Laparoscopic incisional and ventral hernia repair in a district general hospital

Pre- and postsurgical imaging findings of abdominal wall hernias based on the European Hernia Society (EHS) classification

Abdominal wall hernias are common and can present as technical challenges to surgeons. When large, hernias diminish quality of life. Various classifications of incisional hernias have been proposed; however, there are many terms, sometimes causing confusion (1). Radiologists must know the normal anatomy of the abdominal wall, the CT protocol, and what if any maneuvers can be performed to better identify an abdominal wall defect. The description of the radiological approach for primary and incisional wall hernias is based on the 2007 European Hernia Society classification, with particular emphasis on presurgical and postsurgical imaging findings. This classification provides a simple and reproducible method to describe hernias to offer proper surgical management. We highlight this classification so that radiologists and surgeons can have a unified language.

Laparoscopic ventral hernia repair in patients with obesity: should we be scared of body mass index?

BACKGROUND

Obesity is a risk factor for ventral hernia development and affects up to 60% of patients undergoing ventral hernia repair. It is also associated with a higher rate of surgical site occurrences and an increased risk of recurrence after ventral hernia repair, but data is lacking on the differences between obesity classes.

METHODS

Between 2008 and 2018, 322 patients with obesity underwent laparoscopic ventral hernia repair in our department: class I n = 231 (72%), II n = 55 (17%), III n = 36 (11%). We compared short and long-term outcomes between the three classes.

RESULTS

Patients with class III obesity had a longer median length of hospital stay compared to I and II (5 days versus 4 days in the other groups, p = 0.0006), but without differences in postoperative complications or surgical site occurrences. After a median follow up of 49 months, there were no significant differences in the incidence of seroma, recurrence, chronic pain, pseudorecurrence and port-site hernia. At multivariate analysis, risk factors for recurrence were presence of a lateral defect and previous hernia repair; risk factors for seroma were immunosuppression, defect > 15 cm and more than one previous hernia repair; the only risk factor for postoperative complications was chronic obstructive pulmonary disease.

CONCLUSION

Class III obesity is associated with longer length of hospital stay after laparoscopic ventral hernia repair, but without differences in postoperative complications and long-term outcomes compared with class I and class II obesity.

Postoperative outcomes of ventral hernia repair in veterans

BACKGROUND

Ventral hernia repair is a common procedure with reported 15% to 37% morbidity and 0.3% to 1.4% mortality rates. This study examines the 30-day morbidity and mortality of open and laparoscopic ventral hernia repair in veterans, along with the impact of body mass index on these outcomes.

METHODS

The Veterans Affairs Surgical Quality Improvement Program was queried for all ventral hernia repairs during the period 2008 to 2015. In this retrospective analysis, we compared outcomes of open ventral hernia repair versus laparoscopic ventral hernia repair and among different body mass index classes.

RESULTS

A total of 19,883 patients were identified (92.6% male, mean age 59.7, 53.1% obese, and 71.6% with American Society of Anesthesiologists class ≥III). There were 95 (0.5%) mortalities, and complications occurred in 1,289 (6.5%) patients. Open ventral hernia repair was performed in 60.2%; 14.5% were recurrent, and 3.3% were performed as an emergency operation. When compared with open ventral hernia repair, the laparoscopic ventral hernia repair group had higher mean body mass index, less patients with American Society of Anesthesiologists class ≥III, fewer emergency operations, longer operative time, less complications, decreased mortality, and shorter duration of stay. Body mass index 35.00 to 49.99 was predictive of overall complications in the open ventral hernia repair group.

CONCLUSION

Ventral hernia repair can be performed in the veteran population with outcomes comparable to those in the private sector. Morbid obesity has a negative impact on ventral hernia repair outcomes that is most prominent following open surgery. Laparoscopic ventral hernia repair may offer superior outcomes when compared to open ventral hernia repair and may be considered.

Laparoscopic ventral hernia repair using only 5-mm ports

BACKGROUND

The technique of laparoscopic ventral hernia repair has been evolving since it was first described over 20 years ago. We report a new technique where polyester mesh was back loaded through a 5-mm port site, coming into contact with the skin. This avoids the need for any 10-12-mm ports.

METHODS

A prospective database of laparoscopic ventral hernia repairs was examined. A single surgeon performed 344 laparoscopic ventral hernia repairs using this technique over 60 months. Follow-up was conducted by both clinical and independent phone review.

SURGICAL TECHNIQUE

Laparoscopic access was achieved via a 5-mm optical port, adding two, or occasionally three, 5-mm extra ports. Hernia contents were reduced and the extra-peritoneal fat excised; 5-mm tooth graspers were placed through the lateral port and then in a retrograde fashion through the uppermost port. The port was removed, and the mesh pulled back into the abdominal cavity and positioned with a minimum of 3-cm overlap. The mesh was fixed using absorbable tacks and sutures.

RESULTS

Most patients had primary umbilical hernias. There was one case of mesh infection due to enteric organisms. This occurred in a patient undergoing repair of a stoma site hernia, resulting from a Hartmann's procedure for perforated diverticulitis. There was no other evidence of acute or chronic mesh infection despite cutaneous contact with the mesh. In this series, there was an overall hernia recurrence rate of 2.4%.

CONCLUSION

Laparoscopic ventral hernia repair using only 5-mm ports is a safe, effective technique with no extra risk of infection.

Robotic Ventral Hernia Repair and Endoscopic Component Separation: Outcomes

BACKGROUND AND OBJECTIVES

Robot-assisted hernia repair, combined with endoscopic component separation, has reduced recurrence and complication rates and allowed immediate intervention in obese patients. We sought to study surgical outcomes in this high-risk group of patients in a community hospital.

METHODS

We conducted a retrospective chart review of ventral, incisional, and umbilical hernia repairs performed at a small community hospital by a single surgeon from March 2014 through November 2016, with statistical analysis of the surgical outcomes. Patients included were those who underwent hernia repair during the study period and had a body mass index (BMI) >30. Patients were followed up for a minimum of 6 months (range, 6-37).

RESULTS

Forty-seven hernia repairs were performed, including 33 combined and 14 control cases. The demographics of each group were comparable when comparing sex, age, BMI, and ASA classification. Mean follow-up was 19.39 months in the study group and 28.64 months in the control group. There were no significant differences in total operative time, estimated blood loss, conversion rates, or hospital length of stay. Two complications occurred in each of the study and control groups, with no recurrences in the study group and 3 in the control group and no mortalities.

CONCLUSION

Robotic laparoscopic repair of abdominal wall defects offers significant advantages, including easier primary defect closure. Our analyses showed that combining robot-assisted hernia repair with mesh and endoscopic component separation is an effective intervention in obese patients.