common. If there is a suspicion of recurrence, these should all be imaged appropriately to avoid unnecessary operative intervention. A higher BMI is an independent risk factor for recurrence in LVHR. Consideration should be given to using transfascial sutures or other fixation methods to improve recurrence rates in this difficult patient group.

Comparison of anchoring capacity of mesh fixation devices in ventral hernia surgery

BACKGROUND

A reliable method of fixation of intraperitoneal mesh is required both in laparoscopic and open surgery for ventral hernia. We evaluated anchoring capacity of 3 fixation devices available for clinical use.

MATERIALS AND METHODS

Anchoring capacity of 3 commercially available fixation devices were compared by counting the number of sheets anchored by a single firing under a fixed pressure. A total of 5 trials were conducted for each device.

RESULTS

The number of sheets fixed (mean+/-SD) were, 12.4+/-1.1 for a coil type; 11.4+/-1.3 for a helical type; and 5.8+/-0.5 for a staple type tacker. The fixation capacity of the staple type was significantly lower than the other 2 types (P<0.0001). However, there was not statistically significant difference between the coil type and the helical type tackers.

CONCLUSIONS

The helical and coil type tackers in ventral hernia equally provide deep penetration that may contribute to strong fixation of the intraperitoneal mesh to the abdominal wall.

Laparoscopic ventral hernia repair: innovative anatomical closure, mesh insertion without 10-mm transmyofascial port, and atraumatic mesh fixation: a preliminary experience of a new technique

BACKGROUND

Generous overlap by a well-transfixed mesh is important in laparoscopic ventral hernia repair (LVHR). Mesh is usually introduced through a 10-mm trocar and fixed by tackers or transfixed by sutures. Ten-millimeter trocar sites are more prone to hernia development. Transfixation done using a suture passer inflicts some trauma and the site may become painful. This study reports a mesh insertion technique avoiding a 10-mm myofascial port, double-breasted fascial closure of the hernial defect, and transfixation in a relatively atraumatic manner.

METHODS

This prospective study was conducted by enrolling the patients attending our surgery clinic. They were candidates for LVHR. Informed consent was obtained from each patient before the procedure. The study was approved by the Ethical Review Board of the Hospital and conducted as per good clinical practice (GCP) guidelines.

RESULTS

Between April 2004 and June 2006, 29 ventral hernia patients were enrolled without any exclusion. All patients had LVHR performed with this technique. Mean operative time and hospital stay were 65 min and <1 day, respectively. There were no perioperative complications, conversion, infection, trocar site or recurrent herniation or mortality. The majority of the patients were operated on as day-care surgery. Patients were followed up telephonically for the first 48 h and then by visiting us regularly. There was no postoperative visible bulge.

CONCLUSION

Mesh insertion by avoiding 10-mm trocar, double-breasted defect closure, and transfixation using atraumatic needles is a technically easy, safe, and patient-friendly procedure.