Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia

Background: This study reviewed our experience with laparoscopic ventral postoperative (incisional) hernia repair. Methods: Clinical data from the first 100 cases were analyzed retrospectively. Results: Between 1997 and 2000, 64 women and 36 men (mean age, 58.4 ± 13.6 years; range, 27–87 years) underwent laparoscopic hernioplasty. Hernias (mean diameter, 6.2 ± 3.7 cm) were in a midline (74%), subcostal (10%), or other incision location, and were recurrent in 25%, of the patients. The mean operative time was 119 ± 77 min. Extensive adhesiolysis was necessary in 37 cases. There was no mortality. The recorded complications included inadvertent enterotomies (n = 6), seromas (n = 11), prolonged ileus (n = 4), and prolonged fever (n = 3). Seven cases were converted; to repair accidental enterotomies (n = 4) due to difficult adhesiolysis (n = 2), or to control bleeding (n = 1). Six patients underwent reoperation because of enetric leak (n = 3) or bowel obstruction (n = 3). There were two documented recurrences (2%). The mean follow-up period was 19 months (range, 12–54 months). Conclusions: Laparoscopic intraperitoneal approach to postoperative ventral (incisional) hernia repair may be associated with significant complications and morbidity, which can be prevented in part by meticulous technique and liberal conversions. The justification of this procedure is the low recurrence rate, according to preliminary results.     

A comparative analysis of expanded polytetrafluoroethylene and small intestinal submucosa--implications for patch repair in ventral herniorrhaphy

BACKGROUND: Small intestinal submucosa and expanded polytetrafluoroethylene are commonly used as adjuncts to repair in ventral herniorrhaphy. Despite their overlapping indications, the physical characteristics of the two materials are quite distinct. This study compares the in vivo properties of two bioprosthetic products, small intestinal submucosa (SiS Gold; Cook Biotech, West Lafayette, IN) and lyophilized small intestinal submucosa (LyoSiS; Cook Biotech), with expanded polytetrafluoroethylene (ePTFE; W.L. Gore and Associates, Flagstaff, AZ). METHODS: Six pigs underwent placement of duplicate samples of each material (SiS Gold, LyoSiS, and ePTFE) within the abdomen as peritoneal onlays (total of six samples per pig). Gross characteristics were evaluated and random samples harvested for histological analysis at 8 wk following implantation. The percentage of contraction was determined by comparing pre-implant to post-implant area. Neovascularity (percent area blood vessels, %A(bv)) was quantitatively assessed by immunohistochemical staining with an endothelial marker, CD-31 antibody. Sites of active collagen deposition were identified and distinguished from pre-existing collagen using a pro-collagen antibody to characterize tissue incorporation and remodeling. RESULTS: Compared with the original area of 22.75 cm(2), significant contraction was observed in SiS Gold, LyoSiS, and ePTFE at 8 wk (post-implant area; 7.6 cm(2), 5.7 cm(2), and 11.2 cm(2) respectively, P < 0.0001). The post-implant areas represent contraction of 67% for SiS Gold, 75% for LyoSiS, and 51% for ePTFE. The ePTFE implants experienced significantly less contraction than both the SiS Gold and LyoSiS implants (P = 0.002). No statistical difference in contraction was noted when SiS was compared with LyoSiS. Compared to SiS Gold, LyoSiS had a higher density of capillary ingrowth (2.7% A(bv)versus 2.2% A(bv), P = 0.01). As expected, vascular ingrowth was absent from the ePTFE samples. Qualitative analysis with pro-collagen antibody revealed new collagen deposition within the lamellar matrix of both SiS Gold and LyoSiS. In contrast, a similar analysis of ePTFE demonstrated a pattern of collagen encapsulation compared with the tissue infiltration and incorporation observed with SIS grafts. CONCLUSION: The host response to ePTFE, SiS Gold and LyoSiS differs at 8 wk following implantation; SiS Gold and LyoSiS undergo tissue ingrowth and remodeling whereas ePTFE undergoes little or no incorporation or morphological change. The physical properties of the materials differ as well; SiS Gold, and LyoSiS experience significantly more contraction than ePTFE. Future comparative analysis may help determine which characteristic, contraction or incorporation, contributes more to long-term success in the patch repair of ventral hernia.     

Laparoscopic repair of abdominal wall hernias using an intraperitoneal onlay prosthetic patch of expanded polytetrafluoroethylene (eptfe)

The surgical treatment of ventral abdominal wall hernias is still an unsolved problem despite considerable number of conventional methods. Mesh to replace or reinforce the defect by anterior approach has marginally reduced the recurrence rate, but not the infection rate. The authors describe the technique of laparoscopic repair of abdominal wall hernias using an intraperitoneal onlay prosthetic patch of expanded polytetrafluoroethylene (ePTFE) in two cases. Postoperative complications and the advantages of this technique and other published laparoscopic procedures are discussed and compared to the open ventral repairs. It is concluded that laparoscopic prosthetic ventral hernioplasty is a feasible and safe method. It appears to have less morbidity, especially with regard to the infection rate and recurrences, when compared to the open approach. However, authors believe that prospective randomized trials will be needed for further evaluation.     

Repair of complex giant ventral hernias with polypropylene and omentoplasty

The Authors in this report describe their experience with complex giant ventral hernias repaired by omentoplasty and polypropylene meshes. They explain their own technique of using the omentum when there is a lack of tissue and the need of an autologous tissue to place between the viscera and the above-lying polypropylene mesh. Among the 5 patients repaired, 4 had a giant sub-umbilical midline ventral hernia and one had a giant border ventral hernia. In all patients, the omentum was placed between the viscera and the mesh, which was fixed by interrupted sutures to the above-lying musculoaponeurotic plane. No complications, signs of bowel obstruction, or recurrences occurred. The Authors stress the omentum as an ideal tissue because of its biocompatibility and prevention of adhesions and fistulas allowing the use of a rigid and efficient prosthesis such as polypropylene. Thus, on the basis of their own short- and long-term good results, they suggest, whenever possible and necessary, the use of omentoplasty to repair complex giant ventral hernias.     

Surgical repair of incisional ventral hernias: tension-free technique using prosthetic materials (expanded polytetrafluoroethylene Gore-Tex Dual Mesh)

Repairing an incisional ventral hernia is a major challenge for a surgeon. The high recurrence rates observed during hernia repair by tissue approximation led to development of tension-free procedures by using prosthetic materials. The purpose of this study is to report the results of a tension-free repair technique using expanded polytetrafluoroethylene Gore-Tex Dual Mesh (Gore-Tex Soft Tissue Patch, W.L. Gore and Associates Inc, Flagstaff, AZ) in patients with primary or recurrent incisional ventral hernias. Over 3 years, 52 patients with incisional hernias have undergone this procedure in our clinic. Fourteen of them had recurrent hernias which had been primarily repaired by Mayo hernioplasty. Six of our patients had irreducible hernias preoperatively. Twenty-five patients had hernias on midline incisions, and the rest of them had hernias on transverse abdominal incisions. The median patient age was 65 years, and all were operated on under general anesthesia. The majority of the patients had 4 to 6 days of hospitalization. A subcutaneous seroma developed in eight patients. They all were treated by multiple paracentesis. Four of our patients experienced wound infection and were treated by mesh removal. None of the patients presented with cardiovascular or pulmonary complications. During the follow-up period, no other hernia recurrence, except the cases with mesh removal, has been noticed. The tension-free incisional hernia repair using expanded polytetrafluoroethylene mesh is, to our experience, a safe and easy procedure with no major morbidity or recurrence.     

Results of expanded polytetrafluoroethylene patches in moderate and large incisional hernias

Summary Incisional hernia is a common problem seen by the general surgeon, with one alternative for repair being the use of a prosthetic material. This study analyzes the results obtained with an expanded polytetrafluoroethylene patch (e-PTFE) in the management of 53 moderate and large incisional hernias, using a predesigned operating approach. A specific technique was indicated depending on the result of evaluation of the transverse diameter of the hernial orifice and the status and trophy of the rectal muscles and their sheaths. The PTFE prosthesis was used in 30 cases as reinforcement, while in the remaining 23 cases it was placed as the only retention plane. All patients were reviewed a minimum of 6 months and a maximum of 78 months postoperatively, with an average follow-up of 40 months. There were no postoperative respiratory or haemodynamic complications and there was no operating mortality. There was wound infection in two cases (3.7%), and four recurrences were detected (7.5%). On the basis of our clinical experience, we believe that e-PTFE is an acceptable mode of treatment for incisional hernias. With the predesigned operative approach, the infection rate was low with a recurrence rate of 7.5% at a mean follow-up of 40 months.     

Hernia repair with expanded polytetrafluoroethylene.

Prostheses of expanded polytetrafluoroethylene (e-PTFE) were used to repair 89 abdominal wall defects in which primary closure would produce undue tension on tissue. Over a 52-month period (median follow-up: 24 months), we observed three wound infections, one in a clean wound, and four hernia recurrences. No other complications were noted. Twenty-one e-PTFE grafts were placed directly over intraperitoneal viscera without clinical evidence of adhesions leading to intestinal obstruction. In grafts inspected postoperatively, no apparent evidence of fatigue or fragmentation was observed. Histologic findings concurred with experimental data obtained during animal trials revealing the creation of a new mesothelial lining. These results encourage the use of e-PTFE prostheses for the repair of abdominal wall hernias, particularly when the parietal peritoneum is absent.     

Repairing large duodenal injuries in dogs by expanded polytetrafluoroethylene patch

BACKGROUND: One of the most challenging problems in clinical surgery is management of injured duodenum. In this experimental study, we treated large duodenal defects by an expanded polytetrafluoroethylene (ePTFE, Gore-Tex; W.L. Gore, Elkton, MD) soft-tissue patch and compared it with the jejunal serosal patch. MATERIALS AND METHODS: A duodenal defect (about 50% of the total circumference) was created in the second portion of the duodenum in 20 dogs. The effectiveness and gross and histological examinations of the ePTFE patch technique was compared with the jejunal serosal patch. RESULTS: No significant difference was found in early survival rates (90.9% versus 88.9%; P = 0.711). The whole grafted area was covered by neomucosa at the end of the sixth week in all animals with the ePTFE patch. The scar was small; no significant narrowing of lumen was noted and serosal healing was uniformly complete. In histological examination, complete coverage of the ePTFE grafts by neomucosa consisting of columnar epithelium with short villous formations was observed. CONCLUSION: Use of the ePTFE patch method is easy, reliable, and comparable to the jejunal serosal patch. It can be used in the treatment of large duodenal defects, which cannot be repaired by duodenorraphy.     

Persistent posterior seroma after laparoscopic repair of ventral abdominal wall hernias with expanded polytetrafluoroethylene mesh: prevalence,independent predictors and detached tacks

Purpose

A persistent seroma located posterior to a mesh (PPS) remains a little known complication after laparoscopic ventral hernia repair (LVHR). The aim of this large case series was to analyse the prevalence and clinical course as well as identify related factors and independent predictors of PPS.

Methods

All 1288 adult patients who underwent a LVHR with an expanded polytetrafluoroethylene mesh (ePTFE) between January 2003 and July 2014 were reviewed. Those who underwent an abdominal computed tomography (CT) scan more than 3 months afterwards (n = 166) were included and their scans were analysed. The primary outcome measure was the prevalence of a PPS and its characteristics. The secondary outcome measures were identification of significantly related factors and independent predictors of PPS.

Results

A PPS was observed in 14 of 166 analysed CT scans (8.4%). Eleven patients were symptomatic; conservative treatment (wait-and-see policy) was successful in eight. Three underwent relaparoscopy with removal of a thick neoperitoneum. Several instances of tack and/or mesh detachment were identified on CT scans and during relaparoscopy. Independent predictors were: > 3 trocars (RR 5.0, 95% CI 1.6–15.8) and use of a mesh larger than > 300 cm² (RR 9.9, 95% CI 1.9–51.2).

Conclusions

A PPS is a relatively common complication after LVHR with an ePTFE mesh of usually larger hernias. A “wait-and-see” approach seems justified in most cases. Some require laparoscopic excision of the thick neoperitoneum. A PPS can cause tack and mesh detachment but the clinical consequences are unclear. Recurrences have not been observed in this series.

     

Repair of large abdominal wall defects with expanded polytetrafluoroethylene (PTFE).

Most abdominal wall incisional hernias can be repaired by primary closure. However, where the defect is large or there is tension on the closure, the use of a prosthetic material is indicated. Expanded polytetrafluoroethylene (PTFE) patches were used to repair incisional hernias in 28 patients between November 1983 and December 1986. Twelve of these patients (43%) had a prior failure of a primary repair. Reherniation occurred in three patients (10.7%). Wound infections developed in two patients (7.1%), both of whom had existing intestinal stomas, one with an intercurrent pelvic abscess. The prosthetic patch was removed in the patient with the abscess, but the infection was resolved in the other without sequelae. Septic complications did not occur after any operations performed in uncontaminated fields. None of the patients exhibited any undue discomfort, wound pain, erythema, or induration. Complications related to adhesions, erosion of the patch material into the viscera, bowel obstruction, or fistula formation did not occur. Based on this clinical experience, the authors believe that the PTFE patch appears to represent an advance in synthetic abdominal wall substitutes.     

Preliminary experience with expanded polytetrafluoroethylene grafts.

This early clinical experience of members of the New England Society for Vascular Surgery with expanded polytetrafluoroethylene (PTFE) grafts was evaluated. Questionnaires were distributed to 52 active members of the Society and 32 answers were received. A total of 186 graft insertions were evaluated, of which 112 were positioned in the lower limb; 106 grafts were inserted for libm salvage. Patency rates for femoral-popliteal bypass grafts were determined by life-table analysis. Our results show a 6 to 9 month cumulative patency rate of 91% for PTFE grafts with a popliteal anastomosis above the knee, and a 52% patency rate for below-knee anastomosis. Two complications, aneurysmal dilatation and graft sepsis, were noted in this series. The new graft material exhibits an early patency rate higher than bovine or Dacron grafts which warrants long-term use and evaluation.     

Repair of full-thickness defects in alimentary tract wall with patches of expanded polytetrafluoroethylene

OBJECTIVES: To test the efficacy of patches of expanded polytetrafluoroethylene (ePTFE) for the repair of full-thickness defects in alimentary tract wall. SUMMARY BACKGROUND DATA: A recent report of successful replacement of duodenal wall with patches of ePTFE was met with skepticism and clearly warranted confirmation as well as evaluation in repair of other segments of the abdominal intestinal tract. METHODS: Defects of 4 cm2 were created in various segments of canine abdominal alimentary tract (stomach, duodenum, small bowel, and colon) as well as in bladder dome. For the duodenum in 13 dogs, three different ePTFE fabrications were used: CVX (cardiovascular), PDX (preclude dura membrane), and DLM (dual mesh plus). In repair of the other areas in six dogs, the PDX patch was used. When the animals were killed, both gross inspection of the parietes and tissue for histologic study became the basis for evaluation. Peritoneal and intraluminal cultures of the specific study viscera were also taken. RESULTS: There were no patch failures. Only six significant adhesions were noted in 3 of the 19 dogs. Serosal surface healing was complete without exception by 1 week in all animals. Patches of CVX and PDX had heaping mucosa at the margin of well-sealed patch edges in the study involving duodenum. However, the DLM patch had an undergrowth of mucosa with partial patch separation by 1 week, beginning patch extrusion into gut lumen at 3 weeks, and total separation of patch with complete mucosal repair at 6 weeks. The fate of the PDX patches at 6 weeks in stomach, small bowel, colon, and bladder was identical to what had been observed for the PDX patch in the duodenum. All peritoneal and bladder cultures had no growth, whereas the contents of the alimentary tract grew expected flora. CONCLUSIONS: These observations suggest that ePTFE may well be an acceptable membrane for at least temporary replacement of full-thickness hollow viscus defects, even in the face of heavy bacterial contamination, and that certain structural configurations of ePTFE may provide a base for increasing absorptive mucosal surface area.     

Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia

Background: The purpose of this study was to determine whether laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch (LIPP) repair of a ventral hernia is superior to open prefascial polypropylene mesh (OPPM) repair in a tertiary care university hospital in an urban environment. Methods: Data on 39 consecutive patients undergoing either LIPP repair (n= 21) or OPPM repair (n= 18) were compared. Results: Findings showed that LIPP repair is characterized by less painful recovery and shorter hospital stay, with 90% of patients treated successfully as outpatients as compared with 7% in the OPPM group. The total facility costs for the LIPP repair ($8,273 ± $2,950) was significantly lower than for the OPPM repair ($12,461 ± $5,987) (p < 0.05). Two serious delayed complications in the LIPP group were treated by reoperation (colocutaneous fistula, mesh infection), but the higher readmission costs in this group did not negate the overall cost advantage for LIPP repair. In the follow-up evaluation, 1 hernia recurrence was found in the LIPP repair group, and none in the OPPM group. Conclusions: Initial experience suggests that LIPP repair has advantages over OPPM repair in terms of decreased hospitalization, postoperative pain, and disability. Refinements in the technique to reduce complications may make LIPP repair the procedure of choice for repair of ventral hernias. Received: 5 June 1998/Accepted: 15 October 1999     

Intraperitoneal underlay ventral hernia repair utilizing bilayer expanded polytetrafluoroethylene and polypropylene mesh

A prospective study of patients with ventral hernias was undertaken to study the experience with an open intraperitoneal underlay technique utilizing a bilayer prosthetic mesh. From September 1998 to March 2001, 102 patients underwent repair with a bilayer expanded polytetrafluoroethylene (ePTFE) and polypropylene mesh placed intraperitoneally and fixed in place with full-thickness abdominal muscle wall sutures to achieve a 5-cm underlay of the fascial defect circumferentially. There were 67 females and 35 males ranging in age from 29 to 76 years (mean 53 years). Average patient weight was 207 lb with 64 patients in the obese category. Forty patients presented with recurrent hernias. Mean operative time was 103 minutes with an average diameter hernia defect size of 15 cm. Median hospital stay was 3 days. There was no surgical mortality, and major morbidity occurred in six patients (2 wound infections, one deep vein thrombosis, one myocardial infarction, one pneumonia, and one pulmonary embolus). Mean follow-up is 28 months (range 12-42 months). No recurrence has been found with 100 per cent follow-up to date. No bowel obstruction or enteric fistulas have occurred during the follow-up period. The open intraperitoneal underlay mesh technique can be performed with a zero per cent early recurrence rate. Bilayer prosthetic mesh composed of ePTFE and polypropylene can be safely placed intraperitoneally without causing intestinal obstruction or enteric fistula.     

Repair of diaphragmatic rupture by laparoscopic implantation of a polytetrafluoroethylene patch

Diaphragmatic hernias after blunt traumatic damage are serious complications, and diagnosis often might be delayed. In most cases, early symptoms are missed, but in the further posttraumatic period, patients experience recurrence of pulmonary dysfunction or intestinal symptoms such as obstruction, nausea, and pain. Most of these defects are diagnosed by laparotomy performed to investigate other major abdominal lesions. These diaphragmatic ruptures are managed by suturing using a thoracic or abdominal approach. An original diaphragmatic repair technique using a patch is presented. A 40-year-old woman was admitted to our clinic because of chronic abdominal pain. Chest x-ray and computed tomography scan showed a migration of the large intestine into the left hemithorax. A large diaphragmatic hernia was diagnosed and repaired laparoscopically using a patch. In the reported patient, laparoscopic suture of a diaphragmatic hernia using a polytetrafluoroethylene (PTFE) (GORETEX) patch proved to be safe, successful, elegant, and uneventful.     

Repair of recurrent ventral hernias by an internal “binder”

A technic for the repair of massive recurrent incisional hernia is described. Use of a polypropylene mesh prosthesis as an intraperitoneal “binder” permits reconstruction of the abdominal wall when primary closure is impossible. Intraoperative testing of the repair provides reassurance that unrestricted postoperative activity will not invite recurrence.