Laparoscopic repair of an abdominal hernia using an expanded polytetrafluoroethylene patch secured by a four-corner tacking technique

Laparoscopic incisional hernia repair in a porcine model: what do transfixion sutures add?

BACKGROUND

The aim of this study was to evaluate the need for transfixion sutures during laparoscopic ventral hernia repair with mesh.

METHODS

Incisional hernias were created in 14 Yucatan mini-pigs. Animals were randomized to undergo laparoscopic hernia repair either with spiral tacks alone (Tacks) or with tacks and 4 Prolene transfixion sutures (Sutured) using Composix E/X mesh (Davol Inc.). At 4 weeks, exploratory laparoscopy was performed to assess the repair and score adhesions. The abdominal wall was harvested for tensile strength analysis and histologic evaluation. Continuous variables were compared using a two-tailed nonpaired t-test. Results are presented as mean +/- standard deviation.

RESULTS

The mean hernia size was 8.5 +/- 0.5 cm by 5.5 +/- 0.7 cm, with no difference between groups. The operative time was significantly longer ( p = 0.006) for the Sutured group (62.1 +/- 16.8 min) than for the Tacks group (32.3 +/- 7.0 min). The number of tacks per repair was equivalent between groups. At necropsy, the mesh in all cases was well incorporated, reperitonealized, and without evidence of migration. No hernias recurred. However, the Sutured group had a significantly ( p < or = 0.05) higher adhesion score (5.4 +/- 3.3) than the Tacks group (2.0 +/- 2.7). The tensile strength of the repair zone was no different between groups (Sutured 4.8 +/- 1.5 N/cm, Tacks 3.8 +/- 1.4 N/cm). On histologic examination, the ratio of inflammatory cells to fibroblasts was similar between groups (Sutured 0.2 +/- 0.6, Tacks 0.2 +/- 0.3). Only 82% of tacks in each group penetrated the fascia, and the depth of tack penetration was similar between groups (Sutured 3.7 +/- 0.3 mm, Tacks 3.9 +/- 0.4 mm).

CONCLUSIONS

In a porcine model, the use of transfixion sutures was associated with longer operative times and more adhesions, without improvement in tensile strength or mesh incorporation. A human clinical trial is needed to determine the optimal method of securing abdominal wall mesh.

The use of double-straight needle device in laparoscopic incisional and ventral hernia repair

Incisional and ventral hernias are good indications for laparoscopic hernia repair. A successful repair requires complete covering of the hernia defect, adequate tension of the prosthesis, and secure stapling by a hernia stapler. The authors introduce their technique using a double-straight needle device. This technique is easy and quick and achieves adequate fixation between the prosthesis and the abdominal wall, which reduces operating time and provides cosmetic benefit.

Laparoscopic ventral hernia repair

PURPOSE

A retrospective study was carried out of patients who underwent laparoscopic ventral abdominal wall hernia repair (excluding groin hernias) between January 1994 and January 1999.

PATIENTS AND METHODS

Laparoscopic ventral hernia repair was performed on 202 patients for defects ranging from 1.5 cm to 12 cm in diameter. Of these, 35 patients had multiple hernial defects. After reduction of the hernial contents and adhesiolysis, a polypropylene mesh was used intraperitoneally in all patients, such that there was a margin of at least 3 cm from the edge of the defect as well as the previous scar.

RESULTS

The mean operating time decreased from 90 minutes in the initial 3 years to 50 minutes in the last 2 years. Postoperatively, the mean hospital stay was 1.8 days. Patients complained of somatic abdominal pain at the site of mesh insertion for a mean of 7 days. There were two postoperative hernia recurrences at a mean follow-up of 2.9 years. The incidence of seroma formation postoperatively was 32% in the first 3 years but declined to 18% subsequently with postoperative abdominal-wall pressure dressings. There were no postoperative sequelae related to bowel adhesions. Negligible wound sepsis (superficial wound infection in five patients), decreased morbidity, and all the other advantages of a minimally invasive surgical approach were evident in this group of patients.

CONCLUSION

These promising early results need to be confirmed by a prospective controlled trial, especially recurrence rates and incidence of postoperative adhesions.

Endo-organ full-thickness excision for gastric cancer: report of a case

We performed endo-organ full thickness gastric excision to treat a high-risk patient with T2 gastric cancer. The patient, a 75-year-old white man with a gastric adenocarcinoma located just below the gastroesophageal junction, had a history of chronic obstructive pulmonary disease and cor pulmonale, and developed markedly elevated pulmonary artery pressures under general anesthesia. The less invasive endo-organ approach was utilized because of these severe morbidities. The carcinoma was staged laparoscopically, then removed utilizing the full-thickness endo-organ excision technique. This case report serves to demonstrate that full thickness endo-organ gastric excision may be indicated not only for certain early gastric cancers, but also for high-risk patients who cannot tolerate open surgery due to advanced age or serious illness.

Transabdominal inguinal hernioplasty combined with abdominal aortic aneurysm repair

The number of patients being encountered with abdominal aortic aneurysm (AAA) and inguinal hernia is increasing. We describe herein a technique of performing a concomitant one-stage operation for both disorder. After conventional transperitoneal AAA repair, transabdominal preperitoneal hernia repair is carried out through the same incision using a prosthesis made from the same material as the graft used for AAA. The maneuver is similar to that of laparoscopic hernioplasty. We employed this technique in the treatment of four patients, none of whom developed any complications such as infection or recurrence of the inguinal hernia. Thus, we conclude that this one-stage operation for AAA and inguinal hernia may bring physical and economic benefits to patients who have both diseases concomitantly.