Revisional Laparoscopic Parastomal Hernia Repair

Background:

We herein report a laparoscopically performed re-do operation on a patient who had previously undergone a laparoscopic parastomal hernia repair.

Case Report:

We describe the case of a 71-year-old patient who presented within 3 months of her primary laparoscopic parastomal hernia repair with recurrence. On relaparoscopy, dense adhesions to the mesh were found, and the mesh had migrated into the hernia sac. This had allowed loops of small bowel to herniate into the sac. The initial part of the procedure involved the lysis of adhesions. A piece of Gore-Tex DualMesh with a central keyhole and a radial slit was cut so that it could provide at least 3 cm to 5 cm of overlap of the fascial defect. The tails of the mesh were wrapped around the bowel, and the mesh was secured to the margins of the hernia with circumferential metal tacking and 4 transfascial sutures. The patient remains in satisfactory condition and no recurrence or any surgery-related problem has been observed during 8 months of follow-up.

Conclusion:

Revisional laparoscopic repair of parastomal hernias seems feasible and has been shown to be safe and effective in this case. The success of this approach depends on longer follow-up reports and standardization of the technical elements.     

Laparoscopic Paraesophageal Hernia Repair. How I do it

Introduction  The approach to paraesophageal hernias has changed radically over the last 15 years, both in terms of indications for the repair and of surgical technique. Discussion  Today we operate mostly on patients who are symptomatic and the laparoscopic repair has replaced in most cases the open approach through either a laparotomy or a thoracotomy. The following describes a step by step approach to the laparoscopic repair of paraesophageal hernia. Presented at the 49th Annual Meeting of the Society for Surgery of the Alimentary Tract, San Diego, California, May 17–21, 2008     

改良完全腹膜外腹腔镜疝修补术31例报告

目的评价改良的完全腹膜外腹腔镜疝修补(totally extraperitoneal laparoscopic hernia repair,TEP)手术方法的可行性和安全性。方法2007年1月~8月,在全麻下行改良TEP31例。用一次性吸引器头的塑料外套管对手术区域的腹膜前间隙进行初步分离,再将国产单腔气囊导管小心置入腹膜外间隙,充气扩张建立腹膜外间隙。术中不固定补片。结果手术全部成功,手术时间(69.8±21.8)min,术中出血量(7.6±4.2)ml,术后住院时间(2.6±1.3)d。术中腹膜破裂5例,术后阴囊积液2例,无其他手术并发症。31例随访1~7个月,(4.2±2.4)月,未见复发及腹股沟区慢性疼痛等并发症。结论改良TEP是一种安全可行的无张力疝修补技术,腹股沟区慢性疼痛症状少。     

A Prospective Randomized Study of Lichtenstein Open Tension-free Versus Laparoscopic Totally Extraperitoneal Techniques for Inguinal Hernia Repair

Ideal technique for effective inguinal hernia repair is still controversial. Although open tension free mesh techniques of inguinal hernia repair offers good results but the superiority of laparoscopic technique was reported for postoperative pain, discomfort and earlier return back to work. A prospective, randomized study was conducted to compare Lichtenstein open tension free mesh technique with the laparoscopic totally extraperitoneal technique. 62 male patients with Lichtenstein open tension free mesh technique and 61 male patients with totally extraperitoneal technique were operated and compared postoperatively. The patients were followed-up for 24 months with a median of 18 months. In terms of recurrence, postoperative pain, analgesic requirement, complications, hospital stay lenght, duration of limitation of normal daily activities there were no significant differences between the two groups. Operating time for totally extraperitoneal hernia repair was 16 minutes longer than Lichtenstein open tension free technique. The totally extraperitoneal technique was considerably expensive than Lichtenstein technique, however the duration of returning back to work was shorter in patients repaired with totally extraperitoneal technique.

In conclusion in primary inguinal hernia repair Lichtenstein technique should be preferred and the totally extraperito neal technique should be considered for recurrent and bilateral hernias.     

Laparoscopic Paraesophageal Hernia Repair

Background and Objective:

Paraesophageal hernias are uncommon yet potentially lethal conditions. Their repair has now been facilitated by laparoscopic technology. We present a series of 20 patients with paraesophageal hernias repaired laparoscopically.

Methods:

Twenty patients with paraesophageal hernias had laparoscopic repairs. Eighteen patients had primary repair of their hiatal defect. Two required mesh reinforcement. Fifteen patients had a fundoplication procedure performed concomitantly.

Results:

Long-term follow-up is available on 17 patients. There was no in-hospital morbidity or mortality. Average length of stay was 2.3 days. One patient recurred in the immediate postoperative period. There were no other recurrences. The only death in the series occurred in the oldest patient 18 days postoperatively. He had been discharged from the hospital and died of cardiac failure. No patients have had complications from a paraesophageal hernia postoperatively.

Conclusion:

Laparoscopic repair of paraesophageal hernias is possible. Preoperative work-up should include motility evaluation to assess esophageal peristalsis as the majority of these will need a concomitant anti-reflux procedure. This data helps the surgeon to determine whether or not a complete or partial wrap should be done. Repair of the diaphragmatic defect can be accomplished in the majority of patients without the use of prosthetic material with excellent results.     

Evaluation of the Rebound Hernia Repair Device for Laparoscopic Hernia Repair

Background:

The characteristics of the ideal type of mesh are still being debated. Mesh shrinkage and fixation have been associated with complications. Avoiding shrinkage and fixation would improve hernia recurrence rates and complications. To our knowledge, this is the first study of a device with a self-expanding frame for laparoscopic hernia repair.

Methods:

Six Rebound Hernia Repair Devices were placed laparoscopically in pigs. This device is a condensed polypropylene, super-thin, lightweight, macro-porous mesh with a self-expanding Nitinol frame. The devices were assessed for adhesions, shrinkage, and histological examination. Laboratory and radiologic evaluations were also performed.

Results:

The handling properties of the devices facilitated their laparoscopic placement. They were easily identified with simple x-rays. The mesh was firmly integrated within the surrounding tissue. One device was associated with 3 small adhesions. The other 5 HRDs had no adhesions. We noted no shrinkage or folding. All devices preserved their original size and shape.

Conclusions:

At this evaluation stage, we found that the Rebound Hernia Repair Device may serve for laparoscopic hernia repair and has favorable handling properties. It prevents folding and shrinkage of the mesh. It may eliminate the need for fixation, thus preventing chronic pain. The Nitinol frame also allowed radiologic evaluation for gross movement. Further studies will be needed to evaluate its clinical application.     

Laparoscopic repair of a paraesophageal hiatus hernia without fundoplication

We treated a case of paraesophageal hiatus hernia by laparoscopic repair. The procedure included a reduction of the gastric fundus and duodenal bulbus, closure of the diaphragmatic defect, mesh wrapping of the closure, gastropexy to the diaphragm, and a gastrostomy. Preoperative monitoring of the pH for 24h showed no reflux. Intraoperative intraluminal manometry of the esophagus after hernia reduction showed the pressure of the lower esophageal sphincter to be normal, and thus an antireflux procedure was not deemed to be necessary. The patient was put on a soft diet from postoperative day 2. A postoperative upper gastrointestinal series showed no gastroesophageal reflux. No complications or recurrence of the hiatus hernia have been observed in the 12 months since the operation. Laparoscopic repair of a paraesophageal hiatus hernia with normal pressure of the lower esophageal sphincter, so that fundoplication is not needed, is thus considered to be possible.     

Laparoscopic Repair of Left Lumbar Hernia After Laparoscopic Left Nephrectomy

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.     

开放与腹腔镜无张力疝修补术治疗老年腹股沟疝的对比研究

目的比较开放和腹腔镜完全腹膜外无张力疝修补治疗老年腹股沟疝的疗效。方法 2006年1月～2010年1月136例老年腹股沟疝行开腹无张力填充式腹股沟疝修补术（开放组,n=72）或腹腔镜完全腹膜外腹股沟疝修补术（totally extraperitoneal hernioplasty,TEP）（TEP组,n=64）,比较2种术式疗效。结果开放组手术时间（65.3±18.1）min,明显短于TEP组（78.1±12.6）min（t=4.742,P=0.000）。开放组住院费用（4960.2±1033.3）元,明显低于TEP组（6998.0±1632.2）元（t=8.796,P=0.000）。开放组术后24 h和1周疼痛评分明显高于TEP组（Z=-7.144,P=0.000;Z=-6.408,P=0.000）;术后住院时间（4.9±2.4）d明显长于TEP组（3.6±1.5）d（t=-3.733,P=0.000）。136例无严重并发症。开放组72例随访8～46个月,平均15个月,其中〉24个月11例;TEP组64例随访4～35个月,平均14个月,其中〉24个月9例,2组均无术后复发。结论 2种术式治疗老年腹股沟疝是安全有效的。TEP疼痛轻,恢复快,应首选,尤其适用于双侧腹股沟疝修补;开放无张力疝修补术费用低,易开展,非常适用于合并有心肺疾病无法耐受全麻或CO2气腹的老年患者。     

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.     

Experience of Laparoscopic Incisional Hernia Repair in Kidney and/or Pancreas Transplant Recipients

Despite the wide popularity of laparoscopic incisional hernia repair (LIHR) in the nontransplant population, there are very few reports of LIHR available in abdominal organ transplant patients and none exclusively on kidney and/or pancreas (KP) transplant patients. We retrospectively reviewed a consecutive series of LIHR in KP transplant recipients performed over a period of 4 years and compared the results with LIHR in non‐transplant patients during the same period. A total of 36 transplant patients were compared with 62 nontransplant patients. There were five patients converted to the open procedure in the transplant and four in nontransplant patients (p‐NS). There were three seromas and one patient had a bowel perforation in the transplant group versus eight seromas, one bowel perforation and one small bowel obstruction noted in the nontransplant group. One patient in each group had a mesh infection requiring explant. Patients were followed up for a mean period of 2.2 years in the transplant group and 3 years in the nontransplant group. Overall there were five recurrences in the transplant group and four in the nontransplant group (p = NS). These results suggest that that LIHR is a safe and effective alternative to open repair.