Laparoscopic mesh repair of incisional hernia following right lower quadrant renal transplantation

The development of an incisional hernia after lower quadrant renal transplantation is an infrequent complication, but poses a difficult surgical challenge due to the proximity of the incision to the allograft and the pelvic rim. We describe the first such case of a laparoscopic repair of a recurrent incisional hernia after renal transplantation in the literature.     

Spontaneous rupture of an L-shaped kidney

A case of spontaneous renal rupture caused by obstruction due to a ureteral stone in the L-shaped kidney of a young obese, diabetic man is reported. the role of CT beside excretory urography and ultrasound is emphasized in the diagnosis of crossed renal ectopia, and the transabdominal approach is recommended to resolve its complications needing operative management.     

Evaluation of the impact of body mass index on outcome among renal mass patients treated with hand-assisted laparoscopic radical nephrectomy

PURPOSE: Although there are empiric data to show that obesity is not a contraindication for laparoscopic radical nephrectomy, similar data are lacking for the use of hand-assisted laparoscopic radical nephrectomy (HALRN) in obese patients. We evaluate whether obese patients undergoing HALRN to manage a renal mass are more likely than nonobese patients to experience poor intraoperative and perioperative outcomes. PATIENTS AND METHODS: Between June 1, 1999, and May 31, 2006, 150 patients underwent HALRN for the management of a solid renal mass at our institution. We abstracted detailed demographic, clinical, and follow-up data on all patients in this cohort. As our primary analysis, we evaluated associations between body mass index (BMI) and estimated blood loss, operative time, length of stay, and complications using linear and logistic regression models. RESULTS: There was no evidence that obese patients experienced a statistically significant or clinically relevant increase in blood loss (P = 0.97), operative times (P = 0.87) or length of stay (P = 0.62) compared with persons of normal weight. In contrast, although there was no evidence of a linear trend toward complications in patients with a higher BMI (P = 0.19), obese patients were almost three times more likely to experience a complication compared with normal-weight persons (odds ratio: 2.88; 95% confidence interval: 1.01-8.16). Adjusting for relevant clinical covariates individually did not markedly alter these associations. CONCLUSIONS: Obesity is not a contraindication for HALRN to manage a renal mass; however, obese patients should be aware that they may be at increased risk for certain complications after surgery, notably ileus and incisional hernias.     

"Open" abdominal surgery for large incisional hernias. Proposal of a personal technique

Incisional hernia is still a serious complication of abdominal surgery because of its substantial incidence. We have to reduce the rate of complications and, if possible, correct the aesthetic defect due to the pathology itself. The complications are directly related to different factors (surgeon, technique, type of mesh used, patients with associated pathologies etc.). We propose an "open" technique to repair incisional hernias using a polypropylene mesh, sutured in a space created between two peritoneal sheaths, located in an intraparietal site (retromuscular and extraperitoneal), with suturing of the subcutaneous tissue, and without a subcutaneous drainage. We studied 26 patients, including obese subjects, from 2003 to 2006. The follow-up was 24 months. Good short- and long-term results were observed. We had two cases of seroma, treated conservatively. No prosthetic infections were reported, no recurrences were observed and a good final aesthetic result was achieved. In view of the fact that incisional hernia admittedly presents different problems from case to case, surgical experience and an imaginative surgical approach will always be useful in relation to the rigid technical times involved.     

Effects of increased intra-abdominal pressure in severe obesity

This article gives an overview, citing animal and clinical studies, of the effects of increased intra-abdominal pressure (IAP) in severe obesity. Animal studies demonstrate that increased IAP increases pleural pressure, cardiac filling pressures, femoral venous pressure, renal venous pressure, systemic blood pressure, and vascular resistance, renin and aldosterone levels, and intracranial pressure. Thus, the comorbidities presumed secondary to increased IAP in obese patients include congestive heart failure, hypoventilation, venous stasis ulcers, gastroesophageal reflux, urinary stress incontinence, incisional hernia, pseudotumor cerebri, proteinuria, and systemic hypertension.     

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.     

Repair of giant incisional abdominal wall hernias using open intraperitoneal mesh

Background Very large and complex incisional hernias, especially those involving loss of abdominal wall, present a particular challenge to the surgeon. Aims The open intraperitoneal technique was used prospectively for the repair of incisional hernias in a selected group of patients with large defects, often those with major loss of abdominal wall, overweight patients, and previous failures of incisional repair. Materials and methods Between 1 January 1999 and 31 December 2005, out of 275 patients operated on for incisional hernia repair, 61 of them, most of whom were obese with multiorificial recurrent or giant hernias and contraindicated for laparoscopy, were treated using an open intraperitoneal mesh technique. There were 50 females and 11 males, with a mean age of 61. The median ASA score of the group was 2.3, with a mean BMI of 34 kg/m² and a mean hernia surface of 182 cm². Sixty-four percent of the patients had undergone one or more previous incisional hernia repairs. Results Mean operating time was 130 min, with an average hospital stay of 13 days. None of the patients died. Postoperative complications occurred in 21% of the patients; most of which were minor, but two cases (3.3%) developed deep abscesses requiring surgery and removal of the mesh. A recurrence rate of 5% was found after a mean follow-up of 35 months (8–88). Conclusion Open intraperitoneal mesh repair appears to be a good option for the treatment of complex incisional hernia (at least 10 cm in diameter or multiorificial) in obese patients contraindicated for laparoscopy.     

Hand-assisted laparoscopic renal surgery: hand-port incision complications

BACKGROUND AND PURPOSE: Hand-assisted laparoscopic (HAL) renal surgery is an accepted standard of practice. We report our complications at the hand port-site incision in various HAL urologic procedures. PATIENTS AND METHODS: Data and follow-up were complete for 54 patients who underwent HAL nephrectomy. HAL partial nephrectomy, or HAL nephroureterectomy at our institution from October 2001 to April 2003. A retrospective review of the patients' charts was performed to identify the incidence of postoperative hand port-site complications. The mean patient age was 59 years, and the mean follow-up was 5.4 months. RESULTS: Five complications were observed in four patients (9.3%). One patient had a superficial wound infection (1.9%) and an incisional hernia (1.9%) that was surgically repaired. One patient had a superficial incisional breakdown that healed well after conservative measures. One obese patient with severe chronic obstructive pulmonary disease eviscerated through his hand-port incision after a coughing spell. This was repaired operatively, and the patient healed well with the aid of an abdominal binder. One patient developed an enterocutaneous fistula at her hand-port site that healed well after both operative and conservative management. CONCLUSIONS: The technique of HAL renal surgery is safe and effective. Complications associated with the hand-port incision exist, and as they become better defined, the surgeon may take extra steps toward their recognition and prevention.     

Incisional hernia risk after hand-assisted laparoscopic surgery

Hand-assisted laparoscopic surgery (HALS) bridges traditional open surgery and pure laparoscopy. The HALS technique provides the necessary site for organ retrieval, reduces operative time, and realizes the postoperative benefits of laparoscopic techniques. Although the reported rates of incisional hernia should be theoretically low, we sought to determine our incidence of hernia after HALS procedures. A retrospective review of all HALS procedures was performed from July 2006 to June 2011. All patients who developed postoperative incisional hernias at the hand port site were confirmed by imaging or examination findings. Patient factors were reviewed to determine any predictors of hernia formation. Over the 5 years, 405 patients undergoing HALS procedures were evaluated: colectomy (264), nephrectomy (107), splenectomy/pancreatectomy (18), and ostomy reversal (10). The overall incidence of incisional hernia was 10.6 per cent. There were three perioperative wound dehiscences. The mean body mass index was significantly higher in the hernia group versus the no hernia cohort (32.1 vs 29.2 kg/m(2); P = 0.001). The hernia group also had a higher incidence of renal disease (18.6 vs 7.2%; P = 0.018). Mean time to hernia formation was 11.4 months (range, 1 to 57 months). Follow-up was greater than 12 months in 188 (46%) of patients, in which the rate of incisional hernia was 17 per cent. The rate of incisional hernia formation after hand-assisted laparoscopic procedures is higher than the reported literature. Because the mean time to hernia development is approximately 1 year, it is important to follow these patients to this end point to determine the true incidence of incisional hernia after hand-assisted laparoscopy.     

Incisional infection after colorectal surgery in obese patients

In a prospective study of 189 colorectal operations, the subcutaneous fat layer in the abdominal incisional wound was measured for correlation with wound infection. The infection rate was 20% when the fat layer was greater than or equal to 3.5 cm and 6.8% when the thickness was less than or equal to 3 cm (statistically significant difference). This c. threefold rise indicates that in obese patients special attention should be directed to antibiotic and other prophylaxis against incisional infection.     

Results of incisional hernia repair. A retrospective study of 172 unselected hernioplasties.

The records of 172 patients with repair of incisional hernia in 1976-1985 were reviewed. Follow-up data were collected with a questionnaire and the 40% of patients with symptoms were clinically re-examined. The follow-up time was 3 months to 12 years, mean 4.5 years. The median time between primary operation and first symptoms of incisional hernia was 7 months. Sex, age, smoking, chronic lung disease, obesity, fascial diastasis, site of hernia, surgeon's experience, closure method and suture material were among the factors evaluated as possibly causal. At the time of follow-up 34% of the patients had recurrent hernia. A multifactorial logistic regression analysis revealed obesity as the only factor clearly impairing the result of incisional hernioplasty--good in 87% of the patients with normal weight and in 61% of the overweight. Repeat hernioplasty was performed in 35 cases, but succeeded in only 17. In obese patients repair of an incisional hernia that does not cause serious symptoms is not indicated. More careful selection of patients would improve the results of incisional hernia repair.     

Laparoscopic repair of large incisional hernias

BACKGROUND: Traditional approaches to incisional hernias (IH)--particularly in cases with large fascial defects--are plagued by a significant recurrence rate as well as frequent wound infections. The laparoscopic repair of incisional hernias was designed to offer a minimally invasive and tension-free technique that yields less morbidity and fewer recurrences than the standard open repair. Several years ago, we adopted the laparoscopic technique in our department and set out to appraise its touted advantages. METHODS: During the years 1997-2000, 103 patients underwent laparoscopic IH repair with implanted Dual Gore-tex mesh. Forty percent of them were obese, and 41% had undergone more than one previous attempt at conventional repair. All patients were discharged home within 24-72 hs. RESULTS: In three patients, the operation was converted to open surgery due to severe adhesions and technical difficulties. In two cases, inadvertent enterotomies were repaired laparoscopically, and since there was no major spillage, the repair was continued as planned, with no adverse consequences. Twelve patients underwent additional laparoscopic procedures at the initial operation. Two graft infections and four recurrences were observed during the 1-49 month follow-up period. CONCLUSIONS: Laparoscopic IH repair is technically feasible and safe in patients with large fascial defects as well as in obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence.     

Use of Intraperitoneal ePTFE Gore Dual-Mesh Plus in a Giant Incisional Hernia After Kidney Transplantation: A Case Report

We evaluated the incidence of and predisposing factors for an incisional hernia after kidney transplantation. Numerous techniques have been used to repair postoperative fascial dehiscences or simple incisional hernias, but no clear treatment exists for giant hernias. Our aim was to obtain (1) a safe procedure to repair a large abdominal defect and reinforce the surrounding, fragile zones and (2) a simple, rapid technique to reduce the operative time. Herein we have described the surgical repair of a giant incisional hernia using intraperitoneal Gore ePTFE dual-mesh plus (Gore-Tex; W. L. Gore, Flagstaff, Ariz, USA) in a 55-year-old man status-post renal transplantation. Total necrosis of distal graft ureter had caused a giant urinoma. The patient was reexplored on day 2 posttransplantation with a primary fascial approximation. Thirty days after transplantation we discovered a large incisional hernia and performed a repair. No drain was used. The patient continued immunosuppressive therapy (cyclosporine, mycophenolate mofetil, prednisolone) and was discharged on postoperative day 4 with no complications. An ultrasonographic follow-up at 1 year revealed the prosthesis to be correctely positioned. Incisional hernia is not rare after renal transplantation but the real incidence is unknown. Immunosuppressive therapy, prolonged pretransplantation dialysis, obesity, and diabetes are probably the major causes of incisional hernias in these patients. Surgical complications of renal transplantation surgery, such as wound hematoma, urinoma, and lymphocele, are the most important predisposing factors for an incisional hernia. The use of intraperitoneal ePTFE dual-mesh is feasible, safe, and easy to repair a large incisional hernia in a kidney transplant patient.     

The partial underlay preperitoneal with panniculectomy repair for incisional abdominal hernia in the morbidly obese

BackgroundBecause of high frequency, high morbidity, and difficulty of repair, incisional hernias in obese patients represent a particularly vexing and common problem for surgeons. The objective of this study was to describe a highly selective technique for incisional hernia repair with panniculectomy in the morbidly obese. We also describe perioperative characteristics and preliminary outcomes for a limited series of patients who underwent this procedure.MethodsWe performed a preperitoneal partial mesh underlay with a panniculectomy (PUPP) on 10 patients with incisional hernias and a body mass index (BMI)>40 kg/m². The hernia repair was performed by a general surgery team, and the panniculectomy was performed by a plastic surgery team. We retrospectively analyzed perioperative variables for each patient. Phone interviews were conducted to obtain follow-up.ResultsMean patient age was 53 years (range 32–75 yr) with mean BMI of 46 kg/m² (range 41–60 kg/m²). Patients had a history of 3.4 average prior abdominal operations, and a median of 3 prior hernia repairs. The average operative time was 371 minutes with a mean estimated blood loss of 162 ccs. Three patients experienced a minor wound complication. There were no major wound complications, and the 30-day mortality rate was zero. At a median and average follow-up time of 805 and 345 days, respectively, one patient developed a hernia recurrence. Patients were satisfied with their appearance and the hernia repair, with mean satisfaction scores of 4.3 and 4.9 out of 5 (very satisfied), respectively.ConclusionThe PUPP hernia repair is a viable option for incisional herniorrhaphy and concurrent panniculectomy in the morbidly obese.     

Does pretransplant obesity affect the outcome in kidney transplant recipients?

The effect of obesity on renal transplant outcome remains unclear due to conflicting published studies. The purpose of this study was to assess whether obesity affects the outcome in renal transplant patients. METHODS: We retrospectively analyzed 33 obese (BMI >30; mean = 34.1 +/- 3.68; group I) and 35 nonobese (BMI < or = 30; mean = 23.6 +/- 3.18; group II) renal transplants performed at our center between March 1999 to December 2002. These two groups were well matched with respect to age, sex, donor source, hypertension, diabetes, ischemic heart disease, hyperlipidemia, native kidney disease (PCKD, 6 vs 4; diabetic, 5 vs 4; glomerulonephritis, 6 vs 7; FSGS, 2 vs 2 and IgA, 2 vs 7), HLA mismatch and immunosuppressants medications (Neoral, 21 vs 25; tacrolimus, 11 vs 10; Cellcept, 28 vs 31; Prednisone, 33 vs 35; ATG, 7 vs 8; Basiliximab, 14 vs 13 and Rapamycin, 5 vs 2, groups I and II, respectively). Follow-up was from 7 months to 4.4 years. RESULTS: Significant differences were noted in operating time, wound infection, perinephric hematoma, lymphocele, and number of hospital days. There were no significant differences between the two groups in the incidence of wound dehiscence, deep vein thrombosis, pulmonary embolism, atelectasis, urine leak, delayed graft function, acute rejection rate, and the following posttransplant variables: diabetes mellitus, myocardial infarction, hyperlipidemia, hypertension, and incisional hernia. We conclude that obesity significantly increases operating time, wound complications, and hospitalizations.     

Incisional hernia at the trocar site in laparoscopic surgery

The main aim of this study was to evaluate the incidence of incisional hernia at the trocar site, as well as to contribute towards defining the etiopathogenetic factors responsible. One hundred and fifty cases of patients undergoing laparoscopic surgery were studied retrospectively from the clinical and ultrasonographical points of view. The laparoscopic gaps examined numbered approximately 600 in all. The incidence of incisional hernia was 2%, exclusively located in the periumbilical area. There were no incisional hernias in extra-umbilical areas, which we usually do not suture. A symptomatic extra-umbilical incisional hernia occurred at a 5 mm site in a patient previously operated on in another hospital. Particular attention needs to be paid to periumbilical gap suture, exposed to the trauma of trocar fixing, especially in obese and diabetic patients. In selected cases the other gaps should be sutured, including the 5 mm ones.     

Central rupture and bulging of low-weight polypropylene mesh following recurrent incisional sublay hernioplasty

A recurrent incisional hernia resulting from the rupture of low-weight polypropylene mesh is rarely reported in the literature. Three patients with recurrent incisional hernia due to low-weight polypropylene mesh central rupture were operated 5, 7 and 13 months after initial sublay hernioplasty. The posterior myofascial layer was fully reconstructed in all patients during the hernioplasty, whereas the anterior myofascial layer was only partially reconstructed. The recurrent hernia was managed using heavy-weight polypropylene mesh; in two patients, a new sublay hernioplasty was performed and in one patient an “open preperitoneal flat mesh technique” was performed under local anaesthesia as a day case procedure. If closing of the anterior myofascial layer cannot be ensured during the incisional hernioplasty, the use of low-weight polypropylene meshes should be avoided; preference should be given to the heavy-weight polypropylene meshes.     

Laparoscopic repair of large incisional hernias

Incisional hernias after abdominal operations are a significant cause of long-term morbidity and have been reported to occur in 3 to 20 per cent of laparotomy incisions. Traditional primary suture closure repair is plagued with up to a 50 per cent recurrence rate. With the introduction of prosthetic mesh repair recurrence decreased, but complications with mesh placement emerged ushering in the development of laparoscopic incisional herniorrhaphy. The records of patients who underwent laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001 were reviewed. Patient demographics, hernia defect size, recurrence, operative time, and procedure-related complications were evaluated. Fifty patients (22 male and 28 female, mean age 57 years with range of 24-83) were scheduled for laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001. The average patient was obese with a mean body mass index of 35.8 kg/m2 (range 16-57 kg/m2). Two patients (4%) had primary ventral hernias. Forty-eight patients (96%) had incisional hernias with 22 (46%) of these previously repaired with prosthetic mesh. Mean defect size was 206.1 cm2 (range 48-594 cm2). The average mesh size was 510.2 cm2 (range 224-1050 cm2). Gore-Tex DualMesh and Bard Composite Mesh were used in 84 and 16 per cent of the repairs, respectively. Mean operating time was 97 minutes. There were no deaths. Complications were seen in 12 per cent patients (six occurrences) and included two small bowel enterotomies, a symptomatic seroma requiring aspirate, a mesh reaction requiring a short course of intravenous antibiotics, and trocar site pain (two patients). There were no recurrences during a mean follow-up of 41 months (range 3-74 months). We conclude that laparoscopic incisional herniorrhaphy offers a safe and effective repair for large primary and recurrent ventral hernia with low morbidity.     

Incisional hernia in action: the use of vacuum-assisted closure and porcine dermal collagen implant

In this paper, we describe our experience in the successful use of vacuum-assisted closure (VAC) and porcine dermal collagen (PDC) mesh reconstruction of a complicated contaminated abdominal wall defect resulting from a strangulated incisional hernia with late jejunal perforation in a 57-year-old obese and diabetic woman.     

Kosten- und Risikoanalyse der Hernienreparation

In comparison to the conventional technique of incisional or umbilical hernia repair with sublay mesh augmentation, incisional hernias in obese patients can be surgically treated with minor surgical trauma by laparoscopic intraperitoneal onlay mesh (IPOM) repair. However, although shortened operation time, hospital stay and faster postoperative reconvalescence might be possible with IPOM repair, the economic calculation including mesh costs is significantly higher. In this study the two operation techniques were compared and the perioperative advantages and disadvantages of both methods were analyzed based on the German diagnosis-related groups (DRG) system.