Laparoscopic incisional hernia repair: evaluation of effectiveness and experiences

Laparoscopic repair reduces incidence of surgical site infections for all ventral hernias

BACKGROUND

The role of laparoscopic repair of ventral hernias remains incompletely defined. We hypothesize that laparoscopy, compared to open repair with mesh, decreases surgical site infection (SSI) for all ventral hernia types.

METHODS

MEDLINE, EMBASE, and Cochrane databases were reviewed to identify studies evaluating outcomes of laparoscopic versus open repair with mesh of ventral hernias and divided into groups (primary or incisional). Studies with high risk of bias were excluded. Primary outcomes of interest were recurrence and SSI. Fixed effects model was used unless significant heterogeneity, assessed with the Higgins I square (I(2)), was encountered.

RESULTS

There were 5 and 15 studies for primary and incisional cohorts. No difference was seen in recurrence between laparoscopic and open repair in the two hernia groups. SSI was more common with open repair in both hernia groups: primary (OR 4.17, 95%CI [2.03-8.55]) and incisional (OR 5.16, 95%CI [2.79-9.57]).

CONCLUSIONS

Laparoscopic repair, compared to open repair with mesh, decreases rates of SSI in all types of ventral hernias with no difference in recurrence. These data suggest that laparoscopic approach may be the treatment of choice for all types of ventral hernias.

Cost-benefit analysis comparing laparoscopic and open ventral hernia repair

OBJECTIVE

Laparoscopic surgery is a successful treatment option offering significant advantages to patients compared with open ventral hernia repair. A cost-benefit analysis was performed to compare the clinical results and economic costs of the open and laparoscopic techniques for anterior abdominal wall hernia repair, in order to determine the more efficient procedure.

MATERIAL AND METHODS

We performed a prospective study of 140 patients with primary and incisional hernia, and analyzed clinical data, morbidity, costs of surgery and hospital stay costs.

RESULTS

The cost of disposable surgical supplies was higher with laparoscopic repair but reduced the average length of stay (P<.001) and patient morbidity (P<.001). The total cost of the laparoscopic procedure was, therefore, less than initially estimated, yielding a savings of 1,260€ per patient (2,865€ vs. 4,125€).

CONCLUSIONS

Laparoscopic ventral hernia repair is associated with a reduced complication rate, a lower average length of stay and with lower total costs. Laparoscopic repair can save 1.260€ for each patient, and so this procedure should be considered a cost-effective approach.

Simple technique to manage redundant skin after laparoscopic ventral hernia repair

INTRODUCTION

The redundant skin left behind after laparoscopic ventral hernia repair overlies a dead space that is a potential site for seroma formation. This predisposes patients to surgical-site infection and compromises the cosmetic outcome of the procedure, which is a key feature of the minimally invasive approach. We present a simple technique to deal with this problem.

MATERIALS AND SURGICAL TECHNIQUE

This technique was used in six patients who underwent laparoscopic ventral hernia repair. Two patients were men and four were women. At the end of the procedure, glue (fibrin sealant) was injected in the dead space underneath the redundant skin and pressure was applied for some time; this attached the excessive skin to the underlying tissue. This obliterated the potential dead space, reducing the chances of seroma formation, and improved the cosmetic outcome of the procedure. Patients were reviewed 8 weeks after the procedure, and their body contours had returned to normal, with no skin redundancy.

DISCUSSION

Minimally invasive surgery offers the advantage of a shorter hospital stay, faster recovery and improved cosmetic outcome, achieving better patient satisfaction as a result. This simple technique at the end of laparoscopic ventral hernia repair, in which the redundant skin is attached to the underlying tissue, improves the immediate postoperative cosmetic outcome and also obliterates any potential dead space for seroma formation.

Laparoscopic ventral incisional hernia repair: evidence-based guidelines of the first Italian Consensus Conference

PURPOSE

The laparoscopic treatment of ventral incisional hernias is the object of constant attention and is becoming increasingly widespread in the international scientific-surgical community; however, there is ample debate on its technical details and indications. In order to establish a common approach on laparoscopic ventral incisional hernia repair, the first Italian Consensus Conference was organized in Naples (Italy) on 14-15 January 2010.

METHODS

The format of the Consensus Conference was freely adapted from the standards of the National Institute of Health and the Italian Health Institute. The parties involved included the followings: a Promotional Committee, a Scientific Committee, a group of Experts, the Jury Panel and a Scientific Secretariat.

RESULTS

Eleven statements, regarding three large chapters on the indications, the technical details and the management of complications were drafted on the basis of literature references collected by the Scientific Committee, documents developed by the Experts, reports presented and discussed during the Consensus Conference, and discussion among the members of the Jury.

CONCLUSIONS

The laparoscopic approach is safe and effective for defects larger than 3 cm in diameter; old age, obesity, previous abdominal operations, recurrence and strangulation are not absolute contraindications. Ensuring an adequate overlap, careful adhesiolysis and correct fixing of the prosthesis are among the technical details recommended. Complications and recurrences are comparable to, and in some cases, less numerous than with the open approach.

Combined intraperitoneal monitoring and total extraperitoneal repair of McBurney's incisional hernia

BACKGROUND

McBurney's incisional hernia after appendectomy is rare. Although the open surgical approach, either through direct suturing or through mesh repairs, mostly achieves a satisfactory outcome, postoperative wound pain usually impedes patient's early ambulation. Accordingly, laparoscopic ventral hernia repair has emerged as a minimally invasive technique in modern surgical practice. We described a different approach of laparoscopic incisional hernia repair.

CASE REPORT

A 76-year-old woman with a history of appendectomy presenting with a bulging mass over the right lower quadrant of the abdomen beneath the operation scar was admitted to our hospital. Computed tomography revealed defects in the abdominal muscle layers without evidence of bowel incarceration. The patient was diagnosed with postappendectomy incisional hernia for which laparoscopic hernia repair was performed through a combined intraperitoneal and extraperitoneal approach. The patient's postoperative course was excellent.

CONCLUSIONS

Combined extraperitoneal approach and intraperitoneal monitoring for McBurney's incisional hernia is feasible in selected cases.

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 repair of abdominal wall hernias]

Repair of abdominal wall defects is a challenge for all general surgeons and a variety of methods have been described in the past. Traditionally, primary suture repair was shown to have a high recurrence rate in long-term follow-up studies. Herniorrhaphies that apply a large prosthetic mesh are appear to have a lower failure rate, but extensive dissection of soft tissue contributes to an increased incidence of wound infections and wound-related complications. The method of laparoscopic incisional hernia repair was developed in the early 1990s. This technique is based on the same physical and surgical principles as the open underlay procedure. The laparoscopic intraperitoneal onlay mesh (IPOM) technique and mesh materials were developed further in subsequent years, and there have been numerous reports on successful use of the IPOM technique even for extremely large hernia openings in obese and elderly patients. Reduced surgical trauma and lower infection and recurrence rates are key advantages of the minimally invasive repair. Therefore, this operation has increased in popularity promising shorter hospital stay, improved outcome, and fewer complications than traditional open procedures.