Laparoscopic Incisional Hernia Repair in Liver Transplant and Other Immunosuppressed Patients

We report the early results of laparoscopic incisional hernia repair in a small group of immunosuppressed patients and compare these results with a cohort of patients with open repair. We describe a modification used to secure the cephalad portion of the Gore-Tex mesh in high epigastric incisional hernias often encountered after liver transplantation. Data were gathered retrospectively for all incisional hernia repairs by our group from March 1996 to January 2001. Twelve of 13 attempted patients had successful completion of their laparoscopic hernia repairs with no reported recurrences to date. Two of these procedures were performed for recurrent hernias. We completed nine of nine attempted laparoscopic hernia repairs in liver transplant patients with epigastric incisional hernias. We repaired two of three attempted lower midline incisional hernias in renal disease patients. One of these patients was soon able to reuse his peritoneal dialysis catheter. A total of 15 patients, 12 with liver transplants, underwent open repair of their incisional hernias. These patients had seven recurrences and/or serious mesh infections with five patients electing repeated operations. In our initial series, laparoscopic mesh repair of incisional hernias is practical and safe in the abdominal organ transplant population with a low incidence of early recurrence and serious infections.     

腹腔镜与开放式巨大腹壁切口疝补片修补术的对比分析

目的:比较开放手术及腹腔镜补片修补巨大腹壁切口疝的手术效果。方法:回顾分析我院2003年1月至2007年6月收治的43例巨大腹壁切口疝患者的临床资料。根据手术方式分为腹腔镜组(16例)和开放组(27例),对两组手术时间、术后并发症、术后住院时间等进行对比分析。结果:两组手术时间、术后并发症发生率无明显差异。开放手术组2例发生切口感染,1例经冲洗引流2个月治愈,另1例再次手术取出补片。腹腔镜手术组术后住院时间和手术出血量明显少于开放手术组。术后随访4~48个月,平均21个月,两组均无复发病例。结论:腹腔镜下应用补片修补巨大腹壁切口疝同样安全、合理,且具有患者创伤小、康复快和术后住院时间短等优点。     

Laparoscopic incisional hernia mesh repair with the "double-crown" technique: a case-control study

BACKGROUND: Incisional hernia is a main complication of abdominal surgery. Laparoscopic hernia mesh repair has been demonstrated to be as effective as open repair. However, the mesh fixation method is, to date, a matter of debate, and there are few clinical studies evaluating a single technique. This was a case-control study to assess the "double-crown" fixation method. METHODS: From March 2000 to November 2005, we prospectively collected operative and outcome data on 94 laparoscopic mesh repairs of large incisional hernias performed by using the double-crown technique. The data were compared with those from a retrospective review of 87 matched open incisional hernia repairs done from January 1995 to January 2000. RESULTS: The open and laparoscopic repair groups were comparable in patient age, sex, and hernia size. Operative time was significantly longer in the laparoscopic group; the duration of hospitalization and number of early postoperative complications (e.g., wound infection and prolonged ileus) were significantly greater in the open group. Recurrence rate after a mean follow-up of 38 months (range, 12-72) was 2.1% in the laparoscopic group and 6.9% in the open repair group (mean follow-up, 8 years; range, 5-10) (P > 0.05). CONCLUSIONS: Medium-term results indicate that laparoscopic incisional hernia repair with the double-crown technique has a low complication rate and a comparable recurrence rate to open repair.     

Laparoscopic ePTFE mesh repair of incisional and ventral hernias

Incisional hernia is a relatively frequent complication of abdominal surgery. The use of mesh to repair incisional and ventral hernias results in lower recurrence rates compared with primary suture techniques. The laparoscopic approach may be associated with lower postoperative morbidity compared with open procedures. Long-term recurrence rates after laparoscopic ventral and incisional hernias are not well defined. A prospective study of the initial experience of a standardized technique of laparoscopic incisional and ventral hernia repair carried out in a tertiary referral hospital was undertaken between January 2003 and February 2007. Laparoscopic hernia repair was attempted in 71 patients and was successful in 68 (conversion rate 4%). The mean age of the patients identified was 63.1 years (39 men and 31 women). Multiple hernial defects were identified in 38 patients (56%), and the mean overall size of the fascial defects was 166 cm(2). The mean mesh size used was 403 cm(2). The mean operative time was 121 minutes. There were six (9%) major complications in this series, but there were no deaths. Hernia recurrence was noted in four patients (6%) at a mean follow up of 20 months. Our preliminary experience indicates that laparoscopic incisional and ventral hernia repair is technically feasible and has acceptable postoperative morbidity and low early recurrence rates.     

Laparoscopic treatment of ventral hernias

The use of mesh in incisional hernia repair has reduced the rate of hernia recurrence. Laparoscopic placement of mesh is a promising alternative to the classical open approach. Recent studies involving large numbers of patients have shown the laparoscopic approach to be feasible in 95% of cases; the incidence of postoperative complications was low and hernia recurrence occurred in 3-5% at three years. Several retrospective studies and one randomized study comparing open versus laparascopic ventral hernia repair suggest that the laparoscopic repair yields better results (fewer postoperative complications and lower recurrence rate) than the classical open approach.     

Laparoscopic treatment of ventral hernias

The use of mesh in incisional hernia repair has reduced the rate of hernia recurrence. Laparoscopic placement of mesh is a promising alternative to the classical open approach. Recent studies involving large numbers of patients have shown the laparoscopic approach to be feasible in 95% of cases; the incidence of postoperative complications was low and hernia recurrence occurred in 3-5% at three years. Several retrospective studies and one randomized study comparing open versus laparascopic ventral hernia repair suggest that the laparoscopic repair yields better results (fewer postoperative complications and lower recurrence rate) than the classical open approach.     

腹腔镜联合开腹补片修补术对巨大切口疝及肠黏连紧密腹壁切口疝患者临床研究

目的分析腹腔镜结合开腹补片修补术对腹部切口疝患者治疗效果。 方法回顾性分析湖北省肿瘤医院肝胆胰外科自2011年2月至2018年2月收治的腹壁切口疝患者133例，其中62例行开腹补片修补术为对照组，余71例行腹腔镜结合开腹补片修补术为观察组；观察患者手术状况、术后恢复状况，术后1 d采用ELISA法检测血清氧化应激指标，包含胰岛素（InS）、β-内啡肽（β-EP）、生长激素（GH）和总抗氧化能力（T-AOC）含量，术后对患者随访1年，记录患者术后并发症和复发率情况。 结果观察组患者术中失血量低于对照组，差异有统计学意义（P<0.05）；观察组患者术后下床活动时间、肠功能恢复时间、首次进食时间、肠鸣音恢复时间及住院时间均低于对照组，差异有统计学意义（P<0.05）；术后1 d观察组患者血清InS、GH及T-AOC含量高于对照组，β-EP含量低于对照组，差异有统计学意义（P<0.05）；观察组患者并发症发生率低于对照组，差异有统计学意义（P<0.05）。 结论腹腔镜联合开腹补片修补术对巨大切口疝及肠黏连紧密腹壁切口疝患者疗效显著，患者创伤小、术后恢复快，且术后并发症发生率和复发率降低。     

Long-term outcomes in laparoscopic vs open ventral hernia repair

OBJECTIVE: To investigate whether there was a difference in morbidity, recurrence rate, and length of hospital stay between patients undergoing open or laparoscopic incisional hernia repair. DESIGN AND SETTING: Single-institution cohort study. We compared prospectively collected patient cohorts undergoing laparoscopic or open intraperitoneal onlay mesh repair. Statistical analysis was performed by Fisher exact test and analysis of variance. PATIENTS: Between October 1995 and December 2005, data from 360 consecutive patients who had undergone open or laparoscopic intraperitoneal onlay mesh repair of a ventral hernia were prospectively collected in a database and were supplemented by record review. MAIN OUTCOME MEASURES: Morbidity, hernia recurrence, and length of hospital stay. Postoperative complications of Clavien grade II or greater were considered major complications. RESULTS: Intraperitoneal onlay mesh repair was performed in 233 patients by the open approach and in 127 patients using the laparoscopic approach. The groups were similar for sex and body mass index (calculated as the weight in kilograms divided by the height in meters squared); the mean age of the laparoscopic group was 3 years younger; and the mesh was larger in the laparoscopic group. Mean follow-up was 30 and 36 months for the laparoscopic and open groups, respectively; the conversion rate was 4%. Major morbidities were 15% in the open group vs 7% in the laparoscopic group (P = .01). Recurrence rates were 9% in the open group vs 12% in the laparoscopic group (P = .36). Postoperative inpatient admission was more frequent after the open procedure than after the laparoscopic procedure (28% vs 16%, respectively; P<.05). CONCLUSIONS: Outcomes did not differ with respect to recurrence rates after long-term follow-up; however, the lower rate of major morbidity and increased outpatient-based procedure rates favor laparoscopic repair in this study.     

Mesh repair of incisional hernia: comparison of laparoscopic and open repair.

OBJECTIVE: To compare our results of open and laparoscopic mesh repair of incisional hernias. DESIGN: Retrospective cohort study. SETTING: Teaching hospitals, The Netherlands. SUBJECTS: All patients who had had a laparoscopic (n = 25) or an open (n = 76) mesh repair of incisional hernia between January 1996 and January 2000. INTERVENTIONS: Physical examination at the time of the study. MAIN OUTCOME MEASURES: Morbidity and recurrence. RESULTS: The groups were comparable. 11 patients (14%) developed postoperative infections after open repair and 1 (4%) after laparoscopic repair (p = 0.29). Median hospital stay was 5 days (range 1-19) in the open group and 4 (range 1-11) in the laparoscopic group (p = 0.28). The 2-year cumulative incidence of recurrence was 18% after open repair (median follow-up of 17 months (range 1-46) and 15% after laparoscopic repair (median follow-up of 15 months, range 1-44). Recurrences in the laparoscopic group were all among the first 7 cases in which the mesh was fixed with staples alone. CONCLUSION: There were fewer infections and hospital stay was shorter in the laparoscopic group, but not significantly so. Recurrence rates were comparable.     

Laparoscopic versus open ventral hernia mesh repair: a prospective study

Background An incisional hernia develops in 3% to 13% of laparotomy incisions, with primary suture repair of ventral hernias yielding unsatisfactory results. The introduction of a prosthetic mesh to ensure abdominal wall strength without tension has decreased the recurrence rate, but open repair requires significant soft tissue dissection in tissues that are already of poor quality as well as flap creation, increasing complication rates and affecting the recurrence rate. A minimally invasive approach was applied to the repair pf ventral hernias, with the expectation of earlier recovery, fewer postoperative complications, and decreased recurrence rates. This prospective study was performed to objectively analyze and compare the outcomes after open and laparoscopic ventral hernia repair. Methods The outcomes for 50 unselected patients who underwent laparoscopic ventral hernia repair were compared with those for 50 consecutive unselected patients who underwent open repair. The open surgical operations were performed by the Rives and Stoppa technique using prosthetic mesh, whereas the laparoscopic repairs were performed using the intraperitoneal onlay mesh (IPOM) repair technique in all cases. Results The study group consisted of 100 patients (82 women and 18 men) with a mean age of 55.25 years (range, 30–83 years). The patients in the two groups were comparable at baseline in terms of sex, presenting complaints, and comorbid conditions. The patients in laparoscopic group had larger defects (93.96 vs 55.88 cm²; p = 0.0023). The mean follow-up time was 20.8 months (95% confidence interval [CI], 18.5640–23.0227 months). The mean surgery durations were 90.6 min for the laparoscopic repair and 93.3 min for the open repair (p = 0.769, nonsignificant difference). The mean postoperative stay was shorter for the laparoscopic group than for the open hernia group (2.7 vs 4.7 days; p = 0.044). The pain scores were similar in the two groups at 24 and 48 h, but significantly less at 72 h in the laparoscopic group (mean visual analog scale score, 2.9412 vs 4.1702; p = 0.001). There were fewer complications (24%) and recurrences (2%) among the patients who underwent laparoscopic repair than among those who had open repair (30% and 10%, respectively). Conclusions The findings demonstrate that laparoscopic ventral hernia repair in our experience was safe and resulted in shorter operative time, fewer complications, shorter hospital stays, and less recurrence. Hence, it should be considered as the procedure of choice for ventral hernia repair.     

Recurrent inguinal hernia: a ten-year review

BACKGROUND: This study evaluates the results obtained in recurrent inguinal hernia repair over the past ten years in a general hospital using laparoscopic (LAP) and open tension-free mesh (Lichtenstein) procedures. METHODS: A prospective controlled study with 258 recurrent inguinal hernias in 235 patients over a ten-year period. The main outcome measurements were recurrence rate, operating time, hospital stay, postoperative complications, and cost. RESULTS: There were 10 recurrences (4.3%): 7 in the Lichtenstein group (5.7%) and 3 (2.2%) in the LAP group (P = nonsignificant [NS]). There were 15 (12.2%) postoperative complications in the Lichtenstein group and 6 (4.4%) in the LAP group (P =0.04). The operating room costs were higher in the LAP group, but this difference was offset by a significantly shorter hospital stay, shorter operating time, and earlier return to work. CONCLUSION: Laparoscopic repair is an effective option for the treatment of recurrent inguinal hernia. The TEP approach combines the advantages of minimal invasive surgery and those of tension-free mesh repair, reducing operating time, postoperative morbidity, and recurrence rate.     

Laparoscopic repair of incisional and ventral hernia

The application of laparoscopic principles to ventral or incisional hernia repair has recently been shown to be a safe and effective alternative to open procedures. In this study we analyzed our recent experience with laparoscopic incisional-ventral hernia repair. The outcomes of 75 consecutive patients (January 2002 to July 2006) who underwent laparoscopic repair for incisional-ventral hernia were reviewed. Patient's demographics, hernia parameters, and intraoperative and postoperative data were collected. Of the 75 patients, 44 were females and 31 males. Mean age was 59.1 yrs (range 29-80 yrs). Mean BMI was 25.9 (range 19.4-36.7). Twenty-one patients had primary ventral hernias while 54 patients had an incisional hernia. Fifty-three patients had a single defect and 22 patients multiple defects. In 45 cases the incisional hernia was a primary hernia; in 4 cases it was a first recurrence; in 2 cases a 2nd recurrence; and in 3 cases a 3rd recurrence. The mean defect size was 52,7 cm2 (range 4-432). Laparoscopic hernia repair was successfully performed in 71 cases (94.7%). The mean mesh size was 211 cm2 (range 63-694). Mean operating time was 101 min (range 50-220 min). The mean hospital stay was 4.7 days. The postoperative morbidity rate was 14%. After a mean follow-up of 24.6 months (range 7-56) the recurrence rate was 7% (5/71). Laparoscopic repair of incisional-ventral hernias seems to be safe and effective. Medium-term outcomes were promising with a relatively low rate of conversion to open surgery, a low complication rate and a low risk of recurrence.     

腹腔镜下腹腔内网片植入法和开放式肌后筋膜前补片修补法治疗腹壁切口疝的疗效比较

【摘要】 目的〓比较腹腔镜下腹腔内网片植入法(IPOM)和开放式肌后筋膜前补片修补法(Sublay)治疗腹壁切口疝的疗效。方法〓回顾性分析30例腹腔镜应用IPOM法和28例开放式应用Sublay法治疗腹壁切口疝的病例,比较其手术疗效及术后患者生活质量。结果〓两组手术时间、平均住院时间、术中出血量及术后并发症比较,腹腔镜组均明显优于开放手术组,有统计学差异(P<0.05)。结论〓应用腹腔镜行IPOM治疗腹壁巨大切口疝安全可行,具有有创伤小,住院时间短,恢复快,术后并发症少的优点。     

Laparoscopic treatment of subxiphoid incisional hernias in cardiac transplant patients

BACKGROUND: Symptomatic subxiphoid incisional hernias present difficult surgical problems, especially in immuno-suppressed cardiac transplant patients. Here, we describe the laparoscopic repair of subxiphoid incisional hernias in patients with a history of cardiac transplantation. METHODS: Four patients with subxiphoid hernias who had previously undergone heart transplantation were identified from a prospective database. Each underwent a laparoscopic repair with mesh implantation. RESULTS: Three patients had a previous open repair. The mean age was 62.5 years, an average of 64.3 months after transplantation. At the time of surgery, all patients were immunosuppressed, and each had a subxiphoid, poststernotomy incisional hernia. Gore dual mesh was used in 2 patients, while Parietex mesh was used in 2. Mean operative time was 122 minutes, and all were completed laparoscopically. The mean length of stay was 6.5 days, and the mean defect size was 286.25 cm(2). There was a significant correlation between hernia size and length of stay (P=0.037). Postoperatively, one patient (25%) developed pulmonary edema, and 1 patient (25%) had a prolonged ileus. CONCLUSION: Symptomatic subxiphoid incisional hernias are a challenging surgical problem in patients with a history of sternotomy. Laparoscopic repair is safe and effective in immunosuppressed patients who have previously undergone cardiac transplantation.     

Incisional hernia—comparison of mesh repair with Cardiff repair: an university hospital experience

Background: Incisional hernia is a frequent complication of abdominal surgery. Various types of repair are recommended for incisional hernia. Suture and mesh repair are compared in the present study. Method: One hundred seventy one patients with incisional hernia underwent Cardiff repair (far and near sutures with reinforcement sutures) which was used as an open suture repair while onlay polypropylene mesh was used in the mesh repair technique. Result: Cardiff repair was performed in 116 patients with no mortality with recurrence in two patients with mean follow up of 7.1 years. Both these patients with recurrence had a defect measuring more than 10 cm in width. Mesh repair was carried out in 55 patients with no recurrence in mean follow up of 37 months. Seroma formation was noted in 7 (12.72%) with mesh repair as compared to 4 (3.44%) patients with Cardiff repair. Conclusion: We recommend Cardiff repair for primary and small to medium size incisional hernias. Onlay polypropylene mesh is ideal for tension-free hernia repair, recurrent incisional hernia and hernia defects wider than 10 cm.     

Retromuscular sutured incisional hernia repair: a randomized controlled trial to compare open and laparoscopic approach

To compare the early and intermediate results of the open and laparoscopic tension-free repair of incisional hernia, 24 patients were randomized prospectively to undergo laparoscopic or open repair of incisional hernia with retromuscular placement of the prosthesis using transabdominal sutures for mesh fixation. All the procedures were completed as planned. The mean duration of surgery was not significantly different between the 2 groups (P=0.15). Time to oral solid food intake was longer in the open group (P=0.002). The analgesic requirement was lower in the laparoscopic group (P=0.05). One patient after open surgery and 2 in the laparoscopic group suffered postoperative complications (P=0.71). Postoperative stay was shorter in the laparoscopic group (P=0.006). No readmission or recurrence was registered within 6 months from surgery in either group. Laparoscopic incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible alternative to open techniques. However, larger studies and long-term follow-up are required to further evaluate the true effectiveness of this operation.     

Incisional hernia repair in Sweden 2002

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.     

Laparoscopic incisional hernia repair: our experience with 105 consecutive cases

Conventional repair of incisional hernia is associated with significant complications and a high recurrence rate (30-50%). The laparoscopic approach offers an effective alternative and reduces the recurrences to less than 5%. The aim of this study was to review our experience with laparoscopic incisional hernia repair. Medical records of all patients who underwent laparoscopic incisional hernia repair from January 2002 to December 2006 were reviewed. Demographic and postoperative data were recorded. The study population consisted of 105 patients, 72 females (68.5%) and 33 males (31.5%); the mean age was 56 years (range: 17-83 years). The mean fascial defect size was 116.9 cm2 and the average mesh size used was 256 cm2. Operative time was 118 min and the average hospital stay was 5 days. An expanded polytetrafluoroethylene (ePTFE) prosthesis was used In all patients. Perioperative complications occurred in 33 patients (31.4%) including seroma, cellulitis at the trocar site and prolonged ileus. During the follow-up there were 3 hernia recurrences (2.8%). Our study shows that laparoscopic incisional hernia repair resulted in a moderate rate of perioperative complications, a short hospital stay and a low recurrence rate. Hence the laparoscopic technique should be considered an effective and safe alternative to conventional incisional hernia repair.     

Open and laparoscopic approach in incisional hernia repair with ePTFE prosthesis

BACKGROUND: The aim of this retrospective study was to analyze the results of incisional hernia laparoscopic and open surgery, focusing on the morbidity and postoperative implications. MATERIALS AND METHODS: A group of 106 (42 men, 64 women) patients suffering from incisional hernias were treated with either a laparoscopic (30) or an open (76) placement of a prosthetic mesh between January 1997 and December 2004. The age and gender of the patients, the size and type of the mesh, operation note, the length of postoperative hospital stay, and morbidity were recorded. RESULTS: An expanded polytetrafluoroethylene (ePTFE) mesh was used in 103 patients, whereas a polypropylene mesh was used in 3 patients. In the open technique, 3 patients with the ePTFE prosthetic material developed a mesh infection and required a mesh removal, which was easily performed under local anesthesia. Moreover, 2 patients from the same group developed a hernia recurrence. As for the laparoscopic approach, the only complication observed was one hernia recurrence. Finally, it should be mentioned that 1 patient with a polypropylene mesh developed a colocutaneous fistula. CONCLUSIONS: The benefits of the laparoscopic mesh technique, compared to the open technique, include a shorter hospital stay, less postoperative pain, and possibly, a reduction in wound and mesh complications. Regarding the recurrence rate, the two techniques show similar results.     

Does resident post graduate year influence the outcomes of inguinal hernia repair?

INTRODUCTION: We evaluated the effect of the postgraduate medical education level (PGY) of surgery residents on recurrence of inguinal hernia, complications, and operative time. METHODS: Post hoc analysis was performed on prospectively collected data from a multicenter Veterans Affairs (VA) cooperative study. Men were randomly assigned to open or laparoscopic inguinal hernia repairs with mesh. Surgery residents performed repairs with designated attending surgeons present throughout all procedures. PGY level of the resident was recorded for each procedure. All patients were followed for 2 years for hernia recurrence and complications. PGY levels were grouped as follows: group I = PGY 1 and 2; group II = PGY 3; group III = PGY >/= 4; rates of recurrence, complications and mean operative time were compared. RESULTS: A total of 1983 patients underwent hernia repair. group III residents had significantly lower recurrence rates for open repairs when compared with group I (adjusted odds ratio = 0.24, 95% confidence interval [CI], 0.06, 0.997). The recurrence rate was similar among the groups for laparoscopic repair (P > 0.05) Complication rates were not different for either repair (P > 0.05). Mean operative time was significantly shorter for group III compared with group I for both open (-6.6 minutes; 95% CI, -11.7, -1.5) and laparoscopic repairs (-12.9 minutes; 95% CI, -19.8, -6.0) and between group II and group I for laparoscopic repair (-15.0; 95% CI, -24.3, -5.7). CONCLUSIONS: Despite the presence of an attending surgeon, open hernia repairs performed by junior residents were associated with higher recurrence rates than those repaired by senior residents. Lower resident level was associated with increased operative time for both open and laparoscopic repair.