Evaluation of port site hernias, chronic pain and recurrence rates after laparoscopic ventral hernia repair: a monocentric long-term study

Onlay Repair Using Self-Gripping Mesh for Lateral Trocar Site Hernia After Laparoscopic Incisional Hernia Repair: A Case Report With Short- and Mid-Term Outcomes

Introduction

Trocar site hernia (TSH) is an uncommon complication after laparoscopic surgery, but it may potentially require surgical intervention. The available data have shown the importance of prediction and prevention; the optimal surgical approach for TSH remains unclear, and its long-term outcome is scarcely available. Here, we present a case of a lateral TSH after laparoscopic incisional hernia repair, which was successfully repaired using the onlay technique with a self-gripping mesh.

Case presentation

A 74-year-old woman presented with an abdominal incisional hernia at the midline after an open cholecystectomy. She underwent laparoscopic surgery for incisional hernia with intraperitoneal onlay mesh repair. Fascial closure was performed for trocar sites. After 12 months, she noticed a painful bulge in the left upper quadrant suggestive of TSH. At the time of diagnosis, her body mass index was 32 kg/m2. TSH repair was performed under general anesthesia. A 3 × 3 cm defect was identified, and the hernial content was found to be the omentum. Defect closure was performed using interrupted sutures followed by placement of a self-gripping mesh (11 × 11 cm in size, obtaining a 4-cm overlap for the defect). The operative time was 80 minutes. The postoperative course was uneventful except for a spontaneously resolved seroma. Computed tomography scan at the 1-year follow-up and physical examination at the 2-year visit showed no recurrence.

Conclusion

Our proposed onlay repair using self-gripping mesh may be considered as the treatment of choice for cases of lateral TSH after laparoscopic incisional hernia repair.

Laparoscopic Intraperitoneal Onlay Mesh (IPOM): Short- and Long-Term Results in a Single Center

The laparoscopic intraperitoneal onlay mesh repair (IPOM) approach has become the most widely adopted technique in the last decade. The role of laparoscopic IPOM in the last years has been resizing due to several limitations. The aim of the present study is to evaluate short- and long-term outcomes in patients who underwent laparoscopic IPOM. This retrospective single-center study describes 170 patients who underwent laparoscopic IPOM for ventral hernia at the General Surgery Unit of Parma University Hospital from 1 January 2016 to 31 December 2020. We evaluated patient, hernia, surgical and postoperative characteristics. According to the defect size, we divided the patients into Group 1 (Ø < 30 mm), Group 2 (30 < Ø < 50 mm) and Group 3 (Ø > 50 mm). A total of 167 patients were included. The mean defect diameter was 41.1 ± 16.3 mm. The mean operative time was different among the three groups (p < 0.001). Higher Charlson Comorbidity Index, obesity and incisional hernia were related to postoperative seroma and obesity alone with SSO. p < 0.001 Recurrence was significantly higher in larger defects (Group 3) and incisional hernia. p < 0.001. This retrospective study suggests that laparoscopic IPOM is a feasible and safe surgical technique with an acceptable complication rate, especially in the treatment of smaller defects up to 5 cm.

A propensity-score matched analysis of ventral-TAPP vs. laparoscopic IPOM for small and mid-sized ventral hernias. Comparison of perioperative data, surgical outcome and cost-effectiveness

PURPOSE

Laparoscopic techniques have been used and refined in hernia surgery for several years. The aim of this study was to compare an established method such as laparoscopic intra-peritoneal onlay mesh repair (lap. IPOM) with ventral Transabdominal Preperitoneal Patch Plasty (ventral-TAPP) in abdominal wall hernia repair.

METHODS

Patient-related data of 180 laparoscopic ventral hernia repairs between June 2014 and August 2020 were extracted from our prospectively maintained database. Of these patients, 34 underwent ventral-TAPP and 146 lap. IPOM. After excluding hernias with a defect size > 5 cm and obtaining balanced groups with propensity-score matching, a comparative analysis was performed in terms perioperative data, surgical outcomes and cost-effectiveness.

RESULTS

Propensity-score matching suggested 27 patients in each of the two cohorts. The statistical evaluation showed that intake of opiates was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.001). The Visual Analogue Scale (VAS) score after lap. IPOM repair was significantly higher at movement (p = 0.008) and at rest (p = 0.023). Also, maximum subjective pain during hospital stay was significantly higher in the lap. IPOM group compared to ventral-TAPP patients (p = 0.004). No hernia recurrence was detected in either group. The material costs of ventral-TAPP procedure (34.37 ± 0.47 €) were significantly lower than those of the lap. IPOM group (742.57 ± 128.44 € p = 0.001). The mean operation time was 65.19 ± 26.43 min in the lap. IPOM group and 58.65 ± 18.43 min in the ventral-TAPP cohort. Additionally, the length of hospital stay in the lap. IPOM cohort was significantly longer (p = 0.043).

CONCLUSION

Ventral-TAPP procedures represent an alternative technique to lap. IPOM repair to reduce the risk of complications related to intra-peritoneal position of mesh and fixating devices. In addition, our study showed that postoperative pain level, material costs and hospital stay of the ventral-TAPP cohort are significantly lower compared to lap. IPOM patients.

Drain-site hernia after laparoscopic rectal resection: A case report and review of literature

BACKGROUND

Drain-site hernia (DSH) has an extremely low morbidity and has rarely been reported. Small bowel obstruction is a frequent concurrent condition in most cases of DSH, which commonly occurs at the ≥ 10 mm drain-site. Here we report a rare case of DSH at the lateral 5 mm port site one month postoperatively without visceral incarceration. Simultaneously, a brief review of the literature was conducted focusing on the risk factors, diagnosis, and prevention strategies for DSH.

CASE SUMMARY

A 76-year-old male patient was admitted to our institution with intermittent abdominal pain and a local abdominal mass which occurred one month after laparoscopic radical resection of rectal cancer one year ago. A computed tomography scan showed an abdominal wall hernia at the 5 mm former drain-site in the left lower quadrant, and that the content consisted of the large omentum. An elective herniorrhaphy was performed by closing the fascial defect and reinforcing the abdominal wall with a synthetic mesh simultaneously. The postoperative period was uneventful. The patient was discharged seven days after the operation without surgery-related complications at the 1-mo follow-up visit.

CONCLUSION

Emphasis should be placed on DSH despite the decreased use of intra-abdominal drainage. It is recommended that placement of a surgical drainage tube at the ≥ 10 mm trocar site should be avoided. Moreover, it is advisable to have a comprehensive understanding of the risk factors for DSH and complete closure of the fascial defect at the drainage site for high-risk patients.

Laparoscopic Repair of a Rare Abdominal Wall Deformity and Review of the Literature

Linea arcuate herniae (LAH) are rare and usually asymptomatic but can present with generalized abdominal pain in the absence of bulging and are impalpable. Diagnosis is dependent on cross-sectional imaging, and operative approach to their management is debatable. Here, we report the case of a 56-year-old female with abdominal pain diagnosed with a linea arcuate hernia by computed tomography (CT) scan. She went on to have laparoscopic primary suture closure of the hernial defect with reinforcing underlay mesh. LAH are effectively elucidated with CT. Although there are concerns regarding mesh-related complications, we advocate a laparoscopic approach and repair with prosthetic mesh reinforcement, fixated with sutures. Long-term follow-up of these patients is still required.

A case of Spigelian hernia after laparoscopic incisional hernia repair

Laparoscopic ventral hernia repair with intraperitoneal onlay mesh reinforcement is often performed in clinical practice. We herein describe a patient who developed a Spigelian hernia at the edge of the mesh due to rupture of the muscular layer in the abdominal wall. A 69-year-old woman developed a left-sided abdominal bulge 15 months after laparoscopic ventral hernia repair. CT showed a 33-mm defect in the abdominal wall at the lateral edge of the left abdominal rectus muscle with an intestinal prolapse through the defect. She was diagnosed with a Spigelian hernia and underwent operation. The hernia orifice was located at the aponeurosis of the transverse abdominal muscle where the thread had been used to fix the mesh through all layers of the abdominal wall. This report details a case of a Spigelian hernia after laparoscopic ventral hernia repair.

Ventral hernia repair by totally extraperitoneal approach (VTEP): technique description and feasibility study

BACKGROUND

The repair of ventral hernias by intra-peritoneal patch (IPOM) involves a risk of pain due to stapling as well as intestinal adhesions. Extraperitoneal placement of the patch without fixation can prevent these drawbacks. Techniques of endoscopic preperitoneal repair were previously described by others. The aim of this article is to describe our technique and to evaluate the feasibility and short-term results.

METHODS

The totally endoscopic technique consists of dividing the median aponeurotic structures, while preserving the proper linea alba, to create a unique retro-muscular space, in which the patch is deployed without any fixation. Hundred twelve consecutive patients were operated on for ventral hernias (82 umbilical, 20 epigastric, 10 combined). Perioperative data including duration of operation, technical problems, conversions and complications, as well as postoperative pain, time to resume daily activities and time off work were prospectively assessed.

RESULTS

98 (87.5%) patients were operated in ambulatory surgery, and 14 (12.5%) in overnight stay. The mean sizes of the hernia and the patch were 9 (1-50) cm² and 225 (50-500) cm², respectively. The mean operation duration was 75 (30-270) min. The peritoneum was opened in 43 (38.4%) cases and closed by suture in 41 instances. There were 5 (4.5%) conversions to IPOM and 4 (3.6%) complications (1 seroma, 1 urine retention, 1 transitory ileus, and 1 intestinal obstruction) which were reoperated. The mean VAS value of postoperative pain was 2.45 (0-8), pain was scored 0 by 17 (15%) patients. The mean times to resume daily activity and work were 4 (1-15) days and 11.5 (1-30) days, respectively.

CONCLUSION

Our results suggest that VTEP is safely feasible by surgeons skilled in laparoscopy, and might contribute to minimize pain, though this must be established by comparative studies.

Primary non-complicated midline ventral hernia: is laparoscopic IPOM still a reasonable approach?

PURPOSE

Ventral hernia repair has become a common procedure, but the way in which it is performed still depends on surgeon's skill, experience, and habit. The initial open approach is faced with extensive dissection and a high risk of infection and prolonged hospital stay. To tackle these problems, minimally invasive procedures are gaining interest. Several new techniques are emerging, but laparoscopic intra-peritoneal onlay mesh (IPOM) is still the mainstay for many surgeons. We will discuss why laparoscopic IPOM is still a valuable approach in the treatment of primary non-complicated midline hernias and review the current literature.

METHODS

We performed a literature search across PubMed and MEDLINE using the following search terms: "Laparoscopic hernia repair", "Ventral hernia repair" and "Primary ventral hernia". Articles corresponding to these search terms were individually reviewed by the primary author and selected on relevance.

CONCLUSION

Laparoscopic IPOM still is a good approach for the efficient treatment of primary non-complicated midline hernias. Several techniques are emerging, but are faced with increased costs, technical difficulties, and low study patient volume. Further research is warranted to show superiority and applicability of these new techniques over laparoscopic IPOM, but until then laparoscopic IPOM should remain the go-to technique.

Fecal incontinence after transanal endoscopic microsurgery

PURPOSE

Transanal endoscopic microsurgery (TEM) procedure could potentially influence the development of fecal incontinence later in life. The aim of our study was to assess long-term functional outcomes after TEM and to determine possible variables related to incontinence.

METHODS

Patients, enrolled in a prospectively collected TEM operation database, were interviewed using a postal questionnaire. The questionnaire consisted of EuroQol (EQ)-5D-5L quality of life questionnaire, Wexner fecal incontinence grading scale, and additional questions about other perianal operations and obstetric history for women. We divided patients into two groups: no or minor fecal incontinence (Wexner score of 2 and less) and non-minor incontinence (Wexner score of 3 or more).

RESULTS

One hundred thirty-two patients were included in the study. Patients' median follow-up time was 96 (12-168) months from their operation. Thirty-eight patients (28.8%) reported Wexner score of 3 or more, and they reported significantly worse quality of life in all tested life spheres. They were older at the time of the operation (63 (18-82) vs. 68 (50-89) years; p = 0.004), underwent longer operations (50 (10-140) vs. 60 (15-210) min; p = 0.017), and more often were operated for malignant lesions (17 (18.3%) vs. 14 (36.8%); p = 0.040). Older age at the time of operation was an independent risk factor in multivariate model (OR 1.057, 95% CI 1.010-1.106; p = 0.016).

CONCLUSIONS

Fecal incontinence after TEM is more common than thought previously, resulting in significantly impaired quality of life. Older age at the time of operation was an independent risk factor for developing significant fecal incontinence.