Laparoscopic repair of ventral / incisional hernias

Factors predicting prolonged hospitalization after abdominal wall hernia repair - a prospective observational study

Objective: The aim of this study was to identify the factors predicting prolonged hospitalization following abdominal wall hernia repair.

Material and Methods: This was a prospective observational study which included patients operated for elective and emergency abdominal wall hernias. Details of the patients including demographic profile, hernia characteristics, and perioperative factors were collected. Patients were followed up till discharge from the hospital to record the postoperative local and systemic complications. Patients who stayed for more than three days were considered as longer hospital stay. Analysis was performed to identify factors associated with the longer hospital stay.

Results: A total of 200 consecutive patients of abdominal wall hernia were included over a period of two years. Female sex (p< 0.05), obesity (p= 0.022), and smoking and alcohol consumption (0.002) led to a prolonged hospital stay. Patients with incisional hernias (p< 0.05), American Society of Anesthesiologists (ASA) class of two or more (p= 0.002), complicated hernia (p= 0.007), emergency surgeries (p= 0.002), general anesthesia (p= 0.001), longer duration of surgery (>60 minutes, p< 0.05), usage of drain (p< 0.05), and surgical site infection (SSI, p= 0.001) were significantly associated with increased length of hospital stay. Whereas, age distribution, socio-economic status, co-morbidities, recurrent surgery, type of hernia repair and the level of surgeon did not affect the length of hospital stay.

Conclusion: The risk factors associated with prolonged hospital stay in patients undergoing abdominal wall hernia repair were female sex, obesity, smoking and alcoholism, incisional hernia, complicated hernias, higher ASA class, and prolonged duration of surgeries.

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.

Risk factors for the development of flank hernias and bulges following surgical flank approaches to the kidney in adults

Objectives

To evaluate the incidence and risk factors for the development of flank incisional hernias or bulges following surgical flank approaches to the kidney.

Patients and methods

In all, 100 consecutive adult patients who underwent variable renal surgeries via flank approaches were included in this prospective study. The incidence and risk factors for flank hernias and bulges were studied at 1- and 6-months postoperatively.

Results

At 6 months postoperatively, the incidence of flank bulge was 14% and for lumbar hernia was 10%. The univariate analysis showed 13 significant factors to be associated with the occurrence of a flank bulge or hernia following flank incisions. When the significant risk factors in the univariate analysis were studied by multivariate analysis, using a logistic regression analysis, four independent risk factors were identified. These were: body mass index (BMI) ≥26.3 kg/m² (P = 0.04), the use of a self-retaining retractor during surgery (P = 0.02), not preserving or identifying the neurovascular bundle (NVB) during surgery (P = 0.028), and postoperative abdominal distention (P = 0.001). Moreover, all cases included in our study who underwent en masse wound closure, developed surgical wound infection or who had constipation developed postoperative flank bulge or hernia.

Conclusion

High BMI, the use of self-retaining retractor, not identifying or preserving the NVB, postoperative abdominal distention, en masse wound closure, surgical wound infection, and constipation are significant risk factors associated with postoperative flank hernia and bulge.

Comparison of mesh fixation devices for laparoscopic ventral hernia repair: an experimental study on human anatomic specimens

BACKGROUND

As there is a lack of clarity in terms of the tensile strength of mesh fixation for laparoscopic ventral hernia repair (LVHR), our aim was to investigate the immediate tensile strength of currently available mesh fixation devices on human anatomic specimens.

METHODS

Sixteen recently deceased body donators (mean body mass index of 24.4 kg/m²) were used to test the immediate tensile strength (Newton) of 11 different LVHR mesh fixation devices.

RESULTS

Each of the 11 different laparoscopic fixation devices was tested 44 times. Non-articulating tackers provided higher fixation resistance to tensile stress in comparison to articulating tackers (5.1-mm ReliaTack™: 16.9 ± 8.7 N vs. 12.2 ± 5.6 N, p = 0.013; 7-mm ReliaTack™: 19.8 ± 9.4 N vs. 15.0 ± 7.0 N, p = 0.007). Absorbable tacks with a greater length, i.e. ≥6 mm (7-mm ReliaTack™, 6-mm SorbaFix™ and 7.2-mm SecureStrap™) had significantly higher fixation tensile strength than tacks with a shorter length, i.e. < 6 mm (5.1-mm ReliaTack™ and 5.1-mm AbsorbaTack™) (p < 0.001). Furthermore, transfascial sutures (PDS 2-0 sutures 26.3 ± 5.6 N) provided superior fixation tensile strength than 5.1-mm AbsorbaTack™ (13.6 ± 7.3 N) and cyanoacrylate glues such as LiquiBand FIX8™ (3.5 ± 2.4 N) (p < 0.001, respectively). There was a significant deterioration in fixation capacity in obese body donators with a body mass index > 30 kg/m² (13.8 ± 8.0 vs. 17.9 ± 9.7 N, p = 0.044).

CONCLUSIONS

Although articulating laparoscopic tackers improve accessibility and facilitate the utilization of tacks within the fixation weak spot adjacent to the trocar placement, an articulating shaft that is not ergonomic to use may limit mechanisms of force transmission. For mesh fixation in LVHR, transfascial sutures and tacks with a longer length provide better immediate fixation tensile strength results.

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 ventral incisional hernia repair: evidence-based guidelines of the first Italian Consensus Conference

PURPOSE

The laparoscopic treatment of ventral incisional hernias is the object of constant attention and is becoming increasingly widespread in the international scientific-surgical community; however, there is ample debate on its technical details and indications. In order to establish a common approach on laparoscopic ventral incisional hernia repair, the first Italian Consensus Conference was organized in Naples (Italy) on 14-15 January 2010.

METHODS

The format of the Consensus Conference was freely adapted from the standards of the National Institute of Health and the Italian Health Institute. The parties involved included the followings: a Promotional Committee, a Scientific Committee, a group of Experts, the Jury Panel and a Scientific Secretariat.

RESULTS

Eleven statements, regarding three large chapters on the indications, the technical details and the management of complications were drafted on the basis of literature references collected by the Scientific Committee, documents developed by the Experts, reports presented and discussed during the Consensus Conference, and discussion among the members of the Jury.

CONCLUSIONS

The laparoscopic approach is safe and effective for defects larger than 3 cm in diameter; old age, obesity, previous abdominal operations, recurrence and strangulation are not absolute contraindications. Ensuring an adequate overlap, careful adhesiolysis and correct fixing of the prosthesis are among the technical details recommended. Complications and recurrences are comparable to, and in some cases, less numerous than with the open approach.

Laparoscopic repair of suprapubic hernias: transabdominal partial extraperitoneal (TAPE) technique

BACKGROUND

Suprapubic hernias are considered difficult to repair laparoscopically due to deficient posterior rectus sheath and proximity to important neurovascular structures and the urinary bladder.

METHODS

We retrospectively reviewed 72 patients (18 males, 54 females) who, between 1998 and 2008, had undergone laparoscopic repair for suprapubic hernial defects located less than 5 cm from the pubic arch. Five patients (6.9%) had recurrent hernias. A peritoneal flap was dissected distally to facilitate a mesh overlap of at least 5 cm from the hernial defect. The lower margin of the mesh was fixed under direct vision to Cooper's ligaments bilaterally. The raised peritoneal flap was reattached to the anterior abdominal wall thereby partially extraperitonealizing the mesh.

RESULTS

Mean diameter of the hernial defect was 5.2 cm (range=3.1-7.3 cm) as measured intraperitoneally. Mean size of the mesh used was 328.8 cm2 (range=225-506 cm2). Mean operating time was 116 min (range=64-170 min). Overall complication rate was 27.8%. There were no conversions. No recurrences were observed at a mean follow-up of 4.8 years (range=1.2-6.9 years) and a follow-up rate of 84.7%

CONCLUSION

A mesh overlap of at least 5 cm and fixation of the lower margin of the mesh under direct vision to Cooper's ligaments appears to confer increased strength and durability and contribute to low hernia recurrence rates in patients with suprapubic hernias.