Safety and efficacy of laparoendoscopic single-site surgery for abdominal wall hernias

Return to Work Following Isolated Opening Wedge High Tibial Osteotomy

PURPOSE

Patients with isolated medial compartment osteoarthritis and varus deformity may undergo high tibial osteotomy (HTO) to reduce the contact pressure in the medial compartment. The purpose of this investigation is (1) examine the timeline of return to work (RTW) following HTO and (2) evaluate RTW stratified by occupational intensity.

METHODS

Consecutive patients undergoing HTO were reviewed retrospectively at a minimum of 2-years postoperatively. Patients completed a subjective work questionnaire, a visual analogue scale for pain, Single Assessment Numerical Evaluation, and a satisfaction questionnaire.

RESULTS

Thirty-eight patients were included at an average of 9.0 ± 3.3 years postoperatively. Thirty-seven patients (average age 43.4 ± 7.8 years, 91.9% with a Kellgren-Lawrence grade of III/IV) were employed within 3 years prior to surgery. Eighteen patients (48.6%) underwent subsequent surgery with 14 patients (37.8%) receiving a salvage knee arthroplasty at an average of 6.1 ± 3.5 years following HTO. Thirty-five patients (94.5%) returned to work at an average of 2.9 ± 2.0 months. The rate of RTW for sedentary, light, moderate, and heavy duties were 87.5%, 100%, 100%, and 93.3%, respectively, while the duration until RTW was 1.0 months, 1.1 months, 2.4 months, and 3.3 months, respectively.

CONCLUSION

In a young and active population with osteoarthritis or varus deformity, an HTO allows patients to return to work; however, patients with high-intensity occupations may be absent from work longer than those with lesser physically demanding occupations. HTO is not a definitive treatment option as nearly 40% of patients underwent knee arthroplasty by 6.1 years postoperatively.

LEVEL OF EVIDENCE

IV, case series.

Single-incision laparoscopic repair of Spigelian hernia

Introduction:

Spigelian hernias represent only 1% to 2% of all abdominal wall hernias. The treatment, however, remains controversial but depends on institutional expertise. This case series reports the first experience with single-incision laparoscopic totally extraperitoneal (SILTEP) repair of Spigelian hernias with telescopic extraperitoneal dissection in combination with inguinal hernia repair.

Methods:

From February 2013 to April 2014, all patients referred with inguinal or Spigelian hernias, without histories of extraperitoneal intervention, underwent SILTEP repair with telescopic extraperitoneal dissection. A single-port device, 5.5 mm/52 cm/30° angled laparoscope, and conventional straight dissecting instruments were used for all cases. Extraperitoneal dissection was performed under direct vision with preservation of preperitoneal fascia overlying retroperitoneal nerves. Inguinal herniorrhaphy was performed with lightweight mesh that covered low-lying Spigelian defects. High-lying Spigelian defects were repaired with additional mesh.

Results:

There were 131 patients with 186 (92 direct) inguinal hernias and 7 patients with 8 Spigelian hernias (6 incidental, including 1 bilateral and 2 preoperatively diagnosed), with a mean age of 51.3 years and a mean body mass index of 25.1 kg/m². An additional piece of mesh was used for 3 hernias. All Spigelian hernias were associated with direct inguinal hernias, and 8 combined inguinal and Spigelian hernias were successfully repaired with SILTEP repair with telescopic extraperitoneal dissection as day cases. There were no clinical recurrences during a mean follow-up period of 6 months (range, 1–15 months).

Conclusions:

Combined Spigelian and inguinal hernias can be successfully treated with SILTEP herniorrhaphy with telescopic extraperitoneal dissection. The high incidence of Spigelian hernias associated with direct inguinal hernias suggests a high index of suspicion for Spigelian hernias during laparoscopic inguinal herniorrhaphy.

Single-incision laparoscopic intraperitoneal onlay mesh repair for the treatment of multiple recurrent inguinal hernias

Introduction:

Despite an exponential rise in laparoscopic surgery for inguinal herniorrhaphy, overall recurrence rates have remained unchanged. Therefore, an increasing number of patients present with recurrent hernias after having failed anterior and laparoscopic repairs. This study reports our experience with single-incision laparoscopic (SIL) intraperitoneal onlay mesh (IPOM) repair for these hernias.

Materials and methods:

All patients referred with multiply recurrent inguinal hernias underwent SIL-IPOM from November 1 2009 to October 30 2013. A 2.5-cm infraumbilical incision was made and a SIL surgical port was placed intraperitoneally. Modified dissection techniques, namely, “chopsticks” and “inline” dissection, 5.5 mm/52 cm/30° angled laparoscope and conventional straight dissecting instruments were used. The peritoneum was incised above the symphysis pubis and dissection continued laterally and proximally raising an inferior flap, below a previous extraperitoneal mesh, while reducing any direct/indirect/femoral/cord lipoma before placement of antiadhesive mesh that was fixed into the pubic ramus as well as superiorly with nonabsorbable tacks before fixing its inferior border with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.

Results:

There were 9 male patients who underwent SIL-IPOM. Mean age was 55 years old and mean body mass index was 26.8 kg/m². Mean mesh size was 275 cm². Mean operation time was 125 minutes with hospital stay of 1 day and umbilical scar length of 21 mm at 4 weeks' follow-up. There were no intraoperative/postoperative complications, port-site hernias, chronic groin pain, or recurrence with mean follow-up of 20 months.

Conclusions:

Multiply recurrent inguinal hernias after failed conventional anterior and laparoscopic repairs can be treated safely and efficiently with SIL-IPOM.

Single-port parastomal hernia repair by using 3-D textile implants

Background:

Parastomal hernias (PSHs) are a frequent complication and remain a surgical challenge. We present a new option for single-port PSH repair with equilateral stoma relocation using preshaped, prosthetic 3-dimensional implants and flat mesh insertion in intraperitoneal onlay placement for additional augmentation of the abdominal wall.

Methods:

We describe our novel technique in detail and performed an analysis of prospectively collected data from patients who underwent single-port PSH repair, focusing on feasibility, conversions, and complications.

Results:

From September 2013 to January 2014, 9 patients with symptomatic PSHs were included. Two conversions to reduced-port laparoscopy using a second 3-mm trocar were required because of difficult adhesiolysis, dissection, and reduction of the hernia sac content. No major intra- or postoperative complications or reoperations were encountered. One patient incurred a peristomal wound healing defect that could be treated conservatively.

Conclusion:

We found that single-port PSH repair using preshaped, elastic 3-dimensional devices and additional flat mesh repair of the abdominal wall is feasible, safe, and beneficial, relating to optimal coverage of unstable stoma edges with wide overlap to all sides and simultaneous augmentation of the midline in the IPOM technique. The stoma relocation enables prolapse treatment and prevention. The features of a modular and rotatable multichannel port system offer benefits in clear dissection ongoing from a single port. Long-term follow-up data on an adequate number of patients are awaited to examine efficacy.

Laparoscopic ventral/incisional hernia repair: updated Consensus Development Conference based guidelines [corrected]

BACKGROUND

The Executive board of the Italian Society for Endoscopic Surgery (SICE) promoted an update of the first evidence-based Italian Consensus Conference Guidelines 2010 because a large amount of literature has been published in the last 4 years about the topics examined and new relevant issues.

METHODS

The scientific committee selected the topics to be addressed: indications to surgical treatment including special conditions (obesity, cirrhosis, diastasis recti abdominis, acute presentation); safety and outcome of intraperitoneal meshes (synthetic and biologic); fixing devices (absorbable/non-absorbable); abdominal border and parastomal hernia; intraoperative and perioperative complications; and recurrent ventral/incisional hernia. All the recommendations are the result of a careful and complete literature review examined with autonomous judgment by the entire panel. The process was supervised by experts in methodology and epidemiology from the most qualified Italian institution. Two external reviewers were designed by the EAES and EHS to guarantee the most objective, transparent, and reliable work. The Oxford hierarchy (OCEBM Levels of Evidence Working Group*. "The Oxford 2011 Levels of Evidence") was used by the panel to grade clinical outcomes according to levels of evidence. The recommendations were based on the grading system suggested by the GRADE working group.

RESULTS AND CONCLUSIONS

The availability of recent level 1 evidence (a meta-analysis of 10 RCTs) allowed to recommend that not only laparoscopic repair is an acceptable alternative to the open repair, but also it is advantageous in terms of shorter hospital stay and wound infection rate. This conclusion appears to be extremely relevant in a clinical setting. Indications about specific conditions could also be issued: laparoscopy is recommended for the treatment of recurrent ventral hernias and obese patients, while it is a potential option for compensated cirrhotic and childbearing-age female patients. Many relevant and controversial topics were thoroughly examined by this consensus conference for the first time. Among them are the issue of safety of the intraperitoneal mesh placement, traditionally considered a major drawback of the laparoscopic technique, the role for the biologic meshes, and various aspects of the laparoscopic approach for particular locations of the defect such as the abdominal border or parastomal hernias.

Single-port onlay mesh repair of recurrent inguinal hernias after failed anterior and laparoscopic repairs

Background and Objectives:

Despite the exponential increase in the use of laparoscopic inguinal herniorrhaphy, overall recurrence rates have remained unchanged. Therefore, a growing number of patients are presenting with recurrent hernias after conventional anterior and laparoscopic repairs have failed. This study reports our experience with single-incision laparoscopic (SIL) intraperitoneal onlay mesh (IPOM) repair of these hernias.

Methods:

Patients referred with two or more recurrences of inguinal hernia underwent SIL-IPOM from November 1, 2009, to June 24, 2014. A 2.5-cm infraumbilical incision was made, and an SIL port was placed intraperitoneally. Modified dissection techniques were used: chopstick and inline dissection, 5.5-mm/52-cm/30° angled laparoscope, and conventional straight dissecting instruments. The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.

Results:

Nine male patients underwent SIL-IPOM. Their mean age was 53 years and mean body mass index was 26.8 kg/m². Mean mesh size was 275 cm². Mean operation time was 125 minutes, with a hospital stay of 1 day. The umbilical scar length was 23 mm at the 6-week follow-up. There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.

Conclusion:

Inguinal hernias recurring after two or more failed conventional anterior and laparoscopic repairs can be safely and efficiently treated with SIL-IPOM.

Single-incision laparoscopic ventral hernia repair with suprapubic incision

Single-incision laparoscopic ventral hernia repair appears to offer a virtually scarless methodology for this procedure.

Introduction:

Although natural orifice transluminal endoscopic surgery promises truly scarless surgery, this has not progressed beyond the experimental setting and a few clinical cases in the field of ventral hernia repair. This is mainly because of the problem of sterilizing natural orifices, which prevents the use of any prosthetic material because of unacceptable risks of infection. Single-incision laparoscopic ventral hernia repair has gained more widespread acceptance by specialized hernia centers. Even so, there is a special subset of patients who are young and/or scar conscious and find any visible scar unacceptable. This study illustrates an innovative way of performing single-incision laparoscopic ventral hernia repair by a transverse suprapubic incision below the pubic hair/bikini line in 2 young male patients who had both umbilical and epigastric hernias as well as attenuated linea alba in the upper abdomen.

Case Description:

Both patients underwent successful laparoscopic repair, and both were highly satisfied with the procedure, which produced no visible scars on their abdomen.

Discussion:

Willingness to adopt new innovative procedures, such as single-incision laparoscopic surgery, has allowed modification of the incision site to produce invisible scars and hence become highly attractive to the young and scar-phobic segment of the population.