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. Surg Endosc. 2009;23:900-905. [PMID: 18813981 DOI: 10.1007/s00464-008-0159-7]

Ventral ETEP Versus REPA, Comparison of Two Novel Minimally Invasive Techniques for Midline Defects

Introduction: This report aimed to compare ventral extended vision extraperitoneal (ETEP) and preaponeurotic repair (REPA) techniques in terms of surgical procedure, outcomes, and patient evolution. Methods: This was a retrospective study performed at a tertiary care academic center between 2017 and 2022. All consecutive patients operated on for midline hernias and rectus diastasis using REPA and ETEP were included. Follow-up visits were at 15 days, 30 days, and 6 months postoperative. Age, sex, BMI, American Surgical Anesthesiologic Classification (ASA), surgical time, need for conversion to open surgery, time of stay, seroma, hematoma, surgical site infection (SSI), recurrence, and re-interventions were assessed. Results: For the present study, 148 patients were included. From them, 62 patients received the REPA procedure and 86 were operated on using the ETEP technique. REPA average time was 105 minutes (interquartile range [IR] 80-130), and ETEP average time was 120 minutes (RIC 95-285) (p = 0.03). Ambulatory procedures were 32.3% (n = 20) REPA and 20.9% (n = 18) ETEP (p = 0.23). In REPA, the mean time for drain extraction was 11.92 days and 8 days in ETEP (p < 0.001). Seroma incidence was identified in 40.3% (n = 25) of the REPA cases and 5.8% (n = 5) of the ETEP procedures (p = 0.001). In a multivariate analysis for seroma incidence REPA technique was associated with a significant risk of its incidence [odds ratio (OR) 16, 67 95% confidence interval ((CI95) 4.67-59.52), p < 0.001]. Conclusion: REPA and ETEP are safe and reproducible. Both approaches reported short hospitalization times and almost no major complications. We found a longer surgical time in ETEP and a higher incidence of seroma in REPA.

Primary closure of the midline abdominal wall defect during laparoscopic ventral hernia repair: analysis of risk factors for failure and outcomes at 5 years follow-up

BACKGROUND

The primary aim of this prospective study is to report bulging and recurrence rates and to analyze the risk factors responsible for failure, after laparoscopic ventral hernia repair (LVHR) with primary closure of defect (PCD) using a running suture and intraperitoneal mesh placement, at 5-year follow-up. The secondary endpoint is to evaluate 30-day postoperative complications, seroma, and pain.

METHODS

PCD failure was defined as the presence of postoperative bulging and/or recurrence. Pain was evaluated using a visual analogue scale (VAS). After surgery, fifty-eight patients underwent clinical examination and computed tomography scan to diagnose bulging, recurrence, and seroma (classified according to the Morales-Conde classification).

RESULTS

At 60 months follow-up, recurrence was observed in five patients (8.6%), while bulging, not needing a surgical treatment, occurred in fifteen patients (25.9%). Chronic obstructive pulmonary disease (COPD) is the only risk factor responsible for both outcomes together, bulging and recurrences (p = 0.029), while other considered risk factors as gender, age, body mass index, diabetes, smoke habits, primary or incisional hernia and the ratio defect width/transverse abdominal axis did not achieve the statistically significance. Clinical seroma was diagnosed at one month in eight patients (13.8%). Seromas were observed at one year of follow-up. During the follow-up, pain reduction occurred.

CONCLUSION

LVHR has evolved toward more anatomical concepts, with the current trend being the abdominal wall anatomical reconstruction to improve its functionality, reducing seroma rates. Based on results obtained, PCD is a reliable technique with excellent recurrence rate at 5 years follow-up, even when the defect closure may generate tension at the midline. On the other hand, this tension could be related with high bulging rate at long-term, particular in case of patients with COPD.

Acceptability and barriers to adopting physical therapy and rehabilitation as standard of care in hernia disease: a prospective national survey of providers and preliminary data

PURPOSE

Physical therapy (PT) and rehabilitation are widely utilized in a variety of disease processes to improve function, return to activities of daily living (ADLs), and promote overall recovery. However, hernia repair has struggled to adopt this practice despite operations occurring in one of the most dynamic parts of the body - the abdominal core. This study sought to understand perspectives and perceived barriers regarding the incorporation of PT and rehabilitation in hernia care.

METHODS

A standardized rehabilitation protocol was developed by the Abdominal Core Health Quality Collaborative (ACHQC), a national quality improvement initiative specific to hernia disease, and launched in 2019. Empiric data from the ACHQC was then obtained to describe preliminary utilization. A prospective electronic survey was then deployed to all surgeons participating in the ACHQC to aid in interpreting the identified trends. The survey included questions regarding the current use of PT in their practice, as well as further opinions on the functionality, benefit, and barriers to its use.

RESULTS

We identified 1,544 patients who were listed as receiving some form of postoperative rehabilitation, of which 992 (64.2%) had a primary diagnosis of ventral hernia and 552 (35.8%) had an inguinal hernia. Among patients who had a ventral hernia, 863 (87.0%) received self-directed rehabilitation exercises compared to 488 (88.4%) of inguinal hernia patients. The subsequent survey exploring these trends was completed by 46 ACHQC surgeons (10.2%). More than half (52%) reported using PT for hernia patients, primarily in abdominal wall reconstruction cases (92%). Of those who did not report using PT, 50% cited unknown clinical benefit and another 27% cited unknown PT resources. PT utilization was typically concentrated to the postoperative period (58%), while 42% reported also using it preoperatively. Despite 72% of respondents citing a perceived benefit of PT in hernia patients, overall use of PT was primarily reported as 'occasional' by 42%, with another 27% reporting 'rarely.' Perceived benefits of PT included increased core strength, stability, mobility, patient satisfaction, education, independence, earlier return to work and ADLs, overall improved recovery, and decreased risk of postoperative issues. Reported barriers to implementing PT in practice or adapting the ACHQC Rehabilitation Protocol included lack of education, lack of evidence of clinical benefit, and difficulties operationalizing the protocol.

CONCLUSION

A national survey of hernia surgeons demonstrated willingness to adopt PT and rehabilitation protocols in their clinical practices and noted a high perceived benefit to patients. However, lack of education and evidence regarding the protocol may represent important barriers to overcome in widely disseminating these resources to patients. These gaps can be addressed through dedicated educational venues and additional studies establishing PT and rehabilitation as critical future adjuncts for the recovery of hernia repair patients.

Short-term outcomes of minimally invasive retromuscular ventral hernia repair using an enhanced view totally extraperitoneal (eTEP) approach: systematic review and meta-analysis

Background

The enhanced view totally extraperitoneal (eTEP) approach is becoming increasingly more widely accepted as a promising technique in the treatment of ventral hernia. However, evidence is still lacking regarding the perioperative, postoperative and long-term outcomes of this technique. The aim of this meta-analysis is to summarize the current available evidence regarding the perioperative and short-term outcomes of ventral hernia repair using eTEP.

Study design

A systematic search was performed of PubMed, EMBASE, Cochrane Library and Web of Science electronic databases to identify studies on the laparoscopic or robotic-enhanced view totally extraperitoneal (eTEP) approach for the treatment of ventral hernia. A pooled meta-analysis was performed. The primary end point was focused on short-term outcomes regarding perioperative characteristics and postoperative parameters.

Results

A total of 13 studies were identified involving 918 patients. Minimally invasive eTEP resulted in a rate of surgical site infection of 0% [95% CI 0.0–1.0%], a rate of seroma of 5% [95% CI 2.0–8.0%] and a rate of major complications (Clavien–Dindo III–IV) of 1% [95% CI 0.0–3.0%]. The rate of intraoperative complications was 2% [95% CI 0.0–4.0%] with a conversion rate of 1.0% [95% CI 0.0–3.0%]. Mean hospital length of stay was 1.77 days [95% CI 1.21–2.24]. After a median follow-up of 6.6 months (1–24), the rate of recurrence was 1% [95% CI 0.0–1.0%].

Conclusion

Minimally invasive eTEP is a safe and effective approach for ventral hernia repair, with low reported intraoperative complications and good outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10029-021-02557-8.

Is fascial defect closure with intraperitoneal onlay mesh superior to standard intraperitoneal onlay mesh for laparoscopic repair of large incisional hernia?

INTRODUCTION

The ideal surgical technique for large incisional hernia repair has not yet been identified. The aim of this study was to evaluate surgical outcomes of standard intraperitoneal onlay mesh (sIPOM) versus fascial defect closure with intraperitoneal onlay mesh (IPOM-Plus) for large incisional hernia repair.

METHODS

Of 49 patients who underwent laparoscopic incisional hernia repair between November 2005 and December 2016, 26 cases with large incisional hernia (transverse diameter ≥10 cm) were examined to compare surgical outcomes between sIPOM (n = 12) and IPOM-Plus (n = 14). Statistical analysis was performed using the Mann-Whitney U-test and Fisher's exact test. P < 0.05 was considered to be statistically significant.

RESULTS

We compared sIPOM with IPOM-Plus for similar hernia types during median follow-up periods of 53 and 21 months, respectively. The operation time was 150 min for sIPOM and 148 min for IPOM-Plus (P = 0.6220). Early postoperative complications including seroma formation were observed in four sIPOM patients (33%) and three IPOM-Plus patients (21%) (P = 0.6652). Significantly more mesh bulged with sIPOM than with IPOM-Plus (50% vs 0%; P = 0.0082). Chronic pain lasting 3 months after the operation was found in two cases of IPOM-Plus (14%), but this was not statistically significant. Postoperative hospital stay was longer for sIPOM patients than for IPOM-Plus patients. Only one recurrence was observed in the sIPOM group (8%), but this was not statistically significant.

CONCLUSION

For large incisional hernia repair, IPOM-Plus seems to be more effective than sIPOM in terms of reducing mesh bulging.

[Hybrid repair of postoperative ventral hernia]

AIM

To develop new technique of abdominal wall repair for postoperative ventral hernia without disadvantages which are intrinsic for open and laparoscopic surgery.

MATERIAL AND METHODS

Combined open and laparoscopic hernia repair was used in 18 patients with postoperative ventral hernia. Open stage provided safe dissection of abdominal adhesions and defect closure by autoplasty, laparoscopic procedure consisted of prosthesis deployment without separation of abdominal wall layers. Two types of composite endoprostheses with anti-adhesive coating were used for abdominal wall repair.

RESULTS

There were no cases of recurrence or infectious complications in long-term period (from 3 to 106 months).

CONCLUSION

Hybrid repair of postoperative ventral hernia is safe and effective procedure. Further studies are necessary to assess cost-effectiveness ratio of this method in view of expensive composite endoprostheses and laparoscopic supplies.

Laparoscopic intracorporeal rectus aponeuroplasty (LIRA technique): a step forward in minimally invasive abdominal wall reconstruction for ventral hernia repair (LVHR)

BACKGROUND

Closing the defect (CD) during laparoscopic ventral hernia repair began to be performed in order to decrease seroma, to improve the functionality of the abdominal wall, and to decrease the bulging effect. However, tension at the incision after CD in large defects is related to an increased rate of pain and recurrence. We present the preliminary results of a new technique for medium midline hernias as an alternative to conventional CD.

METHODS

A prospective controlled study was conducted from January 2015 to January 2017 to evaluate an elective new procedure (LIRA) performed on patients with midline ventral hernias (4-10 cm width). The posterior rectus aponeurosis was opened lengthwise around the hernia defect using a laparoscopic approach to create two flaps and was then sutured. The size of the flaps was estimated using a mathematical formula. An on-lay mesh was placed intraperitoneal overlapping the fascia defect. The data analyzed included patient demographics, operative parameters, and complications. A computerized tomography was performed preoperatively and postoperatively (1 month and 1 year) to evaluate recurrence, distance between rectus and seroma.

RESULTS

Twelve patients were included. Mean width of the defect was 5.5 cm. Average VAS (24 h) was 3.9, 1.1 (1 month), and 0 (1 year). Mean preoperative distance between rectus was 5.5 cm; postoperative was 2.2 cm (1 year). Radiological seroma at first month was detected in 50%. Mean follow-up was 15 months.

CONCLUSION

The LIRA technique could be considered as an alternative to conventional CD or endoscopic component separation for medium defects under 10 cm in width. This technique obtained a "no tension" effect that could be related to a lower rate of postoperative pain with no recurrence or bulging, being a safe, feasible, and reproducible technique.

[Postoperative ventral hernia - unsolved issues of surgical tactics]

Currently, there is no unified opinion on some problematic issues of surgical treatment of postoperative ventral hernias. Current approaches and surgical aspects of primary and recurrent postoperative ventral are reviewed in the article.

Meta-analysis of closure of the fascial defect during laparoscopic incisional and ventral hernia repair

Background

Laparoscopic incisional and ventral hernia repair (LIVHR) is being used increasingly, with reported outcomes equivalent to those of open hernia repair. Closure of the fascial defect (CFD) is a technique that may reduce seroma formation and bulging after LIVHR. Non-closure of the fascial defect makes the repair of larger defects easier and reduces postoperative pain. The aim of this systematic review was to determine whether CFD affects the rate of adverse outcomes, such as recurrence, pseudo-recurrence, mesh eventration or bulging, and the rate of seroma formation.

Methods

A systematic search was performed of PubMed, Ovid, the Cochrane Library, Google Scholar and Scopus to identify RCTs that analysed CFD with regard to rates of adverse outcomes. A meta-analysis was done using fixed-effect methods. The primary outcome of interest was adverse events. Secondary outcomes were seroma, postoperative pain, mean hospital stay, mean duration of operation and surgical techniques employed.

Results

A total of 16 studies were identified involving 3638 patients, 2963 in the CFD group and 675 in the non-closure of facial defect group. Significantly fewer adverse events were noted following CFD than non-closure (4·9 per cent (79 of 1613) versus 22·3 per cent (114 of 511)), with a combined risk ratio (RR) of 0·25 (95 per cent c.i. 0·18 to 0·33; P &lt; 0·001). CFD resulted in a significantly lower rate of seroma (2·5 per cent (39 of 1546) versus 12·2 per cent (47 of 385)), with a combined RR of 0·37 (0·23 to 0·57; P &lt; 0·001), and shorter duration of hospital stay. No significant difference was noted in postoperative pain.

Conclusion

CFD during LIVHR reduces the rate of seroma formation and adverse hernia-site events.

A novel reconstruction method for giant incisional hernia: Hybrid laparoscopic technique

BACKGROUND AND OBJECTIVES:

Laparoscopic reconstruction of ventral hernia is a popular technique today. Patients with large defects have various difficulties of laparoscopic approach. In this study, we aimed to present a new reconstruction technique that combines laparoscopic and open approach in giant incisional hernias.

MATERIALS AND METHODS:

Between January 2006 and August 2012, 28 patients who were operated consequently for incisional hernia with defect size over 10 cm included in this study and separated into two groups. Group 1 (n = 12) identifies patients operated with standard laparoscopic approach, whereas group 2 (n = 16) labels laparoscopic technique combined with open approach. Patients were evaluated in terms of age, gender, body mass index (BMI), mean operation time, length of hospital stay, surgical site infection (SSI) and recurrence rate.

RESULTS:

There are 12 patients in group 1 and 16 patients in group 2. Mean length of hospital stay and SSI rates are similar in both groups. Postoperative seroma formation was observed in six patients for group 1 and in only 1 patient for group 2. Group 1 had 1 patient who suffered from recurrence where group 2 had no recurrence.

DISCUSSION:

Laparoscopic technique combined with open approach may safely be used as an alternative method for reconstruction of giant incisional hernias.

Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20^th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4^th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.

Long-term outcomes of 1326 laparoscopic incisional and ventral hernia repair with the routine suturing concept: a single institution experience

PURPOSE

This retrospective chart analysis reports and assesses the long-term (beyond 10 years) safety and efficiency of a single institution's experience in 1326 laparoscopic incisional and ventral hernia repairs (LIVHR), defending the principle of the suturing defect (augmentation repair concept) prior to laparoscopic reinforcement with a composite mesh (IPOM Plus). This study aims to prove the feasibility and validity of IPOM Plus repair, among other concepts, as a well-justified treatment of incisional or ventral hernias, rendering a good long-term outcome result.

METHODS

A single institution's systematic retrospective review of 1326 LIVHR was conducted between the years 2000 and 2014. A standardized technique of routine closure of the defect prior to the intraperitoneal onlay mesh (IPOM) reinforcement was performed in all patients. The standardized technique of "defect closure" by laparoscopy approximating the linea alba under physiological tension was assigned by either the transparietal U reverse interrupted stitches or the extracorporeal closure in larger defects. All patients benefited from the implant Parietex composite mesh through an Intraperitoneal Onlay Mesh placement with transfacial suturing.

RESULTS

LIVHR was performed on 1326 patients, 52.57% female and 47.43% male. The majority of our patients were young (mean age 52.19 years) and obese (average BMI 32.57 kg/m2). The mean operating time was 70 min and hospital stay 2 days, with a mean follow-up of 78 months. On the overall early complications of 5.78%, we achieved over time the elimination of the dead space by routine closure of the defect, thus reducing seroma formation to 2.56%, with a low risk of infection <1%. Post-op sepsis occurred in only nine cases. Three secondary serosal breakdowns and two late perforations were re-operated, and three diabetic patients had infected hematomas, necessitating mesh removal. Through technical improvement in the suturing concept and our growing experience, we managed to reduce the incidence of transient pain to a low acceptable rate of 3.24% (VAS 5-7) that decreased to 2.56% on a chronic pain stage, which is comparable to the literature. On the overall rate of late complications of 10.74%, we noticed also that by reducing the dead space, the chronic pain, skin bulging, and rate of recurrence were reduced to, respectively, 2.56, 1.50, and 4.72%. One case of mortality was due to a tracheal stenosis, responsible for an acute respiratory syndrome. On a second-look follow-up of 126 patients (9.5%), 45.23% were adhesion free, 42.06% had minor adhesions classified as Müller I, and 12.69% had serosal adhesions classified as Müller II.

CONCLUSION

Our long series confirms the unexpected high rate of feasibility in the suturing concept or augmentation technique, and confers additional benefits to the conventional advantages of LIVHR in terms of reducing the overall morbidity, with a low rate of recurrences. Based on our experience and study, the current best indications for a successful LIVHR procedure should be tailored upon the limitations of the defect's width and proper patient selection, to restore adequately the optimal functionality of the abdominal muscles and provide better functional and cosmetic outcomes.

Primary fascial closure with laparoscopic ventral hernia repair: systematic review

Laparoscopic ventral hernia repair (LVHR) has grown in popularity. Typically, this procedure is performed with a mesh bridge technique that results in high rates of seroma, eventration (bulging), and patient dissatisfaction. In an effort to avoid these complications, there is growing interest in the role of laparoscopic primary fascial closure with intraperitoneal mesh placement. This systematic review evaluated the outcomes of closure of the central defect during LVHR. A literature search of PubMed, Cochrane databases, and Embase was conducted using PRISMA guidelines. MINORS was used to assess the methodologic quality. Primary outcome was hernia recurrence. Secondary outcomes were surgical-site infection, seroma formation, bulging, and patient-centered items (satisfaction, chronic pain, functional status). Eleven studies were identified, eight of which were case series (level 4 data). Three comparative studies examined the difference between closure and nonclosure of the fascial defect during laparoscopic ventral incisional hernia repairs (level 3 and 4 data). These studies suggested that primary fascial closure (n = 138) compared to nonclosure (n = 255) resulted in lower recurrence rates (0-5.7 vs. 4.8-16.7 %) and seroma formation rates (5.6-11.4 vs. 4.3-27.8 %). Follow-up periods for both groups were similar (1-108 months). Only one study evaluated patient function and clinical bulging. It showed better outcomes with primary fascial closure. Closure of the central defect during LVHR resulted in less recurrence, bulging, and seroma than nonclosure. Patients with closure were more satisfied with the results and had better functional status. The quality of the data was poor, however. A randomized controlled trial to evaluate the role of closure of the central defect during LVHR is warranted.

Recurrence and Pseudorecurrence after Laparoscopic Ventral Hernia Repair: Predictors and Patient-focused Outcomes

Laparoscopic ventral hernia repair (LVHR) is gaining popularity as an option to repair abdominal wall hernias. Bulging after repair remains common after this technique. This study evaluates the incidence and factors associated with bulging after LVHR. Between 2000 and 2010, 201 patients underwent LVHR at two affiliated institutions. Patients who developed recurrence or pseudorecurrence (seroma or eventration) were analyzed with univariate and multivariate analyses to identify predictors of these complications. Of the 201 patients who underwent LVHR, 40 (19.9%) patients developed a seroma, 63 (31.3%) patients had radiographically proven eventration, and 25 (12.4%) patients had a hernia recurrence. On multivariate analysis, seromas were associated with number of prior ventral hernia repairs, surgical site infections, and prostate disease. Mesh eventration was associated with hernia size and surgical technique. Tissue eventration was associated with primary hernias and surgical technique. Hernia recurrence was associated with incisional hernias and mesh type used. Recurrence and pseudorecurrence are important complications after LVHR. Large hernia size, infections, and surgical technique are important clinical factors that affect outcomes after LVHR.

Closure versus non-closure of hernia defect during laparoscopic ventral hernia repair with mesh

PURPOSE

Laparoscopic ventral hernia repair with mesh versus laparoscopic ventral hernia defect closure with mesh reinforcement. The primary end-point was recurrence.

METHODS

Retrospective review of patients who underwent laparoscopic ventral hernia repair for small- and medium-sized hernias between July 2000 and September 2011. These patients were divided: (1) repair with mesh alone (non-closure group) and (2) those with hernia defect closure and mesh reinforcement (closure group). The closure group was further divided by technique: percutaneous versus intracorporeal closure of the defect.

RESULTS

128 patients were studied: 93 patients (72.66 %) in the non-closure group and 35 patients (27.34 %) in the closure group. Follow-up was available in 105 patients (82.03 %) at a mean of 797.2 days (range 7-3,286 days). In the non-closure group there were 14 patients (15.05 %) with postoperative complications and 8 patients (22.86 %) in the closure group, four of which were seromas. Fourteen patients (19.18 %) developed recurrent hernias in the non-closure group with an average time to presentation of 23.17 months (range 5.3-75.3). Two patients (6.25 %) developed recurrent hernias in the percutaneous group with an average time to presentation of 12.95 months (range 9.57-16.33). There have been no recurrences in patients whose defect was closed intracorporeally.

CONCLUSION

Although our study demonstrated a difference in recurrence rates of 19.18 % in the non-closure group versus 6.25 % in the closure group, the difference did not reach statistical significance. A larger series with longer follow-up may demonstrate clinical significance.

Trans-cutaneous Closure of Central Defects (TCCD) in laparoscopic ventral hernia repairs (LVHR)

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) has been reported to have lower recurrence rates, fewer surgical site infections, and shorter hospital stays compared to open repair. Despite improved surgical outcomes with standard LVHR (sLVHR), seroma formation, eventration (or bulging of mesh or tissue), and hernia recurrence remain common complications. Our objective was to evaluate outcomes with trans-cutaneous closure of central defects in LVHR compared to sLVHR.

METHODS

A retrospective review of 176 patients who underwent elective LVHR between January 2007 and December 2010 was performed. Of the 176 patients, 36 (20.5 %) had the LVHR-TCCD (trans-cutaneous closure of central defects) procedure and 140 (79.5 %) had sLVHR. The LVHR-TCCD cases were compared to a 1:1 case-matched control (n = 36). The case control group was matched by hernia type (primary versus secondary), hernia size, Ventral Hernia Working Group (VHWG) grade, institution, and follow-up duration. Patient demographics, co-morbidities, hernia characteristics, operative details, imaging data, and complications were collected. Patient satisfaction (using a 10-point, Likert-type scale), late postoperative pain (using the visual analogue scale), and patient functional status (using the Activities Assessment Scale; AAS) were analyzed. Continuous data were analyzed with either the unpaired Student's t test or the Mann-Whitney U-test, while Fischer's exact test was used to compare categorical data.

RESULTS

Patient demographics, co-morbidities, hernia size, hernia type, mesh type, and surgical histories were similar between the LVHR-TCCD group and the case control group. The LVHR-TCCD patients had significantly lower rates of seroma formation (5.6 % versus 27.8 %; p = 0.02), mesh eventration (0.0 % versus 41.4 %; p = 0.0002), tissue eventration (4.0 % versus 37.9 %; p = 0.003), clinical eventration (8.3 % versus 69.4 %; p = 0.0001), and hernia recurrence (0.0 % versus 16.7 %; p = 0.02) when compared to the sLVHR case control. Postoperative infectious complications and early complications classified by the Dindo-Clavien system were similar between the groups. Median follow-up was 24 months (range: 7-34 months) for both groups. Compared to the case control group, patients having undergone LVHR-TCCD had higher patient satisfaction scores (8.8 ± 0.4 versus 7.0 ± 0.5; p = 0.008), cosmetic satisfaction scores (8.8 ± 0.4 versus 7.0 ± 0.6; p = 0.01), and AAS functional status scores (79.1 ± 1.9 versus 71.3 ± 2.3; p = 0.002). There was no difference in worst pain scores or the prevalence of chronic pain.

CONCLUSIONS

The incidence of seroma, mesh and tissue eventration, and hernia recurrence was significantly lower following LVHR-TCCD when compared to sLVHR. Subjective improvement in overall patient satisfaction, cosmetic satisfaction, and functional status was reported with closing the central defect. The LVHR-TCCD technique may be superior for treating ventral hernias due to lower complication rates and higher patient satisfaction and functional status.

Laparoscopic transcutaneous closure of central defects in laparoscopic incisional hernia repair

PURPOSE

The aim of this technical report is to investigate the safety, efficacy, and outcome of transcutaneous closure of central defects (TCCD) for laparoscopic incisional hernia repair (LIHR).

METHODS

Twenty-two patients with incisional hernias underwent a LIHR-TCCD repair. After clearance of the abdominal wall from adhesions, laparoscopic central closures were performed transcutaneously with 0-polypropelene sutures placed every 1 cm of the defect starting at the cranial-most edge of the hernia and ending at the caudal-most edge of the hernia. A standard LIHR was performed with coated polyester mesh placed with at least 6 cm of overlap with mesh on all borders. Transfascial sutures with 0-polypropelene sutures were placed every 4 cm circumferentially, and titanium tacks were used to secure the mesh to the peritoneum every 1 cm.

RESULTS

The mean age was 52 years and the mean body mass index was 35 kg/m. The mean hernia defect was 4.7 cm×7.2 cm with a mean area of 37 cm. There were no mortalities and no major perioperative morbidities. Minor complications included 2 (9%) cases of pneumonia/pneumonitis. There were no clinically significant seromas, no radiographic or clinical eventrations, and no hernia recurrences with a mean follow-up of 21 months.

CONCLUSIONS

LIHR-TCCD is safe and technically feasible in incisional hernias of width <10 cm. By closing the central defect, seromas and eventrations can be reduced.

Outcomes of laparoscopic ventral hernia repair with routine defect closure using "shoelacing" technique

INTRODUCTION

Laparoscopic approach has become standard for many ventral hernia repairs. The benefits of minimal access include reduced wound complications, faster functional recovery, and improved cosmesis, among others. However, "bridging" of hernia defects during traditional laparoscopic ventral hernia repair (LVHR) often leads to seromas or bulging and, importantly, does not restore a functional abdominal wall. We have modified our approach to LVHR to routinely utilize transabdominal defect closure ("shoelacing" technique) prior to mesh placement. Herein, we aim to analyze outcomes of LVHR with shoelacing.

METHODS

Consecutive patients undergoing LVHR with shoelacing were reviewed retrospectively. Main outcome measures included patient demographics, previous surgical history, intraoperative time, mesh type and size, postoperative complications, length of hospitalization, and hernia recurrence.

RESULTS

Forty-seven consecutive patients underwent LVHR with defect closure. Average body mass index (BMI) was 32 kg/m2 (range 22-50 kg/m2). Eighteen (38%) patients had an average of 1.5 previous repairs (range 1-3). Mean defect size was 82 cm2 (range 16-300 cm2), requiring a median of 4 (range 2-7) transabdominal stitches for shoelacing. Two patients required endoscopic component separation to facilitate defect closure. Mean mesh size used was 279 cm2 (range 120-600 cm2). Mean operative time was 134 min (range 40-280 min). There were no intraoperative complications. Average length of hospitalization was 2.9 days (range 1-10 days). There were two major postoperative complications [one pulmonary embolism (PE), one stroke]; however, there was no wound-related morbidity or significant seromas. At mean follow-up of 16.2 months, there have been no recurrences.

CONCLUSIONS

LVHR with defect closure confers a strong advantage in hernia repair, shifting the paradigm towards more physiologic abdominal wall reconstruction. In this series, we found our approach to be safe and comparable to historic controls. While providing reliable hernia repair, the addition of defect closure in our patients essentially eliminated postoperative seroma. We advocate routine use of the shoelace technique during laparoscopic ventral hernia repair.