Current Status and Challenges of Laparoscopy in Ventral Hernia Repair

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.

Comparison of mesh fixation devices for laparoscopic ventral hernia repair: an experimental study on human anatomic specimens

BACKGROUND

As there is a lack of clarity in terms of the tensile strength of mesh fixation for laparoscopic ventral hernia repair (LVHR), our aim was to investigate the immediate tensile strength of currently available mesh fixation devices on human anatomic specimens.

METHODS

Sixteen recently deceased body donators (mean body mass index of 24.4 kg/m²) were used to test the immediate tensile strength (Newton) of 11 different LVHR mesh fixation devices.

RESULTS

Each of the 11 different laparoscopic fixation devices was tested 44 times. Non-articulating tackers provided higher fixation resistance to tensile stress in comparison to articulating tackers (5.1-mm ReliaTack™: 16.9 ± 8.7 N vs. 12.2 ± 5.6 N, p = 0.013; 7-mm ReliaTack™: 19.8 ± 9.4 N vs. 15.0 ± 7.0 N, p = 0.007). Absorbable tacks with a greater length, i.e. ≥6 mm (7-mm ReliaTack™, 6-mm SorbaFix™ and 7.2-mm SecureStrap™) had significantly higher fixation tensile strength than tacks with a shorter length, i.e. < 6 mm (5.1-mm ReliaTack™ and 5.1-mm AbsorbaTack™) (p < 0.001). Furthermore, transfascial sutures (PDS 2-0 sutures 26.3 ± 5.6 N) provided superior fixation tensile strength than 5.1-mm AbsorbaTack™ (13.6 ± 7.3 N) and cyanoacrylate glues such as LiquiBand FIX8™ (3.5 ± 2.4 N) (p < 0.001, respectively). There was a significant deterioration in fixation capacity in obese body donators with a body mass index > 30 kg/m² (13.8 ± 8.0 vs. 17.9 ± 9.7 N, p = 0.044).

CONCLUSIONS

Although articulating laparoscopic tackers improve accessibility and facilitate the utilization of tacks within the fixation weak spot adjacent to the trocar placement, an articulating shaft that is not ergonomic to use may limit mechanisms of force transmission. For mesh fixation in LVHR, transfascial sutures and tacks with a longer length provide better immediate fixation tensile strength results.