Atypical Hernias

Laparoscopic Ventral Hernia Repair

The laparoscopic approach to ventral hernia repair is a safe and effective approach for both elective and emergent repair. The preoperative technical considerations include assessment of incarceration and potential for extensive adhesiolysis, size of defect, and atypical hernia locations. Preoperative considerations include weight loss and lifestyle modification. There are multiple methods of fascial defect closure and mesh fixation that the surgeon may consider via a laparoscopic approach, making it adaptable to varying clinical scenarios and anatomic challenges. Compared with open repair laparoscopic repair is associated with reduced surgical wound site infection, and compared with robotic repair outcomes are similar.

[Results of abdominal wall closure using the 4:1 suture/wound lenght technique]

Background

Laparotomy is a daily procedure for the general surgeon and its main complication is the formation of hernias.

Objective

To determine if the suture length to wound length ratio 4:1 for wall closure decreases the incidence of hernia.

Material and methods

Data from patients (n = 86) in whom abdominal wall closure was performed from August 2017 to January 2018 were prospectively reviewed. Patients who could not undergo adequate follow-up, those managed with open abdomen, or those with use of non-absorbable suture materials were excluded. 2 groups were formed: in one, the suture length to wound length ratio 4:1 technique was used as wall closure, and in the other it was used conventional suture; the length of the wound-suture length was measured, and the follow-up was post-surgical. For statistical analysis it was used descriptive statistics and inferential statistics (chi-squared and Mann-Withney's U).

Results

The 2 groups had similar characteristics in all the inclusion criteria. There was a statistically significant difference in dehiscence and hernias. For both complications, the 4:1 suture is a protective factor. For the first it was obtained: p = 0.000, relative risk (RR) 0.114 with 95% confidence interval (95% CI) 0.030-0.437, and for the second, p = 0.000, RR .091, 95% CI 0.027-0.437.

Conclusions

Abdominal wall closure using 4:1 suture/wound length was shown to decrease the incidence of hernia.

Primary Petit Hernia: From Diagnosis to Open Surgical Approach

Lumbar hernias are quite rare, even more so when primary or of spontaneous nature. These defects in the lumbar region demand a comprehensive knowledge of the anatomy of the lateral abdominal wall and paraspinal muscles. Given the proximity of bone structures, they can pose a surgical challenge when trying to achieve an ideal dissection and appropriate mesh overlap. The authors report the case of a primary Petit's hernia that underwent an open anterior surgical approach with the use of a preperitoneal mesh. In addition to the described surgical technique, the article also aims to detail the diagnosis and anatomic classification of this rare pathology.

[Management of lateral abdominal wall hernias]

Lateral abdominal wall hernias are rare and inconsistently defined, which is why the use of the European Hernia Society classification makes sense, not least for the purpose of comparing the quality of surgical results. A distinction must be made between true fascial defects and denervation atrophy. Based on the available literature, there is generally a low level of evidence with no consensus on the best operative strategy. The proximity to bony structures and the complex anatomy of the three-layer abdominal wall make the technical treatment of lateral hernias difficult. The surgical variations include laparoendoscopic, robotic, minimally invasive, open or hybrid approaches with different mesh positions in relation to the layers of the abdominal wall. The extensive preperitoneal mesh reinforcement open, transabdominal peritoneal (TAPP) laparoscopic repair or total extraperitoneal (TEP) endoscopic repair has met with the greatest approval. The extent of the required medial mesh overlap is determined by the distance between the medial defect boundary and the lateral edge of the straight rectus abdominus muscles. The medially directed preperitoneal and retroperitoneal dissection can be extended into the homolateral retrorectus compartment by laterally incising the posterior rectus sheath or by crossing the midline behind the intact linea alba into the contralateral retrorectus compartment. The intraperitoneal onlay mesh (IPOM) technique is a suitable procedure only for smaller defects with possible defect closure but it is also important as an exit strategy in the case of a defective peritoneum. Individualized prehabilitative and preconditioning measures are just as important as the assessment of preoperative anamnestic and clinical findings and risks with radiographic cross-sectional imaging diagnostics.

ROBOTIC TRANS-ABDOMINAL PREPERITONEAL APPROACH (TAPP) APPROACH FOR LATERAL INCISIONAL HERNIAS

Background:

Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as multiple nearby bony structures and paucity of aponeurotic tissue that make it particularly challenging to repair.

Aim:

To describe a robotic assisted surgical technique for incisional lumbar hernia repair.

Methods:

Retrospective data was collected from four patients who underwent robotic-assisted repair of their lumbar hernias after open nephrectomies.

Results:

Age ranged from 41-53 y. Two patients had right sided flank hernias while the other two on the left. One patient had a recurrent hernia on the left side. The patients were placed in lateral decubitus position contralateral to the hernia defect side. A trans-abdominal preperitoneal approach was used in all cases. Each case was accomplished with two 8 mm robotic ports, a 12 mm periumbilical port, and a 5 mm assistance port that allowed docking on the ipsilateral hernia side. The hernias were identified, a preperitoneal plane was created, and the hernia sac completely dissected allowing for complete visualization of the defect. All defects were primarily closed. Polypropylene or ProGrip^TM mesh was applied with at least 5 cm overlap and secured using either #0 Vicryl^® transfacial sutures, Evicel^® or a combination of both. The peritoneal space was closed with running suture and the ports were removed and closed. The average surgical length was 4 hr. The post-operative length of stay ranged from 0-2 days.

Conclusion:

The robotics platform may provide unique advantages in the repair of lateral incisional hernias and represents a safe, feasible and effective minimally invasive approach for the correction of lateral incisional hernias.

Comparative analysis of 2 surgical techniques in the treatment of subxiphoid incisional hernia. Observational study

INTRODUCTION

The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears. The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years, especially postoperative complications and the recurrence rate.

METHODS

It is an observational, retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit. We analysed the comorbidities, surgical techniques (preperitoneal hernia repair or TP, and adjusted double mesh technique) and postoperative variable, especially the hernia recurrence. The postoperative complications were summarized flowing the Clavien-Dindo classification.

RESULTS

42 patients were operated: 22 (52,4%) TP and 20 (47,6%) adjusted double mesh technique. All the complications registered were minor (grade I) and it appeared mostly in TP group (P = .053). The average follow up was 25.8 ± 15.1 months; there were no statistically significant differences in hernia recurrence comparing two treatment groups (P = .288).

CONCLUSIONS

According to our results, TP is the ideal technique to repair a subxiphoid incisional hernia. Adjusted double mesh technique may represent an effective approach with a low complication rate, although globally analyzing the recurrence rate, aponeurosis closure over the preperitoneal mesh entails less impact on it.

Comparative analysis of 2 surgical techniques in the treatment of subxiphoid incisional hernia. Observational study

INTRODUCTION

The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears. The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years, especially postoperative complications and the recurrence rate.

METHODS

It is an observational, retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit. We analysed the comorbidities, surgical techniques (preperitoneal hernia repair or TP, and adjusted double mesh technique) and postoperative variable, especially the hernia recurrence. The postoperative complications were summarized flowing the Clavien-Dindo classification.

RESULTS

42 patients were operated: 22 (52,4%) TP and 20 (47,6%) adjusted double mesh technique. All the complications registered were minor (grade I) and it appeared mostly in TP group (P=.053). The average follow up was 25.8±15.1 months; there were no statistically significant differences in hernia recurrence comparing two treatment groups (P=.288).

CONCLUSIONS

According to our results, TP is the ideal technique to repair a subxiphoid incisional hernia. Adjusted double mesh technique may represent an effective approach with a low complication rate, although globally analyzing the recurrence rate, aponeurosis closure over the preperitoneal mesh entails less impact on it.

Robotic assisted treatment of flank hernias: case series

BACKGROUND

Flank hernias are uncommon, surgical treatment is challenging and the minimally-invasive approach not always feasible. The aim of this study was to report the safety and feasibility of the robotic-assisted repair.

METHODS

The study was approved by the local ethic committee (2019-01132 CE3495). A retrospective search on a prospectively collected dataset including demographic and clinical records on robotic surgery at our institution was performed to identify patients treated for a flank hernia. Patients were followed-up 6 months.

RESULTS

From January 2018 to December 2019, out of 190 patients who underwent robotic-assisted hernia surgery, seven with incisional flank hernia were included. Median age was 69.0 years (IQR 63.2-78.0), BMI was 27.3 kg/m² (IQR 25.8-32.3) and two patients were male (29%). All patients were referred to surgery because of pain, whereas one of them described recurrent episodes of small bowel obstruction. The median hernia defect measured 25 mm ((IQR 21-40), median mesh diameter was 10 cm (IQR 10-12.5) and median operative time was 137 min (IQR 133-174). No intraoperative complication occurred. Postoperatively, one patient developed a pneumonia, which required antibiotics. Length of hospital stay was 4.0 days (IQR 3.0-7.7). Six months after surgery, neither recurrence nor chronic pain were recorded.

CONCLUSIONS

Robotics in abdominal wall hernia surgery remains a matter of debate, despite a growing interest from the surgical community. In our reported experience with flank hernias, we found the robotic-assisted approach to be safe and feasible for the treatment of this uncommon clinical entity.

EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances

Background

Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management.

Methods

The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed.

Results

Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence.

Conclusion

This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.

Application of the novel enhanced transabdominal preperitoneal (ETAP) technique for laparoscopic suprapubic incisional hernia repair

Suprapubic incisional hernia is a special type of incisional hernia, the optimal choice of surgery for which remains controversial. Inspired by advantages of laparoscopic incisional hernia repair and inguinal hernia repair, we developed a novel laparoscopic surgery procedure for suprapubic incisional hernia repair: the enhanced transabdominal preperitoneal (ETAP) technique. To create a peritoneal flap, the peritoneum was dissected from 2 cm above the abdominal wall defect to 2 cm below the pubic arch, then the hernia defect was closed with a full-thickness transabdominal suture. Following the position of mesh to cover the defect with an 5-cm overlap on all sides, the peritoneal flap was closed with continuous suture. In this study, a total of 57 patients with suprapubic incisional hernia underwent laparoscopic ETAP. The mean hernia size was 61.5 cm², the average mesh size was 173.6 cm², the mean operating time was 90 min, the mean blood loss was 34 cc, and the average hospital stay was 2.6 days. In the follow-up period, which ranged from 12 to 45 months, the overall incidence of complications was 17.86%. Six patients developed seroma without herniation, six patients suffered from obvious postoperative pain, and four patients experienced urinary retention. All complications resolved without treatment. No recurrence was observed. In conclusion, the laparoscopic ETAP technique contributes to reduced rates of suprapubic incisional hernia repair and mesh-induced complications.

Evaluation of the effects of absorbable and nonabsorbable tacks on laparoscopic suprapubic hernia repair: A retrospective cohort study

BACKGROUND

The contradictory results of fixation methods concerning the pubic region are an obstacle to define a standardized procedure for laparoscopic repair of suprapubic hernia (LRSPH). This study aims to evaluate the effects of different tacks on LRSPH.

MATERIALS AND METHODS

Seventy-three patients (70 females, three males) with suprapubic hernia were admitted and had LRSPH. Absorbable tacks were used in 42 (57.5%) patients (AG group), whereas nonabsorbable tacks were used in 31 (42.5%) patients (NAG group). Patient characteristics and demographics, previous operations, previous hernia repairs, size of the defect, size of the mesh, type of the mesh, type of the tacks, operative time, conversion rate, complications, recurrences, follow-up time, numeric pain rating scale (NRS), prolonged use of analgesics and early termination of analgesics were evaluated as variables.

RESULTS

NRS results were significantly lower in the AG group regarding the postoperative day one (p < 0.001) and 10 (p:0.004), whereas there was no statistically significant difference on postoperative sixth week. Prolonged use of analgesics was significantly higher in NAG, whereas early termination of analgesics was significantly higher in AG (p < 0.001). There was no patient with complaints of pain that restricted daily activities on sixth month and the following annually visits.

CONCLUSION

Absorbable tacks had satisfactory results with a reduction of pain and lower rates of using analgesics. However, considering the similar results of groups on long-term follow-up, it would be inaccurate to explain this situation with the property of absorption. Although the failure of attempts to bony structures during fixation with absorbable tacks could explain the lack of deep penetration, further studies are required to verify this view.

A New Approach to an Old Technique—The S.U.T.R. First Technique

Ventral and incisional hernias of the abdominal wall are common problems treated by surgeons around the globe. Incisional hernias are common postoperative complications of abdominal laparotomies with a reported incidence of up to 20 per cent. The increasing use of prosthetic mesh in open ventral hernia repairs necessitated the development of different operative techniques used in the repairs. It also required that surgeons become facile with placement of the mesh in different anatomical positions on the abdominal wall. One of the most common locations is placement of the mesh in the underlay position. Many surgeons who use the underlay technique have expressed significant concerns. Among these are fear of an inadvertent bowel injury while placing the mesh, poor visualization during mesh placement, and the inability to use the underlay technique for difficult hernias. We present a very useful, if not, novel technique of open hernia repair using mesh in the underlay position that helps to 1) prevent complications, 2) facilitate easier mesh fixation, 3) simplify open repair of atypical ventral hernias, and 4) reduce total operative time while still adhering to the important fundamental principles of a tension-free hernia repair. This technique as we describe it has been compared with the old parachute technique, but we think this is a significant improvement of that seldom used technique. We believe the use of this technique for the underlay position makes open ventral hernia repair safer, faster, and easier; however, our goal for this article is to describe the procedure in detail. In addition, we recently have started using this technique to fix the mesh when doing the retrorectus approach as well.

Laparoscopic repair of large suprapubic hernias

INTRODUCTION

Suprapubic hernia is the term to describe ventral hernias located less than 4 cm above the pubic arch in the midline. Hernias with an upper margin above the arcuate line encounter technical difficulties, and the differences in repair methods forced us to define them as large suprapubic hernias.

AIM

To present our experience with laparoscopic repair of large suprapubic hernias that allows adequate mesh overlap.

MATERIAL AND METHODS

Nineteen patients with suprapubic incisional hernias who underwent laparoscopic repair between May 2013 and January 2015 were included in the study. Patients with laparoscopic extraperitoneal repair who had a suprapubic hernia with an upper margin below the arcuate line were excluded.

RESULTS

Two men and 17 women, with a mean age of 58.2, underwent laparoscopic repair. Most of the incisions were midline vertical (13/68.4%). Twelve (63.1%) of the patients had previous incisional hernia repair (PIHR group); the mean number of previous incisional hernia repair was 1.4. Mean defect size of the PIHR group was higher than in patients without previous repair - 107.3 cm² vs. 50.9 cm² (p < 0.05). Mean operating time of the PIHR group was higher than in patients without repair - 126 min vs. 77.9 min (p < 0.05). Although all complications occurred in the PIHR group, there was no statistically significant difference.

CONCLUSIONS

Laparoscopic repair of large suprapubic hernias can be considered as the first option in treatment. The low recurrence rates reported in the literature and the lack of recurrence, as observed in our study, support this view.

Standard of Open Surgical Repair of Suprapubic Incisional Hernias

BACKGROUND

Suprapubic incisional hernias (SIH) are a rare wall defect, whose surgical management is challenging because of limited literature. The proximity of the hernia to bone, vascular, nerve, and urinary structures, and the absence of posterior rectus sheath in this location imply adequate technique of surgical repair. We aimed to describe a cohort of female patients operated on for SIH after gynecological surgery using a homogeneous surgical technique and to report surgical outcomes.

METHODS

The records of all consecutive patients operated on for SIH in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh placed inferiorly in the preperitoneal space of Retzius, with large overlap, and fixed on the Cooper's ligaments, through the muscles superiorly and laterally with strong tension, in a sublay or underlay position.

RESULTS

The cohort included 71 female patients. SIH were recurrent in 31% of patients and was related to cesarean in 32 patients (45.1%) and to gynecologic surgery in 39 patients (54.9%). The mesh was totally extraperitoneal in 76.1% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 29.6%. After a median follow-up of 30.3 months, the recurrence rate was 7%.

CONCLUSION

The open approach for SIH repair was safe and efficient. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of SIH surgical management.

Posterior Component Separation with Transversus Abdominis Release: Technique, Utility, and Outcomes in Complex Abdominal Wall Reconstruction

BACKGROUND

Ventral hernia formation is a frequent and increasingly difficult problem. Nonmidline hernias, parastomal hernias, hernias near bony landmarks, and recurrent ventral hernias (especially after anterior component separation) present particular challenges. Typical reconstructive techniques may struggle to reestablish abdominal domain and to create a lasting repair. Posterior component separation with transversus abdominis release is a novel technique that offers a durable solution to a variety of complex ventral hernias.

METHODS

The posterior rectus sheath is incised and the retrorectus plane is developed. In a modification of the Rives-Stoppa technique, the transversus abdominis is released medial to the linea semilunaris to expose a broad plane that extends from the central tendon of the diaphragm superiorly, to the space of Retzius inferiorly, and laterally to the retroperitoneum. This preserves the neurovascular bundles innervating the medial abdominal wall. Mesh is placed in a sublay fashion above the posterior layer. In an overwhelming majority of patients, the linea alba is reconstructed, creating a functional abdominal wall with wide mesh reinforcement.

RESULTS

The technique is reliable and durable, with a 5 percent recurrence rate at 2 years. Although wound complications occur with a frequency similar to that of other techniques, they tend to be less severe, rarely requiring operative débridement. The technique is applicable to a broad range of hernias, including midline, parastomal, flank, subcostal, and recurrent hernias after prior component separations.

CONCLUSION

Posterior component separation with transversus abdominis release is a versatile, easy-to-learn technique of hernia repair that offers a reliable, durable solution to complex abdominal wall reconstruction.

Lateral Abdominal Wall Defects: The Importance of Anatomy and Technique for a Successful Repair

Flank and lateral abdominal wall defects can be an extremely challenging phenomenon for surgeons to undertake. Their rarity and specific idiosyncrasies in regard to embryologic and anatomical characteristics must be taken into consideration when formulating an operative plan. We will discuss these cardinal points including technical recommendations by notable experts in the field to gain a better understanding in the diagnosis and treatment of this infrequent but morbid occurrence.

A rare nonincisional lateral abdominal wall hernia

A 68-year-old woman presented a rare lateral abdominal wall hernia. Three month before admission to Chungbuk National University Hospital, she found a large protruding mass measuring 8 cm in diameter in the midaxillary line just below the costal margin upon heavy coughing. She had no history of abdominal trauma, infection, or operation previously. The mass was easily reduced manually or by position change to left lateral decubitus. CT scan showed a defect of the right transversus abdominis muscle and internal oblique muscle at the right flank with omental herniation. Its location is different from that of spigelian hernia or lumbar hernia. The peritoneal lining of the hernia sac was smooth and there was no evidence of inflammation or adhesion. The hernia was successfully repaired laparoscopically using Parietex composite mesh with an intraperitoneal onlay mesh technique. The patient was discharged uneventfully and did not show any evidence of recurrence at follow-up visits.