Trans-fascial closure in laparoscopic ventral hernia repair

Laparoscopic intraperitoneal onlay mesh (IPOM) with fascial repair (IPOM-plus) for ventral and incisional hernia: a systematic review and meta-analysis

PURPOSE

Despite advancements in laparoscopic ventral hernia repair (LVHR) using the intraperitoneal onlay mesh technique (sIPOM), recurrence remains a common postoperative complication. The objective of this systematic review and meta-analysis is to compare the efficacy of defect closure (IPOM-plus) versus non-closure in ventral and incisional hernia repair. The aim is to determine which technique yields better outcomes in terms of reducing recurrence and complication rates.

METHODS

A comprehensive literature review was conducted in the PubMed, Web of Science, Cochrane Library, Embase, and ClinicalTrials.gov databases from their inception until October 1, 2022, to identify all online English publications that compared the outcomes of laparoscopic ventral hernia repair with and without fascia closure.

RESULTS

Three randomized controlled trials (RCTs) and eleven cohort studies involving 1585 patients met the inclusion criteria. The IPOM-plus technique was found to reduce the recurrence of hernias (OR = 0.51, 95% CI [0.35, 0.76], p < 0.01), seroma (OR = 0.48, 95% CI [0.32, 0.71], p < 0.01), and mesh bulging (OR = 0.08, 95% CI [0.01, 0.42], p < 0.01). Subgroup analysis revealed that body mass index (BMI) (OR = 0.43, 95% CI [0.29, 0.65], p < 0.0001), type of article (OR = 0.51, 95% CI [0.35, 0.76], p = 0.0008 < 0.01), geographical location (OR = 0.54, 95% CI [0.36, 0.82], p = 0.004 < 0.01), follow-up time (OR = 0.50, 95% CI [0.34, 0.73], p = 0.0004 < 0.01) had a significant influence on the postoperative recurrence of the IPOM-plus technique.

CONCLUSION

The IPOM-plus technique has been shown to greatly reduce the occurrence of recurrence, seroma, and mesh bulging. Overall, the IPOM-plus technique is considered a safe and effective procedure. However, additional randomized controlled studies with extended follow-up periods are necessary to further evaluate the IPOM-plus technique.

Laparoscopic treatment of ventral hernias: the Italian national guidelines

Primary and incisional ventral hernias are significant public health issues for their prevalence, variability of professional practices, and high costs associated with the treatment In 2019, the Board of Directors of the Italian Society for Endoscopic Surgery (SICE) promoted the development of new guidelines on the laparoscopic treatment of ventral hernias, according to the new national regulation. In 2022, the guideline was accepted by the government agency, and it was published, in Italian, on the SNLG website. Here, we report the adopted methodology and the guideline's recommendations, as established in its diffusion policy. This guideline is produced according to the methodology indicated by the SNGL and applying the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Fifteen recommendations were produced as a result of 4 PICO questions. The level of recommendation was conditional for 12 of them and conditional to moderate for one. This guideline's strengths include relying on an extensive systematic review of the literature and applying a rigorous GRADE method. It also has several limitations. The literature on the topic is continuously and rapidly evolving; our results are based on findings that need constant re-appraisal. It is focused only on minimally invasive techniques and cannot consider broader issues (e.g., diagnostics, indication for surgery, pre-habilitation).

Ventral hernia repair with a hybrid laparoscopic technique

BACKGROUND

Ventral hernias are increasingly managed with minimally invasive laparoscopic surgery. Invasive open surgery is typically used for the repair of large-sized hernias (>10 cm diameter). The two methods are often considered mutually exclusive. We report a hybrid technique for repair of medium to large-sized hernias.

METHODS

Data was collected prospectively from 44 hernias repaired using the hybrid technique from 2012 to 2020. Operative data was examined and follow-up conducted by both clinical and phone review. As for surgical technique, laparoscopic access was established via a 5 mm optical port and two (or more) 5 mm ports were added under vision. Hernia contents were reduced and extraperitoneal fat excised around the defect. Hernias with diameters ranging from 5 to 10 cm were fixed using the hybrid technique. A small incision was made directly over the hernia and polyester mesh was placed intraabdominally before defect closure with a transfascial suture. Pneumoperitoneum was re-established and mesh fixation achieved using absorbable tacks and/or fixation sutures.

RESULTS

Of the 44 ventral hernias repaired with the hybrid technique, 43 were secondary hernias from incisional defects. Average hernia diameter was 6.6 cm. 86% of patients were discharged within the first 48 h. Four patients (9%) had recurrences during the study period. Minor complications occurred in 8 patients (18%): 3 (7%) had post-operative wound infection, 3 patients (7%) developed post-operative seroma. Two patients (5%) had clinically significant wound haematoma.

CONCLUSION

Laparoscopic hybrid ventral hernia repair can be safely performed by a combination of laparoscopic and open techniques, offering an alternative method in the management of medium-sized ventral hernias.

Comparison of two fascial defect closure methods for laparoscopic incisional hernia repair

PURPOSE

Currently there is no consensus regarding the optimal surgical approach to an incisional hernia measuring less than 10 cm. Certain hernia features including defect size, intra-abdominal adhesions, and overlying scar/skin properties contribute to choosing an open versus a laparoscopic approach. This retrospective cohort study was designed to compare incisional hernia defects repaired with laparoscopic suture closure to a hybrid approach with open defect closure, both with laparoscopic intraperitoneal onlay mesh (IPOM) reinforcement.

METHODS

We identified 164 consecutive patients who underwent incisional hernia repair from two centers, North York General Hospital (NYGH) and Humber River Hospital (HRH) between 2015 and 2020. Patients were grouped by totally laparoscopic or hybrid fascial closure. Both techniques included laparoscopically placed intra-peritoneal mesh with 5 cm of overlap in all directions. Patients were analyzed by age, sex, body mass index (BMI), ASA class and hernia size. Primary outcomes included surgical site infection (SSI), other wound complications including seroma/hematoma, length of hospital stay, pain reported at follow-up appointment, and hernia recurrence.

RESULTS

Post-operative pain, surgical site infections and seromas did not differ between the totally laparoscopic and hybrid approach. The recurrence rates were 5.8% and 6.8% for the laparoscopic and hybrid group, respectively, which were not significantly different. The time to recurrence was 15 months (range 8-12) in the laparoscopic group and 7 months (range 6-36) in the hybrid group, also not significantly different. The hernia defect size and BMI were significantly higher in the hybrid group, without increased wound complications.

CONCLUSION

These results suggest that a hybrid approach to incisional ventral hernia repair with open defect closure is comparable to a totally laparoscopic closure. The hybrid technique can help facilitate fascial closure and resection of the hernia sac in patients with higher BMI and hernia defects up to 6 cm.

Hybrid approach to ventral wall hernia repair: a single-institution cohort study

Background

Ventral hernias pose a substantial challenge for surgeons. Even though minimally invasive surgery and hernia repair have evolved rapidly, there is no standardised method that has been widely accepted as standard of practice. Hybrid ventral hernia repair (HVR) is an alternative surgical approach, which has not been adopted widely to date. It combines laparoscopic mesh insertion with closure of the hernia defect. The aim of this retrospective cohort study is to evaluate short- and long-term outcomes in patients undergoing HVR.

Methods

Between October 2012 and June 2016, 56 HVRs were performed at St Mary’s Hospital, Imperial College London. The medical records of these patients were reviewed retrospectively for demographics, comorbidities, previous surgeries, operative technique, complications and recurrences over a 3-year follow-up.

Results

HVRs were performed by four surgeons. Mean age was 48 years with a mean body mass index (BMI) of 32.8 kg/m2. 71.4% had incisional hernias and 28.6% had primary hernias. The number of hernia defects ranged from 1 to 4, with average defect size 42.9 cm2 (range 8–200 cm2). Adhesiolysis was performed in 66.1% of patients. Recurrence occurred in 2 patients (3.6%), 16.1% of patients developed postoperative seroma, 0.3% had respiratory complications, 0.3% had paralytic ileus and 0.2% had urinary retention. Only 2 patients required epidural postoperatively, both had a defect size of 150.0 cm2. There were no reoperations within 90 days. Mean length of hospital stay was 2 days (1–10 days). Over the follow-up period, 2 patients (3.6%) developed chronic pain.

Conclusion

The hybrid technique is safe and feasible, and has important benefits including low rates of seroma formation, chronic pain and hernia recurrence. Future investigations may include randomised controlled trials to evaluate the benefits of VHR, with careful assessment of patient-reported outcome measures including quality of life and postoperative pain.

Seroma prevention strategies in laparoscopic ventral hernia repair: a systematic review

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) has been increasing in popularity over the years. Seroma formation is a common complication of LVHR. The aim of this study is to review the current evidence on seroma prevention strategies following LVHR.

METHODS

A systematic search of PubMed, Embase (1946-13 February 2019) and Medline (1946-13 February 2019) databases was conducted using terms which include "seroma", "hernia, ventral" and "laparoscopy". All studies are comparative retrospective or prospective human adult studies in peer-reviewed journals describing at least one intra-operative intervention designed to decrease the rate of seroma formation in laparoscopic ventral hernia repair.

RESULTS

The database searches identified 3762 citations, and 21 studies were included for final analysis. Five studies compared the different methods of mesh fixation, nine studies compared primary defect closure (PFC) and bridged repair, two studies compared the effect of different types of meshes, two studies looked into the use of electrical cauterization, one study compared single- site laparoscopy with conventional laparoscopy, one study looked into the use of fibrin sealant and one study compared transabdominal preperitoneal placement of mesh with conventional repair. PFC appears to be the most promising with large studies showing a low rate of seroma formation with additional benefits of decreasing wound infection and recurrence rate. Cauterisation of hernia sac and injection of fibrin sealant also show promising results but are mainly derived from small studies. Other strategies did not demonstrate benefit.

CONCLUSION

Currently, primary fascial closure appears to be the most promising strategy available to decrease seroma formation after LVHR based on the results of large studies. Other promising strategies that decrease dead space such as cauterisation of the sac and fibrin sealant injection will require further multicentre trials to confirm benefit before an increase in operative time and cost can be justified for their routine use.

Complete intracorporeal defect closure using unidirectional barbed suture in laparoscopic incisional hernia repair: Preliminary experience with short-term follow-up

INTRODUCTION

Surgical techniques to close defects in laparoscopic incisional hernia repair vary across the literature. We herein demonstrate our original and standardized surgical technique for laparoscopic incisional hernia repair with complete intracorporeal defect closure using barbed suture.

MATERIALS AND SURGICAL TECHNIQUE

Complete intracorporeal defect closures were indicated for defects less than or equal to 6 cm in transverse diameter. We performed a defect closure with a running suture using barbed suture in a caudal to cranial direction, with tissue bites and inter-suture spacing of 1 cm each. The hernial sac was incorporated into the suturing to reduce possible dead space. After the procedure, intraperitoneal onlay mesh was placed. Seven patients underwent this procedure. The median total operative time was 188 min, and the median time specifically for defect closure was 25 min. There was no seroma, mesh bulge, persisting pain, or hernia recurrence at follow-up.

DISCUSSION

Our proposed technique is simple and can be safely performed with good short-term outcomes.

Novel Transabdominal Preperitoneal Hernioplasty Technique for Recurrent Inguinal Hernia: Overlapping of Whole Posterior Wall with Newly Added Mesh and Pre-Existing Mesh by Closing Hernia Defect

Purpose: In some patients with recurrent inguinal hernias who have undergone previous laparoscopic herniorrhaphy, dissecting the entire posterior wall is difficult due to mesh adhesion. We applied a novel transabdominal preperitoneal (TAPP) hernioplasty technique that involves closing of the hernia defect and implantation of a newly added mesh while preserving the pre-existing mesh for inguinal hernia recurrence after laparoscopic herniorrhaphy. This study was performed to evaluate this novel technique for treatment of recurrent inguinal hernias. Methods: We evaluated 24 adult patients (23 male, 1 female; mean age, 55.8 ± 14.0 years; range, 26-77 years) with recurring inguinal hernias. A modified TAPP (mTAPP) procedure involving closing of the defect and implantation of an 8 × 6-cm² newly added mesh was performed. The new technique covered the whole posterior wall with pre-existing mesh. Results: Among the 24 patients, there were 12 direct hernias and 12 indirect hernias. The mean postoperative pain scores after 1 week were 2.5 and 2.0 in patients with direct and indirect hernias, respectively, and the mean duration until return to normal activities was 8.5 and 7.5 days in patients with direct and indirect hernias, respectively. The mean follow-up period was 21.0 ± 17.0 (range, 2-56) months. No chronic inguinodynia or rerecurrence was observed. Conclusions: In this novel mTAPP procedure for recurring inguinal hernias, closing sutures prevented mesh migration, and complete posterior wall overlap was possible using the pre-existing mesh and newly added mesh. The mTAPP procedure was an effective operation with few recurrences and complications.

Laparoscopic versus hybrid approach for treatment of incisional ventral hernia: a prospective randomized multicenter study of 1-month follow-up results

PURPOSE

The seroma rate following laparoscopic incisional ventral hernia repair (LIVHR) is up to 78%. LIVHR is connected to a relatively rare but dangerous complication, enterotomy, especially in cases with complex adhesiolysis. Closure of the fascial defect and extirpation of the hernia sack may reduce the risk of seromas and other hernia-site events. Our aim was to evaluate whether hybrid operation has a lower rate of the early complications compared to the standard LIVHR.

METHODS

This is a multicenter randomized-controlled clinical trial. From November 2012 to May 2015, 193 patients undergoing LIVHR for primary incisional hernia with fascial defect size from 2 to 7 cm were recruited in 11 Finnish hospitals. Patients were randomized to either a laparoscopic (LG) or to a hybrid (HG) repair group. The outcome measures were the incidence of clinically and radiologically detected seromas and their extent 1 month after surgery, peri/postoperative complications, and pain.

RESULTS

Bulging was observed by clinical evaluation in 46 (49%) LG patients and in 27 (31%) HG patients (p = 0.022). Ultrasound examination detected more seromas (67 vs. 45%, p = 0.004) and larger seromas (471 vs. 112 cm³, p = 0.025) after LG than after HG. In LG, there were 5 (5.3%) enterotomies compared to 1 (1.1%) in HG (p = 0.108). Adhesiolysis was more complex in LG than in HG (26.6 vs. 13.3%, p = 0.028). Patients in HG had higher pain scores on the first postoperative day (VAS 5.2 vs. 4.3, p = 0.019).

CONCLUSION

Closure of the fascial defect and extirpation of the hernia sack reduce seroma formation. In hybrid operations, the risk of enterotomy seems to be lower than in laparoscopic repair, which should be considered in cases with complex adhesions.

CLINICAL TRIAL NUMBER

NCT02542085.

Decreased re-operation rate for recurrence after defect closure in laparoscopic ventral hernia repair with a permanent tack fixated mesh: a nationwide cohort study

PURPOSE

To investigate whether defect closure in laparoscopic ventral hernia repair reduces the re-operation rate for recurrence compared with no defect closure.

METHODS

Data were extracted from the Danish Ventral Hernia Database. Adults with an elective laparoscopic ventral hernia repair with tacks used as mesh fixation were included, if their first repair was between the 1st of January 2007 and the 1st of January 2017. Patients with defect closure were compared with no defect closure. Re-operation rates are presented as crude rates and cumulated adjusted re-operation rates. Sub-analyses assessed the effect of the suture material used during defect closure and also whether defect closure affected both primary and incisional hernias equally.

RESULTS

Among patients with absorbable tacks as mesh fixation, 443 received defect closure and 532 did not. For patients with permanent tacks, 393 had defect closure and 442 did not. For patients with permanent tacks as mesh fixation, the crude re-operation rates were 3.6% with defect closure and 7.2% without defect closure (p = 0.02). The adjusted cumulated re-operation rate was significantly reduced with defect closure and permanent tacks (hazard ratio = 0.53, 95% confidence interval = 0.28-0.999, p = 0.05). The sub-analysis suggested that defect closure was only beneficial for incisional hernias, and not primary hernias. We did not find any benefits of defect closure for patients with absorbable tacks as mesh fixation.

CONCLUSION

This nationwide cohort study showed a reduced risk of re-operation for recurrence if defect closure was performed in addition to permanent tacks as mesh fixation during laparoscopic incisional hernia repair.

Laparoscopic and percutaneous repair of a large midline incisional hernia extending to the bilateral subcostal region: A case report

INTRODUCTION

Optimal surgery for a midline incisional hernia extending to the subcostal region remains unclear. We report successful hybrid laparoscopic and percutaneous repair for such a complex incisional hernia.

PRESENTATION OF CASE

An 85-year-old woman developed a symptomatic incisional hernia after open cholecystectomy. Computed tomography revealed a 14 × 10 cm fascial defect. Four trocars were placed under general anesthesia. Percutaneous defect closure was performed using multiple non-absorbable monofilament threads, i.e., a "square stitch." Each thread was inserted into the abdominal cavity from the right side of the defect and pulled out to the left side. The right side of the thread was subcutaneously introduced anterior to the hernia sac. The threads were sequentially tied in a cranial to caudal direction. A multifilament polyester mesh with resorbable collagen barrier was selected and fixed using absorbable tacks with additional full-thickness sutures. The cranial-most limit of mesh fixation was at the level of the subcostal margin, and the remaining part was draped over the liver surface. The postoperative course was uneventful, with no seroma, mesh bulge, or hernia recurrence at 1, 3, 6, and 12 months of follow-up.

DISCUSSION

The advantages of our technique are the minimal effect on the scar in the midline during defect closure, the minimal damage to the ribs and obtaining more overlap during mesh fixation. The disadvantage is the postoperative pain.

CONCLUSION

Our proposed hybrid surgical approach may be considered as the treatment of choice for a large midline incisional hernia extending to the bilateral costal region.

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.

Clinical Characteristics and Laparoscopic Treatment of Supravesical Hernia

AIM

Inguinal hernias may be direct or indirect, and supravesical hernias, a subtype of inguinal hernias, are often mistaken as direct hernias as their symptoms are similar. The purpose of this study was to describe the characteristics of supravesical hernias and to introduce a minimally invasive surgical method as a treatment for supravesical hernias.

MATERIALS AND METHODS

Thirty-seven patients with supravesical hernias were treated using laparoscopic herniorrhaphy and wall defect suture with a mesh implant from September 2012 to December 2016 at Damsoyu hospital, Seoul, Korea. Patient characteristics and surgical outcomes were retrospectively evaluated.

RESULTS

All 37 patients were men with external supravesical hernias. The mean age was 55.3 (range 32-79) years; 23 patients had right-sided, 12 had left-sided, and 2 had bilateral hernias. Comorbidities included lipoma (7/37), contralateral indirect hernia (1/37), and contralateral direct hernia (14/37). No recurrences were reported at the end of the study period.

CONCLUSIONS

Laparoscopic transabdominal defect closure with a mesh implant herniorrhaphy seems to be an effective, minimally invasive treatment option for supravesical hernia.

The Novel Technique of Transabdominal Preperitoneal Hernioplasty Herniorrhaphy for Direct Inguinal Hernia: Suture Repair of Hernia Defect Wall

BACKGROUND

Conventional laparoscopic surgeries of direct inguinal hernia include two methods, transabdominal preperitoneal hernioplasty (TAPP) and totally extraperitoneal hernioplasty. Both methods are performed using synthetic mesh without suturing the hernia defect and require extensive mesh coverage for not only Hesselbach's triangle but also indirect ring. For minimally invasive operation, suture of direct hernia defect was devised and performed. The purpose of this study is to evaluate the efficacy of defect wall suture of laparoscopic herniorrhaphy for direct inguinal hernia patients.

METHODS

We evaluated 210 direct inguinal hernia patients who received TAPP in Damsoyu Hospital, Seoul, Republic of Korea from September 2012 to December 2015. The patients were categorized into two groups according to TAPP techniques; cTAPP group had conventional TAPP without defect wall suture, and rTAPP group had defect wall suture TAPP. There were 99 patients in a cTAPP group and 111 patients in rTAPP group.

RESULTS

Operation time and postoperative hospital stay showed no difference between two groups. The postoperative pain score within the first week was significantly lower in rTAPP group than in cTAPP group (P < .001). The mean timing of a return to normal activities for rTAPP group was 3.8 days, which was shorter than 4.6 days of cTAPP group (P < .001). There was no difference in complication and recurrence rates between two groups.

CONCLUSIONS

Defect wall suture for direct inguinal hernia had shorter operation time, faster recovery time, reduced pain, and an acceptable rate of recurrence and complication. This TAPP surgery with hernia defect wall suture that requires smaller dissection area is an effective method for treating direct inguinal hernia.