Laparoscopic cure of small ventral hernias with composite mesh

Application of bridging mesh repair in giant ventral incisional hernia

Achieving ideal abdominal wall reconstruction in giant ventral incisional hernia has been a challenging for surgeons. This study aimed to verify the safety and efficacy of bridging repair by comparing it with primary fascial closure (PFC) repair in the treatment of giant ventral incisional hernia. We retrospectively analyzed the clinical data of 92 patients with giant ventral incisional hernia who underwent mesh repair at our medical institution from January 1, 2014 to December 31, 2020. Patients were divided into 2 groups: the bridging repair group with 40 patients in whom repair was completed using the bridging technique and the PFC group with 52 patients in whom primary fascial closure was achieved and all patients underwent mesh reinforcement during the operation. The main outcome measures were recurrence rate and morbidity, especially intra-abdominal hypertension (IAH). Follow-up time of both groups lasted at least 24 months after surgery. After a median of 46 months and 65 months of follow-up, respectively, in the two groups, bridging repair did not increase the long-term recurrence rate (2.56%) in the larger defect area group compared to the PFC group (1.96%). There were no significant differences in perioperative morbidity, IAH, incidence of postoperative chronic pain, and sensory impairment of the abdominal wall between both groups. The application of bridging surgery in the treatment of complex giant ventral incisional hernias is safe and effective and does not significantly increase the postoperative recurrence rate.

Laparoscopic Spigelian Hernia Repair: A Systematic Review

PURPOSE

Spigelian hernias (SHs) account for 1% to 2% of abdominal wall hernias. Traditionally they have been repaired using an open technique. Since 1992, laparoscopic methods have become increasingly popular with various techniques being described in the literature. This systematic review aims to represent the current trends in laparoscopic repair of SHs.

MATERIALS AND METHODS

The databases MEDLINE and EMBASE were searched for appropriate terms regarding SH repair. Papers describing laparoscopic repair of SH were included.

RESULTS

Fifty articles were identified for the final review. No randomized controlled trials comparing laparoscopic techniques were identified. Two hundred thirty-seven SHs were repaired by various techniques. Intraperitoneal onlay mesh technique was the most popular repair method with minimal complications and recurrences reported in all techniques.

CONCLUSIONS

There are a number of laparoscopic techniques available to the surgeon repairing a SH. Overall, laparoscopic repair of the SH is a safe and acceptable method.

Assessment of predictive factors for recurrence in laparoscopic ventral hernia repair using a bridging technique

AIM

To assess the long-term incidence and predictive factors for recurrence after laparoscopic ventral hernia repair using a bridging technique.

METHODS

The study group consisted of 213 consecutive patients operated by laparoscopy for primary ventral (n = 158) or incisional hernia (n = 55) between 2001 and 2014. Patients had a repair without fascia closure by intra-peritoneal onlay placement of a Parietex^® composite mesh centred on the defect with an overlap of at least 3 cm. Clinical outcome was assessed by a combination of office consultation, patient's electronic medical file review and telephone interview.

RESULTS

There were 144 men and 69 women with a mean age of 55 ± 12 years and a BMI of 32 ± 6. With a mean follow-up of 69 ± 44 months, a recurrent hernia was noted in 16 patients (7.5%). Univariate analysis showed a statistically significant higher recurrence rate in the following conditions: incisional hernia (15%), BMI ≥ 35 (21%), defect width >4 cm (27%), defect area >20 cm² (27%), mesh overlap <5 cm (32%) and ratio of mesh area to defect area (M/D ratio) ≤12 (48%). Multivariate logistic analysis revealed that M/D ratio was the only independent predictive factor for recurrence (coefficient -0.79, OR 0.46, p < 0.002). With a M/D ratio ≤8, between 9 and 12, between 13 and 16, and ≥17, the recurrence rate was, respectively, 70, 35, 9 and 0% (p < 0.001).

CONCLUSIONS

In laparoscopic repair of ventral hernia using a bridging technique, an overlap of at least 5 cm is not all that is required to prevent hernia recurrence. The M/D ratio is the most important predictive factor for recurrence. A ratio of 13 appears as the threshold under which that technique cannot be recommended and 16 as the threshold over which the risk of recurrence is virtually nil. If a satisfactory M/D ratio cannot be achieved, other surgical repair should be proposed to the patient.

Tissue integration and inflammatory reaction in full-thickness abdominal wall repair using an innovative composite mesh

PURPOSE

When composite meshes are used in abdominal wall repair, seroma formation may persist and delay the desired integration leading to recurrence. This study compares tissue integration and inflammatory response in abdominal wall repair with composites with different absorbable synthetic barriers.

METHODS

Full-thickness defects created in the abdominal wall of rabbits were repaired using polypropylene prosthesis or the following composites: Physiomesh™ (Phy); Ventralight™ (Vent) and "new composite mesh" (Ncm) not yet used clinically in humans. The collected seroma was evaluated for IFN-γ/IL-4 by ELISA. Tissue integration, anti- (IL-13/TGFβ-1/IL-10/IL-4) and pro-inflammatory (TNF-α/IL-6/IFN-γ/VEGF) cytokine mRNA expression and TGFβ/VEGF immunolabeling were evaluated at 14 and 90 days post-implant.

RESULTS

Seroma was observed in 10 of 12 Phy/Vent and 4 of 12 Ncm. Wound fluid IFN-γ showed a time-dependent significant increase in Vent and tendency to decrease in Ncm, while all composites exhibited IL-4 upward trend. Prostheses were fully infiltrated by an organized connective tissue at end time although the area had shown prior seroma. A stable mesothelium was developed, except in adhesion areas. Vent/Phy displayed a significant increase in TNF-α/IFN-γ-mRNA over time. Significant decrease in VEGF mRNA was observed in Phy/Ncm, while a significant increase of TGFβ-1 mRNA was evident in all composites over time. Ncm exhibited the highest TGFβ protein expression area at short term and the greatest percentage of VEGF positive vessels at end time.

CONCLUSION

Ncm could be an appropriate candidate to improve clinical outcome showing the lower development of seroma and optimal tissue integration with minimal pro-inflammatory cytokine response over time and consistent pro-wound healing cytokine expression.

Outcomes of open intraperitoneal incisional hernia repair based on patient-reported outcomes

PURPOSE

The outcomes of open incisional hernia repair from the patients' point of view have variations over time, and only continuous follow-up would reflect the real outcomes. The purpose of this study is to validate a standard measurement instrument in the form of a questionnaire to report the evolutionary outcomes of a specific open technique to repair incisional hernias.

METHODS

Prospective study follows up a cohort of 82 consecutive patients submitted to elective intraperitoneal open hernioplasty of midline incisional hernias. The follow-up consisted in an interview and physical examination 30 days after surgery, at 6 months, 1 year, 2 years, 3 years, and 4 years. Primary outcome measure was reporting the outcomes of hernia repair according to a standardized scale obtained from a questionnaire.

RESULTS

There was no correlation between complications suffered by patients and score results (p = 0.722). The length of hospital stay was 6.5 ± 4.3 days, and a prolonged hospital stay was related to complications (p = 0.002) and did not influence the score results (p = 0.365). The final score demonstrated that patients had a very good impression on this procedure 1 month after surgery (p = 0.003). This impression shifted to an excellent perception 1 year after surgery remaining similar until the last control (p < 0.0001).

CONCLUSIONS

In this series, the intraperitoneal hernioplasty was a procedure associated with minor morbidity and without recurrences 4 years after the operation. The outcomes from the patients' point of view were excellent 1 year after the procedure with a tendency to improve in the long term.

Laparoscopic treatment of incisional hernia. State of the art in 2012

OBJECTIVE

The objective of this review is to evaluate the results of laparoscopic treatment of ventral hernias using intra-peritoneal prosthetic mesh through a review of published surgical series.

METHODS

All large series of patients treated for an incisional hernia by laparoscopy and published between 2002 and 2011 were identified. The results of controlled randomized series comparing this technique with open surgical repair were analyzed.

RESULTS

Twenty-two series with a total of 7057 patients were analyzed (range 51-1242); the mean Body Mass Index (BMI) was 32 (range: 28.5-46), and the mean size of the hernia defect was 10.6 cm (range: 6-14.9 cm). The mean rate of conversion to open surgical repair was 2.7%. Mean operative duration was 90 ± 33 minutes. Mortality was 0.8%, usually due to an unrecognized intestinal injury (1.6%), which occurred more frequently with second or iterative hernia repairs. Hospital stay averaged 2.5 days. The infection rate was 0.3% and the rate of hernia recurrence was 4.6% (with a mean follow-up of 36 months). No statistically significant differences were found in terms of post-operative complications or hernia recurrence in the randomized studies comparing laparoscopic to open anterior abdominal surgical repair. However, duration of hospital stay was shorter after laparoscopy in some studies.

CONCLUSION

Laparoscopic repair of ventral incisional hernia is technically feasible and reliable for large hernia defects, even in obese patients. This approach should be reserved for patients with no history of previous hernia repair in order to avoid the risk of intestinal injury. It appears to allow for a shortened duration of hospitalization.

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

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

Pain, quality of life and recovery after laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) is a well established procedure in the treatment of ventral hernias. It is our clinical experience that patients suffer intense postoperative pain, but this issue and other recovery parameters have not been studied in detail.

METHODS

Thirty-five patients with hernias >3 cm prospectively underwent LVHR using "double-crown" titanium tack mesh fixation. Pre- and postoperative pain was measured on a 0-100-mm visual analogue scale (VAS) and health-related quality of life was measured using the Short Form 36 questionnaire (SF-36). Several other recovery parameters were measured systematically in the 6 months follow-up period.

RESULTS

We observed no recurrences or severe complications in the follow-up period (n = 31 at day 30 and n = 28 after 6 months). The median in-hospital stay was 2 days (range 0-5). Patients reported significantly more pain during activity than at rest at all times (p < 0.05). The median VAS-pain score during activity vs. at rest at discharge was 60 and 31, respectively. The median VAS-pain score during activity on the day of operation (day 0) was 78; it returned to baseline values at day 30 (p = 0.148) and, after 6 months, it was below the preoperative score (p = 0.01). The scores for general well-being and fatigue returned to baseline values at days 3 and 30, respectively, and at 6 months, they had both significantly improved compared with preoperative values (p = 0.005). The SF-36 scores were significantly worse in three domains at day 30 (p < 0.005). After 6 months, the bodily pain score had increased significantly compared with preoperative values (p < 0.005) and all eight scales were comparable to the Danish reference population scores. Patients resumed normal daily activities after a median of 14 days (range 1-38). Smokers and patients with hard physical demands at work took a significantly longer amount of time to resume work compared with non-smokers (30 vs. 9 days, p < 0.005) and patients with light work demands (29 vs. 9 days, p < 0.05), respectively. VAS-pain scores were strongly correlated to general well-being (r = -0.8, p < 0.001), patient satisfaction (r = -0.67, p < 0.001) and quality of life (r = -0.63, p < 0.001). We found no significant correlation between the number of tacks used (median 59) and postoperative pain.

CONCLUSION

LVHR was associated with considerable postoperative pain and fatigue in the first postoperative month, prolonging the time of convalescence and significantly affecting patients' quality of life up to 6 months postoperatively. Mesh fixation with fibrin glue or other non-invasive/degradable products seems promising for reducing pain and it should be investigated in future randomised trials.