Laparoscopic Repair of Ventral Incisional Hernias: Pros and Cons

Preaponeurotic endoscopic repair (REPA) of diastasis recti: a single surgeon's experience

BACKGROUND

Diastasis recti is a pathology that affects not only the abdominal wall but also the stability of lumbopelvic muscles, consequently altering urinary and digestive functionality. Preaponeurotic endoscopic repair (REPA) is an endoscopic alternative to tummy tuck for the treatment of diastasis. In this study, the outcomes of REPA application by a single surgeon are presented.

METHODS

A total of 172 patients underwent REPA for the treatment of diastasis recti between August 2017 and December 2019. One hundred twenty-four patients were followed for at least one year. Sixty-three patients responded to a survey on satisfaction and quality of life 12 months after surgery.

RESULTS

Three (2.4%) recurrences occurred, of which two occurred in the same patient. The main postoperative complications observed were 12 (9.7%) seromas, 3 (2.4%) haematomas, a single wound infection, 3 (2.4%) cases of skin fold formation, and a case of trophic skin lesion that required negative pressure therapy. Quality of life after surgery, as reported by 63 patients who responded to the survey, was satisfactory.

CONCLUSIONS

REPA is a safe and effective technique for diastasis recti treatment, representing a valid alternative to abdominoplasty. Since there is no need to access the peritoneal cavity and the mesh is onlay, there are no risks of bowel damage or adhesions between the intestine and prosthesis.

What's New in the Management of Incarcerated Hernia

Management of incarcerated hernias is a common issue facing general surgeons across the USA. When hernias are not able to be reduced, surgeons must make decisions in a short time frame with limited options for patient optimization. In this article, we review assessment and management options for incarcerated ventral and inguinal hernias.

Erratum: Addendum: Abdominal Wall Reconstruction: An Integrated Approach

[This corrects the article DOI: 10.1055/s-0038-1667062.].

Robotic retromuscular ventral hernia repair and transversus abdominis release: short-term outcomes and risk factors associated with perioperative complications

BACKGROUND

Retromuscular ventral hernia repairs have become increasingly popular, both with and without transversus abdominis release. We aim to describe our 90-day outcomes in patients who underwent robotic retromuscular ventral hernia repair (RRVHR).

METHODS

All patients were subcategorized into those who underwent a TAR (TAR+) as part of their repair, and those who did not (TAR-). Patient demographics, comorbidities, hernia characteristics, and LOS were studied. Perioperative complications were reviewed in four different time frames up to 90 days. All hernias and complications were classified using the recommended classification systems. Appropriate univariate analyses and multivariate regression analyses were performed to determine the hernia characteristics which required a TAR technique, and risk factors which associated with the development of complications.

RESULTS

Of 454 robotic ventral hernia repairs, 101 patients who underwent RRVHR were included into the study. Of these, 54 patients underwent RRVHR with TAR while the remaining 47 patients underwent repair without TAR. Incisional hernias, off-midline locations, and larger size defects were factors that required the addition of a TAR. In 9.9% patients, an unplanned TAR was performed. Postoperative pain assessment was similar in both groups. LOS was significantly longer for TAR + group (p < 0.001). The median Comprehension Complication Index^® score was 8.7 (range: 0-42.4) for all patients and was significantly higher for TAR+ group (p = 0.014). Complications were higher in the TAR+ group as compared to the TAR- group (p = 0.028), though this difference did not persist in follow-up. Most complications were minor (Clavien-Dindo grade-I and -II). The development of complications was only associated with the presence of an incarcerated hernia at repair.

CONCLUSION

RRVHR is safe and feasible. 9.9% of our cohort required a TAR that was unplanned, particularly incisional hernias. TAR patients may be more prone to complications in the immediate post-operative period, however, the difference between patients with and without TAR adjuncts resolved at 90 days.

Patient selection criteria for an effective laparoscopic intraperitoneal ventral hernia repair in day surgery

The laparoscopic treatment of abdominal wall defects is currently a valid alternative to the open technique, given the possibility to significantly reduce the length of hospital stay and, consequently, to allow its carrying out in a day surgery setting. The comparison between the two methods has also been the subject of a Cochrane meta-analysis performed by Sauerland et al. (Cochrane Database Syst Rev 3: CD007781, 2011), which pointed out how, in spite of many clinical trials indicating the superiority of laparoscopy in terms of invasiveness and postoperative pain control, the quality of evidence is low due to the excessive variability among the different series in terms of reported complications. Moreover, what should be the selection criteria of patients fit for laparoscopic treatment in day surgery is not yet defined. This retrospective study considered 94 patients with primary or recurrent incisional wall hernias treated with laparoscopic technique over a 7-year period of time, from 2011 to 2018. The aim was to define the selection criteria for an effective day surgery laparoscopic treatment, considering as outcome the rate of conversion to ordinary hospitalization (discharge > POD1). Discharge > POD 1 was necessary in 15 cases out of 94 (16%). Concerning this outcome, statistically significant risk factors were ASA score > I (p = 0.022), number of hernia orifices > 1 (p = 0.001), recurrent hernias (p = 0.002) and hernia diameter > 10 cm (p < 0.0001). These factors were confirmed by univariate binary logistic analysis. A stepwise model of multivariate analysis showed as determinants for adverse events ASA score > 1 (OR 5.2, 95% CI 1.1-25.6, p = 0.043) and hernias > 10 cm (OR 7.0, 95% CI 1.1-46.4, p = 0.045). This work highlighted some useful criteria for preoperative selection of patients fit for laparoscopic abdominal wall defects repair in a day surgery setting. In particular, criteria related to a favorable clinical outcome were ASA score < II and a hernia diameter < 10 cm.

Laparoscopic repair of ventral/incisional hernias with the "Slim-Mesh" technique without transabdominal fixation sutures: preliminary report on short/midterm results

This study details our experience with a new laparoscopic technique called "Slim-Mesh" without using transabdominal full-thickness stitches, to treat ventral and incisional hernias (V/IH). Since 2009-May 2015, 28 consecutive patients with V/IH were treated in our center, with this new SM technique. Fifty percent males were included in this retrospective study, averaging 59 years (range 31-81 years). Mean body mass index was 26 and VH size was <10 cm in 24 cases and in 4 cases was larger, up to 22 cm. Mean operative time in the 28 V/IH patients was 97 min (range 57-160 min) and in those with V/IH larger than 10 cm it was 135 min. In 14.2% of patients laparoscopy diagnosed others V/IH previously undetected by physical examination and CT-scan. In all patients a composite mesh was used, up to 30 cm in size. In this series we had one intraoperative complication (3.6%) with transient bradycardia, but no conversion occurred; no early postoperative complication was detected. Mean length of hospital stay was 3.0 days. Mean follow-up time was 40 months (range 13-78 months). Late surgical complications included one case (3.6%) of incisional hernia recurrence and one case of 10 mm trocar site incisional hernia. This new surgical technique for V/IH repair, makes easy the handling and fixation of the composite mesh without using transabdominal fixation sutures, and appears in our experience fast, and simple.

Does negative pressure wound therapy applied to closed incisions following ventral hernia repair prevent wound complications and hernia recurrence? A systematic review and meta-analysis

Background

Despite advances in surgical technique, ventral hernia repair (VHR) remains associated with significant postoperative wound complications.

Objective

A systematic review and meta-analysis was performed to identify whether the application of negative pressure wound therapy to closed incisions (iNPWT) following VHR reduces the risk of postoperative wound complications and hernia recurrence.

Methods

The PubMed/MEDLINE, EMBASE and SCOPUS databases were searched for studies published through October 2015. Publications that met the following criteria were included: adult patients undergoing VHR; comparison of iNPWT with conventional dressings; and documentation of wound complications and/or hernia recurrence. The methodological quality of included studies was independently assessed using the Methodological Index for Non-Randomized Studies guidelines. Outcomes assessed included surgical site infection (SSI), wound dehiscence, seroma, and hernia recurrence. Meta-analysis was performed to obtain pooled ORs.

Results

Five retrospective cohort studies including 477 patients undergoing VHR were included in the final analysis. The use of iNPWT decreased SSI (OR 0.33 [95% CI 0.20 to 0.55]; P<0.0001), wound dehiscence (OR 0.21 [95% CI 0.08 to 0.55]; P=0.001) and ventral hernia recurrence (OR 0.24 [95% CI 0.08 to 0.75]; P=0.01). There was no statistically significant difference in the incidence of seroma formation (OR 0.59 [95% CI 0.27 to 1.27]; P=0.18).

Conclusion

For patients undergoing VHR, current evidence suggests a decreased incidence in wound complications using incisional NPWT compared with conventional dressings.

Prosthetic mesh "slim-cigarette like" for laparoscopic repair of ventral hernias: a new technique without transabdominal fixation sutures

Prosthetic mesh rolled up and fixed with stitches like a slim cigarette ("slim-mesh") for laparoscopic ventral hernia (VH) repair is an new technique which allows an easy intraperitoneally introduction, distension and circumferential fixation of a prosthetic mesh without transabdominal fixation sutures even for meshes larger than 16 cm up to 30 cm for the "slim-mesh" repair of wide ventral hernias. We report the technique of laparoscopic repair of VH with "slim-mesh". This technique enables an easy intra-peritoneally introduction of the mesh through the trocar because it reduces consistently its size, it allows a rapid intra-abdominal handling of the mesh and a fast and easy fixation for VH repair. The average time of surgery with "slim-mesh" for treatment of all 28 VH was 97 min ranging from 57 to 160 min. The average time for the repair of the 24 VH smaller than 10 cm was 91 and 135 min for the four VH larger than 10-22 cm. This new surgical technique leads to a reduction of surgical risks avoiding the use of transfascial sutures with the associated complications. This new surgical procedure in our experience is fast, safe, simple and also easily reproducible by surgeons in laparoscopic training. This technique may be used in wide VH (larger than 10-22 cm) that generally require open surgery.

Laparoscopic versus open incisional and ventral hernia repair: a systematic review and meta-analysis

BACKGROUND

Laparoscopic incisional and ventral hernia repair (LIVHR) is an alternative approach to conventional open incisional and ventral hernia repair (OIVHR). A consensus on outcomes of LIVHR when compared with OIVHR has not been reached.

METHODS

As the basis for the present study, we performed a systematic review and meta-analysis of all randomized controlled trials comparing LIVHR and OIVHR.

RESULTS

Eleven studies involving 1,003 patients were enrolled. The incidences of wound infection were significantly lower in the laparoscopic group than that in the open group (laparoscopic group 2.8 %, open group 16.2 %; RR = 0.19, 95 % CI 0.11-0.32; P < 0.00001). The rates of wound drainage were significantly lower in the laparoscopic group than that in the open group (laparoscopic group 2.6 %, open group 67.0 %; RR = 0.06, 95 % CI 0.03-0.09; P < 0.00001). However, the rates of bowel injury were significantly higher in the laparoscopic group than in the open group (laparoscopic group 4.3 %, open group 0.81 %; RR = 3.68, 95 % CI 1.56-8.67; P = 0.003). There were no significant differences between the two groups in the incidences of hernia recurrence, postoperative seroma, hematoma, bowel obstruction, bleeding, and reoperation. Descriptive analyses showed a shorter length of hospital stay in the laparoscopic group.

CONCLUSIONS

Laparoscopic incisional and ventral hernia repair is a feasible and effective alternative to the open technique. It is associated with lower incidences of wound infection and shorter length of hospital stay. However, caution is required because it is associated with an increased risk of bowel injury compared with the open technique. Given the relatively short follow-up duration of trials included in the systematic review, trials with long-term follow-up are needed to compare the durability of laparoscopic and open repair.

Evaluation of absorbable mesh fixation devices at various deployment angles

BACKGROUND

Hernia repair failure may occur due to suboptimal mesh fixation by mechanical constructs before mesh integration. Construct design and acute penetration angle may alter mesh-tissue fixation strength. We compared acute fixation strengths of absorbable fixation devices at various deployment angles, directions of loading, and construct orientations.

METHODS

Porcine abdominal walls were sectioned. Constructs were deployed at 30°, 45°, 60°, and 90° angles to fix mesh to the tissue specimens. Lap-shear testing was performed in upward, downward, and lateral directions in relation to the abdominal wall cranial-caudal axis to evaluate fixation. Absorbatack™ (AT), SorbaFix™ (SF), and SecureStrap™ in vertical (SSV) and horizontal (SSH) orientations in relation to the abdominal wall cranial-caudal axis were tested. Ten tests were performed for each combination of device, angle, and loading direction. Failure types and strength data were recorded. ANOVA with Tukey-Kramer adjustments for multiple comparisons and χ (2) tests were performed as appropriate (p < 0.05 considered significant).

RESULTS

At 30°, SSH and SSV had greater fixation strengths (12.95, 12.98 N, respectively) than SF (5.70 N; p = 0.0057, p = 0.0053, respectively). At 45°, mean fixation strength of SSH was significantly greater than SF (18.14, 11.40 N; p = 0.0002). No differences in strength were identified at 60° or 90°. No differences in strength were noted between SSV and SSH with different directions of loading. No differences were noted between SS and AT at any angle. Immediate failure was associated with SF (p < 0.0001) and the 30° tacking angle (p < 0.01).

CONCLUSIONS

Mesh-tissue fixation was stronger at acute deployment angles with SS compared to SF constructs. The 30° angle and the SF device were associated with increased immediate failures. Varying construct and loading direction did not generate statistically significant differences in the fixation strength of absorbable fixation devices in this study.

Delayed primary closure of contaminated abdominal wall defects with non-crosslinked porcine acellular dermal matrix compared with conventional staged repair: a retrospective study

INTRODUCTION

Synthetic mesh has been used traditionally to repair abdominal wall defects, but its use is limited in the case of bacterial contamination. New biological materials are now being used successfully for delayed primary closure of contaminated abdominal wall defects. The costs of biological materials may prevent surgeons from using them. We compared the conventional staged repair of contaminated abdominal wall defects with a single-stage procedure using a non-crosslinked porcine acellular dermal matrix.

METHODS

A total of 14 cases with Grade 3 contaminated abdominal wall defects underwent delayed primary closure of the abdomen using a non-crosslinked porcine acellular dermal matrix (Strattice™ Reconstructive Tissue Matrix, LifeCell Corp., Branchburg, NJ, USA). The results were compared with a group of 14 patients who had received conventional treatment for the repair of contaminated abdominal wall defects comprising a staged repair during two separate hospital admissions employing synthetic mesh. Treatment modalities, outcomes, and costs were compared.

RESULTS

In all cases treated with delayed primary closure employing non-crosslinked porcine acellular dermal matrix, there were no complications related to its use. Two patients died due to unrelated events. Although treatment costs were estimated to be similar in the two groups, the patients treated with porcine acellular dermal matrix spent less time as an inpatient than those receiving conventional two-stage repair.

CONCLUSIONS

Delayed primary closure of contaminated abdominal wall defects using a non-crosslinked porcine acellular dermal matrix may be a suitable alternative to conventional staged repair. In our patients, it resulted in early restoration of abdominal wall function and shorter hospitalization. The costs for treating contaminated abdominal wall defects using porcine acellular dermal matrix during a single hospital admission were not higher than costs for conventional two-stage repair. Further randomized studies are needed to expand upon these findings.

Cost-utility analysis of repair of reducible ventral hernia

BACKGROUND

Patient-reported outcomes are an important metric of the effectiveness of care. Ventral hernia repair is a procedure where the effectiveness can best be quantified using health-related quality of life. This study sought to quantify quality of life with respect to costs of ventral hernia repair.

METHODS

This observational study of patients diagnosed with a ventral hernia between 2004-2011 in a single center identified 3 groups of patients: (1) Patients diagnosed with ventral hernias managed with observation, (2) patients diagnosed with ventral hernias who underwent operative repair only when incarceration occurred, and (3) patients with ventral hernias who underwent herniorraphy before incarceration. The Short Form (SF)12v2 was administered to measure quality of life. The direct costs of care were obtained from Financial Services. Patients were surveyed about direct, non-health costs to obtain a societal perspective. A cost-utility analysis was performed.

RESULTS

The SF-12v2 was administered to 243 patients; 80 were observed, 69 underwent repair of an incarcerated hernia, and 94 underwent repair of a nonincarcerated hernia. The response rates were similar among groups-59%, 55%, and 52%. Quality of life as measured by utility score was less at 0.68 (95% CI, 0.65-0.71) in patients who did not undergo repair compared with those after repair of a nonincarcerated hernia, 0.76 (95% CI, 0.73-0.79; P < .001). The elective repair of a nonincarcerated hernia was cost-effective with an incremental cost effectiveness ratio of $8,646 per quality-adjusted life-year.

CONCLUSION

The prompt elective repair of ventral hernias is cost-effective.

Laparoscopic incisional hernia repair in an ambulatory surgery-extended recovery centre: a review of 259 consecutive cases

PURPOSE

The high prevalence of incisional hernias and an average stay of 3-10 days for open procedures have made this pathology both a health problem and an economic issue. A protocol was developed for performing this procedure in an Ambulatory Surgery Center (ASC) with extended recovery.

METHODS

From January 2000 to December 2011, data about all laparoscopic incisional hernia repairs were gathered prospectively. The patients' clinical features, hernia type, intraoperative and postoperative complications and reasons for hospital admission are studied.

RESULTS

A total of 259 patients have been operated for incisional hernia (185) or recurrent hernioplasty (74) in our ASC. Laparoscopic repair was successful in 254 patients (98.07 %). Conversion to open surgery was necessary in five patients (1.93 %). A total of 50 patients (19.69 %) in whom surgery was completed laparoscopically were discharged the same day of surgery, 179 (70.47 %) at 24 h and 25 (9.84 %) required a stay of over 24 h. Postoperative pain was severe in 10 % of patients, moderate in 40 %, and mild in 50 %. Complications, mostly minor and self-limiting, were observed in 25 patients (9.84 %) during hospital stay. Five major complications that occured were: bile peritonitis, an acute peritonitis, due to an inadvertent intestinal perforation, and one intestinal obstruction by partial detachment of the mesh, an intra-abdominal hematoma and a colo-cutaneous fistula. There were no deaths in the series. The mean follow-up of patients was 29.35 months (range 12-129 months). The recurrence rate was 7.03 % (n = 18). Four trocar-site hernias were detected.

CONCLUSIONS

It is essential to create a protocol with selection criteria that take into account the patient, his entourage, the anesthetic-surgical procedure, and a team dedicated to surgical laparoscopic surgery in an ASC with extended recovery to achieve good results in terms of morbidity and patient safety.

A modified approach to component separation using biologic graft as a load-sharing onlay reinforcement for the repair of complex ventral hernia

BACKGROUND

Components separation has been proposed as a means to close large ventral hernia without undue tension. We report a modification on open components separation that allows for the incorporation of onlaid noncrosslinked porcine acellular dermal matrix (Strattice, LifeCell Corp, Branchburg, NJ) as a load-sharing structure.

METHODS

This was a retrospective case series including all cases using Strattice from July 2008 through December 2009. Data evaluated included patient demographics, comorbidities associated with risk of recurrence, hernia grade, and postoperative complications. The primary outcomes were hernia recurrence and surgical site occurrences.

RESULTS

There were 58 patients; 60.8% presented with a recurrent incisional hernia. Average length of follow-up was 384 days. There were 4 hernia recurrences (7.9%). Complications included surgical site infection (20.7%), seroma (15.5%), and hematoma (5%) requiring intervention. Four deaths occurred in the series due to causes unrelated to the hernia repair, only 1 within 30 days of operation.

CONCLUSIONS

This series demonstrates that components separation reinforced with noncrosslinked porcine acellular dermal matrix onlay is an efficacious, single-stage repair with a low rate of recurrence and surgical site occurrences.

Staged laparoscopic ventral and incisional hernia repair when faced with enterotomy or suspicion of an enterotomy

Enterotomy is a significant complication of laparoscopic ventral or incisional hernia repair (LVHR) and can be devastating if missed. Enterotomy occurs in 2.6% of patients undergoing LVHR and is missed 21.8% of the time. Controversy exists regarding the management of known or potential enterotomies. Approaches for managing recognized enterotomies during hernia repair are usually employed immediately; in a nonstaged fashion; and include laparoscopic enterotomy repair with immediate LVHR, laparotomy for repair of enterotomy with concomitant LVHR, or conversion to laparotomy for both enterotomy and hernia repair. The staged approach for managing recognized or potential enterotomies is less commonly employed and involves laparoscopic repair of enterotomy, admission, and delayed but definitive laparoscopic hernia repair in the same hospitalization. The presence of known or potential enterotomies during LVHR presents a difficult problem and may be a contraindication for immediate placement of prosthetic because of increased risks posed for abdominal infection, reoperation, prosthetic removal, hernia recurrence, and death. The staged approach--with a 2- to 5-day delay--represents a safe solution to this challenging problem. We present 4 cases managed via staged approach due to an enterotomy, risk factors, and suspicion for missed or delayed enterotomies augmented by a review of the literature.

Laparoscopic ventral hernia repair

Ventral hernias, whether naturally occurring or the result of previous surgery, comprise one of the most common problems confronting general surgeons. As many as 25% of laparotomy incisions develop a hernia over long-term follow-up, which is a difficult problem with many treatment algorithms. Laparoscopic ventral hernia repair has improved over the last decade and has proven to be an effective treatment option. With fewer wound complications and low recurrence rates, it is a useful tool in the surgeon's armamentarium. Care should be taken regarding patient selection, operative technique, and mesh size to ensure adequate repair of the hernia, thereby preventing recurrence at a later date. The first attempt at a hernia repair has the highest chance of long-term success, so it is important that the surgeon take all the factors into mind before proceeding with operative repair.

Emergency laparoscopic treatment of acute incarcerated incisional hernia

BACKGROUND

The emergency treatment of incisional hernias can be accomplished by a laparoscopic approach in order to avoid the common complications following open techniques.

METHODS

From January 2001 to September 2007, we performed 48 emergency laparoscopic treatments of incarcerated hernias.

RESULTS

In our hospital, 320 patients with incisional hernia and 65 patients with primary abdominal wall hernia were treated laparoscopically. Forty-eight patients (30 females and 18 males) underwent emergency surgery. The mean operative time was 62 min (range 45–80 min). The average length of hospital stay was 4 days (range 3–6 days). We had eight post-surgical seromas, all of which were treated successfully by needle aspiration. We saw no mesh sepsis and no metabolic or surgical complications. We had no recurrence nor the need for a second operation. Mortality was nil.

CONCLUSIONS

The results of this series prove the feasibility of emergency laparoscopic surgery in incarcerated incisional hernias using new-generation meshes.

Degree of adhesions after repair of incisional hernia

Results of this study suggest that ultrasound can be used to quantitatively estimate the degree of adhesions between intestine and the abdominal wall.

Background and Objectives:

Laparoscopic treatment of incisional hernias reduces surgical traumas and postoperative pain. It requires intraperitoneal placement of a foreign body that might cause adhesions, leading to postoperative complications. The aim of this study was to improve reliability of ultrasound in quantitatively estimating adhesions to exploit the other advantages of ultrasound, such as availability and versatility.

Methods:

The ultrasound examination was performed by using a hand-held 3.5MHz curved linear probe. The image data were analyzed prior to scan conversion. Two square regions of interest were defined, one in the abdominal wall and one in the underlying bowels. A cross correlation-based algorithm tracked each region by using a time span of 3 frames. Subtracting the 2 displacement functions from each other yielded a relative displacement function, indicating the degree of bowel adhesions. This was compared with the intraoperative findings.

Results and Conclusions:

The method was proven to be a rapid and robust method for quantitatively estimating the degree of bowel adhesions. It is limited to evaluation of adhesions between bowel and abdominal wall. However, this ultrasound technique could assist in the safe placement of ports prior to redo laparoscopic surgery.

Which patients benefit most from laparoscopic ventral hernia repair? A comparative study

PURPOSE

To establish which patients suffering ventral hernia benefit the most from laparoscopic approach.

METHODS

From January 2005 to October 2008, 126 patients underwent surgery due to incisional hernia at our University Hospital. Patients were assigned to laparoscopic surgery (n=60) or conventional surgery (n=66) at the surgeon's discretion. Patients were subdivided according to the greater diameter of the defect: (G1, defect <5 cm; G2, defect 5 to 15 cm; and G3, defect >15 cm). Data on patient demographic, clinical, and perioperative variables were collected prospectively.

RESULTS

Groups were comparable in terms of sex, body mass index, American Society of Anesthesiologists score, size of defect, and proportion of primary repairs. Four patients were converted to open surgery. Mean hospital stay in the group with the smaller hernias (G1 was 3.16 d laparoscopic surgery vs. 2.87 d conventional surgery, P>0.05). Hospital stay for patients who underwent laparoscopy was shorter in G3 (4.25 d Lap vs. 12.6 d Open; P=0.02).

CONCLUSIONS

Patients with very large incisional hernias are those who benefit the most from laparoscopic treatment.

Laparoscopic versus open surgical techniques for ventral or incisional hernia repair

BACKGROUND

There are many different techniques currently in use for ventral and incisional hernia repair. Laparoscopic techniques have become more common in recent years, although the evidence is sparse.

OBJECTIVES

We compared laparoscopic with open repair in patients with (primary) ventral or incisional hernia.

SEARCH STRATEGY

We searched the following electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, metaRegister of Controlled Trials. The last searches were conducted in July 2010. In addition, congress abstracts were searched by hand.

SELECTION CRITERIA

We selected randomised controlled studies (RCTs), which compared the two techniques in patients with ventral or incisional hernia. Studies were included irrespective of language, publication status, or sample size. We did not include quasi-randomised trials.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data independently. Meta-analytic results are expressed as relative risks (RR) or weighted mean difference (WMD).

MAIN RESULTS

We included 10 RCTs with a total number of 880 patients suffering primarily from primary ventral or incisional hernia. No trials were identified on umbilical or parastomal hernia. The recurrence rate was not different between laparoscopic and open surgery (RR 1.22; 95% CI 0.62 to 2.38; I(2) = 0%), but patients were followed up for less than two years in half of the trials. Results on operative time were too heterogeneous to be pooled. The risk of intraoperative enterotomy was slightly higher in laparoscopic hernia repair (Peto OR 2.33; 95% CI 0.53 to 10.35), but this result stems from only 7 cases with bowel lesion (5 vs. 2). The most clear and consistent result was that laparoscopic surgery reduced the risk of wound infection (RR = 0.26; 95% CI 0.15 to 0.46; I(2)= 0%). Laparoscopic surgery shortened hospital stay significantly in 6 out of 9 trials, but again data were heterogeneous. Based on a small number of trials, it was not possible to detect any difference in pain intensity, both in the short- and long-term evaluation. Laparoscopic repair apparently led to much higher in-hospital costs.

AUTHORS' CONCLUSIONS

The short-term results of laparoscopic repair in ventral hernia are promising. In spite of the risks of adhesiolysis, the technique is safe. Nevertheless, long-term follow-up is needed in order to elucidate whether laparoscopic repair of ventral/incisional hernia is efficacious.

GOALS-incisional hernia: a valid assessment of simulated laparoscopic incisional hernia repair

The Global Operative Assessment of Laparoscopic Skills (GOALS) is a valid and reliable measure of basic, non-procedure-specific laparoscopic skills. GOALS-incisional hernia (GOALS-IH) was developed to evaluate performance of laparoscopic incisional hernia repair (LIHR). The purpose of this study was to assess the validity and reliability of GOALS-IH during LIHR simulation. GOALS-IH assesses 7 domains with a maximum score of 35. A total of 12 experienced surgeons and 10 novices performed LIHR on the Surgical Abdominal Wall simulator. Performance was assessed by a trained observer and by self-assessment using GOALS-IH, basic GOALS and a visual analog scale (VAS) for overall competence. Both interrater reliability and internal consistency were high (.76 and .95 respectively). Experienced surgeons had higher mean GOALS-IH scores than novices (32.3 ± 2 versus 22.7 ± 5). There was excellent correlation between GOALS-IH and other measures of performance (GOALS r = .93 and VAS r = .93). GOALS-IH is easy to use, valid and reliable for assessment of simulated LIHR.

Laparoscopic incisional hernia repair with fibrin glue in select patients

Hi-Tex dual-sided mesh fixed to the abdominal wall with fibrin glue was successful in the repair of incisional hernia in select patients.

Background and Objective:

Laparoscopic treatment of incisional hernias can be performed using different types of fixation devices and prosthesis. We present a case series of 19 patients with incisional hernias with a diameter of <6cm, who underwent laparoscopic repair using Hi-tex dual-side mesh, positioned intraperitoneally, fixed to the abdominal wall by fibrin glue (Tissucol).

Methods:

Nineteen patients with incisional hernias <6cm in diameter were enrolled in this study and treated laparoscopically with Hi-tex and Tissucol. Surgical complications and patient outcomes were assessed with a clinical follow-up.

Results:

Laparoscopic repair of incisional hernias by using Hi-tex mesh affixed to the parietal wall with fibrin glue was feasible and easy in patients with parietal defects <6cm in diameter. Mean operating time was 30 minutes. Mean hospital stay was 1.5 days. Almost no postoperative pain, major surgical complications, seroma formation, relapses, or prosthesis infection occurred during a mean follow-up of 20 months.

Conclusions:

In select patients, Hi-tex mesh affixed using fibrin glue allows laparoscopic repair of incisional hernias with very good patient outcomes, especially in terms of postoperative pain and seroma formation.

Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair

Despite advances in surgical technique and prosthetic technologies, the risks for recurrence and infection are high following the repair of incisional ventral hernias. High-quality data suggest that all ventral hernia repairs should be reinforced with prosthetic repair materials. The current standard for reinforced hernia repair is synthetic mesh, which can reduce the risk for recurrence in many patients. However, permanent synthetic mesh can pose a serious clinical problem in the setting of infection. Assessing patients' risk for wound infection and other surgical-site occurrences, therefore, is an outstanding need. To our knowledge, there currently exists no consensus in the literature regarding the accurate assessment of risk of surgical-site occurrences in association with or the appropriate techniques for the repair of incisional ventral hernias. This article proposes a novel hernia grading system based on risk factor characteristics of the patient and the wound. Using this system, surgeons may better assess each patient's risk for surgical-site occurrences and thereby select the appropriate surgical technique, repair material, and overall clinical approach for the patient. A generalized approach and technical considerations for the repair of incisional ventral hernias are outlined, including the appropriate use of component separation and the growing role of biologic repair materials.

The comparison of heavyweight mesh and lightweight mesh in an incisional animal model

PURPOSE

An incisional hernia may occur through the incision area following a surgical operation, through the trocar opening and even through drainage exit points. Various synthetic surgical meshes have recently been used for the surgical repair of incisional hernias. In this study, we analysed the burst strength forces of heavyweight mesh and lightweight mesh in an incisional animal model.

METHODS

Following experimental formation of incisional hernias in 32 Wistar albino rats, they were divided into four groups. Polypropylene suture was used for closure of the abdominal incision in Group 1. In Groups 2, 3 and 4, polyester, polypropylene + polyglactin and polypropylene meshes, respectively, were fixed on the surface of the fascia after closing the defects in the rats. Polypropylene and polyester meshes are classified as heavy mesh. Light mesh is composed of a non-absorbable part (polypropylene) and an absorbable part (polyglactin), which will disappear 80 days after implantation. The rats were sacrificed at the end of the experiment. The pullout force of the fascia and meshes were recorded by use of a digital tension meter.

RESULTS

The mean pullout forces for Groups 1, 2, 3 and 4 were found to be 123.4 +/- 13.3, 292.33 +/- 17.4, 281.66 +/- 16.3 and 310.60 +/- 26.1 N, respectively.

CONCLUSION

At the end of the experiment, the polypropylene (25 g/cm(2)) present in the lightweight mesh was found to lose only a small percentage of the burst strength compared to the polypropylene (85 g/cm(2)) present in the heavyweight mesh.

Surgical Abdominal Wall (SAW): a novel simulator for training in ventral hernia repair

Laparoscopic ventral hernia repair (LVHR) is a relatively common procedure that requires advanced minimally invasive surgical skills to perform. The role for simulation is increasingly supported as an effective way to teach surgical skills and accelerate the learning curve. This article describes The University of Maryland's Surgical Abdominal Wall, an inexpensive procedure-specific physical simulator for LVHR, and summarizes the authors' early experiences using this model in a curriculum for surgery residents.