Single port laparoscopic repair of primary and incisional ventral hernia

The Effects of Having Surgeon's Hands in Line of Vision During Single-Incision Laparoscopic Surgery: A Feasibility Study

Aim: Single-incision laparoscopic surgery (SILS) provides improved cosmesis compared with multiport laparoscopy. However, it involves hand-clashing and cross-triangulation, making it challenging even for experienced surgeons to adopt in their practice. This study aims to assess the effect of providing an additional view of the surgeon's hands on task performance in SILS. Methods: Surgically naive participants were recruited via volunteer sampling and instructed to perform tasks using a laparoscopic trainer set and a singular triport access device. A head-mounted camera was worn by the participant and angulated inferiorly to provide an additional view of the operators' hands. Both views were displayed on a 90″ monitor. Tasks were performed with and without the additional view in an alternating manner. Attempts were recorded and assessed blindly for duration and success. Chi-squared and Mann-Whitney U tests were applied as required. A P value <.05 was considered significant. Results: A total of 467 attempts were conducted by 30 volunteers. The pass rates were 79.09% and 69.23% for the additional and traditional views, respectively (P = .015). A trend toward shorter durations was seen in attempts using the additional view (P = .128). Males (P = .003) and PC video game players (P = .022) were more likely to pass and mobile video game players were more likely to fail (P = .003). Conclusion: The use of a head-mounted camera to directly visualize surgeon's hands enhances performance in an ex vivo setting. More research is needed to assess clinical impact.

Laparoscopic Versus Open Ventral Hernia Repair: Experience at a Tertiary Care Center in Western Rajasthan

Background

Ventral hernias are the second most common type of hernias accounting for 21-35% of all hernia types. Ventral hernia includes incisional, umbilical, epigastric, and Spigelian hernias, among others. Currently, patients and surgeons prefer laparoscopic repair of ventral hernias. This study aimed to compare laparoscopic with open hernia repair in terms of various operative and patient parameters.

Methodology

This was a prospective observational study conducted in the Department of General Surgery, Dr. Sampurnanand Medical College, Jodhpur. All patients admitted with a diagnosis of ventral hernia for mesh repair (open as well as laparoscopic) were included. Laparoscopic and open hernia repair were compared in terms of operative time, postoperative hospital stay, time to resume routine activity, postoperative complications, and recurrence.

Results

Among the 50 patients included in the study (25 patients each in the laparoscopic and open groups), the mean operative time was 57.52 ± 5.80 minutes in the laparoscopic group and 59.8 ± 11.15 minutes in the open group. The mean hospital stay in the laparoscopy and open groups was 7.4 ± 1.58 days and 9.88 ± 2.96 days, respectively (p-value = 0.0006; significant). Postoperative pain (using the visual analog scale score) was less in patients who underwent laparoscopic surgery (p-value = 0.001; significant). Seroma and surgical site infections were the most common complications which were observed more in the open hernia repair group. Recurrence was seen in one case operated by the open technique.

Conclusions

Laparoscopic ventral hernia repair is technically safer, effective, and feasible with better clinical outcomes in patients seeking treatment in a government hospital.

Laparoscopic versus Open Repair of Para-Umbilical Hernia- A Prospective Comparative Study of Short Term Outcomes

INTRODUCTION

Para-Umbilical Hernia (PUH) is one of the most common surgical problems. Since the prosthetic repair has become the standard of practice for inguinal hernia management, the same has been adapted for para-umbilical hernia management with better outcome. There is still debate going on regarding the optimal surgical approach. There are very few prospective studies comparing the laparoscopic and open method of para-umbilical hernia mesh repair. This study compared the short term outcomes following laparoscopic versus open mesh repair of PUH.

AIM

To compare the early complications of open repair with laparoscopic repair of PUH. To compare the post-operative hospital stay of open repair with laparoscopic repair of PUH.

MATERIALS AND METHODS

This was a prospective comparative clinical study done from August 2014 to August 2016. All the patients above the age of 13 who attended our surgical outpatient department with PUH were taken into our study. Exclusion criteria included 1) Patients with obstructed or strangulated PUH 2) Patients with abdominal malignancies 3) Patients with coagulopathy, severe cardiopulmonary disease, ascites and renal failure 4) Patients who had PUH repair in combination with another major surgical operation such as laparoscopic cholecystectomy and inguinal hernia repair 5) Patients with recurrent PUH. Institute Ethical Committee clearance was obtained for this study.

RESULTS

Out of 40 patients with PUH, 20 received open meshplasty and 20 patients received laparoscopic meshplasty. Postoperative pain and length of hospital stay is significantly less in laparoscopic PUH repair. Postoperative complications like wound infection, seroma, and haematoma are relatively less in laparoscopic group though statistically not significant.

CONCLUSION

Laparoscopic PUH repair has significantly better outcome in terms of postoperative pain and postoperative hospital stay.

Safety and efficacy of laparoendoscopic single-site surgery for abdominal wall hernias

In a specialized hernia center, laparoendoscopic single-site surgery was found to be safe and effective for many types of abdominal wall hernias including parastomal hernias.

Background:

Laparoendoscopic single-site surgery has rapidly progressed from the animal laboratory to clinical use since mass production of multichannel ports began in 2007. Indeed, it has now been shown to be feasible and safe for many commonly performed operations.

Methods:

This study cohort comprised 22 unselected patients with abdominal wall hernias of varying types: multiply recurrent inguinal (n=2), suprapubic (n=1), ventral/incisional (n=17), and parastomal hernias (n=2), who underwent laparoendoscopic single-site ventral hernia repair between December 2009 and February 2011. Standard dissecting instruments and a 52cm/5.5mm/30^°angle laparoscope were used.

Results:

Patients included 14 men and 8 women, with a median age of 56 (range, 32 to 78) years and a mean body mass index of 31.5±4.7kg/m². The mean mesh size was 460cm² (range, 225 to 884cm²). Mean operation time was 125 minutes for ventral/incisional hernias and 270 minutes for parastomal hernias. No conversions to multiport or open surgeries were necessary. There was no mortality or morbidity, and no recurrence at 6- to 18-month follow-up. The mean satisfaction score was 2.7 (range, 2 to 3) with no patients reporting dissatisfaction with the procedure.

Conclusion:

This series, though relatively small, represents a diverse group of patients with varying abdominal wall hernias, including parastomal hernias. These successful laparoendoscopic single-site surgeries, with no complications, demonstrate safety and efficacy, albeit in a specialized hernia center. This study is a prelude to the eventual validation of laparoendoscopic single-site hernia surgery with prospective randomized controlled trials.

SILS Incisional Hernia Repair: Is It Feasible in Giant Hernias? A Report of Three Cases

Aim. Three incisional ventral abdominal wall hernias were repaired by placing a 20 × 30 cm composite mesh via single incision of 2 cm. Methods. All three cases had previous operations and presented with giant incisional defects clinically. The defects were repaired laparoscopically via single incision with the placement of a composite mesh of 20 × 30 cm. Nonabsorbable sutures were needed to hang and fix the mesh only in the first case. Double-crown technique was used in all of the cases to secure the mesh to the anterior abdominal wall. Results. The mean operation time was 120 minutes. The patients were mobilized and led for oral intake at the first postoperative day. No morbidity occurred. Conclusion. Abdominal incisional hernias can be repaired via single incision with a mesh application in experienced centers.

Single-incision laparoscopic surgery - current status and controversies

Scarless surgery is the Holy Grail of surgery and the very raison d’etre of Minimal Access Surgery was the reduction of scars and thereby pain and suffering of the patients. The work of Muhe and Mouret in the late 80s, paved the way for mainstream laparoscopic procedures and it rapidly became the method of choice for many intra-abdominal procedures. Single-incision laparoscopic surgery is a very exciting new modality in the field of minimal access surgery which works for further reducing the scars of standard laparoscopy and towards scarless surgery. Natural orifice translumenal endoscopic surgery (NOTES) was developed for scarless surgery, but did not gain popularity due to a variety of reasons. NOTES stands for natural orifice translumenal endoscopic surgery, a term coined by a consortium in 2005. NOTES remains a research technique with only a few clinical cases having been reported. The lack of success of NOTES seems to have spurred on the interest in single-incision laparoscopy as an eminently doable technique in the present with minimum visible scarring, rendering a ‘scarless’ effect. Laparo-endoscopic single-site surgery (LESS) is, a term coined by a multidisciplinary consortium in 2008 for single-incision laparoscopic surgery. These are complementary technologies with similar difficulties of access, lack of triangulation and inadequate instrumentation as of date. LESS seems to offer an advantage to surgeons with its familiar field of view and instruments similar to those used in conventional laparoscopy. LESS remains a evolving special technique used successfully in many a centre, but with a significant way to go before it becomes mainstream. It currently stands between standard laparoscopy and NOTES in the armamentarium of minimal access surgery. This article outlines the development of LESS giving an overview of all the techniques and devices available and likely to be available in the future.

Trans-fascial laparoscopic mesh fixation: a procedural comparison using the standard suture passer versus iMESH stitcher™ device

INTRODUCTION

Laparoscopic mesh repair has become an increasingly common method for repairing incisional hernias. The current method for fixating mesh to the abdominal wall includes tacking the mesh to the peritoneum and fascia and suturing the mesh to the fascia with trans-fascial sutures. The iMESH Stitcher™ is a stitching device developed to both simplify and expedite this procedure by passing the suture from one arm of the iMESH stitcher™ to the other. The device enables a stitch to be created in three quick moves using only one hand. We compared both the efficacy and procedure time of trans-fascial mesh fixation when performed with the iMESH stitcher™ as compared to the standard suture passer method.

METHODS

A mesh patch was installed on the internal abdominal wall of two pigs. Surgical residents and Medical students were participants in the study and were trained in both techniques. Each participant was asked to perform six fixations with each technique. The procedural time required for both fixation techniques was recorded. Participants were asked to assess subjectively the relative difficulty of each technique on a scale of 1-10 (10 = most difficult).

RESULTS

Sixteen residents and students performed a total of 12 mesh fixations, each performing 6 fixations with each technique. Average mesh fixation suture time using the suture passer technique was 44 s for residents and 47 s for students. Average fixation suture time using the iMESH stitcherTM was 17 s for residents and 15 s for students. The average difficulty score for the suture passer technique was 6.1 as compared to 2.9 with iMESH stitcher™.

CONCLUSION

Trans-fascial fixation with the iMESH Stitcher™ took significantly less time than the standard suture passer method. The iMESH Stitcher™ significantly simplifies the procedure of transfascial fixation and potentially reduces technical difficulties.

Single-port access prosthetic repair for primary and incisional ventral hernia: toward less parietal trauma

BACKGROUND

Although still under development, single-port access (SPA) approach may be of interest in patients prone to port-side incisional hernia, ensuring absence of increased fascial incision. This forms the basis for evaluating SPA for prosthetic ventral hernia repair. We report a new SPA technique of ventral hernia repair using working-channel endoscope, standard laparoscopic instruments, and 10-mm port.

METHODS

Prospective experience with SPA prosthetic repair of primary and incisional ventral hernia in 52 patients for 55 ventral hernias is presented. Median (range) patient age was 46 years (26-85 years), and BMI was 28 kg/m2 (20-38 kg/m2). Mean fascial defect was 16.2 cm2 for primary hernia (n=23) and 48.3 cm2 for incisional hernia (n=32). Intraperitoneal composite mesh repair was achieved through single 10-mm flank port using working-channel endoscope. Meshes were fixed using absorbable tackers and transfascial stitches.

RESULTS

SPA repair of primary and incisional ventral hernia was completed in all cases without conversion to standard laparoscopy. Median (range) operative time was 54 min (39-95 min). Mesh size ranged from 118 to 500 cm2. No intra- or postoperative complications were recorded, except two seromas. Median (range) hospital stay was 1 day (1-5 days). One patient presented prolonged postoperative pain on mesh fixation that resolved after 3 months. No recurrence or port-site incisional hernias have been recorded at median (range) follow-up of 16 months (3-28 months).

CONCLUSIONS

SPA prosthetic repair of primary and incisional ventral hernia is easily feasible according to natural exposition by pneumoperitoneum and gravity. In the present series, SPA ventral hernia repair appears to be safe for experienced SPA surgeons. It may decrease parietal trauma and scarring in patients prone to incisional hernia. SPA repair may be associated with a decrease in rate of port-site incisional hernia compared with multiport laparoscopy, but this has to be verified by randomized trial with standard laparoscopic approach on long-term follow-up.

[Single incision laparoscopic surgery]

One of the aims of the new technologies and techniques in minimally invasive surgery (MIS) is to achieve a surgery without or with minimal visible scars. Natural orifice transluminal endoscopic surgery (NOTES) might be considered to be a paradigm of this development but it has not yet been possible to implement this universally. Nevertheless, the resultant innovation of research into NOTES has enabled "bridge technologies" to be introduced that allow MIS to be developed with the required standards of efficiency and safety. The aim of this paper is to review the concept of single incision surgery and to classify the available tools for its development and implementation.