Surgical progress in inguinal and ventral incisional hernia repair

Comparison of Common Postoperative Complications Between Lichtenstein Open Repair and Laparoscopic Transabdominal Pre-peritoneal (TAPP) Repair for Unilateral Inguinal Hernia

Introduction

Laparoscopic transabdominal pre-peritoneal (TAPP) repair is a minimally invasive technique that is becoming the procedure of choice among surgeons for inguinal hernia repair and research work is still going on comparing TAPP repair with Lichtenstein open mesh repair. The objective of our study is to compare common postoperative complications in Lichtenstein mesh repair and laparoscopic TAPP repair for unilateral inguinal hernia in our unit.

Methods

Between August 2016 and August 2018, patients with unilateral inguinal hernia and ASA grade I/II were selected in the surgical outpatient department (OPD) and prospectively randomized into two equal groups. Lichtenstein open mesh repair was done in Group-I and laparoscopic TAPP repair in Group-II. The visual analog scale (VAS) was used for the assessment of the intensity of pain.

Results

A total of 100 patients with a diagnosis of unilateral inguinal hernia were included in the study. Overall, our study showed that there was less postoperative pain in those patients who underwent TAPP repair as compared to patients with Lichtenstein mesh repair (p= <0.05). There were more postoperative complications in Group-I as compared to Group-II.

Conclusion

Laparoscopic TAPP repair for inguinal hernia is associated with less postoperative pain and other postoperative complications in addition to a shorter hospital stay as compared to Lichtenstein mesh repair. Thus, this is helping in the early return of patients to daily life activities.

Laparoscopic closure of the vaginal rings in the standing horse using a tacked intraperitoneal slitted mesh (TISM) technique

BACKGROUND

Indirect inguinal herniation (IIH) is a potentially life-threatening condition in stallions. The ideal preventive measure for breeding stallions ensures a minimally invasive closure of the vaginal ring that avoids recurrence of IIH while preserving both testicles.

OBJECTIVES

To describe a minimally invasive laparoscopic tacked intra-peritoneal slitted mesh (TISM) technique in the standing horse to close the vaginal rings and to evaluate its efficacy in preventing recurrence of IIH in stallions.

STUDY DESIGN

Retrospective case series.

METHODS

Medical records of 17 stallions with a history of IIH were reviewed retrospectively. The surgical procedure was performed on the standing horse through a flank approach using four laparoscopic portals. The vaginal ring was covered with a commercial mesh. The mesh was partially cut to create a slitted mesh with two flaps: the dorsal flap was passed under the spermatic cord and ductus deferens and the ventral flap above. The mesh was secured in place with laparoscopic tacks. Long-term follow-up was obtained by a structured telephone interview of the owners.

RESULTS

A total of 32 laparoscopic vaginal rings closures were successfully performed in 17 horses. No major intra- or postoperative complications occurred. None of the horse suffered from re-occurrence. Nine of the 13 active breeding stallions were breeding again with similar semen quality as before treatment, 4/13 will resume their breeding activity during the next breeding season. None of the horses were castrated and none of the owners reported abnormal size or shape of the testicles. In three stallions, post-operative pain and activity limitations were noted that gradually resolved after 6 months.

MAIN LIMITATIONS

The lack of large numbers to compare the results of different mesh and tack combinations, the lack of follow-up veterinary examinations and the limited number of laparoscopic rechecks.

CONCLUSION

The TISM technique is an effective minimally invasive technique to surgically reduce the size of the vaginal ring and thereby prevent recurrence of IIH.

"Complex abdominal wall" management: evidence-based guidelines of the Italian Consensus Conference

To date, there is no shared consensus on a definition of a complex abdominal wall in elective surgery and in the emergency, on indications, technical details, complications, and follow-up. The purpose of the conference was to lay the foundations for a homogeneous approach to the complex abdominal wall with the primary intent being to attain the following objectives: (1) to develop evidence-based recommendations to define “complex abdominal wall”; (2) indications in emergency and in elective cases; (3) management of “complex abdominal wall”; (4) techniques for temporary abdominal closure. The decompressive laparostomy should be considered in a case of abdominal compartment syndrome in patients with critical conditions or after the failure of a medical treatment or less invasive methods. In the second one, beyond different mechanism, patients with surgical emergency diseases might reach the same pathophysiological end point of trauma patients where a preventive “open abdomen” might be indicated (a temporary abdominal closure: in the case of a non-infected field, the Wittmann patch and the NPWT had the best outcome followed by meshes; in the case of an infected field, NPWT techniques seem to be the preferred). The second priority is to create optimal both general as local conditions for healing: the right antimicrobial management, feeding—preferably by the enteral route—and managing correctly the open abdomen wall. The use of a mesh appears to be—if and when possible—the gold standard. There is a lot of enthusiasm about biological meshes. But the actual evidence supports their use only in contaminated or potentially contaminated fields but above all, to reduce the higher rate of recurrences, the wall anatomy and function should be restored in the midline, with or without component separation technique. On the other site has not to be neglected that the use of monofilament and macroporous non-absorbable meshes, in extraperitoneal position, in the setting of the complex abdomen with contamination, seems to have a cost effective role too. The idea of this consensus conference was mainly to try to bring order in the so copious, but not always so “evident” literature utilizing and exchanging the expertise of different specialists.

Mesh repair of paraumblical hernia, outcome of 58 cases

Background

According to the literature, defects in para-umbilical hernias up to 2 cm in diameter could be sutured primarily. For defects larger than 2 cm in dimeters, mesh repair is recommended. The aim of this study is to evaluate the outcome of para-umbilical hernia repair with proline mesh regardless of its size.

Methods

In this retrospective study, patients with para-umbilical hernia, who were managed by onlay mesh placement were presented, and followed for 1–6 years. Several variables were studied including patients' socio-demographic data, post-operative complications, morbidity and mortality.

Results

The series includes 58 patients, the age ranged from 18 to 85 years with median age of 44 years and inter-quartile range of 13.5 years. Mean body mass index was (30.9 ± 4.2). From 49 female patients; 43 (87.8%) were multipara. Forty seven cases (81%) presented for the first time, and 11 cases (19%) had recurrent hernias. Twenty patients (34.5%) had hernia defect ≤2 cm, while 38 patients (65.5%) had hernia size >2 cm. Superficial surgical site infection was found in 6 patients (10.34%). Seroma was found in one female patient (1.72%). One patient (1.72%) had recurrent hernia after 19 months.

Conclusion

Mesh onlay repair by open surgery can be applied to all sizes of para umbilical hernias, it has low recurrence rate and the rates of morbidity and recurrence are comparable with international standard.

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Defect in para-umbilical hernias up to 2 cm in diameter may be sutured primarily. For defects larger than 2 cm, mesh repair is recommended.

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A retrospective study of 58 paraumblical hernias that were treated with onlay mesh.

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The aim of this study is to confirm the outcome of para-umbilical hernia repair with proline mesh regardless of its size.

Laparoscopic repair of traumatic flank hernias

INTRODUCTION

Traumatic flank hernias (TFH) are caused by a blunt abdominal trauma with resultant detachment of the oblique musculofascial complex at the iliac crest and/or costal margin. Given such proximity to the bony structures and essential absence of healthy fascia to anchor the mesh, TFH represent a challenging surgical problem. Although laparoscopic repair of ventral hernias has become very common, no series of laparoscopic repairs of TFH has been reported to date. We present a series of patients undergoing laparoscopic repair of TFH.

METHODS

After retrospective review of prospective hernia database at two Hernia centers, patients undergoing laparoscopic TFH repair were identified and analyzed. Main outcome measures included patient demographics, surgical technique, intraoperative data, and post-operative outcomes.

RESULTS

From December 2007 to December 2013, 14 patients underwent laparoscopic repair of a TFH. Eleven patients had chronically incarcerated viscera within the defect. Operative steps included complete reduction of the hernia sac, pre/retroperitoneal dissection to expose the entire lateral edge of a psoas muscle, defect closure with transabdominal sutures, wide mesh overlap, and transabdominal suture fixation with selective use of bone anchors. The mean operative time was 174 min (range 125-230). Mean estimated blood loss was 65 cc. Mean mesh size was 295 cm². There were no peri-operative complications. Mean hospital stay was 3.1 days and all patients returned to full activities by 6 weeks. At a mean follow-up of 35 months, there have been no recurrences.

CONCLUSION

Laparoscopic approach to TFH is feasible and safe. It is associated with minimal hospital stay and fast functional recovery. The key components of our approach include wide pre/retroperitoneal with defect closure and subsequent wide mesh underlay coverage with fixation to bony structures using anchors/screws. We believe that the laparoscopic approach should safely considered for the majority of patients with TFH.

Laparoscopic versus Open Repair of Para-Umbilical Hernia- A Prospective Comparative Study of Short Term Outcomes

INTRODUCTION

Para-Umbilical Hernia (PUH) is one of the most common surgical problems. Since the prosthetic repair has become the standard of practice for inguinal hernia management, the same has been adapted for para-umbilical hernia management with better outcome. There is still debate going on regarding the optimal surgical approach. There are very few prospective studies comparing the laparoscopic and open method of para-umbilical hernia mesh repair. This study compared the short term outcomes following laparoscopic versus open mesh repair of PUH.

AIM

To compare the early complications of open repair with laparoscopic repair of PUH. To compare the post-operative hospital stay of open repair with laparoscopic repair of PUH.

MATERIALS AND METHODS

This was a prospective comparative clinical study done from August 2014 to August 2016. All the patients above the age of 13 who attended our surgical outpatient department with PUH were taken into our study. Exclusion criteria included 1) Patients with obstructed or strangulated PUH 2) Patients with abdominal malignancies 3) Patients with coagulopathy, severe cardiopulmonary disease, ascites and renal failure 4) Patients who had PUH repair in combination with another major surgical operation such as laparoscopic cholecystectomy and inguinal hernia repair 5) Patients with recurrent PUH. Institute Ethical Committee clearance was obtained for this study.

RESULTS

Out of 40 patients with PUH, 20 received open meshplasty and 20 patients received laparoscopic meshplasty. Postoperative pain and length of hospital stay is significantly less in laparoscopic PUH repair. Postoperative complications like wound infection, seroma, and haematoma are relatively less in laparoscopic group though statistically not significant.

CONCLUSION

Laparoscopic PUH repair has significantly better outcome in terms of postoperative pain and postoperative hospital stay.

Chronic inguinal pain after laparoscopic intraperitoneal onlay mesh (IPOM) repair for inguinal hernia treated successfully with laparoscopic selective neurectomy: A case report

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Laparoscopic IPOM repair for inguinal hernia may cause chronic neuropathic pain.

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Laparoscopic IPOM repair for inguinal hernia should be avoided as much as possible.

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Laparoscopic selective neurectomy is an option for chronic neuropathic pain.

Introduction

Laparoscopic intraperitoneal onlay mesh (IPOM) repair is occasionally used for inguinal hernia repair. Here, we report a case of chronic neuropathic pain after laparoscopic IPOM repair for inguinal hernia, which was treated successfully with laparoscopic selective neurectomy.

Presentation of case

A 59-year-old man with bilateral inguinal hernia underwent laparoscopic repair. Transabdominal preperitoneal repair was performed on the left side, whereas IPOM repair was performed on the right side due to a peritoneal defect. At postoperative month 1, he presented with severe pain and numbness distributed from the right inguinal region to the inner thigh region. The symptoms had persisted for 1 year despite medical treatment. We diagnosed that the symptoms might be due to the entrapment of nerves in the contracted mesh, and performed a second surgery via laparoscopic approach 13 months after the first surgery. On laparoscopic exploration, the lateral side of the mesh was contracted and involved nerve branches. We ligated and cut off these nerve branches. His symptoms resolved immediately after the surgery. At postoperative month 12, he has passed without any pain, numbness, and hernia recurrence.

Discussion

Laparoscopic exploration would be useful to figure out chronic neuropathic pain after laparoscopic inguinal hernia repair.

Conclusion

Laparoscopic IPOM repair for inguinal hernia should be avoided as much as possible because it may cause chronic neuropathic pain. Laparoscopic selective neurectomy is an option for patients with chronic neuropathic pain after laparoscopic hernia repair.

A comparison of post operative pain and hospital stay between Lichtenstein's repair and Laparoscopic Transabdominal Preperitoneal (TAPP) repair of inguinal hernia: A randomized controlled trial

Objective:

To compare the open Lichtenstein repair and laparoscopic mesh repair for direct inguinal hernias in terms of immediate post operative pain and length of hospital stay.

Methods:

This randomized control trial was conducted at Benazir Bhutto Hospital Rawalpindi from January 2009 to June 2010. All patients presenting in the surgical OPD with direct inguinal hernia, ASA I/II, were randomly divided in two equal groups. Group-I, patients underwent Lichtenstein’s repair and Group-II had hernioplasty by laparoscopic method (TAPP). Post operative pain intensity assessed by VAS and hospital stay measured in hours.

Results:

A total 60 patients of direct inguinal hernia were studied. The mean age was 61.48±7. The range of postoperative pain experienced was 5.55 as per VAS among all patients. In group-I (open hernioplasty) majority of patients (53.33%, n=16) experience severe type of pain where as in group-II, moderate severity of pain was reported by large number of patients (63.34%, n=19). The mean post operative pain intensity as per VAS was 6.23 in group-I and 4.43 in group-II patients. The mean length of hospital stay was slightly less (35.10 hrs) in group-I as compared to group-II (38.70 hrs).

Conclusion:

There is definitely less post operative pain after laparoscopic repair but hospital stay is same in both the procedures but laparoscopic procedure does increase the cost.

An in vivo analysis of Miromesh--a novel porcine liver prosthetic created by perfusion decellularization

BACKGROUND

Bioprosthetics derived from human or porcine dermis and intestinal submucosa have dense, homogenous, aporous collagen structures that potentially limit cellular penetration, undermining the theoretical benefit of a "natural" collagen scaffold. We hypothesized that Miromesh-a novel prosthetic derived from porcine liver by perfusion decellularization-provides a more optimal matrix for tissue ingrowth.

METHODS

Thirty rats underwent survival surgery that constituted the creation of a 4 × 1 cm abdominal defect and simultaneous bridged repair. Twenty rats were bridged with Miromesh, and 10 rats were bridged with non-cross-linked porcine dermis (Strattice). Ten Miromesh and all 10 Strattice were rinsed in vancomycin solution and inoculated with 10(4) colony-forming units of green fluorescent protein-labeled Staphylococcus aureus (GFP-SA) after implantation. Ten Miromesh controls were neither soaked nor inoculated. No animals received systemic antibiotics. All animals were euthanized at 90 d and underwent an examination of their gross appearance before being sectioned for quantitative bacterial culture and histologic grading. A pathologist scored specimens (0-4) for cellular infiltration, acute inflammation, chronic inflammation, granulation tissue, foreign body reaction, and fibrous capsule formation.

RESULTS

All but one rat repaired with Strattice survived until the 90-d euthanization. All quantitative bacterial cultures for inoculated specimens were negative for GFP-SA. Of nine Strattice explants, none received a cellular infiltration score >0, consistent with a poor tissue-mesh interface observed grossly. Of 10 Miromesh explants also inoculated with GFP-SA, seven of 10 demonstrated cellular infiltration with an average score of +2.7 ± 0.8, whereas sterile Miromesh implants received an average score of 0.8 ± 1.0. Two inoculated Miromesh implants demonstrated acute inflammation and infection on histology.

CONCLUSIONS

A prosthetic generated from porcine liver by perfusion decellularization provides a matrix for superior cellular infiltration compared with non-cross-linked porcine dermis.

Laparoscopic plug removal for femoral nerve colic pain after mesh & plug hernioplasty

Background

Inguinal hernias account for 75 % of abdominal wall hernias, with a lifetime risk of 27 % in men and 3 % in women. Major complications are recurrence, chronic pain, and surgical site infection, but their frequency is low. Few studies have reported a calcified mesh causing neuropathy by chronic compression of the femoral nerve after mesh & plug inguinal hernia repair. This is the first report of laparoscopic plug removal for femoral colic due to femoral nerve irritation cause by a calcified plug after mesh & plug inguinal hernia repair.

Case presentation

In July 2013, a 53-year-old man presented to our hospital with a chief complaint of colic pain in the left lower limb while walking. The patient had undergone left inguinal hernia repair about 10 years earlier and reported no chronic pain after the operation. Physical examination revealed a colic pain exacerbated by left thigh movement, especially during flexion, but the patient was pain-free at rest and had no sensory loss. Axial computed tomography and magnetic resonance imaging showed that the inward-projecting plug was extremely close to the femoral nerve. Because of the radicular symptoms and the absence of orthopedic and urological disease, we strongly suspected that the neuralgia was associated with the previous hernia operation and advised exploratory laparotomy, which revealed the plug bulging inward into the abdominal cavity. Moreover, the tip of the plug was firmly calcified and compressing the femoral nerve, which lay just beneath the plug, especially during hip flexion. We explanted the plug and his pain resolved after the operation. The patient remains pain free after 20 months of follow up.

Conclusion

In this study, laparoscopic hernioplasty proved useful for plug removal because laparoscopic instruments can easily grasp perilesional tissue, and laparoscopic approach has the benefit of isolating the plug for removal while preserving the onlay patch, and helpful for restoring peritoneal defects. Laparoscopic plug removal effectively resolved colic pain in the left thigh due to compression of the femoral nerve by a calcified plug.

Tissue integration and inflammatory reaction in full-thickness abdominal wall repair using an innovative composite mesh

PURPOSE

When composite meshes are used in abdominal wall repair, seroma formation may persist and delay the desired integration leading to recurrence. This study compares tissue integration and inflammatory response in abdominal wall repair with composites with different absorbable synthetic barriers.

METHODS

Full-thickness defects created in the abdominal wall of rabbits were repaired using polypropylene prosthesis or the following composites: Physiomesh™ (Phy); Ventralight™ (Vent) and "new composite mesh" (Ncm) not yet used clinically in humans. The collected seroma was evaluated for IFN-γ/IL-4 by ELISA. Tissue integration, anti- (IL-13/TGFβ-1/IL-10/IL-4) and pro-inflammatory (TNF-α/IL-6/IFN-γ/VEGF) cytokine mRNA expression and TGFβ/VEGF immunolabeling were evaluated at 14 and 90 days post-implant.

RESULTS

Seroma was observed in 10 of 12 Phy/Vent and 4 of 12 Ncm. Wound fluid IFN-γ showed a time-dependent significant increase in Vent and tendency to decrease in Ncm, while all composites exhibited IL-4 upward trend. Prostheses were fully infiltrated by an organized connective tissue at end time although the area had shown prior seroma. A stable mesothelium was developed, except in adhesion areas. Vent/Phy displayed a significant increase in TNF-α/IFN-γ-mRNA over time. Significant decrease in VEGF mRNA was observed in Phy/Ncm, while a significant increase of TGFβ-1 mRNA was evident in all composites over time. Ncm exhibited the highest TGFβ protein expression area at short term and the greatest percentage of VEGF positive vessels at end time.

CONCLUSION

Ncm could be an appropriate candidate to improve clinical outcome showing the lower development of seroma and optimal tissue integration with minimal pro-inflammatory cytokine response over time and consistent pro-wound healing cytokine expression.

Behaviour of a new composite mesh for the repair of full-thickness abdominal wall defects in a rabbit model

Introduction

Composite biomaterials designed for the repair of abdominal wall defects are composed of a mesh component and a laminar barrier in contact with the visceral peritoneum. This study assesses the behaviour of a new composite mesh by comparing it with two latest-generation composites currently used in clinical practice.

Methods

Defects (7x5cm) created in the anterior abdominal wall of New Zealand White rabbits were repaired using a polypropylene mesh and the composites: Physiomesh^TM; Ventralight^TM and a new composite mesh with a three-dimensional macroporous polyester structure and an oxidized collagen/chitosan barrier. Animals were sacrificed on days 14 and 90 postimplant. Specimens were processed to determine host tissue incorporation, gene/protein expression of neo-collagens (RT-PCR/immunofluorescence), macrophage response (RAM-11-immunolabelling) and biomechanical resistance. On postoperative days 7/14, each animal was examined laparoscopically to quantify adhesions between the visceral peritoneum and implant.

Results

The new composite mesh showed the lowest incidence of seroma in the short term. At each time point, the mesh surface covered with adhesions was greater in controls than composites. By day 14, the implants were fully infiltrated by a loose connective tissue that became denser over time. At 90 days, the peritoneal mesh surface was lined with a stable mesothelium. The new composite mesh induced more rapid tissue maturation than Physiomesh^TM, giving rise to a neoformed tissue containing more type I collagen. In Ventralight^TM the macrophage reaction was intense and significantly greater than the other composites at both follow-up times. Tensile strengths were similar for each biomaterial.

Conclusions

All composites showed optimal peritoneal behaviour, inducing good peritoneal regeneration and scarce postoperative adhesion formation. A greater foreign body reaction was observed for Ventralight^TM. All composites induced good collagen deposition accompanied by optimal tensile strength. The three-dimensional macroporous structure of the new composite mesh may promote rapid tissue regeneration within the mesh.

Clinical outcomes of biologic mesh: where do we stand?

After review and evaluation of current clinical data, including significant wound complications, a noteworthy failure rate at 1 year, and high product costs, it is difficult to support the continued use of biologic meshes in incisional hernia repair outside of well-designed and rigorously conducted clinical trials. An industry-sponsored, publicly available registry of biologic prosthetic use for ventral hernia repairs is needed. This straightforward mandate, if properly constructed and implemented, would significantly expand knowledge regarding how these intriguing biomaterials are used and their overall clinical efficacy, thus yielding a more robust basis for the continued use of biologic prosthetics in hernia repair than is currently available.

The safety and usefulness of the single incision, transabdominal pre-peritoneal (TAPP) laparoscopic technique for inguinal hernia

BACKGROUND

The safety and usefulness of the SILS-TAPP (transabdominal pre-peritoneal) procedure remain unclear. The aim of this study was to clarify the safety and usefulness of the SILS-TAPP procedure compared with standard laparoscopic TAPP and TEPP (totally extra-peritoneal pre-peritoneal) procedures.

PATIENTS AND METHODS

85 patients underwent laparoscopic inguinal hernia repairs (TEPP, 30 patients; TAPP, 20 patients; SILS-TAPP, 35 patients) from 2007 to 2011. The operative outcomes of the three groups were compared.

RESULTS

There was no difference in the patients' characteristics among the three groups. The TEPP Group had a longer operation time. One patient in the SILS-TAPP group had an intraoperative complication. One patient in the TAPP group had a postoperative complication, and one patient had ileus and one had an umbilical hernia in the SILS-TAPP group. The postoperative hospital stay was not significantly different among the three groups. There were no recurrences in the TEPP group, 1 case of recurrence (5.0%) in the TAPP group, and 1 case (2.9%) in the SILS-TAPP group.

CONCLUSIONS

The present findings show that the SILS-TAPP repair is safe and feasible for the repair of adult inguinal hernia.

A critical review of biologic mesh use in ventral hernia repairs under contaminated conditions

PURPOSE

We used an evidence-based approach to determine whether the promotions and claims of superiority of biologic mesh over synthetic mesh use in ventral hernia repairs (VHRs) under contaminated conditions were sound and valid.

METHODS

We searched the Medline database to specifically identify review articles relating to biologic mesh and VHR and critically reviewed these studies using an evidence-based approach.

RESULTS

For the past 45 years, four clinical reviews and one systematic review have included biologic meshes as part of a larger discussion on available prosthetics for VHR. All reviews supported biologic mesh use, especially in the setting of contaminated fields. Yet, the primary literature included in these reviews and served as the basis for these conclusions consisted entirely of case series and case reports, which have the lowest level of evidence in determining scientific validity. Furthermore, the FDA has neither cleared nor approved this particular use.

CONCLUSIONS

The cumulative data regarding biologic mesh use in VHRs under contaminated conditions does not support the claim that it is better than synthetic mesh used under the same conditions. The highly promoted and at least moderately utilized practice of placing biologic mesh in contamination is being done outside of the original intended use, and a re-evaluation of or possible moratorium on biologic mesh use in hernia surgery is seriously warranted. Alternatively, an industry-sponsored national registry of patients in whom ventral hernia repairs involved biologic mesh would substantively add to our understanding regarding how these intriguing biomaterials are being used and their overall clinical efficacy.

Is Muscular Atrophy a Contraindication in Laparoscopic Abdominal Wall Defect Repair? A Prospective Study

Laparoscopic surgery for abdominal wall hernias improves short-term results as compared with open hernia surgery. However, no evidence exists to recommend this approach for pseudohernias, which are abdominal wall defects postsurgery caused by denervation and muscular atrophy. The purpose of this study is to analyze whether the laparoscopic approach benefits patients with a pseudohernia. A prospective nonrandomized, single-center clinical study was conducted of 24 patients operated on for pseudohernia. This study was designed with the basic principle of one unit, one surgeon, one mesh, and two techniques (laparoscopic or open double prosthetic repair). The primary end point was assessment of the abdominal wall according to: 1) abdominal perimeter; 2) computed tomography scan; and 3) degree of satisfaction. The secondary end points were intraoperative parameters and comorbidity. Laparoscopy offered no benefits in patients with pseudohernias. Open surgery offered no significant differences in intra- and postoperative morbidity, but if the initial weakness improved with a decrease in abdominal perimeter and visceral content, then there was more than 90 per cent satisfaction ( P < 0.05). The laparoscopic approach does not improve the bulge caused by abdominal muscle atrophy. The option of a muscular and prosthetic reconstruction provides better clinical and cosmetic results.

Comparative analysis of histopathologic effects of synthetic meshes based on material, weight, and pore size in mice

BACKGROUND

While synthetic prosthetics have essentially become mandatory for hernia repair, mesh-induced chronic inflammation and scarring can lead to chronic pain and limited mobility. Mesh propensity to induce such adverse effects is likely related to the prosthetic's material, weight, and/or pore size. We aimed to compare histopathologic responses to various synthetic meshes after short- and long-term implantations in mice.

MATERIAL AND METHODS

Samples of macroporous polyester (Parietex [PX]), heavyweight microporous polypropylene (Trelex[TX]), midweight microporous polypropylene (ProLite[PL]), lightweight macroporous polypropylene (Ultrapro[UP]), and expanded polytetrafluoroethylene (DualMesh[DM]) were implanted subcutaneously in mice. Four and 12 wk post-implantation, meshes were assessed for inflammation, foreign body reaction (FBR), and fibrosis.

RESULTS

All meshes induced varying levels of inflammatory responses. PX induced the greatest inflammatory response and marked FBR. DM induced moderate FBR and a strong fibrotic response with mesh encapsulation at 12 wk. UP and PL had the lowest FBR, however, UP induced a significant chronic inflammatory response. Although inflammation decreased slightly for TX, marked FBR was present throughout the study. Of the three polypropylene meshes, fibrosis was greatest for TX and slightly reduced for PL and UP. For UP and PL, there was limited fibrosis within each mesh pore.

CONCLUSION

Polyester mesh induced the greatest FBR and lasting chronic inflammatory response. Likewise, marked fibrosis and encapsulation was seen surrounding ePTFE. Heavier polypropylene meshes displayed greater early and persistent fibrosis; the reduced-weight polypropylene meshes were associated with the least amount of fibrosis. Mesh pore size was inversely proportional to bridging fibrosis. Moreover, reduced-weight polypropylene meshes demonstrated the smallest FBR throughout the study. Overall, we demonstrated that macroporous, reduced-weight polypropylene mesh exhibited the highest degree of biocompatibility at sites of mesh implantation.

Effect of mesh type and position on subsequent abdominal operations after incisional hernia repair

BACKGROUND

The frequency of subsequent abdominal operations (SAO) and complications attributable to earlier ventral incisional hernia repair (VIHR) are unknown. We examined the effect of repair type and technique on the difficulty and complications of subsequent surgery.

STUDY DESIGN

A cohort of VIHRs at 16 Veterans Affairs hospitals between 1998 and 2002 was examined for postrepair abdominal operation by chart review. The primary independent variable was type and technique of the index VIHR: suture or mesh repair stratified by mesh type and position in relation to abdominal wall musculature. Subsequent surgery characteristics including operative time, inadvertent enterotomy, mesh removal, and length of postoperative stay were determined by chart review. Regression modeling was used to adjust for potential confounding variables.

RESULTS

At a median of 80 months after VIHR in 1,444 patients, 366 (25.3%) experienced SAO. Nearly two-thirds of these involved rerepair of the VIHR with or without a concomitant procedure. Mesh removal was significantly more likely in expanded polytetrafluoroethylene repairs as compared with polypropylene repairs, regardless of technique (odds ratio = 3.6; p = 0.01). On multivariable regression modeling, polypropylene underlay (p = 0.03) and inlay (p = 0.001) and absorbable/biologic mesh (p = 0.05) significantly increased operative time for SAO. Repair type, mesh type, or position had no significant effect on risk of inadvertent enterotomy during the SAO (p≥0.27).

CONCLUSIONS

Subsequent abdominal operations after VIHR are common. Underlay or inlay polypropylene mesh increases SAO operative time, but there was no increased risk of intestinal injury. Earlier repair with expanded polytetrafluoroethylene did not increase operative time, but there was equivalent risk for intestinal injury and increased risk for mesh removal.

Single-incision laparoscopic transabdominal preperitoneal herniorrhaphy for recurrent inguinal hernias: preliminary surgical results

BACKGROUND

Since the early 1990s, laparoscopy has provided surgeons with new and innovative ways to treat various surgical problems. Many of these minimally invasive techniques have gained universal acceptance by demonstrating improved patient outcomes. Single-incision laparoscopic surgery (SILS) was developed with the aim of reducing the invasiveness of traditional laparoscopy. Laparoscopic transabdominal preperitoneal (TAPP) herniorrhaphy via the three-trocar technique is widely used for recurrent inguinal hernia. To the author's knowledge, this report describes first series of SILS TAPP for recurrent inguinal hernia repair.

METHODS

From April 2009 to March 2010, 15 single-incision laparoscopic TAPP repairs of recurrent inguinal hernia were performed by the same surgical team. The data collected prospectively included patient demographics, type of hernia, operative time, complications, postoperative hospital stay, and recurrence. The umbilicus was the sole point of entry for all patients using a single port, and the same operative technique was used in all cases.

RESULTS

The SILS TAPP procedure was performed successfully for all the patients, and none required conversion to an open procedure or a conventional laparoscopic hernia repair by the addition of more entry ports. The mean operative time was 51 ± 17 min. No intra- or postoperative complications were recorded. There was no evidence of early recurrence during a mean follow-up period of 130 ± 77 days.

CONCLUSION

Based on this experience, the author believes that SILS approach is technically feasible and safe using standard and slightly modified instruments for standard TAPP. The cosmetic benefit is clear, but the advantages of SILS TAPP over conventional laparoscopic surgery during long-term follow-up evaluation will require further randomized clinical trials.

Repair of High-Risk Incisional Hernias and Traumatic Abdominal Wall Defects with Porcine Mesh

Complex ventral hernias represent a significant challenge to surgeons. We hypothesized that a wide underlay technique in combination with a novel biologic mesh would result in repair with a low recurrence rate. Medical records of patients undergoing ventral herniorrhaphy with Xen-Matrix biologic mesh were evaluated. All patients were evaluated for hernia recurrence both immediately and after 2 to 3 years. There were 57 patients included in the study. The overall recurrence rate was 7.2 per cent; however, all recurrences were early and were likely technical failures. The average duration of follow-up was 30.6 months with no further recurrences after the early technical failures. The average number of previous recurrences was 1.5. Fascial closure was obtained over the mesh in 84 per cent of patients, with component separation being necessary in 36 per cent of patients. Lack of fascial reapproximation over the mesh was associated with early recurrence (0 vs 55%, P < 0.0001). Complex ventral hernias can be repaired with a low recurrence rate. Our technique in combination with the XenMatrix biologic mesh provides for durable repair. Whenever possible, the fascia should be closed above the underlay mesh, because this technique provides a more durable repair than using the mesh as a “fascial bridge.”

Laparoscopic repair of potentially contaminated abdominal ventral hernias using a xenograft: a case series

BACKGROUND

The aim of this study was to describe the preliminary experience of definitive single stage laparoscopic reconstruction of the abdominal wall utilizing a tissue matrix in a potentially contaminated surgical field.

METHOD

Retrospective review of potentially contaminated ventral hernias repaired with a minimally invasive technique utilizing biological mesh. Reconstruction required the laparoscopic restoration of the midline with or without a minimally invasive component separation technique and reinforcement with a xenograft (Strattice™ Reconstructive Tissue Matrix, LifeCell, Branchburg, NJ).

RESULTS

We describe the first three cases of a xenograft placed laparoscopically in a potentially contaminated ventral hernia. There were no mesh-related complications or early recurrences during short-term 6 month follow-up.

CONCLUSION

Strattice™ Reconstructive Tissue Matrix appears to be a promising new biological matrix for laparoscopic ventral hernia repair, especially in potentially contaminated fields. Further studies and long-term follow-up are still required.

Effects of mast cell modulation on early host response to implanted synthetic meshes

INTRODUCTION

Mast cells (MCs) and their products (e.g., histamine, serotonin, heparin, prostaglandins, cytokines, etc.) play key roles in controlling local inflammation, wound healing, and foreign body reactions in vivo. Investigation of the role of MCs in mediating local tissue responses to synthetic hernia meshes has been very limited to date. We aimed to determine the effects of MCs/MC products in mice undergoing synthetic mesh implantation.

MATERIALS AND METHODS

Circular samples (5 mm) of heavyweight microporous polypropylene (Trelex), midweight microporous polypropylene (ProLite), lightweight macroporous polypropylene with poliglecaprone (Ultrapro), and 3-dimensional macroporous polyester (Parietex) meshes were implanted subcutaneously in C57BL/6 J mice with and without cromolyn (MC stabilizer/suppressant) treatment (50 mg/kg, daily IP). Two weeks post-implantation, all meshes were explanted and evaluated histologically using H&E and trichrome stains.

RESULTS

Chronic inflammation was focused around individual mesh fibers; inter-fiber inflammation and fibrosis diminished as mesh porosity increased. MC accumulation was seen at the periphery of inflammatory reactions, and in association with mesh-induced fibrosis and neovascularization. Cromolyn treatment resulted in significantly decreased fibrotic responses to all four meshes and reduced inflammation induced by Trelex, ProLite, and Parietex meshes but not Ultrapro.

CONCLUSION

We demonstrated that MCs play important roles in mesh-induced host tissue reactions. Blocking MC degranulation decreased early inflammation and fibrosis induced by most synthetic meshes in this study. Further evaluation and understanding of the role of MCs in mesh-induced tissue reactions will provide new therapeutic approaches to enhance the biocompatibility of surgical meshes and ultimately improve clinical outcomes in patients undergoing hernia repair with synthetic biomaterials.

[Evaluation of a clinical pathway of the inguinal hernia repair in a general surgery service]

OBJECTIVE

The objective of this work is to assess the level of implementation of an inguinal hernia clinical pathway and its impact on the patient satisfaction.

MATERIAL AND METHOD

An inguinal hernia repair clinical pathway was introduced in our service in January 2008. We studied all patients included in the clinical pathway since its introduction. The evaluation variables included: level of implementation, indicators of effectiveness in clinical care, and indicators of satisfaction based on a questionnaire.

RESULTS

During the first year of introducing the clinical pathway we operated on 582 patients for hernia repair. We excluded 85 cases (14.6%) from the study, due to not fulfilling the inclusion criteria. The study was finally conducted with 497 patients, 49 (9.8%) women and 448 (90.2%) men. The mean age of these patients was 56.6 (21-88) years old. A right hernia repair was performed on 273 cases (54.3%) and 224 (45.7% on the left hernia. In 473 (95.2%) it was a primary hernia and a recurrence in 24 (4.8%). In 441(88.7%) it was a unilateral hernia and 56 (11.3%) a bilateral hernia. The mean length of hospital stay was 1.1 (1-119) days. The level of compliance with length of hospital stay was 96.8%. The level of compliance with surgical prevention was 87.7%. Level of document management by the nursing staff was 86.5% and for doctors it was 80,7%. Overall morbidity was 6%. The informed consent was correctly executed in 97,8% of the cases and 98.6% of patients were given a final report on the day of leaving hospital. A total of 369 satisfaction questionnaires were collected, which was a response rate of 74.2%. Almost all (96%) patients were satisfied with the received information, 87.6% said their pain was managed correctly, and 81% found stay appropriate, and 95% said their hospital stay was between acceptable and good. The level of satisfaction with the care received was 97.5%, and 97.4% of the patients studied would recommend the hospital to a friend or family.

CONCLUSION

The introduction of a clinical pathway for inguinal hernia repair has led to a good integration, the services involved in the same. Patients have expressed a high level of satisfaction with the service received, but there are aspects that we must improve: in the information and communication with the patient, the action protocols, evaluation criteria, the VC ¿clinical pathway? Registers, and the satisfaction survey model.

Endoscopic versus open component separation in complex abdominal wall reconstruction

BACKGROUND

Open component separation has a high wound complication rate. Newer endoscopic approaches are described with no comparative trials.

METHODS

A retrospective review (2005-2009) of patients undergoing open or endoscopic component separation was performed.

RESULTS

Forty-four cases were identified (22 endoscopic; 22 open). All perioperative variables were the same except age (65 open vs 55 endoscopic; P<.05). Hospital length of stay was 11 days in the open group versus 8 days in the endoscopic group (P=.09). Wound complications were 52% in the open group versus 27% in the endoscopic group (P=.09). Wound-related interventions occurred in 45% of the open group and 33% of the endoscopic group. Hernia recurrences rates were similar (open, 32%; endoscopic, 27%; P=.99).

CONCLUSIONS

Open and endoscopic components separation have similar rates of recurrence. The endoscopic group had shorter lengths of stay and less major wound complications. The endoscopic approach may be the ideal technique for complex abdominal wall reconstruction.

Human monocyte activation by biologic and biodegradable meshes in vitro

BACKGROUND

Inflammation and wound healing play critical roles in the integration of biologic and biodegradable meshes (BMs) at hernia repair sites. Monocytes/macrophages (M/MØs) are key cells controlling inflammation and wound healing. These cells release inflammatory cytokines and growth factors such as interleukin (IL)-1beta, IL-6, IL-8, and vascular endothelial growth factor (VEGF) upon activation. Although BMs have been increasingly used in hernia repairs worldwide, to date, investigations of inflammatory responses to various BMs have been limited.

METHODS

Mesh samples of three acellular human dermis-derived biologic meshes (AlloDerm, AlloMax, FlexHD) and one biodegradable synthetic mesh (Bio-A) were placed in 96-well plates. Human peripheral blood mononuclear cells (PBMCs) were isolated from six healthy subjects, added to each well, and incubated for 7 days. Culture supernatants were assayed for IL-1beta, IL-6, IL-8, and VEGF levels using a multiplex bead-base immunoassay system (Bio-Plex).

RESULTS

All four meshes induced cytokine expression from activated M/MØs to varying degrees in vitro. FlexHD induced significantly more IL-1beta (2,591 pg/ml) than AlloMax (517 pg/ml), AlloDerm (48 pg/ml), or Bio-A (28 pg/ml) (p < 0.001). AlloMax stimulated a significantly greater quantity of IL-6 (38,343 pg/ml) than FlexHD (19,317 pg/ml), Bio-A (191 pg/ml), or AlloDerm (103 pg/ml) (p < 0.05). Interleukin-8 and VEGF displayed trends similar to that of IL-6. There were no significant differences in cytokine production between AlloDerm and Bio-A.

CONCLUSION

This study demonstrated that human macrophages are activated by human dermis-derived biologic and biodegradable meshes in vitro. A wide range of cytokine and growth factor induction was seen among the different mesh products. These differences in M/MØ activation may be related to the proprietary processing technologies of the studied meshes. The study results raise the possibility that these differences in M/MØ activation could indicate varying intensities of inflammation that control integration of different biologic meshes at the sites of hernia repair.