Laparoscopic ventral hernia repair during the learning curve

Repair of a medium-sized ventral hernia with the UltraPro Hernia System

Mesh repairs are widely accepted as a suitable option for ventral hernia repair. Among the various devices and surgical approaches used for ventral hernia repair, the UltraPro Hernia System (UHS) is considered an effective method of open repair for patients with medium ventral hernia defects between 3 and 5 cm in diameter. However, few clinical studies on this system have been reported. We describe a simple and safe UHS mesh technique for open ventral hernia repair, which was performed successfully under local anesthesia in 23 patients with medium ventral hernia defects. Minor postoperative complications included seroma (n = 3) and a superficial infection (n = 1). There was no incidence of recurrence in 12 months of follow-up. Our results show that the UHS is simple and easily reproducible for medium ventral hernia defects between 3 and 5 cm in diameter.

Learning curve in robotic transabdominal preperitoneal (rTAPP) ventral hernia repair: a cumulative sum (CUSUM) analysis

Purpose

rTAPP-VHR is a novel technique which may be added to a surgeon’s armamentarium. We aim to evaluate the robotic transabdominal preperitoneal ventral hernia repair (rTAPP-VHR) learning curve based on operative times while accounting for peritoneal flap integrity.

Methods

We performed a retrospective analysis of a database collected over a 7-year period. Patients with primary ventral hernias were included and a cumulative sum analysis(CUSUM) was used to create learning curves for three subsets of operative times. A risk-adjusted CUSUM (RA-CUSUM) accounted for repair quality based on peritoneal flap completeness. The flap was considered as incomplete when peritoneal gaps were unable to be closed.

Results

105 patients undergoing rTAPP-VHR were included. Learning curves were created for skin-to-skin, console, and off-console times. Patients were divided into three phases. In terms of skin-to-skin times, both phase 2&3 had a mean 11 min shorter than that of phase 1 (p = 0.0498, p = 0.0245, respectively), with a steady decrease after forty-six cases. An incomplete peritoneal flap was noted in 25/36 patients in phase 1, as compared to 5/24 and 5/45 patients in phase 2&3, respectively. When risk-adjusted for peritoneal flap completeness, gradually decreasing skin-to-skin times were observed after sixty-one cases. In terms of off-console times, the mean across three phases was 14 min, with marked improvement after forty-three cases.

Conclusions

Forty-six cases were needed to achieve steadily decreasing operative times. We can assume that ensuring good-quality repairs, through maintenance of peritoneal flap integrity, was gradually improved after sixty-one cases. Moreover, familiarization with port placements and robotic docking was accomplished after forty-three cases.

What Is the Influence of Simulation-Based Training Courses, the Learning Curve, Supervision, and Surgeon Volume on the Outcome in Hernia Repair?-A Systematic Review

Introduction: In hernia surgery, too, the influence of the surgeon on the outcome can be demonstrated. Therefore the role of the learning curve, supervised procedures by surgeons in training, simulation-based training courses and surgeon volume on patient outcome must be identified. Materials and Methods: A systematic search of the available literature was carried out in June 2018 using Medline, PubMed, and the Cochrane Library. For the present analysis 81 publications were identified as relevant. Results: Well-structured simulation-based training courses was found to be associated with a reduced perioperative complication rate for patients operated on by trainees. Open as well as, in particular, laparo-endoscopic hernia surgery procedures have a long learning curve. Its negative impact on the patient can be virtually eliminated through consistent supervision by experienced hernia surgeons. However, this presupposes availability of an adequate trainee caseload and of well-trained hernia surgeons and calls for a certain degree of centralization in hernia surgery. Conclusion: Training courses, learning curve, supervision, and surgeon volume are important aspects in training and outcomes in hernia surgery.

Defining the characteristics of certified hernia centers in Italy: The Italian society of hernia and abdominal wall surgery workgroup consensus on systematic reviews of the best available evidences

BACKGROUND

The terms "Hernia Center" (HC) and Hernia Surgeon" (HS) have gained more and more popularity in recent years. Nevertheless, there is lack of protocols and methods for certification of their activities and results. The Italian Society of Hernia and Abdominal Wall Surgery proposes a method for different levels of certification.

METHODS

The national board created a commission, with the task to define principles and structure of an accreditation program. The discussion of each topic was preceded by a Systematic Review, according to PRISMA Guidelines and Methodology. In case of lack or inadequate data from literature, the parameter was fixed trough a Commission discussion.

RESULTS

The Commission defined a certification process including: "FLC - First level Certification": restricted to single surgeon, it is given under request and proof of a formal completion of the learning curve process for the basic procedures and an adequate year volume of operations. "Second level certification": Referral Center for Abdominal Wall Surgery. It is a public or private structure run by at least two already certified and confirmed FLC surgeons. "Third level certification": High Specialization Center for Abdominal Wall Surgery. It is a public or private structure, already confirmed as Referral Centers, run by at least three surgeons (two certified and confirmed with FLC and one research fellow in abdominal wall surgery). Both levels of certification have to meet the Surgical Requirements and facilities criteria fixed by the Commission.

CONCLUSION

The creation of different types of Hernia Centers is directed to create two different entities offering the same surgical quality with separate mission: the Referral Center being more dedicated to clinical and surgical activity and High Specialization Centers being more directed to scientific tasks.

Postoperative complications as an independent risk factor for recurrence after laparoscopic ventral hernia repair: a prospective study of 417 patients with long-term follow-up

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) has become widely used. This study evaluates outcomes of LVHR, with particular reference to complications, seromas, and long-term recurrence.

METHODS

A review of a prospective database of consecutive patients undergoing LVHR with intraperitoneal onlay mesh (IPOM) was performed at a single institution. Patient's characteristics, surgical procedures, and postoperative outcomes were analyzed and related to long-term recurrence.

RESULTS

From 2005 to 2014, 417 patients underwent LVHR. Mean age and body mass index (BMI) were 54 years and 31 kg/m². Mesh fixation was carried out with transfascial sutures, completed with absorbable tacks (72 %), metal tacks (24 %), or intraperitoneal sutures (4 %). Intraoperative complications occurred in three patients. Overall morbidity included 8.25 % of minor complications and 2.5 % of major complications without mortality. The overall recurrence rate was 9.8 %. Median time for recurrence was 15.3 months (3-72) and median follow-up was 31.6 months (8-119). In a multivariate analysis, previous interventions (OR 1.44; CI 1.15-1.79; p = 0.01), postoperative complications (OR 2.57; CI 1.09-6.03; p = 0.03), and Clavien-Dindo score >2 (OR 1.43; CI 1.031-1.876; p = 0.02) appeared as independent prognostic factors of recurrence. Minor complications were associated with 14.7 % of recurrence and major complications with 30 % of recurrence. Emergency LVHR (6 %) did not increase the rate of complications. Overall seroma rate was 18.7 %, with 1.4 % of persisting or complicated seroma. BMI (OR 1.05; CI 1.01-1.08; p = 0.026) and vascular surgery history (OR 5.74; CI 2.11-15.58; p < 0.001) were independent predictive factors for seroma. Recurrence did not appear to be related to seroma.

CONCLUSION

LVHR combines the benefits of laparoscopy with those of mesh repair. Seroma formation should no longer be considered as a complication. It is spontaneously regressive in most cases. Postoperative complications and their degree of severity appear to be independent prognostic factors for recurrence, which can be limited with a standardized technique and may make IPOM-LVHR a reference procedure.

Current Status and Challenges of Laparoscopy in Ventral Hernia Repair

Laparoscopic repair of ventral hernias gained strong popularity in the late nineties with some of the early enthusiasm lost later in time. We review the current status and challenges of laparoscopy in ventral hernia repair and best practices in this area. We specifically looked at patient and hernia defect factors, technical considerations that have contributed to the successes, and some of the failures of laparoscopic ventral hernia repair (LVHR). Patients best suited for a laparoscopic repair are those who are obese and diabetic with a total defect size not to exceed 10 cm in width or a "Swiss cheese" defect. Overlap of mesh to healthy fascia of at least 5 cm in every direction, with closure of the defect, is essential to prevent recurrence or bulging over time. Complications specifically related to surgical site occurrence favor the laparoscopic approach. Recurrence rates, satisfaction, and health-related quality of life results are similar to open repairs, but long-term data are lacking. There is still conflicting data regarding ways of fixating the mesh. The science of prosthetic material appropriate for intraperitoneal placement continues to evolve. The field continues to be plagued by single author, single institution, and small nonrandomized observational studies with short-term follow-up. The recent development of large prospective databases might allow for pragmatic and point-of-care studies with long-term follow-up. We conclude that LVHR has evolved since its inception, has overcome many challenges, but still needs better long-term studies to evaluate evolving practices.

Staged laparoscopic ventral and incisional hernia repair when faced with enterotomy or suspicion of an enterotomy

Enterotomy is a significant complication of laparoscopic ventral or incisional hernia repair (LVHR) and can be devastating if missed. Enterotomy occurs in 2.6% of patients undergoing LVHR and is missed 21.8% of the time. Controversy exists regarding the management of known or potential enterotomies. Approaches for managing recognized enterotomies during hernia repair are usually employed immediately; in a nonstaged fashion; and include laparoscopic enterotomy repair with immediate LVHR, laparotomy for repair of enterotomy with concomitant LVHR, or conversion to laparotomy for both enterotomy and hernia repair. The staged approach for managing recognized or potential enterotomies is less commonly employed and involves laparoscopic repair of enterotomy, admission, and delayed but definitive laparoscopic hernia repair in the same hospitalization. The presence of known or potential enterotomies during LVHR presents a difficult problem and may be a contraindication for immediate placement of prosthetic because of increased risks posed for abdominal infection, reoperation, prosthetic removal, hernia recurrence, and death. The staged approach--with a 2- to 5-day delay--represents a safe solution to this challenging problem. We present 4 cases managed via staged approach due to an enterotomy, risk factors, and suspicion for missed or delayed enterotomies augmented by a review of the literature.

Is the outcome of laparoscopic incisional hernia repair affected by defect size? A prospective study

BACKGROUND

This study was performed to determine if defect size after laparoscopic incisional hernia repair is predictive of recurrence during the long-term follow-up evaluation.

METHODS

We performed a prospective clinical study on 310 patients who underwent laparoscopic incisional hernia repair to identify predictable risk factors for hernia recurrence. Univariate and multivariate Cox regression analysis were used. The defect size was analyzed with curve receiver operating characteristic curve.

RESULTS

The overall recurrence rate was 6% after an average follow-up period of 60 months. On univariate analysis of the defect size (categories: <10 cm, 10-12 cm, and >15 cm), obesity, previous repairs, hernia location, surgical time, hospital stay, morbidity, and recurrences were significantly different (P < .001). By multivariate analysis, only obesity and defect size were independent prognostic factors (P < .001).

CONCLUSIONS

The predictive value of defect size is shown. Patients with large defects have a higher risk of recurrence. Our study recommends reserving the laparoscopic technique for hernias not exceeding 10 cm in size, where it can be put to better use.

Which patients benefit most from laparoscopic ventral hernia repair? A comparative study

PURPOSE

To establish which patients suffering ventral hernia benefit the most from laparoscopic approach.

METHODS

From January 2005 to October 2008, 126 patients underwent surgery due to incisional hernia at our University Hospital. Patients were assigned to laparoscopic surgery (n=60) or conventional surgery (n=66) at the surgeon's discretion. Patients were subdivided according to the greater diameter of the defect: (G1, defect <5 cm; G2, defect 5 to 15 cm; and G3, defect >15 cm). Data on patient demographic, clinical, and perioperative variables were collected prospectively.

RESULTS

Groups were comparable in terms of sex, body mass index, American Society of Anesthesiologists score, size of defect, and proportion of primary repairs. Four patients were converted to open surgery. Mean hospital stay in the group with the smaller hernias (G1 was 3.16 d laparoscopic surgery vs. 2.87 d conventional surgery, P>0.05). Hospital stay for patients who underwent laparoscopy was shorter in G3 (4.25 d Lap vs. 12.6 d Open; P=0.02).

CONCLUSIONS

Patients with very large incisional hernias are those who benefit the most from laparoscopic treatment.

Laparoscopic versus open surgical techniques for ventral or incisional hernia repair

BACKGROUND

There are many different techniques currently in use for ventral and incisional hernia repair. Laparoscopic techniques have become more common in recent years, although the evidence is sparse.

OBJECTIVES

We compared laparoscopic with open repair in patients with (primary) ventral or incisional hernia.

SEARCH STRATEGY

We searched the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials. The last searches were conducted in July 2010. In addition, congress abstracts were searched by hand.

SELECTION CRITERIA

We selected randomised controlled studies (RCTs), which compared the two techniques in patients with ventral or incisional hernia. Studies were included irrespective of language, publication status, or sample size. We did not include quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently. Meta-analytic results are expressed as relative risks (RR) or weighted mean difference (WMD).

MAIN RESULTS

We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional hernia. No trials were identified on umbilical or parastomal hernia. The recurrence rate was not different between laparoscopic and open surgery (RR 1.22; 95% CI 0.62 to 2.38; I(2) = 0%), but patients were followed up for less than two years in half of the trials. Results on operative time were too heterogeneous to be pooled. The risk of intraoperative enterotomy was slightly higher in laparoscopic hernia repair (Peto OR 2.33; 95% CI 0.53 to 10.35), but this result stems from only 7 cases with bowel lesion (5 vs. 2). The most clear and consistent result was that laparoscopic surgery reduced the risk of wound infection (RR = 0.26; 95% CI 0.15 to 0.46; I(2)= 0%). Laparoscopic surgery shortened hospital stay significantly in 6 out of 9 trials, but again data were heterogeneous. Based on a small number of trials, it was not possible to detect any difference in pain intensity, both in the short- and long-term evaluation. Laparoscopic repair apparently led to much higher in-hospital costs.

AUTHORS' CONCLUSIONS

The short-term results of laparoscopic repair in ventral hernia are promising. In spite of the risks of adhesiolysis, the technique is safe. Nevertheless, long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral/incisional hernia is efficacious.

Laparoscopic incisional and ventral hernia repair without sutures: a single-center experience with 200 cases

BACKGROUND

Laparoscopic incisional and ventral herniorraphy (LIVH), using a mesh, has gained recognition as an effective method and is associated with lower complication and recurrence. Controversies in the operative technique still exist about biomaterial, method of fixation, and overlap of the mesh over the defect. The aim of this study was to evaluate the outcomes achieved with LIVH in 200 consecutive patients treated in a single hospital, using fixation of the mesh with only tacks. Results of the first 100 (group A) and the last 100 (group B) operations were also compared.

METHODS

From 2003 through 2007, 200 patients underwent LIVH. Overlap of the mesh was 3-5 cm. The mesh was secured with tacks alone, with the "double crown" technique. In group B, adhesiolysis was performed, avoiding high energies.

RESULTS

Mean ventral defect was 107.5 (+/- 95.4) cm2. The recurrent ventral hernia rate was 20%, and the conversion rate was 2.5%. Mean operative time was 77.5 (+/- 33.9) minutes. Mean mesh dimension was 326.4 (+/- 166.8) cm2. The overall morbidity rate was 10.5%. Bowel injuries were 5 (2.5 %). Minor complications were 8.0%. Median postoperative hospital stay was 3 days. Recurrence rate was 3.5%, with a mean follow-up of 22.5 months. Chronic pain was 1%. No difference was seen between groups A and B regarding minor complications, whereas a significant difference was found regarding enterotomies (5 vs. 0; P = 0.024) and recurrences (6 vs. 1; P = 0.056).

CONCLUSIONS

Fixation of the mesh with the sole use of tacks was demonstrated to be safe and effective. Avoiding high energies, no case of enterotomy occurred.

Long-term results of laparoscopic repair of incisional hernias using an intraperitoneal composite mesh

BACKGROUND

This study was designed to evaluate the long-term complications and recurrences of laparoscopic repair of incisional hernias. Very few studies evaluate objectively the long-term results of laparoscopic incisional hernia repair.

METHODS

Data for 200 consecutive patients who underwent laparoscopic incisional hernia repair (LIHR) in a university teaching hospital using a standardized procedure between January 1994 and December 2006 were collected prospectively. The median follow-up was 6 (range, 1-12) years.

RESULTS

The conversion rate from laparoscopic to open approach was 2.5% (205 initial patients). Mean operative time was 51 minutes; 63% of these patients were discharged the day of surgery. Mean hospital stay was 2.6 days. There was an overall postoperative complication rate of 15%. We had four small bowel injuries repaired laparoscopically, and one patient died as a result of a sepsis. Postoperative pain was limited, with a mean analgesics requirement of 6.8 (range, 0-30) days. During a mean follow-up of 60 (range, 12-144) months, the recurrence rate was 6.2%, which developed within 1 year of the operation and associated with body mass index >37, defect size >10 cm, and multiple Swiss-cheese defects (p < 0.01).

CONCLUSIONS

1) Intra-abdominal composite mesh is good tolerance. 2) The recurrence rate is low and within 1 year of the operation. 3) The long-term morbidity with LIHR is moderate. 4) The risk of intestinal injury is not predictable. 5) Reoperations can be performed with sufficient guarantee using laparoscopy.

Technique of Laparoscopic Ventral Hernia Repair Can Be Modified to Successfully Repair Large Defects in Patients With Loss of Domain

Background. Laparoscopic ventral hernia repair (LVHR) can be challenging in patients with large abdominal wall defects and loss of domain (LOD). When hernia contents are reduced, the pneumoperitoneum preferentially fills the sac, leaving no space for mesh manipulation. This study presents a modification for LVHR in LOD patients, as well as outcomes for a series of patients. Methods. Between September 2002 and August 2004, 10 patients with large ventral hernias and LOD underwent attempts at LVHR. The technique is modified by placing additional trocars to allow for fixation from above the mesh. Patient data were harvested from a prospective database and analyzed. Results. All hernias were recurrent in nature. Mean defect size was 626 cm2, requiring 1 to 4 pieces of sutured Gore Dualmesh for a tension-free repair. Three patients' procedures were aborted after adhesiolysis, with concerns about missed enterotomies. All 3 underwent delayed mesh placement within the same hospitalization. Only 2 were successful. The third patient had significant bowel edema precluding mesh placement. Two patients were converted to open repairs (Rives—Stoppa and component separation). There were no mortalities, but there were 2 major complications: inferior vena cava thrombosis and transient abdominal compartment syndrome. In follow-up (7.7 months) there were 2 recurrences secondary to excision of infected mesh. Conclusion. It is possible to obtain a successful LVHR in patients with large defects and LOD. The technique is complex and is modified to allow for mesh fixation from above the mesh. Frequent change in patient positioning allows for visualization below the fascial defect.

Limited-conversion technique: a safe and viable alternative to conversion in laparoscopic ventral/incisional hernia repair

BACKGROUND

During laparoscopic ventral/incisional hernia repair (LVIHR), conversion to conventional (open) technique is required when safe adhesiolysis is not possible, incarcerated bowel in hernial sac cannot be reduced or for repair of iatrogenic enterotomies. A formal laparotomy in these circumstances entails significant morbidity due to factors such as wound infection, prolonged immobility, and longer hospital stay.

MATERIALS AND METHODS

During a period between 1994 and 2007, 1,503 LVIHRs were performed at our centre following a standardized protocol by five consultants and fellows. Out of these, 6 patients had a formal laparotomy in the initial part of our experience and 26 patients had a limited conversion to facilitate completion of LVIHR. We have devised the term "limited conversion" for the procedure wherein bowel reduction/adhesiolysis/enterotomy repair was performed through a small targeted skin incision. This was followed by laparoscopic placement of intraperitoneal mesh.

RESULTS

Conversion to an open procedure was required in 32 (2.1%) out of 1,503 LVIHR procedures. Twenty-six patients underwent a limited conversion and completion of the repair by laparoscopy. All but one of these patients had intraperitoneal placement of mesh by laparoscopic route. The wound complication rate was 3.8% (one patient), the mean hospital stay was 2.1 days, and mean operative time was 124 min.

CONCLUSION

Limited conversion offers a safe alternative to a formal laparotomy in patients with bowel incarcerated in hernial sacs or in patients requiring extensive bowel adhesiolysis. Patient morbidity is reduced due to the targeted skin incision whilst retaining several advantages of a minimal access approach viz. laparoscopic evaluation of the entire abdominal wall and placement of a large intraperitoneal prosthesis.

A simplified laparoscopic ventral hernia repair: the scroll technique

BACKGROUND

Laparoscopic ventral hernia repair has steadily gained recognition as an alternative to the open approach. However, the procedure can be technically challenging. The authors present their simple scroll technique for laparoscopic ventral hernia repair.

METHODS

A total of 174 patients underwent laparoscopic ventral hernia repair using the scroll technique. The technique entails fixation of the rolled mesh to the anterior abdominal wall before it is unfolded. Patient characteristics, operative time, and complications were analyzed and compared with pooled data from the available literature on laparoscopic ventral hernia repair.

RESULTS

The mean operative time was comparable with that reported by others (mean, 102 vs. 100 min). The hospital stay was shorter (mean, 1.8 vs. 2.4 h). During a mean follow-up period of 28 months, the recurrence rate was lower than that reported by others (1.7% vs. 4.3%). There were no mortalities and no cases of inadvertent bowel injury.

CONCLUSION

The authors' scroll technique for laparoscopic repair is simple, feasible, and reproducible, with a short learning curve and a low recurrence rate.

Laparoscopic repair of incisional hernia: Outcomes of 100 consecutive cases comprising 25 wall defects larger than 15 cm

BACKGROUND

Minimal access surgery for incisional hernia repair is still debated, especially for large and giant wall defects. This study was undertaken to analyze the results of the use of the laparoscopic technique in incisional hernias smaller and larger than 15 cm of diameter.

METHOD

From 2002 to 2007 a total of 100 patients with incisional hernia were operated on by laparoscopy and were included in this study. As much as 38 patients were obese, with a body mass index (BMI) > 30 kg/m(2). The mean follow-up span was 24 months (range = 2-58). The fascial defect was recurrent in 19 patients, in 13 after previous repair with mesh and in 6 after repair without mesh. The wall defect was larger than 15 cm in 25 patients and in 6 of them it was 20 cm or larger as measured from within the peritoneal cavity.

RESULTS

The mean operating time was 152 +/- 25 min (range = 45-275), and for defects larger than 15 cm it was 205 +/- 101 min (range = 85-540). Two patients with massive adhesions needed conversion to open surgery, one after an intraoperative injury of an intestinal loop. Postoperative complications occurred in 23 patients; local complications were 10. Pulmonary embolism caused death in one obese patient. Morbidity and hospital stay were similar in obese and nonobese patients and the differences were not statistically relevant (p > 0.05). The outcomes in patients with wall defects larger than 15 cm showed no significant difference with outcomes of the remaining patients with smaller defects (p > 0.05). Recurrence occurred in three cases, and in one case local infection led to removal of the mesh.

CONCLUSIONS

Minimal access procedures can provide good results in the repair of incisional hernia, even when the diameter is larger than 15 cm. Obesity is not a contraindication to laparoscopic repair. Further studies are expected to confirm these promising results.

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.

Pooled data analysis of laparoscopic vs. open ventral hernia repair: 14 years of patient data accrual

BACKGROUND

The purpose of this study was to analyze the published perioperative results and outcomes of laparoscopic (LVHR) and open (OVHR) ventral hernia repair focusing on complications and hernia recurrences.

METHODS

Data were compiled from all English-language reports of LVHR published from 1996 through January 2006. Series with fewer than 20 cases of LVHR, insufficient details of complications, or those part of a larger series were excluded. Data were derived from 31 reports of LVHR alone (unpaired studies) and 14 that directly compared LVHR to OVHR (paired studies). Chi-squared analysis, Fisher's exact test, and two-tailed t-test analysis were used.

RESULTS

Forty-five published series were included, representing 5340 patients (4582 LVHR, 758 OVHR). In the pooled analysis (combined paired and unpaired studies), LVHR was associated with significantly fewer wound complications (3.8% vs. 16.8%, p < 0.0001), total complications (22.7% vs. 41.7%, p < 0.0001), hernia recurrences (4.3% vs. 12.1%, p < 0.0001), and a shorter length of stay (2.4 vs. 4.3 days, p = 0.0004). These outcomes maintained statistical significance when only the paired studies were analyzed. In the pooled analysis, LVHR was associated with fewer gastrointestinal (2.6% vs. 5.9%, p < 0.0001), pulmonary (0.6% vs. 1.7%, p = 0.0013), and miscellaneous (0.7% vs. 1.9%, p = 0.0011) complications, but a higher incidence of prolonged procedure site pain (1.96% vs. 0.92%, p = 0.0469); none of these outcomes was significant in the paired study analysis. No differences in cardiac, neurologic, septic, genitourinary, or thromboembolic complications were found. The mortality rate was 0.13% with LVHR and 0.26% with OVHR (p = NS). Trends toward larger hernia defects and larger mesh sizes were observed for LVHR.

CONCLUSIONS

The published literature indicates fewer wound-related and overall complications and a lower rate of hernia recurrence for LVHR compared to OVHR. Further controlled trials are necessary to substantiate these findings and to assess the health care economic impact of this approach.

[Initial experience in the laparoscopic repair of incisional/ventral hernias in an outpatient-short stay surgery unit]

INTRODUCTION

Hernia is a frequent complication in abdominal surgery. There are a multitude of repair techniques, ranging from classical direct closure of the defect and tension-free mesh repair using open surgery to the recent development of laparoscopic repair.

OBJECTIVE

To evaluate the safety and effectiveness of laparoscopic repair of incisional/ventral hernias and its applicability in an outpatient-short stay surgical unit.

PATIENTS AND METHOD

We performed a prospective study of 135 consecutive patients. All patients had incisional (132 patients) or ventral hernias (2 patients) that were laparoscopically repaired between February 1999 and July 2003. The parameters analyzed were the number of prior abdominal interventions and hernia repairs, the number of defects, their location, operating time, type of mesh, postoperative complications, postoperative length of hospital stay, and recurrence rate during a mean follow-up period of 12 months.

RESULTS

Of the 135 patients, 16 (11.8%) underwent conversion to open surgery. The most frequent location of the defect was infraumbilical. Of the 119 patients who underwent laparoscopic repair, more than one hernia was found in 67. The mean operating time was 72.3 +/- 28.3 min. The most frequent immediate complication was seroma in the hernia sac. A total of 92.4% of the patients were discharged within 24 h of the intervention. The recurrence rate was 5.04%.

CONCLUSION

Laparoscopic repair of incisional/ventral hernias is a safe method that allows outpatient management of this defect. Moreover, the technique presents the advantages of minimally invasive surgery, allowing clear identification of multiple hernial defects, with an acceptable percentage of complications and low recurrence rate.

Perioperative outcomes and complications of laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic techniques are being used increasingly in the repair of ventral hernias and offer the potential benefits of a shorter hospital stay, decreased wound complications, and possibly a lower recurrence rate. Despite good results from high-volume centers, significant complications may occur with this approach and the morbidity of incisional hernia repair may be underestimated. The purpose of this study was to review our experience with laparoscopic ventral hernia repair (LVHR) since its inception at our institution.

METHODS

Medical records of all patients who underwent LVHR at a single institution from May 2000 through December 2003 were reviewed. Preoperative and postoperative variables including complications were analyzed. Follow-up evaluation was by office visit and phone survey with assessment of patient satisfaction scores. Data are expressed as mean +/- SD.

RESULTS

A total of 121 LVHR were performed in 116 patients (52 men, 64 women; mean age, 57 +/- 13 y; mean body mass index, 35 +/- 8). Hernias were recurrent in 35 cases (28.9%), with a mean of 1.4 prior repairs (range, 1-7). The mean defect size was 109 +/- 126 cm2 and the average mesh size used was 256 +/- 192 cm2. Operating time was 147 +/- 45 minutes, and the hospital stay averaged 1.7 +/- 1 days. Twelve cases (9.9%) were converted to open operation, most commonly because of extensive adhesions. Extensive laparoscopic adhesiolysis was necessary in 29 cases (26.6%). Overall, perioperative complications occurred in 33 cases (27.3%), 13 of which (39.3%) were persistent seromas. Major complications were seen in 9 cases (7.4%). There were 4 enterotomies (3.3%): 3 occurred as a result of adhesiolysis and 1 resulted from a trocar injury; 2 were detected intraoperatively and were converted to open operation and 2 presented postoperatively. One of these patients developed sepsis and died. Follow-up evaluation was available for 83.6% of cases at a mean interval of 22 +/- 16 months after repair. The hernia recurrence rate was 9.3% (9 cases) and was detected at a median of 6 months postoperatively. The overall patient satisfaction score was high at 4.3 +/- 1.1 (scale, 1-5).

CONCLUSIONS

Laparoscopic repair is effective for the vast majority of patients with primary or recurrent ventral hernias and results in hernia recurrence rates of less than 10%, with high patient satisfaction scores. Although seroma is the most common complication, major morbidity occurred in 7.4% of the patients in our series. Enterotomy is the most common serious complication and may result in sepsis and death.

A short-term delayed approach to laparoscopic ventral hernia when injury is suspected

Laparoscopic repair is a safe and effective method for treating ventral hernias. Although the risk of bowel injury is low, its management is controversial. When injury is suspected or repaired, the risk of infection might prohibit a repair with prosthetic mesh. The timing of safe mesh placement is unclear. We retrospectively reviewed 9 patients from our prospective laparoscopic ventral hernia database who were treated with a 2- to 6-day delay in mesh placement due to violation of the gastrointestinal tract or risk of unidentified or delayed injury. All 9 patients had large ventral hernias from previous laparotomies (average defect, 399.4 cm2) and presented for elective repair. Three of the patients were morbidly obese, and one was diabetic. The decision to delay mesh placement was made intraoperatively. Reasons for delay were colotomy with repair, extensive serosal tears, resection after enterotomy, and resection for chronic small bowel obstruction. All patients received broad-spectrum antibiotics while awaiting definitive repair. In 7 patients, mesh was successfully placed between postoperative days 2 and 6. Delayed mesh placement failed in 2 patients due to loss of domain with bowel edema. The average length of stay was 9 days (range, 6 to 15 days) and average follow-up was 136 days (range, 36 to 303 days). No early mesh infections or other major complications were reported. A short delay of 2 to 6 days with antibiotic coverage is a safe strategy for managing potential or recognized injury to the gastrointestinal tract during laparoscopic ventral hernia repair.

Laparoscopic ventral hernia repair with the Goretex Dualmesh: long-term results and review of the literature

Since 1993 laparoscopy has become a popular technique of repair of ventral hernias. The authors review the long-term results of a systematic laparoscopic repair of ventral hernias and discuss the current problems compared to open repair. Between 1997 and 2003, 146 patients had a laparoscopic ventral hernia repair using an intraperitoneal Goretex Dualmesh with a 3-5-cm mesh overlap secured with a combination of nonabsorbable sutures and staples. A total of 155 attempts of laparoscopic repair was performed with four conversions. The 151 laparoscopic operations were completed in 105.8 min with a mesh implant being of 341 cm(2). There were two postoperative deaths and two patients had to be reoperated on. Mesh infection was diagnosed in two cases. Mean length of stay was 4.9 days. During a follow- up of 26.6 months eight patients (5.8%) developed a recurrence. Laparoscopic ventral hernia repair is a reproducible technique. Most of the comparative studies have shown an overall lower rate of complications after laparoscopic repair compared to open but with a 2-4% risk of bowel injury. The two other benefits of the laparoscopy are reduced postoperative pain and shorter hospital stay. The recurrence rate is usually between 2 and 7% but no difference has been found compared to open repair. Laparoscopic ventral hernia repair using the Goretex Dualmesh is a reliable operation with a low rate of conversion to open. Despite the risk of serious bowel injury, laparoscopy achieves as good results as the mesh open repair on the long term with the benefit of a decreased complication rate and a shorter hospital stay.

Suture Passer Tip Breakage During Laparoscopic Ventral Hernia Repair

Laparoscopic ventral hernia repair generally employs a tacker and a suture passer to secure the mesh to the abdominal wall. We reviewed cases of Gore Suture Passer tip breakage during these procedures and their management. Surgeons performing laparoscopic ventral hernia repair were asked about encountered complications relating to the Gore Suture Passer instrument. Charts of the patients with significant alteration in the course of their procedure secondary to such complication were reviewed. Two cases of suture passer tip breakage were identified. One required fluoroscopy to localize and recover the tip, resulting in significant prolongation of the operation. The other required conversion to laparotomy with mesh removal; the tip of the Gore Suture Passer was found in the pelvis and the hernia was repaired with a Stoppa technique. The Gore Suture Passer tip may break during laparoscopic ventral hernia repair, which may significantly complicate the case.

Immediate, early, and late morbidity with laparoscopic ventral hernia repair and tolerance to composite mesh

The laparoscopic repair of ventral hernias is still a controversial therapeutic option, and little is known of its medium- and long-term morbidity. The purpose of the study is to evaluate the postoperative morbidity of laparoscopic ventral hernia repair and analyze the clinical factors that might be related to it. 86 consecutive patients who had ventral hernia and underwent endoscopic surgery in a Universitary teaching hospital. Epidemiological, clinical, postoperative complications, tolerance, aesthetic evaluation of the wall and recurrence rate are analyzed. The mean follow-up (100%) was 42 months (range: 1-5 years) and included clinical and ultrasonographic evaluation. The overall postoperative morbidity rate was 23.2%, with one case of mortality following a sepsis due to intestinal perforation; the rate of re-admissions and recurrences was 3.5%. Statistically significant relationships were shown between the complications and infra-umbilical location (P < 0.001), age over 60 years and female sex (P < 0.05). The dynamic ultrasound study showed 91% and 94% of the patients to be adhesion-free at 1 and 3 years respectively. Aesthetic assessment of the wall at 3 years showed persistent asymmetries in 5% of the patients and a 92% degree of personal satisfaction. The morbidity with laparoscopic ventral hernia repair is not negligible. The surgeon must know these complications and be able to treat them appropriately.

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.

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.

Recurrences after laparoscopic ventral hernia repair: results and critical review

We describe the whole cohort of patients operated on laparoscopically for ventral hernias at our institution. Information on early results, complications, and long-term follow-up was collected prospectively. Of 90 operations attempted, five (5.8%) required conversion. Of the remaining 85 patients, 65 (76%) had an incisional hernia, while 20 (24%) had primary defects. Three trocars were routinely employed (Hasson and two 5-mm). The prosthetic mesh used was ePTFE inserted through the first trocar and fixed using helicoidal staplers. Patients were periodically followed in the outpatient clinic for at least 12 months postoperatively and contacted at the time of this review. Mean operative time was 101 min. We had three small bowel injuries repaired laparoscopically. Postoperative pain was limited. Bowel movements, deambulation, and discharge were prompt. We had six (7%) urinary retentions, eight (9%) seromas, three (3.5%) cases of pneumonia, two (2%) cases of postoperative vomiting, and one (1%) prolonged ileus, which resolved spontaneously on postoperative day 2. Mean postoperative stay was 4 days. One patient was readmitted after 4 weeks with incomplete obstruction, resolved conservatively. There were three recurrences (3.5%), which developed within 1 year of the operation, and a trocar-site herniation (1%). The technique appears safe and efficacious.

Laparoscopic repair of ventral hernias: nine years' experience with 850 consecutive hernias

OBJECTIVE

To evaluate the efficacy and safety of laparoscopic repair of ventral hernias.

SUMMARY BACKGROUND DATA

The recurrence rate after standard repair of ventral hernias may be as high as 12-52%, and the wide surgical dissection required often results in wound complications. Use of a laparoscopic approach may decrease rates of complications and recurrence after ventral hernia repair.

METHODS

Data on all patients who underwent laparoscopic ventral hernia repair (LVHR) performed by 4 surgeons using a standardized procedure between November 1993 and October 2002 were collected prospectively (85% of patients) or retrospectively.

RESULTS

LVHR was completed in 819 of the 850 patients (422 men; 428 women) in whom it was attempted. Thirty-four percent of completed LVHRs were for recurrent hernias. The patient mean body mass index was 32; the mean defect size was 118 cm2. Mesh, averaging 344 cm2, was used in all cases. Mean operating time was 120 min, mean estimated blood loss was 49 mL, and hospital stay averaged 2.3 days. There were 128 complications in 112 patients (13.2%). One patient died of a myocardial infarction. The most common complications were ileus (3%) and prolonged seroma (2.6%). During a mean follow-up time of 20.2 months (range, 1-94 months), the hernia recurrence rate was 4.7%. Recurrence was associated with large defects, obesity, previous open repairs, and perioperative complications.

CONCLUSION

In this large series, LVHR had a low rate of conversion to open surgery, a short hospital stay, a moderate complication rate, and a low risk of recurrence.