Closure versus non-closure of hernia defect during laparoscopic ventral hernia repair with mesh

Long-term patient-reported outcome measures (PROMs) after primary ventral or small midline incisional hernia repair

BACKGROUND

Ventral hernia repair is a common elective surgical procedure lacking strong evidence for specific operative approaches. This study aimed to evaluate the outcomes of primary suture repair or polypropylene sandwich mesh repair for ventral hernias. The main outcome measures were the rate of hernia recurrence, and evaluation of long-term complications and patient-reported outcomes.

METHODS

This retrospective cohort study evaluated patient perceived recurrence and pain in patients who had undergone a primary ventral hernia (epigastric, supraumbilical, or umbilical) repair or small (≤20 mm) midline incisional hernia repair 10 years after the procedure. Short-term follow-up occurred up to 6 weeks after the initial operation, while long-term follow-up included patients who were reviewed clinically or interviewed via telephone at or beyond 3 years after the procedure.

RESULTS

Most (75/100, 75.0%) patients had an extra-peritoneal sandwich mesh repair. Short-term follow-up showed minimal pain and normal activities for all patients (97/97, 100%). Long-term follow-up (median 12 years [IQR 11-13]) was achieved in 95.9% (93/97) of patients with only a small number reporting a slight bulge (5/93, 5.4%) and intermittent mild discomfort (8/93, 8.6%). Nine patients (9/97, 9.3%) experienced hernia recurrence, diagnosed at a median of 26 months [interquartile range, IQR, 7-58] post-operatively.

CONCLUSIONS

These findings suggest that an open sandwich mesh technique is a safe and effective method for repairing primary ventral hernias and small midline incisional hernias and is associated with favourable long-term patient-reported outcomes.

Laparoscopic Intraperitoneal Onlay Mesh (IPOM) in the Treatment of Ventral Hernias: Technique Discussion Points

Incisional ventral hernias (IVH) are a common occurrence worldwide. The resolve is fundamentally surgical. In this regard, laparoscopic treatment has become the standard. This paper aims to review intraperitoneal onlay mesh (IPOM) as a surgical solution for IVH and to explore the limitations and advantages in relation to the technique of mesh fixation, defect suture, seroma formation, and recurrence in accordance with the data published. The article is structured as a narrative review and relies on the Scale for the Assessment of Narrative Review Articles (SANRA) convention. In the analysis, we included articles published in the literature regarding the surgical treatment of ventral hernias (umbilical and incisional) through the IPOM technique. We explored data regarding the mesh fixation technique on the anterior abdominal wall (tacks or sutures), indications and limitations of defect closure, incidence of seroma formation, and recurrence rate. Laparoscopic IPOM is a better option for IVH up to 10 cm than the open technique with regard to aesthetics, length of hospital stay, and postoperative pain. There is no difference in recurrence rates. Suturing of the defect should be done to decrease seroma formation and maintain the functionality of the abdominal wall. Ideally, the suture should be done intraperitoneally or laparoscopically. Regarding pain in mesh fixation, there seems to be an increase in the short-term postoperative pain in the suture groups, but at six months, when compared to the tacks groups, there is no difference. New methods are being developed that include different types of glue but require large prospective, randomized trials if they are to be included in the guidelines.

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 intracorporeal rectus aponeuroplasty (LIRA) technique versus intraperitoneal onlay mesh (IPOM plus) for ventral hernia repair: a comparative analysis

PURPOSE

Primary aim of this study is to compare the postoperative outcomes of the laparoscopic intracorporeal rectus aponeuroplasty (LIRA) technique to the intraperitoneal onlay mesh closing the defect (IPOM plus), in terms of recurrence and bulging rates at one-year follow-up; secondary aim is to compare the postoperative complications, seroma and pain at 30 days and one-year after surgery.

METHODS

Patients with midline ventral hernia of 4-10 cm in width were included. Computed tomography scan was performed before, 1 and 12 months after surgery. Pain was evaluated using the visual analogue scale.

RESULTS

Forty-five and forty-seven consecutive patients underwent LIRA and IPOM plus, respectively. Preoperatively, smoke habits and chronic obstructive pulmonary disease rates were statistically significantly higher in the LIRA group (p = 0.0001 and p = 0.012, respectively). Two bulgings (4.4%) occurred in the LIRA group, while in the IPOM plus group occurred 10 bulgings (21.3%) and three recurrences (6.4%) (p = 0.017 and p = 0.085, respectively). Postoperatively, seven (15.6%, Clavien-Dindo I) and four complications (8.5%, two Clavien-Dindo I, two Clavien-Dindo III-b) occurred in the LIRA and in the IPOM plus group, respectively (p = 0.298). One month after surgery, clinical seroma, occurred in five (11.1%) and eight patients (17%) in the LIRA and in the IPOM plus group, respectively (p = 0.416). During follow-up, pain reduction occurred, without statistically significant differences.

CONCLUSIONS

In this study, even if we analysed a small series, LIRA showed lower bulging and recurrence rates in comparison to IPOM plus at one-year follow-up. Further prospective studies, with a large sample of patients and longer follow-up are required to draw definitive conclusions.

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).

Peritoneal Bridging Versus Nonclosure in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial

Introduction

Postoperative seroma and pain are common problems following laparoscopic intraperitoneal onlay mesh (IPOM) repair of ventral hernias. These adverse outcomes may be avoided by dissecting and using the peritoneum in the hernial sac to bridge the hernia defect.

Methods

This was a patient- and outcome assessor-blinded, parallel-design, randomized controlled trial comparing nonclosure and peritoneal bridging approaches in patients scheduled for elective midline ventral hernia repair. The primary endpoint was seroma volume on ultrasonography. The secondary endpoints were postoperative pain, recurrence, and complications.

Results

Between November 2018 and December 2020, 112 patients were randomized, of whom 60 were in the nonclosure group and 52 were in the peritoneal bridging group. The seroma volume in the nonclosure and peritoneal bridging groups were 17 cm3 (6-53 cm3) versus 0 cm3 (0-26 cm3) at 1-month follow-up (P = 0.013). The median volume was zero at the 3-, 6-, and 12-month follow-ups in both groups. No significant differences were observed in early postoperative pain (P = 0.447) and in recurrence rate (P = 0.684). There were 4 (7%) and 1 (2%) perioperative complications that lead to reoperations in simple IPOM (sIPOM) and IPOM with peritoneal bridging (IPOM-pb), respectively.

Conclusions

Seroma was less prevalent after IPOM-pb at 1-month follow-up compared with sIPOM, with similar postoperative pain 1 week after index surgery in both groups. At subsequent follow-ups, the differences in seroma were not statistically significant. Further studies are required to confirm these results. Trial registration (NCT04229940).

Ring closure outcome for laparoscopic ventral hernia repair (IPOM plus) in medium and large defects. Long-term follow-up

BACKGROUND

Despite advances in laparoscopic ventral hernia repair (LVHR) with the Intra-peritoneal onlay mesh technique (IPOM), recurrence continues to be a frequent postoperative complication. The aim of this study is to analyze the long-term recurrence rate in two series, by incorporating in IPOM technique the laparoscopic closure of the defect (IPOM plus). We also want to determine the ring size cut-off point from which the recurrence risk increases in IPOM technique and determine if the cut-off point is modified with IPOM plus technique.

METHODS

A comparative retrospective study was conducted analyzing patients who underwent LVHR. They were divided into 2 groups according to the surgical technique used: IPOM or IPOM plus. We determined in each group the cut-off point where the ring size presents a greater recurrence risk by calculating the better point of sensitivity/specificity relationship of the ROC curve.

RESULTS

Between 2007 and 2018, 286 patients underwent LVHR. The ROC curve for IPOM technique has shown a cut-off point of higher recurrence risk for rings larger than 63 cm². While the ROC curve in IPOM plus group showed an increase in the cut-off point, with a higher recurrence risk in rings > 168 cm². Overall median ring size was 30 cm² (range 4-225; IQR 16-61). However, when comparing the ring size between techniques we found a relatively larger size in IPOM plus (p: 0.013). The recurrence rate in the IPOM group was 19.51% while in the IPOM plus group was 3.57% (p: 0.005).

CONCLUSIONS

For standard LVHR with IPOM technique, the greatest recurrence risk occurs in rings larger than 63 cm². The addition of ring closure (IPOM plus) was associated with a recurrence risk reduction, which occurs in rings larger than 168 cm². These findings would allow expanding the indication for LVHR, using the IPOM plus technique.

Robotic-assisted compared with laparoscopic incisional hernia repair following oncologic surgery: short- and long-term outcomes of a randomized controlled trial

BACKGROUND

Patients with abdominal site cancer are at risk for incisional hernia after open surgery. This study aimed to compare the short- and long-term outcomes of robotic-assisted (RVIHR) with the laparoscopic incisional hernia repair (LVIHR) in an oncologic institute.

METHODS

This is a single-blinded randomized controlled pilot trial. Patients were randomized into two groups: RVIHR and LVIHR.

RESULTS

Groups have similar baseline characteristics (LVIHR: N = 19; RVIHR: N = 18). No difference was noted in the length of hospital stay (RVIHR: 3.67 ± 1.78 days; LVIHR: 3.95 ± 2.66 days) and postoperative complications (16.7 versus 10.5%; p = 0.94). The mean operating time for RVIHR was significantly longer than LVIHR (RVIHR was 355.6 versus 293.5 min for LVIHR; p = 0.04). Recurrence was seen in three patients in LVIHR and two in RVIHR at 24-month follow-up, with no significant difference. (p > 0.99).

CONCLUSION

Laparoscopic and robotic-assisted incisional hernia repair show similar short- and long-term outcomes for cancer patients.

Non-strangulated Spigelian Hernia: A Case Report

Spigelian hernia is a rare type of ventral hernia with an incidence of 0.1-2%. We report a case of a non-strangulated left lower quadrant spigelian hernia and its management. A 74-year-old female presented with progressively worsening left flank pain along with dysuria and frequency related to pyelonephritis. Incidentally, CT of the abdomen and pelvis demonstrated a left spigelian hernia containing intermediate size small bowel without strangulation. Thereafter, she began developing increasing abdominal pain in that area. The hernia was repaired on the same day as admission via laparoscopic intraperitoneal onlay mesh-plus repair. Spigelian hernia possesses an elusive clinical presentation. Though rare, it must be considered in the differential diagnosis of abdominal hernia due to its high risk for acute complications.

Comparison of outcomes of laparoscopic hernioplasty with and without fascial repair (IPOM-Plus vs IPOM) for ventral hernia: A retrospective cohort study

Background

Materials and methods

Results

Conclusions

•

IPOM repair comprises bridging the hernial defect from the peritoneal side with a composite mesh.

•

IPOM-Plus comprises suturing the defect in the fascia before placing the mesh.

•

Seroma formation, injury to bladder or bowel, and mesh bulging were higher after IPOM repair.

•

The AOR of six-month recurrence after IPOM repair was 14.86 times higher than that after IPOM-Plus repair.

•

IPOM-Plus can be preferred over IPOM for its better outcomes.

Endoscopic transversus abdominis release in the treatment of midline incisional hernias: a prospective single-center observational study on 100 patients

BACKGROUND

For W2-3 incisional hernias of the midline, a component separation is often needed to achieve closure of the fascia during repair with a mesh. Posterior component separation has been initially performed via open surgical approach, but more recently interest in minimally invasive reconstruction has grown. The aim of this work is to describe the technical aspects of endoscopic hernia repair with posterior component separation and to assess its feasibility in midline incisional hernias, based on the analysis of the results.

METHODS

We prospectively evaluated and analyzed patients with midline incisional hernias who underwent endoscopic posterior component separation by transversus abdominis release (TAR).

RESULTS

A group of 100 patients was operated between April 2017 and September 2021. The median follow-up was 27 ± 13.5 months, mean age 59 ± 10.2 years, ASA 2.5 ± 0.7; 94% of patients had comorbidity. There were 7 (7%) complications observed in the early postoperative period-retromuscular hematoma (1), infection of the retromuscular space (4), and thrombophlebitis of superficial veins (2). In 4 (4%) patients, late complications were observed-persistent seroma (3) and chronic pain (1). There were no hernia recurrences in the follow-up period.

CONCLUSION

The use of TAR endoscopic separation can reduce the number of unfavorable surgical site events, compared to the published data on a similar open surgery, while maintaining a low recurrence rate.

Closure Versus Non-closure of Hernia Defect in Laparoscopic Ventral Hernia Repair with Mesh: a Systematic Review

There is a controversial premise about choosing a surgical approach in ventral hernia using laparoscopic repair. Some surgeons prefer to use mesh with closure while others prefer to use mesh without closure. This study aims to compare mainly the rate of recurrence in mesh repair with and without closure. A wide range of electronic bibliographic databases such as PubMed, Embase and Education Resources Information Center (ERIC) was searched. Based on the eligibility criteria, all studies which compared the results after hernia repair from 2010 to 2020 were incorporated. Following screening the abstracts, we ended up reviewing seven full-text articles, and data were extracted on important parameters such as demographic attributes of participants, sample size and recurrence rate of hernia. Of the total studies that were reviewed, three were randomized controlled trials (RCT’s) and four retrospective observational studies. The sample size of all included studies varied between 80 and 176. The findings appear promising for the fascial closure as it showed evidence of a significant reduction in the recurrence rate with P = 0.047 in one out of the three randomized controlled trials and in the retrospective observational studies reaching up to 16.7% recurrence reduction rate. Likewise, there is also a reduction in the bulging, surgical site infection and seroma formation with higher patient’s satisfaction and quality of life score. Primary fascial closure appears to be effective as it can decrease the rates of recurrence, seroma formation and bulging, and improve patient’s satisfaction and quality of life. Given the dearth of studies, mainly randomized controlled trials, there is a need to carry out large randomized controlled trials with enough follow-up.

Laparoscopic ventral hernia repair: does IPOM plus allow to increase the indications in larger defects?

PURPOSE

The laparoscopic ventral hernia repair (LVHR) may have a limit of effectiveness, especially in defects greater than 80 cm², with a higher recurrence rate which contraindicates this technique. The purpose of this study is to analyze the indication of LVHR determining and comparing the recurrence rate according to defect size in two series.

METHODS

We analyzed all patients who underwent LVHR between 2007 and 2017. Patients were divided according to the ring size: < o ≥ 80 cm² into group one (G1) and group two (G2) respectively. In both groups, all three techniques were used: intraperitoneal onlay mesh (IPOM), IPOM with closure of the defect (IPOM plus), and IPOM plus + anterior videoscopic component separation (AVCS).

RESULTS

A total of 258 patients underwent LVHR. Mean recurrence rate was 13% in G1 and 24% in G2. A statistically significant difference was found when comparing the IPOM technique among both groups, with a higher recurrence rate when ring size was ≥ 80 cm² (p < 0.5). However, when comparing recurrence rate in IPOM plus and IPOM plus + AVCS between both groups, no significant differences were observed, yielding a p of 0.51 and 0.63, respectively.

CONCLUSION

The IPOM technique has shown a limit of effectiveness in large ventral hernia defects. The combination of techniques (ring closure and AVCS) may be useful to expand the indication for this surgery to larger defects and to reduce the recurrence rate. Prospective randomized studies are required to confirm this trend.

Subcutaneous switching suture technique for hernia defect closure during laparoscopic ventral and incisional hernia repair

INTRODUCTION

A vertical penetration of the thread through the abdominal wall for the hernia defect closure in laparoscopic ventral/incisional hernia repair (LVIHR) is difficult especially in the large defect cases when applying the existing techniques.

MATERIALS

Sixteen LVIHRs were performed using the suture technique for defect closure we newly developed.

SURGICAL TECHNIQUE

With the subcutaneous switching, our technique only requires the suture-passer and easily enables the vertical penetration of the thread through the abdominal muscular wall even in the large defect cases.

DISCUSSION

The defect closure in LVIHR tends to be complicated in the large defect cases. Thus, we devised this technique for the easy, reliable, and firm closure even in the large defect cases. Although the sample size was currently very small, we consider that the favorable outcomes have been obtained through our technique because any noticeable complications, such as mesh bulging or recurrence, have not been observed currently.

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.

Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction

PURPOSE

The abdominal wall and musculoskeletal tendons share many anatomic, physiologic, and functional characteristics. This review aims to highlight these similar characteristics and to present a rationale why the treatment principles of successful musculoskeletal tendon reconstruction, including principles of surgical technique and physical therapy, can be used in the treatment of complex abdominal wall reconstruction or ventral hernia repair.

METHODS

The MEDLINE/PubMed database was used to identify published literature relevant to the purpose of this review.

CONCLUSIONS

There are several anatomical and functional similarities between the linea alba and musculoskeletal tendons. Because of this reason, many of the surgical principles for musculoskeletal tendon repair and ventral hernia repair overlap. Distribution of tension is the main driving principle for both procedures. Suture material and configuration are chosen to maximize tension distribution among the tissue edges, as seen in the standard of care multistrand repairs for musculoskeletal tendons, as well as in the small bites for laparotomy technique described in the STITCH trial. Physical therapy is also one of the mainstays of tendon repair, but surprisingly, is not routine in ventral hernia repair. The evidence surrounding physical therapy prehabilitation and rehabilitation protocols in other disciplines is significant. This review challenges the fact that these protocols are not routinely implemented for ventral hernia repair, and presents the rationale and feasibility for the routine practice of physical therapy in ventral hernia repair.

A new three-step hybrid approach is a safe procedure for incisional hernia: early experiences with a single centre retrospective cohort

Purpose

In this study, a three-step novel surgical technique was developed for incisional hernia, in which a laparoscopic procedure with a mini-laparotomy is combined: so-called ‘three-step incisional hybrid repair’. The aim of this study was to reduce the risk of intestinal lacerations during adhesiolysis and recurrence rate by better symmetrical overlap placement of the mesh.

Objectives

To evaluate first perioperative outcomes with this technique.

Methods

From 2016 to 2020, 70 patients (65.7% females) with an incisional hernia of > 2 and ≤ 10 cm underwent a elective three-step incisional hybrid repair in two non-academic hospitals performed by two surgeons specialised in abdominal wall surgery. Intra- and postoperative complications, operation time, hospitalisation time and hernia recurrence were assessed.

Results

Mean operation time was 100 min. Mean hernia size was 4.8 cm; 45 patients (64.3%) had a hernia of 1–5 cm, 25 patients (35.7%) of 6–10 cm. Eight patients had a grade 1 complication (11.4%), five patients a grade 2 (7.1%), two patients (2.8%) a grade 4 complication and one patient (1.4%) a grade 5 complication. Five patients had an intraoperative complication (7.0%), two enterotomies, one serosa injury, one omentum bleeding and one laceration of an epigastric vessel. Mean length of stay was 3.3 days. Four patients (5.6%) developed a hernia recurrence during a mean follow-up of 19.5 weeks.

Conclusion

A three-step hybrid incisional hernia repair is a safe alternative for incisional hernia repair. Intraoperative complications rate was low.

Peritoneal bridging versus fascial closure in laparoscopic intraperitoneal onlay ventral hernia mesh repair: a randomized clinical trial

BACKGROUND

Many patients develop seroma after laparoscopic ventral hernia repair. It was hypothesized that leaving the hernial sac in situ may cause this complication.

METHODS

In this patient- and outcome assessor-blinded, parallel-design single-centre trial, patients undergoing laparoscopic intraperitoneal onlay mesh ventral hernia repair were randomized (1 : 1) to either conventional fascial closure or peritoneal bridging. The primary endpoint was the incidence of seroma 12 months after index surgery detected by CT, evaluated in an intention-to-treat analysis.

RESULTS

Between September 2017 and May 2018, 62 patients were assessed for eligibility, of whom 25 were randomized to conventional closure and 25 to peritoneal bridging. At 3 months, one patient was lost to follow-up in the conventional and peritoneal bridging groups respectively. No seroma was detected at 6 or 12 months in either group. The prevalence of clinical seroma was four of 25 (16 (95 per cent c.i. 2 to 30) per cent) versus none of 25 patients in the conventional fascial closure and peritoneal bridging groups respectively at 1 month after surgery (P = 0·110), and two of 24 (8 (0 to 19) per cent) versus none of 25 at 3 months (P = 0·235). There were no significant differences between the groups in other postoperative complications (one of 25 versus 0 of 25), rate of recurrent hernia within 1 year (none in either group) or postoperative pain.

CONCLUSION

Conventional fascial closure and peritoneal bridging did not differ with regard to seroma formation after laparoscopic ventral hernia repair.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03344575).

Robotic-assisted ventral and incisional hernia repair with hernia defect closure and intraperitoneal onlay mesh (IPOM) experience

BACKGROUND

The most common technique described for robotic ventral hernia repair (RVHR) is intraperitoneal onlay mesh (IPOM). With the evolution of robotics, advanced techniques including retro rectus mesh reinforcement, and component separation are being popularized. However, these procedures require more dissection, and longer operative times. In this study we reviewed our experience with robotic ventral/incisional hernia repair (RVHR) with hernia defect closure (HDC) and IPOM.

METHODS

Retrospective chart review and follow-up of 31 consecutive cases of ventral/incisional hernia treated between August 2011 and December 2018. Demographics, operative times, blood loss, length of stay (LOS), hernia size, location, and type, mesh size and type, recurrence, conversion to open ventral hernia repair (OVHR) and complications including bleeding, seroma formation and infection were analyzed.

RESULTS

Mean age was 63.9 years old, with median BMI of 31.24 kg/m². Median hernia area was 17 cm². Mean operating time was 142.61 min (SD 59.79). Mean LOS was 1.46 days (range 1-5), with 48% being outpatient, and overnight stay in 32% for pain control. Conversion was necessary in 12.9% cases. Complication rate was 3% for enterotomy. Recurrence was 14.81% after a mean follow-up of 26.96 months. There was significant association of recurrence with COPD history (P = 0.0215) and multiple hernia defects (P = 0.0376).

CONCLUSION

Our recurrence rate (14.81%) compares favorably to those reported in literature (16.7%) for LVHR with HDC and IPOM. Our experience also indicates that IPOM is associated with satisfactory outcomes, low conversion and complications rates, and short LOS.

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.

Is fascial defect closure with intraperitoneal onlay mesh superior to standard intraperitoneal onlay mesh for laparoscopic repair of large incisional hernia?

INTRODUCTION

The ideal surgical technique for large incisional hernia repair has not yet been identified. The aim of this study was to evaluate surgical outcomes of standard intraperitoneal onlay mesh (sIPOM) versus fascial defect closure with intraperitoneal onlay mesh (IPOM-Plus) for large incisional hernia repair.

METHODS

Of 49 patients who underwent laparoscopic incisional hernia repair between November 2005 and December 2016, 26 cases with large incisional hernia (transverse diameter ≥10 cm) were examined to compare surgical outcomes between sIPOM (n = 12) and IPOM-Plus (n = 14). Statistical analysis was performed using the Mann-Whitney U-test and Fisher's exact test. P < 0.05 was considered to be statistically significant.

RESULTS

We compared sIPOM with IPOM-Plus for similar hernia types during median follow-up periods of 53 and 21 months, respectively. The operation time was 150 min for sIPOM and 148 min for IPOM-Plus (P = 0.6220). Early postoperative complications including seroma formation were observed in four sIPOM patients (33%) and three IPOM-Plus patients (21%) (P = 0.6652). Significantly more mesh bulged with sIPOM than with IPOM-Plus (50% vs 0%; P = 0.0082). Chronic pain lasting 3 months after the operation was found in two cases of IPOM-Plus (14%), but this was not statistically significant. Postoperative hospital stay was longer for sIPOM patients than for IPOM-Plus patients. Only one recurrence was observed in the sIPOM group (8%), but this was not statistically significant.

CONCLUSION

For large incisional hernia repair, IPOM-Plus seems to be more effective than sIPOM in terms of reducing mesh bulging.

Deciding on Optimal Approach for Ventral Hernia Repair: Laparoscopic or Open

BACKGROUND

The decision to perform laparoscopic or open ventral hernia repair (VHR) is multifactorial. This study evaluates the impact of operative approach, BMI, and hernia size on outcomes after VHR.

STUDY DESIGN

The International Hernia Mesh Registry was queried for VHR (2007-2017). A predictive algorithm was constructed, factoring the impact of BMI, hernia size, age, sex, diabetes, and operative approach on outcomes.

RESULTS

Of the 1,906 VHRs, 58.8% were performed open, patient mean age was 54.9 ± 13.5 years, BMI was 31.2 ± 6.8 kg/m², and defect area was 44.8 ± 88.1 cm². Patients undergoing open VHRs were more likely to have an infection develop (3.1% vs 0.3%; p < 0.0001), but less likely to have a seroma develop (6.8% vs 15.3%; p < 0.0001) at mean follow-up 23.2 ± 12.0 months. With multivariate regression controlling for confounding variables, patients undergoing laparoscopic VHR had increased risk of seroma (odds ratio [OR] 1.78; 95% CI 1.05 to 3.03), a decreased risk of infection (OR 0.05; 95% CI 0.01 to 0.42), and had worse quality of life at 1, 6, 12, and 24 months postoperatively compared with patients undergoing open repair. Recurrent hernias were associated with subsequent recurrence (OR 2.69; 95% CI 1.24 to 5.81) and need for reoperation (OR 4.93; 95% CI 2.24 to 10.87). Multivariate predictive models demonstrated independent predictors of infection, including open approach, recurrent hernias, and low ratio of BMI to defect size.

CONCLUSIONS

Ideal outcomes are dependent on both patient and operative factors. Open repair in thin patients with large defects should be considered due to reduced complications and improved quality of life. Laparoscopic repair in obese patients and recurrent hernias can decrease the associated risk of infection.

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.

Laparoscopic vs Robotic Intraperitoneal Mesh Repair for Incisional Hernia: An Americas Hernia Society Quality Collaborative Analysis

BACKGROUND

Robotic intraperitoneal mesh placement (rIPOM) has emerged recently as an alternative to laparoscopic intraperitoneal mesh placement (LapIPOM) for minimally invasive incisional hernia repair. We aimed to compare LapIPOM with rIPOM in terms of hospital length of stay (LOS) and 30-day postoperative complications in patients undergoing incisional hernia repair within the Americas Hernia Society Quality Collaborative.

STUDY DESIGN

Propensity score analysis was used to compare matched groups of patients within the Americas Hernia Society Quality Collaborative undergoing LapIPOM vs rIPOM. The primary outcomes measure was hospital LOS and secondary outcomes were 30-day wound events.

RESULTS

Four hundred and fifty-four (71.9%) patients underwent LapIPOM and 177 (28.1%) underwent rIPOM. The laparoscopic group had an increased median LOS (1 vs 0 days; interquartile range 3.00; p < 0.001). The risk of surgical site occurrence was higher in the LapIPOM group vs the rIPOM group (14% vs 5%; p = 0.001); however, surgical site occurrence requiring procedural intervention was similar between the groups (1% vs 0%; p = 1). Operative time longer than 2 hours was more common in the rIPOM group (47% vs 31%; p < 0.05).

CONCLUSIONS

Despite longer operative times using the rIPOM approach, patients undergoing rIPOM had a significantly shorter LOS than LapIPOM, without additional risk of wound morbidity requiring intervention. Additional studies are necessary to identify the best candidates for the rIPOM approach.

Primary fascial closure during laparoscopic ventral hernia repair does not reduce 30-day wound complications

BACKGROUND

Laparoscopic ventral hernia repair (LVHR) is associated with decreased wound morbidity compared to open repair. It remains unclear whether primary fascial closure (PFC) offers any benefit in reducing postoperative seroma compared to bridged repair. We hypothesized that PFC would have no effect on seroma formation following LVHR.

METHODS

A retrospective cohort study was performed using data from the prospectively maintained Americas Hernia Society Quality Collaborative. All patients undergoing LVHR from 2013 to 2016 were included. The primary outcome was seroma formation, diagnosed either clinically or radiographically. Secondary outcomes included surgical site infections (SSI), surgical site occurrences (SSO), and SSO requiring intervention. Patient characteristics and outcomes were compared between groups with univariate analysis using Pearson's chi-squared or Wilcoxon tests. Multivariable logistic regression controlling for patient and hernia characteristics was then performed to investigate the independent effect of PFC on seroma formation.

RESULTS

1280 patients were included in the study. 69% (n = 887) underwent PFC. Patients undergoing bridged repairs had slightly larger defects and were more likely to have a recurrent hernia. The overall rate of seroma formation was 10.4% (n = 133). There was no association on univariate analysis between PFC and wound complications. Similarly, on multivariable analysis, PFC had no significant effect on the risk of seroma formation (OR 0.87, 95% CI 0.58-1.31).

CONCLUSIONS

PFC does not decrease the risk of short-term wound complications. Given that prior studies have also suggested no difference in hernia recurrence, PFC does not appear to improve postoperative outcomes for patients undergoing LVHR.

Meta-analysis of closure of the fascial defect during laparoscopic incisional and ventral hernia repair

Background

Laparoscopic incisional and ventral hernia repair (LIVHR) is being used increasingly, with reported outcomes equivalent to those of open hernia repair. Closure of the fascial defect (CFD) is a technique that may reduce seroma formation and bulging after LIVHR. Non-closure of the fascial defect makes the repair of larger defects easier and reduces postoperative pain. The aim of this systematic review was to determine whether CFD affects the rate of adverse outcomes, such as recurrence, pseudo-recurrence, mesh eventration or bulging, and the rate of seroma formation.

Methods

A systematic search was performed of PubMed, Ovid, the Cochrane Library, Google Scholar and Scopus to identify RCTs that analysed CFD with regard to rates of adverse outcomes. A meta-analysis was done using fixed-effect methods. The primary outcome of interest was adverse events. Secondary outcomes were seroma, postoperative pain, mean hospital stay, mean duration of operation and surgical techniques employed.

Results

A total of 16 studies were identified involving 3638 patients, 2963 in the CFD group and 675 in the non-closure of facial defect group. Significantly fewer adverse events were noted following CFD than non-closure (4·9 per cent (79 of 1613) versus 22·3 per cent (114 of 511)), with a combined risk ratio (RR) of 0·25 (95 per cent c.i. 0·18 to 0·33; P &lt; 0·001). CFD resulted in a significantly lower rate of seroma (2·5 per cent (39 of 1546) versus 12·2 per cent (47 of 385)), with a combined RR of 0·37 (0·23 to 0·57; P &lt; 0·001), and shorter duration of hospital stay. No significant difference was noted in postoperative pain.

Conclusion

CFD during LIVHR reduces the rate of seroma formation and adverse hernia-site events.

Current Status and Challenges of Laparoscopy in Ventral Hernia Repair

Laparoscopic repair of ventral hernias gained strong popularity in the late nineties with some of the early enthusiasm lost later in time. We review the current status and challenges of laparoscopy in ventral hernia repair and best practices in this area. We specifically looked at patient and hernia defect factors, technical considerations that have contributed to the successes, and some of the failures of laparoscopic ventral hernia repair (LVHR). Patients best suited for a laparoscopic repair are those who are obese and diabetic with a total defect size not to exceed 10 cm in width or a "Swiss cheese" defect. Overlap of mesh to healthy fascia of at least 5 cm in every direction, with closure of the defect, is essential to prevent recurrence or bulging over time. Complications specifically related to surgical site occurrence favor the laparoscopic approach. Recurrence rates, satisfaction, and health-related quality of life results are similar to open repairs, but long-term data are lacking. There is still conflicting data regarding ways of fixating the mesh. The science of prosthetic material appropriate for intraperitoneal placement continues to evolve. The field continues to be plagued by single author, single institution, and small nonrandomized observational studies with short-term follow-up. The recent development of large prospective databases might allow for pragmatic and point-of-care studies with long-term follow-up. We conclude that LVHR has evolved since its inception, has overcome many challenges, but still needs better long-term studies to evaluate evolving practices.

Trans-fascial closure in laparoscopic ventral hernia repair

BACKGROUND

Laparoscopic incisional hernia repair has become widely accepted in the management of incisional hernias. There has been recent interest in combining fascial closure along with mesh placement to improve outcomes. We report our experience with this technique.

METHODS

Cases were evaluated retrospectively from 2012 to 2015. There were no exclusions. Cases were included which involved laparoscopic ventral hernia repair with fascial closure and mesh placement. Fascial closure was performed using non-absorbable sutures passed with a suture passage device percutaneously. A 5-cm overlap was performed using intra-peritoneal mesh. Fixation was performed using absorbable tacks in a double crown technique.

RESULTS

One hundred and twelve cases were included. The mean age was 57 years old (range 33-81 years). Fifty-nine were females and 53 were males. The median post-operative stay for the non-fascial closure group was 0 days (range 0-12 days). The median post-operative stay for the fascial closure group was 0 days (range 0-12 days). All cases were followed up clinically at 6 weeks. In the non-fascial closure group, five patients developed a seroma (12 %). One patient developed a wound infection (3 %). Six patients presented with a recurrence over the study period (15 %). In the fascial closure group, four patients had a seroma, which was managed conservatively (5 %). One patient developed a wound infection (1 %). Five patients developed a recurrence over the study period (7 %).

CONCLUSION

We have shown comparable rates for seroma and recurrence to other series. Laparoscopic incisional hernia repair with defect closure is feasible and reduces seroma rate and recurrence.

[Technical principles of incisional hernia surgery]

Many publications are available on the best surgical techniques and treatment of incisional hernias with reports of experiences and randomized clinical studies at the two extremes of the evidence scale. The ultimate proof of the best operative technique has, however, not yet been achieved. In practically no other field of surgery are the variability and the resulting potential aims of surgery so great. The aim of surgery is to provide patients with the optimal recommendation out of a catalogue of possibilities from a holistic perspective. This article describes the surgical techniques using meshes for strengthening (in combination with an anatomical reconstruction) and for replacement of the abdominal wall (with bridging of the defect).

Laparoscopic-assisted Ventral Hernia Repair: Primary Fascial Repair with Polyester Mesh versus Polyester Mesh Alone

Laparoscopic-assisted ventral hernia repair (LAVHR) with mesh is well established as the preferred technique for hernia repair. We sought to determine whether primary fascial closure and/or overlap of the mesh reduced recurrence and/or complications. We conducted a retrospective review on 57 LAVHR patients using polyester composite mesh between August 2010 and July 2013. They were divided into mesh-only (nonclosure) and primary fascial closure with mesh (closure) groups. Patient demographics, prior surgical history, mesh overlap, complications, and recurrence rates were compared. Thirty-nine (68%) of 57 patients were in the closure group and 18 (32%) in the nonclosure group. Mean defect sizes were 15.5 and 22.5 cm2, respectively. Participants were followed for a mean of 1.3 years [standard deviation (SD) = 0.7]. Recurrence rates were 2/39 (5.1%) in the closure group and 1/18 (5.6%) in the nonclosure group ( P = 0.947). There were no major postoperative complications in the nonclosure group. The closure group experienced four (10.3%) complications. This was not a statistically significant difference ( P = 0.159). The median mesh-to-hernia ratio for all repairs was 15.2 (surface area) and 3.9 (diameter). Median length of stay was 14.5 hours (1.7–99.3) for patients with nonclosure and 11.9 hours (6.9–90.3 hours) for patients with closure ( P = 0.625). In conclusion, this is one of the largest series of LAVHR exclusively using polyester dual-sided mesh. Our recurrence rate was about 5 per cent. Significant mesh overlap is needed to achieve such low recurrence rates. Primary closure of hernias seems less important than adequate mesh overlap in preventing recurrence after LAVHR.

Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20^th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4^th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.

Unidirectional barbed sutures as a novel technique for laparoscopic ventral hernia repair

BACKGROUND

Incisional hernias remain a significant complication of abdominal surgeries. Primary closure of the hernia defect has been suggested to improve long-term abdominal wall function. However, this can be technically challenging and time consuming. This study describes laparoscopic use of non-absorbable barbed sutures in primary closure of hernia defects in addition to intraperitoneal mesh.

METHODS

Patients who underwent laparoscopic primary ventral hernia repair with mesh were prospectively reviewed. Two groups were defined: Operations performed with barbed sutures for primary closure in addition to mesh and operations with only mesh without defect repair. The surgical technique involved running the hernia defect with a 2-polypropylene non-absorbable unidirectional barbed suture and subsequently fixing the mesh intraperitoneally with tacks. In both groups, a single transfascial centering suture was also utilized.

RESULTS

Twenty-eight cases with barbed suture and mesh reinforcement and 29 cases with mesh-only were identified. The average dimensions of the ventral hernia defects were 57.8 (6-187) and 44.6 cm(2) (9-156) in the barbed suture with mesh and mesh-only group, respectively, p = 0.23. Median operating time was 78 min (range 35-187 min) in the barbed suture with mesh group versus 62 min (34-155 min) in the mesh-only group, p = 0.44. The median suturing time of closing the ventral hernia defect was 16 min (11-24 min). There were no differences in the pain scores. Mean follow-up for both groups was 8.2 ± 3.6 months (1-17 months) with one hernia recurrence in the mesh-only group, p = 0.41.

CONCLUSIONS

The barbed suture closure system could be used for rapid and effective primary defect closure in laparoscopic ventral hernia repair in addition to intraperitoneal mesh placement. No significant difference in operating time was detected when compared to the mesh-only approach. Further evidence to support these findings and longer follow-up periods is warranted to evaluate short- and long-term complications.

Long-term outcomes of 1326 laparoscopic incisional and ventral hernia repair with the routine suturing concept: a single institution experience

PURPOSE

This retrospective chart analysis reports and assesses the long-term (beyond 10 years) safety and efficiency of a single institution's experience in 1326 laparoscopic incisional and ventral hernia repairs (LIVHR), defending the principle of the suturing defect (augmentation repair concept) prior to laparoscopic reinforcement with a composite mesh (IPOM Plus). This study aims to prove the feasibility and validity of IPOM Plus repair, among other concepts, as a well-justified treatment of incisional or ventral hernias, rendering a good long-term outcome result.

METHODS

A single institution's systematic retrospective review of 1326 LIVHR was conducted between the years 2000 and 2014. A standardized technique of routine closure of the defect prior to the intraperitoneal onlay mesh (IPOM) reinforcement was performed in all patients. The standardized technique of "defect closure" by laparoscopy approximating the linea alba under physiological tension was assigned by either the transparietal U reverse interrupted stitches or the extracorporeal closure in larger defects. All patients benefited from the implant Parietex composite mesh through an Intraperitoneal Onlay Mesh placement with transfacial suturing.

RESULTS

LIVHR was performed on 1326 patients, 52.57% female and 47.43% male. The majority of our patients were young (mean age 52.19 years) and obese (average BMI 32.57 kg/m2). The mean operating time was 70 min and hospital stay 2 days, with a mean follow-up of 78 months. On the overall early complications of 5.78%, we achieved over time the elimination of the dead space by routine closure of the defect, thus reducing seroma formation to 2.56%, with a low risk of infection <1%. Post-op sepsis occurred in only nine cases. Three secondary serosal breakdowns and two late perforations were re-operated, and three diabetic patients had infected hematomas, necessitating mesh removal. Through technical improvement in the suturing concept and our growing experience, we managed to reduce the incidence of transient pain to a low acceptable rate of 3.24% (VAS 5-7) that decreased to 2.56% on a chronic pain stage, which is comparable to the literature. On the overall rate of late complications of 10.74%, we noticed also that by reducing the dead space, the chronic pain, skin bulging, and rate of recurrence were reduced to, respectively, 2.56, 1.50, and 4.72%. One case of mortality was due to a tracheal stenosis, responsible for an acute respiratory syndrome. On a second-look follow-up of 126 patients (9.5%), 45.23% were adhesion free, 42.06% had minor adhesions classified as Müller I, and 12.69% had serosal adhesions classified as Müller II.

CONCLUSION

Our long series confirms the unexpected high rate of feasibility in the suturing concept or augmentation technique, and confers additional benefits to the conventional advantages of LIVHR in terms of reducing the overall morbidity, with a low rate of recurrences. Based on our experience and study, the current best indications for a successful LIVHR procedure should be tailored upon the limitations of the defect's width and proper patient selection, to restore adequately the optimal functionality of the abdominal muscles and provide better functional and cosmetic outcomes.

Primary fascial closure with laparoscopic ventral hernia repair: systematic review

Laparoscopic ventral hernia repair (LVHR) has grown in popularity. Typically, this procedure is performed with a mesh bridge technique that results in high rates of seroma, eventration (bulging), and patient dissatisfaction. In an effort to avoid these complications, there is growing interest in the role of laparoscopic primary fascial closure with intraperitoneal mesh placement. This systematic review evaluated the outcomes of closure of the central defect during LVHR. A literature search of PubMed, Cochrane databases, and Embase was conducted using PRISMA guidelines. MINORS was used to assess the methodologic quality. Primary outcome was hernia recurrence. Secondary outcomes were surgical-site infection, seroma formation, bulging, and patient-centered items (satisfaction, chronic pain, functional status). Eleven studies were identified, eight of which were case series (level 4 data). Three comparative studies examined the difference between closure and nonclosure of the fascial defect during laparoscopic ventral incisional hernia repairs (level 3 and 4 data). These studies suggested that primary fascial closure (n = 138) compared to nonclosure (n = 255) resulted in lower recurrence rates (0-5.7 vs. 4.8-16.7 %) and seroma formation rates (5.6-11.4 vs. 4.3-27.8 %). Follow-up periods for both groups were similar (1-108 months). Only one study evaluated patient function and clinical bulging. It showed better outcomes with primary fascial closure. Closure of the central defect during LVHR resulted in less recurrence, bulging, and seroma than nonclosure. Patients with closure were more satisfied with the results and had better functional status. The quality of the data was poor, however. A randomized controlled trial to evaluate the role of closure of the central defect during LVHR is warranted.

Laparoscopic repair of complicated umbilical hernia with Strattice Laparoscopic™ reconstructive tissue matrix

INTRODUCTION

Complex hernias continue to present a challenge. Surgical techniques for repair are carefully considered to reduce risk for complications. Laparoscopic repairs improve postoperative infection rates, and placement of biologic mesh decreases mesh infection rates. However, laparoscopic repairs using biologic mesh is generally challenging due to difficulty with maneuverability.

PRESENTATION OF CASE

We present a case of a complex ventral hernia that was laparoscopically repaired using a new FDA cleared laparoscopic biologic graft. The patient had multiple comorbidities, including obesity, hepatitis C, endocarditis secondary to IV drug use, tobacco smoking, bilateral inguinal hernia, and recurrent umbilical hernia. The recurrent hernia was larger, irreducible, and discolored compared to original defect. The patient underwent laparoscopic repair with primary closure and reinforcement with Strattice™ Tissue Matrix Laparoscopic (LifeCell Corporation, Branchburg, NJ). At nine months postoperative, the patient had no evidence of recurrence, infection, or chronic pain, demonstrating early success from the surgical management.

DISCUSSION

Presence of multiple comorbidities and incarcerated recurrent hernia increase risk for complications during and/or after hernia repair. Considering these factors, laparoscopic repair with Strattice Laparoscopic and defect closure was a reasonable technique for repair.

CONCLUSION

Laparoscopic suture repair reinforced with biologic dermal tissue matrix was successfully performed during a complex hernia repair.

Laparoscopic repair reduces incidence of surgical site infections for all ventral hernias

BACKGROUND

The role of laparoscopic repair of ventral hernias remains incompletely defined. We hypothesize that laparoscopy, compared to open repair with mesh, decreases surgical site infection (SSI) for all ventral hernia types.

METHODS

MEDLINE, EMBASE, and Cochrane databases were reviewed to identify studies evaluating outcomes of laparoscopic versus open repair with mesh of ventral hernias and divided into groups (primary or incisional). Studies with high risk of bias were excluded. Primary outcomes of interest were recurrence and SSI. Fixed effects model was used unless significant heterogeneity, assessed with the Higgins I square (I(2)), was encountered.

RESULTS

There were 5 and 15 studies for primary and incisional cohorts. No difference was seen in recurrence between laparoscopic and open repair in the two hernia groups. SSI was more common with open repair in both hernia groups: primary (OR 4.17, 95%CI [2.03-8.55]) and incisional (OR 5.16, 95%CI [2.79-9.57]).

CONCLUSIONS

Laparoscopic repair, compared to open repair with mesh, decreases rates of SSI in all types of ventral hernias with no difference in recurrence. These data suggest that laparoscopic approach may be the treatment of choice for all types of ventral hernias.

Laparoscopic repair of incisional hernia in solid organ-transplanted patients: the method of choice?

Due to immunosuppressive (IS) therapy, incisional hernias are overrepresented in the organ-transplanted (Tx) population with larger defects, a high rate of recurrence, and a tendency toward more seromas and infectious problems. Thirty-one Tx/IS patients with a control group of 70 non-IS patients with incisional hernia (6/7 recurrences) were included in a prospective interventional study. Both cohorts were treated with laparoscopic ventral hernia repair (LVHR). Follow-up time and rate was 37 months and 95%. One hundred LVHR's were completed as there was one conversion in the Tx/IS group. No late infections or mesh removals occurred. Recurrence rates were 9.7% vs. 4.2% (P = 0.37) and the overall complication rates were 19% vs. 27% (P = 0.80). The Tx/IS group had a higher mesh-protrusion rate (29% vs. 13%, P = 0.09), but also larger hernias. Polycystic kidney disease was overrepresented in the Tx cohort (44% of kidney-Tx). Incisional hernias in Tx/IS patients may be treated by LVHR with the same low complication rate and recurrence rate as non-IS patients. By LVHR, the highly problematic seroma/infection problems encountered in Tx/IS patients treated by conventional open technique seem almost eliminated. The minimally invasive procedure seems particularly rational in the Tx/Is population and should be the method of choice. (ClinicalTrials.gov number: NCT00455299, date: 5 May 2006).