Laparoscopic ventral hernia repair during pregnancy

How to Treat Hernias in Pregnant Women?

A hernia is a common surgical problem. Although hernias during pregnancy are uncommon, they can be challenging for both the surgeon and the patient if present. To date, there is no consensus in the medical community regarding the elective repair of hernias in pregnant women. The debate mainly concerns three areas: the timing, the approach, and the surgical technique. This study aims to offer a clear pathway in this field based on the best available data. In this study, we collected reviews written in English and published in PubMed from 2010 to 2020 (the exception being three articles that were published before 2010, which we retained since they contained relevant information). We used regular and Medical Subject Headings (MeSH) keywords. Two of the authors screened the collected studies to select the best articles that would fit our inclusion criteria for the review. The articles considered for this review can be classified into retrospective studies, case reports, and reviews. No randomized controlled trials were found. The lack of an agreement about the treatment of ventral hernias in fertile women makes the decision to treat and the process challenging. The treatment significantly depends on two factors: the symptoms and the pregnancy status at diagnosis. If the hernia is incarcerated or strangulated at presentation, an emergency repair is obligatory. If the hernia is symptomatic, but not complicated, elective surgery should be offered. The timing of repair will depend on whether the patient is already pregnant or non-pregnant. In pregnant patients, if the hernia is small and asymptomatic, it may be better to delay the surgery until after delivery or after the last pregnancy. If the hernia is symptomatic and seems to affect the patient's quality of life, it may be better to postpone the repair until the second trimester or after delivery if complications do not occur. Internal herniation (IH) should be suspected as a cause of the abdominal pain in pregnant women who have undergone laparoscopic Roux-en-Y gastric bypass (LRYGB). In pre-pregnancy patients, if the hernia is large and symptomatic, it may be better to do an elective repair and then wait for one or two years before the next pregnancy. However, if the hernia is small or minimally symptomatic, it may be better to hold the repair until after delivery or after the last pregnancy. Pregnancy may be considered a significant risk factor for hernia recurrence. The laparoscopic mesh repair should be offered whenever possible, whereas the open approach may be preferred in complicated cases. The suture repair may be suitable for both small hernias and in cases of gross contamination.

Minimally invasive gynecologic surgery in the pregnant patient: considerations, techniques, and postoperative management per trimester

PURPOSE OF REVIEW

Nonobstetric surgery is performed in 1 : 200 to 1 : 500 of pregnant women in the United States annually. Previously, many argued that laparoscopy was contraindicated during pregnancy because of concerns for uterine injury and fetal malperfusion. Because surgeons have gained more experience with laparoscopy, it has become the preferred treatment modality for many surgical diseases in the gravid patient.

RECENT FINDINGS

Specific preoperative considerations, intraoperative techniques, and postoperative management per trimester will be reviewed to optimize patient and surgical outcomes.

SUMMARY

The advantages of laparoscopic surgery are similar for pregnant and nonpregnant women. Surgery during pregnancy should minimize risks to both the fetus and the mother. Whenever a pregnant woman undergoes nonobstetric surgery, consultations among her surgical team are important to coordinate management. Both anatomic and physiologic changes related to pregnancy may require modifications in management. Surgeons must be aware of considerations, techniques, and postoperative management used for pregnant patients to optimize outcomes for both the fetus and mother.

Umbilical Hernia Repair and Pregnancy: Before, during, after…

Umbilical hernias are most common in women than men. Pregnancy may cause herniation or render a preexisting one apparent, because of progressively raised intra-abdominal pressure. The incidence of umbilical hernia among pregnancies is 0.08%. Surgical algorithm for a pregnant woman with a hernia is not thoroughly clear. There is no consensus about the timing of surgery for an umbilical hernia in a woman either who is already pregnant or planning a pregnancy. If the hernia is incarcerated or strangulated at the time of diagnosis, an emergency repair is inevitable. If the hernia is not complicated, but symptomatic an elective repair should be proposed. When the patient has a small and asymptomatic hernia it may be better to postpone the repair until she gives birth. If the hernia is repaired by suture alone, a high risk of recurrence exists during pregnancy. Umbilical hernia repair during pregnancy can be performed with minimal morbidity to the mother and baby. Second trimester is a proper timing for surgery. Asymptomatic hernias can be repaired, following childbirth or at the time of cesarean section (C-section). Elective repair after childbirth is possible as early as postpartum of eighth week. A 1-year interval can give the patient a very smooth convalescence, including hormonal stabilization and return to normal body weight. Moreover, surgery can be postponed for a longer time even after another pregnancy, if the patients would like to have more children. Diastasis recti are very frequent in pregnancy. It may persist in postpartum period. A high recurrence risk is expected in patients with rectus diastasis. This risk is especially high after suture repairs. Mesh repairs should be considered in this situation.

Abdominal wall hernia and pregnancy: a systematic review

PURPOSE

There is no consensus as to the treatment strategy for abdominal wall hernias in fertile women. This study was undertaken to review the current literature on treatment of abdominal wall hernias in fertile women before or during pregnancy.

METHODS

A literature search was undertaken in PubMed and Embase in combination with a cross-reference search of eligible papers.

RESULTS

We included 31 papers of which 23 were case reports. In fertile women undergoing sutured or mesh repair, pain was described in a few patients during the last trimester of a subsequent pregnancy. Emergency surgery of incarcerated hernias in pregnant women, as well as combined hernia repair and cesarean section appears as safe procedures. No major complications were reported following hernia repair before or during pregnancy. The combined procedure of elective cesarean section and abdominal wall hernia repair was reported in 102 patients without major complications.

CONCLUSIONS

The literature on abdominal wall hernia and pregnancy is sparse. Abdominal wall hernia repair with suture or mesh may cause pain in the last trimester of a subsequent pregnancy. Hernia repair in conjunction with cesarean section appear as the optimal treatment of a pregnant patient with a symptomatic abdominal wall hernia.

Pregnancy following laparoscopic mesh repair of ventral abdominal wall hernia

This report suggests that laparoscopic repair of ventral and incisional hernias in fertile women who intend to have further pregnancies is an acceptable therapeutic option.

Background:

There are no data on laparoscopic repair of ventral and incisional hernias (LRVIH) in fertile women who intend to have further pregnancies. A unique series is described of 8 women who got pregnant and gave birth after LRVIH.

Methods:

Medical records of 875 consecutive patients who underwent LRVIH were reviewed. Women who gave birth after LRVIH were identified. At follow-up, patients answered a questionnaire on pain, discomfort, recurrence, and problems during pregnancy and delivery and underwent a physical examination.

Results:

Eight patients were identified; all agreed to inclusion. Four women received LRVIH for incisional hernia; 4 were operated on for primary ventral hernia. Median age at LRVIH was 29 years (range, 24 to 34). No postoperative complications occurred. Median time between LRVIH and delivery was 22.5 months (range, 12 to 44). Median follow-up after delivery was 23.5 months (range, 2 to 40). Five patients experienced a tearing pain in the area of hernia repair during the last months of pregnancy. This pain was not continually present and disappeared after delivery in all patients. All infants were born healthy at full term. Seven patients had a vaginal birth and one had a caesarean delivery. There were no major complications during pregnancy or delivery. At control examination, all patients were asymptomatic and, with one exception, without signs of recurrence. One patient had a swelling in the repaired area indicating either recurrence or mesh bulging. Being asymptomatic, she refused any further diagnostics.

Conclusion:

LRVIH in fertile women who intend to have further pregnancies is an acceptable therapeutical option that causes no significant problems during pregnancy or delivery.

Epigastric hernia in pregnancy: a management plan based on a systematic review of literature and a case history

Symptomatic epigastric hernia is rare in pregnant women. A case history, management of which prompted a systematic review of the literature and proposed plan for treatment of such cases, is hereby presented. There is paucity of information on management of this condition in the standard literature as searches in Pubmed, Science Direct, Hinari, Medline, African Journal Online, Bioone as well as Cochrane library revealed. There are two schools of thought for the management of hernias in pregnancy-watchful waiting and herniorrhaphy in pregnancy. There is no consensus or definite guideline on the management of epigastric hernias in pregnancy. Based on the literature review, a management algorithm is proposed, which combines the two schools of thought.