Technique and early results of outpatient laparoscopic mesh onlay repair of ventral hernias

Outpatient Laparoscopic Appendectomy: Is It Time to End the Discussion?

BACKGROUND

Laparoscopic appendectomy is typically associated with inpatient hospitalization averaging between 1 and 2 days. In July 2010, a prospective protocol for outpatient laparoscopic appendectomy was adopted at our institution. Patients were dismissed from the post-anesthesia recovery room or day surgery if they met certain predefined criteria. Patients admitted to a hospital room as either full admission or observation status were considered failures of outpatient management.

STUDY DESIGN

An IRB-approved, retrospective review of a prospective database was performed on all patients having laparoscopic appendectomy for uncomplicated appendicitis from July 2010 through December 2014. Study exclusions included age younger than 17 years, pregnancy, interval appendectomy, and gangrenous or perforated appendicitis. Patient demographics, success with outpatient management, morbidity, and readmissions were analyzed.

RESULTS

Five hundred and sixty-three patients underwent laparoscopic appendectomy for uncomplicated appendicitis during this time frame. There were 281 men and 282 women, with a mean age of 35.5 years. Four hundred and eighty-four patients (86%) were managed as outpatients. Seventy-nine patients were admitted for pre-existing conditions (32 patients), postoperative morbidity (10 patients), physician discretion (6 patients), or lack of transportation or support at home (31 patients). Thirty-eight patients (6.7%) experienced postoperative morbidity. Seven patients (1.2%) were readmitted after outpatient management for transient fever, nausea/vomiting, migraine headache, urinary tract infection, partial small bowel obstruction, and deep venous thrombosis. There were no mortalities or reoperations. Including the readmissions, overall success with outpatient management was 85%.

CONCLUSIONS

Outpatient laparoscopic appendectomy can be performed with a high rate of success, low morbidity, and low readmission rate. This protocol has withstood the test of time. Widespread adoption has the potential for substantial health care savings.

Minimally invasive ventral herniorrhaphy: an analysis of 6,266 published cases

BACKGROUND

Over 300,000 ventral abdominal wall hernias are repaired each year in the United States; many of these operations are done with a minimally invasive approach. Despite these numbers, there are few controlled data that evaluate the minimally invasive method of ventral hernia repair.

METHODS

A review of over 6,000 published cases of minimally invasive ventral herniorrhaphy was performed in order to determine major outcome statistics for this procedure.

RESULTS

The mean follow-up period was 20 months. The operative mortality was 0.1%. The mean recurrence rate (weighted) was 2.7%, and the major complication rate (mostly bowel injury and infection) was 3%.

CONCLUSION

The results from published cases of minimally invasive ventral herniorrhaphy appear to be competitive with the historical results of open ventral herniorrhaphy. The major caveats of this review are that most of the data are (1) retrospective/uncontrolled and (2) obtained from specialized centers.

Laparoscopic incisional hernia repair with a self-centring suture

BACKGROUND

Open incisional hernia repair is associated with high morbidity and recurrence rates. Laparoscopic approaches offer improved long-term results with low complication rates.

METHODS

Laparoscopic repair was attempted in 117 consecutive patients (median age 68 (range 31-91) years, 50 men) undergoing 122 operations. A novel mesh centralization technique was employed. Data were recorded prospectively. Follow-up was by clinical review or telephone consultation.

RESULTS

One hundred and eighteen procedures (96.7 per cent) were completed laparoscopically; four required conversion. Forty-one patients (35.0 per cent) had additional, unsuspected defects. The median mesh size was 225 (range 42-600) cm2. Median follow-up was 42 months. Small bowel enterotomy occurred in six patients. Fourteen postoperative seromas were successfully aspirated. Recurrence was detected in nine patients (7.7 per cent). One patient was readmitted with small bowel obstruction that settled with conservative management. There were no enterocutaneous fistulas. One patient died after operation from myocardial infarction.

CONCLUSION

Laparoscopic incisional hernia repair using a self-centring suture provides good long-term results with low complication rates.

Outcomes of the Rives–Stoppa technique in incisional hernia repair: ten years of experience

BACKGROUND

Use of the Rives-Stoppa (R-S) technique has markedly diminished recurrence rate. Our aim was to assess the outcomes of Iranian patients undergoing the R-S technique and to determine factors affecting recurrence rate and time.

METHODS

Over a 10-year period, 86 open abdominal wall incisional hernia repairs were performed using the R-S technique. Prolene and Mersilene meshes were used. Main outcome measures were the rate and time of recurrence and mortality.

RESULTS

Sixty-six women and 20 men underwent the R-S technique (mean age: 51.21 +/- 13.01 years; mean follow up period: 67.60 +/- 32.55 months). The total recurrence rate was 5.8%. Most of these occurred in the first 12 months of follow up. Mersilene was used in 61%. There was no correlation between hernia recurrence and age, gender, defect size, mesh size, mesh type, number of meshes used, type of operation, position of incision, seroma, respiratory complications, ICU admission, or wound complications (P > 0.05). Overall postoperative complication rate was 18.2%. Except for type of operation, there was no correlation between the factors mentioned and recurrence time. Cumulative 5 and 10-year recurrence rate were 4.2 and 12.5%, respectively.

CONCLUSION

The R-S technique is the most promising open technique, with low recurrence rates, excellent long-time results, and minimal serious morbidity. Age might be an important factor in recurrence rate.

Open Rives-Stoppa ventral hernia repair made simple and successful but not for everyone

BACKGROUND

The Rives-Stoppa (RS) repair of ventral incisional hernias (VIHR) is technically difficult. It involves the retromuscular placement of mesh anterior to the posterior fascia and the primary closure of the anterior fascia. Recurrence rates are 0-8%. We proposed that the operation could be done with equal success by placing the mesh in an intraperitoneal position and primarily closing the fascia anterior to the mesh.

METHODS

81 patients who had undergone an open RS-VIHR with intraperitoneal mesh were evaluated for hernia recurrence and factors associated with recurrence.

RESULTS

55 women and 26 men (mean BMI 38+/-9) underwent RS-VIHR (mean age 49+/-11 years). Of these patients, 44 (54%) had a prior VIHR, 30 (37%) had an incarcerated hernia and 34 (42%) had multiple fascial defects. PTFE was used in 83% and Prolene in 12%. Average LOS was 5.8+/-12 days. All received perioperative intravenous antibiotics and 28% were discharged on oral antibiotics. Follow-up averaged 30+/-24 months. Recurrent VIH developed in 12/81 (15%), with three occurring after removal of infected mesh and one after a laparotomy. Excluding these four, the recurrence rate was 10%. There was no correlation between hernia recurrence and age, BMI, hernia size, number of prior repairs, or LOS (t-test p>0.05). Hernia recurrence did not correlate with gender, prior peritoneal contamination, incarceration, multiple defects, adhesions, mesh type, oral antibiotics, cardiac disease, diabetes, tobacco use, or seroma (X(2) p>0.05). Those with a wound infection and/or abscess formation had a significantly higher recurrent hernia rate (60% vs. 8%, X(2) p<0.001). Patients with pulmonary disease had a significantly higher recurrence rate (50% vs. 12%, X(2) p=0.01).

CONCLUSIONS

RS-VIHR with intraperitoneal mesh is a successful and less technically challenging method of repair than prior modifications. Aggressive efforts to identify infection and treat early may prevent abscess formation and subsequent recurrent hernia. Patients with chronic pulmonary disease have an unacceptably high recurrence rate and should not be considered as candidates for elective RS-VIHR.

Mortality following laparoscopic ventral hernia repair: lessons from 90 consecutive cases and bibliographical analysis

The popularity of laparoscopic repair of ventral hernias is increasing due to the apparent advantages of the procedure, but this approach is still a controversial technique. The aim of our study was to evaluate the mortality rate of laparoscopic ventral hernia repair and analyse the literature. The authors performed a prospective study in 90 patients with ventral hernia who were treated by laparoscopic repair. Clinical parameters and intra- and postoperative complications were evaluated. A case of mortality was reported due to a nonrecognised bowel injury. The mean follow-up (100%) was 42 months (range: 1-5 years). A bibliographical analysis was carried out (MEDLINE). Four bowel injuries were presented (4.4%): three recognised, which required conversion (two treated with minilaparotomy and completed afterwards by laparoscopy, and one by laparotomy); and one nonrecognised, which was re-operated on but evolved to sepsis and multiorgan failure and resulted in death in 48 h (1.1%). Four further mortality rates have been documented in the literature (0.6%, 1.1%, 3.1%, and 3.4% of their series). Bowel injury and mortality show a statistically significant tendency to decrease with the number of operations ( P<0.05). In conclusion, in our study the risk of mortality with laparoscopic ventral hernia repair has been higher than 1%, which must be made known. It is a risk that depends on the surgeon's experience but which does not seem to be predictable.

Laparoscopic incisional hernia repair in a porcine model: what do transfixion sutures add?

BACKGROUND

The aim of this study was to evaluate the need for transfixion sutures during laparoscopic ventral hernia repair with mesh.

METHODS

Incisional hernias were created in 14 Yucatan mini-pigs. Animals were randomized to undergo laparoscopic hernia repair either with spiral tacks alone (Tacks) or with tacks and 4 Prolene transfixion sutures (Sutured) using Composix E/X mesh (Davol Inc.). At 4 weeks, exploratory laparoscopy was performed to assess the repair and score adhesions. The abdominal wall was harvested for tensile strength analysis and histologic evaluation. Continuous variables were compared using a two-tailed nonpaired t-test. Results are presented as mean +/- standard deviation.

RESULTS

The mean hernia size was 8.5 +/- 0.5 cm by 5.5 +/- 0.7 cm, with no difference between groups. The operative time was significantly longer ( p = 0.006) for the Sutured group (62.1 +/- 16.8 min) than for the Tacks group (32.3 +/- 7.0 min). The number of tacks per repair was equivalent between groups. At necropsy, the mesh in all cases was well incorporated, reperitonealized, and without evidence of migration. No hernias recurred. However, the Sutured group had a significantly ( p < or = 0.05) higher adhesion score (5.4 +/- 3.3) than the Tacks group (2.0 +/- 2.7). The tensile strength of the repair zone was no different between groups (Sutured 4.8 +/- 1.5 N/cm, Tacks 3.8 +/- 1.4 N/cm). On histologic examination, the ratio of inflammatory cells to fibroblasts was similar between groups (Sutured 0.2 +/- 0.6, Tacks 0.2 +/- 0.3). Only 82% of tacks in each group penetrated the fascia, and the depth of tack penetration was similar between groups (Sutured 3.7 +/- 0.3 mm, Tacks 3.9 +/- 0.4 mm).

CONCLUSIONS

In a porcine model, the use of transfixion sutures was associated with longer operative times and more adhesions, without improvement in tensile strength or mesh incorporation. A human clinical trial is needed to determine the optimal method of securing abdominal wall mesh.

Laparoscopic treatment of ventral hernias: prospective evaluation

We describe 50 patients who recently underwent laparoscopic surgery. Early results, complications, and follow-up data were collected prospectively. Of 50 patients, 34 had an incisional hernia, whereas 16 had a primary defect. Three trocars were inserted. EndoShears or Ultracision was used for tissue manipulation. The prosthetic mesh used was an expanded polytetrafluoroethylene (ePTFE) mesh, inserted through the first trocar and fixed with a helicoidal stapler. Patients were followed-up in the outpatient clinic (mean, 14 months). Every operation was successfully completed, and mean operative time was 103 minutes. There were two small bowel injuries (4%) repaired by minilaparotomy. Postoperative pain was limited. Bowel movements, ambulation, and discharge were prompt. We noted 4 cases of urinary retention (8%), 8 seromas (16%), and 1 prolonged ileus, which resolved on day 5 spontaneously. Mean postoperative stay was 4 days. One patient was readmitted after 4 weeks because of incomplete obstruction, resolved conservatively. There has been only 1 recurrence (2%), 8 months after the operation. The technique appears safe and efficacious.

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 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.

The umbilicus in laparoscopic surgery

BACKGROUND

This study examines the factors related to infection and incisional herniation after laparoscopy at the umbilicus, as compared with those at remote sites.

METHODS

From a prospective database of 561 cholecystectomies, 190 inguinal hernia repairs, 71 Nissen fundoplications, and 51 ventral hernia repairs, 873 consecutive Hasson cannula sites, 748 umbilicus sites, and 125 remote sites were analyzed.

RESULTS

The wound infection rate was found to be 6%: 7% at the umbilicus (9% after cholecystectomy and 2% after other operations [p < 0.05]) and 0% at remote sites (p < 0.05). Excluding cholecystectomy, the umbilical infection rate was 2%, similar to that at remote sites. The postoperative ventral hernia rate was at 0.8%, the same at the umbilicus as elsewhere. The rate was similar for gallbladder and nongallbladder operations and correlated with the postoperative wound infection rate, but not with the preexisting fascial defect rate.

CONCLUSIONS

Wound infection at the umbilicus is similar to that at other sites, except after cholecystectomy. Postoperative ventral hernia at the umbilicus is similar to that at other sites and not related to preexisting fascial defects.

Simple technique for laparoscopic paracolostomy hernia repair

PURPOSE

The aim of this study was to describe a simple, minimally invasive, and effective technique for repair of paracolostomy hernia.

METHODS

Mesh is fastened laparoscopically over the colostomy and hernial defect with wide overlap, without dissecting out the sac or repairing the defect, while ensuring enough room for the colon to prevent obstruction at the level of the mesh.

RESULTS

The technique has been used successfully in four patients, with follow-up of 2 to 12 months. Operating time and length of stay were short, and there was no recurrence or prolapse of the colostomy.

CONCLUSIONS

This seems to be an effective, simple, and minimally invasive technique for repairing a difficult problem. Although the number of cases is small and the follow-up has been short, the technique mimics that used in massive ventral hernia repair with good results.