改良Stoppa技术修补巨大腹壁切口疝和缺损(31例报告)

目的总结应用改良的Stoppa技术修补腹壁巨大切口疝和缺损的经验。方法31例腹壁巨大切口疝，腹壁缺损平均直径14．7cm。将聚丙烯网片或复合补片置入腹肌后筋膜前间隙修补，但对缺损边缘不强行拉拢缝合。结果术后无一例发生皮下积液及切口感染。30例患者获得随访，随访时间2～36个月，平均25个月，无一例复发。结论改良的Stoppa技术是无张力修补巨大腹壁切口疝和缺损安全和合理的方法。     

The use of three different mesh materials in the treatment of abdominal wall defects

Abstract Abstract. Various prosthetic materials have been proposed for the repair of abdominal wall defects. These materials offer tension-free repair and significantly lower recurrence rate. Their respective properties are related to such complications as seroma, infection, fistula formation, intestinal adhesions and removal. We compared the final outcome in treating abdominal wall defects in 56 patients with three different prosthetic materials: conventional polypropylene in a preperitoneal location, expanded polytetrafluoroethylene mesh, and hydrophilic membrane coated polyester mesh in an intraperitoneal location. The hydrophilic coated polyester group exhibited the lowest complication rate and the polypropylene group the highest. Electronic Publication     

Biomaterials for abdominal wall hernia surgery and principles of their applications

This article focuses special attention on the porosity, cellular permeability and molecular permeability of biomaterials and their effect on infection, host tissue incorporation and seroma formation when mesh is used for the repair of abdominal wall hernias. Furthermore, the general principles of the application of biomaterials, regardless of the technique used for their employment, is discussed.Zusammenfassung Diese Arbeit befaßt sich mit der Durchlässigkeit sowohl zellulär als auch molekular von Biomaterialien und ihre Auswirkungen auf Infektion, Serombildung und Akzeptanz in Empfängergewebe bei der Implantation von Netzmaterialien in der Hernienchirurgie. Darüber hinaus werden die allgemeinen Prinzipien der Anwendung von Biomaterialien unabhängig von der jeweiligen Implantationstechnik diskutiert.

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Biomaterialien in der hernienchirurgie und ihre anwendung

     

Repair of giant abdominal wall hernias with full-thickness skin transplants in high-risk patients

The repair of giant abdominal hernias in high-risk obese patients remains a great challenge. There is no single simple surgical procedure to provide correction for this condition, and the risk for recurrence of hernia is high. Moreover, the insertion of a foreign material, i.e., synthetic mesh, adds an increased risk of infection, particularly in the presence of concomitant immunosuppressant therapy or diabetes. Eight patients, classified ASA 3–4, with giant abdominal wall hernias had 3 months pre-treatment with a custom-made compressive garment before abdominal wall repair. Four patients had a stoma at the time of surgery. Abdominal wall reconstruction was undertaken by realignment of the rectus muscles and fascia under tension. The fascia repair was stabilized with a full-thickness skin overlay graft. Early complications included two wound infections and one seroma. Two patients had pulmonary insufficiencies and required intensive care management. One complete recurrence of hernia was noted at follow-up. Full-thickness skin overlay grafts can be recommended in high-risk patients with abdominal wall hernias when the use of foreign material such as synthetic mesh is contraindicated.     

The argument for lightweight polypropylene mesh in hernia repair

The development of polypropylene prosthetics revolutionized surgery for the repair of abdominal wall hernias. A tension-free mesh technique has drastically reduced recurrence rates for all hernias compared to tissue repairs and has made it possible to reconstruct large ventral defects that were previously irreparable. The repair of abdominal wall defects is one of the most commonly performed general surgical procedures, with over 1 million polypropylene implants inserted each year. Surprisingly, little research has been performed to investigate the interaction of abdominal wall forces on a ventral hernia repair or the required amount or strength of the foreign-body material necessary for an adequate hernia repair. The long-term consequences of implantable polypropylene prosthetics are not without concern. The body generates an intense inflammatory response to the prosthetic that results in scar plate formation, increased stiffness of the abdominal wall, and shrinkage of the biomaterial. Reducing the density of polypropylene and creating a 'light weight' mesh theoretically induces less foreign-body response, results in improved abdominal wall compliance, causes less contraction or shrinkage of the mesh, and allows for better tissue incorporation. A review of the laboratory data and short-term clinical follow-up is reviewed to provide a strong basis or argument for the use of 'light weight' prosthetics in hernia surgery.     

A minimally invasive approach for treating postoperative seromas after incisional hernia repair.

BACKGROUND: The most frequent wound complication following repair of large incisional hernias is seroma formation, especially when the use of a mesh onlay requires extensive subcutaneous undermining. Treatment options for postoperative seromas include observation for spontaneous resolution, percutaneous aspiration, closed suction drainage, abdominal binders, and sclerosant. METHODS: A novel technique for treating persistent postoperative seromas is presented herein. This technique involves a 3-puncture minimally invasive approach that can be performed in an outpatient setting. Evacuation of serous fluid and fibrinous debris is followed by argon beam scarification of the seroma cavity lining. Talc slurry is then introduced into the cavity. Three patients have been treated with this technique. RESULTS: All 3 patients had successful ablation of seromas that had persisted despite standard treatment modalities. CONCLUSION: A minimally invasive approach is a reasonable and safe alternative for treating persistent postoperative seromas.     

Laparoscopic Incisional Hernia Repair With Fibrin Glue in Select Patients

Background and Objective:

Laparoscopic treatment of incisional hernias can be performed using different types of fixation devices and prosthesis. We present a case series of 19 patients with incisional hernias with a diameter of <6cm, who underwent laparoscopic repair using Hi-tex dual-side mesh, positioned intraperitoneally, fixed to the abdominal wall by fibrin glue (Tissucol).

Methods:

Nineteen patients with incisional hernias <6cm in diameter were enrolled in this study and treated laparoscopically with Hi-tex and Tissucol. Surgical complications and patient outcomes were assessed with a clinical follow-up.

Results:

Laparoscopic repair of incisional hernias by using Hi-tex mesh affixed to the parietal wall with fibrin glue was feasible and easy in patients with parietal defects <6cm in diameter. Mean operating time was 30 minutes. Mean hospital stay was 1.5 days. Almost no postoperative pain, major surgical complications, seroma formation, relapses, or prosthesis infection occurred during a mean follow-up of 20 months.

Conclusions:

In select patients, Hi-tex mesh affixed using fibrin glue allows laparoscopic repair of incisional hernias with very good patient outcomes, especially in terms of postoperative pain and seroma formation.     

Intraperitoneal modification of the Rives-Stoppa repair for large incisional hernias

Introduction Recurrence rates for open repair of ventral/incisonal hernias historically range from 6% for the classic Rives-Stoppa repair to 35–45% for some of the techniques more commonly used in the United States. We report a modification to the classic Rives-Stoppa repair that allows intraperitoneal placement of the prosthetic, secured with a running suture. The abdominal muscles are closed over the mesh to protect it from any superficial wound problems that might develop and to restore normal architecture of the abdominal wall. Method A chart review was undertaken on all patients undergoing open ventral incisional hernia repair by a single surgeon from 2000 to 2006. All hernias were repaired with the intraperitoneal modification mimicking the principles of the Rives-Stoppa repair. Patient characteristics and operative and postoperative data were collected. Primary outcome was recurrence of hernia. Secondary outcomes were complications and rate of mesh infection. Results One hundred and fifteen patients were evaluated. Thirty-four patients had repair of recurrent ventral hernias. The average patient was obese, female, and 59 years old. Twenty-five patients used tobacco, eleven were diabetic, and seven used chronic corticosteroids. Meshes utilized included ePTFE, coated polyester, coated polypropylene, and biologic mesh. Average size of mesh was 465.4 cm². There were four recurrences (3.4%), three of which were due to mesh infection requiring mesh removal. Recurrence rate not secondary to mesh removal was 0.9%. Complications occurred in 26% with seroma formation being the most frequent (16%). Conclusion The intraperitoneal modification to the original Rives-Stoppa repair leads to a very low recurrence rate for large ventral hernia repairs with minimal complications and low rate of mesh infection. Presented at the 2007 American Hernia Society Meeting, Hollywood, FL, USA.     

Use of biologic mesh for a complicated paracolostomy hernia

Background

Parastomal hernias are among the most frustrating and incapacitating complications of permanent colostomies. Because the traditional surgical options of primary repair with or without ostomy repositioning have led to disappointing results, the use of mesh is indicated, especially in the setting of multiple recurrences.

Methods

After laparoscopic lyses of adhesions, the colostomy is pushed against the lateral abdominal wall, and a bovine pericardium graft is gently stretched and draped over the colostomy (the Sugarbaker technique). Transfascial sutures and tacks are placed along the perimeter of the mesh and around the colon to prevent small bowel herniation.

Results

The patient developed a small seroma postoperatively, which resolved spontaneously. At his 17-month follow-up, the patient had no evidence of recurrence, he was pain free, and he was satisfied with his cosmetic results.

Conclusion

Although several studies indicate the feasibility and efficacy of synthetic permanent mesh repair, the concerns of mesh infection, erosion, and ostomy obstruction still persist. The authors suggest parietalizing the bowel and using a biologic mesh.     

腹腔镜下腹壁切口疝补片修补术的初步经验

目的:探讨腹腔镜下腹壁切口疝修补术的手术方法、安全性等问题。方法:对我院2004年3月～11月间收治的25例腹壁切口疝病人,进行腹腔镜下修补术。结果:24例(96%)手术成功,1例(4%)因腹腔内广泛粘连而中转为剖腹修补。平均手术时间为110min,平均术后住院6d,6例(24%)病人术中发现有一个以上的隐匿性缺损。术后并发症有:术后短期内修补区腹壁明显疼痛21例(84%),腹壁缝合点较长时间疼痛6例(24%),浆液肿3例(12%);无修补区感染,也未发现早期复发的病例。结论:对腹壁切口疝,多数病人是可以经腹腔镜进行粘连松解及补片修补术的,还可在术中发现其他隐性缺损。对腹腔内广泛粘连而影响操作器械的进入及分离者,应及时中转剖腹手术。     

A prospective study between two different techniques for the repair of a large recurrent ventral hernia: a double mesh intraperitoneal repair versus onlay mesh repair

Background: Massive ventral hernias are difficult to repair, especially with multiple recurrences. Numerous methods of repair have been described with an overall recurrence rate up to 33% after first repair and 44% after second repair, mostly occurring within 3 years of the repair. Methods: This is a prospective study on 41 patients who underwent surgery between January 2000 and August 2004 for recurrent large ventral hernias. Patients were randomized into two groups: group A included 22 patients, who were subjected to suture repair with an onlay polypropylene mesh, and group B, which included 19 patients, who were subjected to a tailored double mesh (Vicryl+polypropylene) intraperitoneal repair. Results: Superficial wound infection occurred in two patients (4.8%), one in each group. By a median follow up of 30 months, seroma formation or hernia recurrence was not found in group B in comparison to seven and six cases, respectively, in group A (p≤0.000). There was no intraabdominal complication in the cases subjected to double mesh intraperitoneal repair due to the protective effect of the inner Vicryl layer, which is characterized by its low reactivity. Conclusions: A double mesh intraperitoneal repair (ADMIR) is successful for the repair of recurrent large ventral hernias as it is applicable to all sites of ventral hernias. The mesh is mostly hidden within the abdomen with relatively affordable pain allowing for early mobilization, the complication rate is low and so far no recurrence was reported. A long-term follow up with a larger number of cases is advisable in order to determine the long-term success of this kind of repair.     

Modifications in the abdominal wall after prostheses implant in guinea pigs. Experimental preliminary study

The treatment of giant incisional hernias is often not possible without the use of alloplastic materials (prostheses, meshes). Some of the modern prostheses seem to be quite "biocompatible" from the chemical point of view, but, the manner of using them is associated with certain complications (infection, seroma formation, intestinal obstruction, digestive fistula and failure of the repair). This preliminary experimental study on Guinea pigs had as a purpose the evaluation of the prostheses incorporation in the abdominal wall, the appearance of specific complications and the need of the biomaterial fixation. The macroscopic and microscopic study used 59 Guinea pigs, utilizing polypropylene (Marlex) and polyester (Mersilene and Plastex) prostheses, implanted pre-peritoneal and intraperitoneal, with or without fixation. The lack of incorporation of the prostheses was observed especially with the Plastex mesh (7 cases). Intestinal adhesions have been the rule after intraperitoneal implant of the prostheses; we registered a case of intestinal obstruction and a case of digestive fistula. Concluding, it is recommended the utilization of quality prostheses, especially polypropylene (Marlex) and no longer use of the Romanian polyester mesh (Plastex) which has obvious "biocompatible" problems. The intraperitoneal implant of the prostheses is not indicated. Adequate anchoring af the biomaterials prevents the subsequent migration.     

Long-term pain and recurrence after repair of ventral incisional hernias by open mesh: clinical and MRI study

Background and aims Polypropylene mesh repair of large incisional ventral hernias has become increasingly popular. Long-term effects of the mesh on pain and abdominal muscles are not known.Patients/methods Retromuscular pre-peritoneal polypropylene mesh was placed by open technique in 84 consecutive patients with large ventral hernias (mean defect size 130 cm²). We re-examined the patients after a mean follow-up time of 3 years to find out the frequency of recurrence and chronic pain. We measured the thickness of abdominal muscles of eight patients preoperatively, and postoperatively after 1 year, using magnetic resonance imaging (MRI).Results Recurrent hernias had appeared in four patients (5%) at follow-up. Nine patients (13%) needed occasional pain-relieving drugs, but only three (4%) suffered persistent, severe, pain from the mesh. Some limitation during leisure-time physical activities was found in 10% of patients. Only ten patients (12%) were re-operated on because of wound complications or recurrence. MRI study indicated that abdominal muscles were postoperatively well preserved. Although wound infections (6%) and seroma (9%) were frequent complications, there was no need for meshes to be removed in the follow-up.Conclusion Open ventral herniorrhaphy with mesh is safe, effective and inexpensive. Small, recurrent hernias were infrequent and easy to re-operated on. Severe pain from the mesh was not common. Postoperative MRI study indicated no obvious damage of abdominal muscles after mesh placement.     

Laparoscopic incisional hernia repair

Background Recent advances in laparoscopic surgery have made various abdominal surgeries possible. To avoid wound infection, mesh repair of abdominal incisional hernias is performed laparoscopically. Here we present a new procedure to fix mesh to the abdominal wall. Surgical technique Four anchoring sutures are made using a suture-grasping device; the additional transabdominal sutures are then made with a modified double-needle device. Additional circumferential fixation with tacks is not necessary. Conclusions This new mesh fixation method involves simple suturing techniques and is less time consuming than the conventional procedure.     

Closure versus non-closure of fascial defects in laparoscopic ventral and incisional hernia repairs: a review of the literature

The laparoscopic technique for repairing ventral and incisional hernias (VIH) is now well established. However, several issues related to laparoscopic VIH repair, such as the high recurrence rate for hernias with large fascial defects and in extremely obese patients, are yet to be resolved. Additional problems include seroma formation, mesh bulging/eventration, and non-restoration of the abdominal wall rigidity/function with only bridging of the hernial orifice using standard laparoscopic intraperitoneal onlay mesh repair (sIPOM). To solve these problems, laparoscopic fascial defect closure with IPOM reinforcement (IPOM-Plus) has been introduced in the past decade, and a few studies have reported satisfactory outcomes. Although detailed techniques for fascial defect closure and handling of the mesh have been published, standardized techniques are yet to be established. We reviewed the literature on IPOM-Plus in the PubMed database and identified 16 reports in which the recurrence rate, incidence of seroma formation, and incidence of mesh bulging were 0–7.7, 0–11.4, and 0 %, respectively. Several comparison studies between sIPOM and IPOM-Plus seem to suggest that IPOM-Plus is associated with more favorable surgical outcomes; however, larger-scale studies are essential.     

A complication of the use of Prolene Mesh in the repair of abdominal wall hernias

Summary The use of Prolene Mesh has become standard practice in the repair of inguinal hernias and has so far proved to be virtually free of complications [Liechtenstein 1987]. Its use in the repair of other difficult hernias, particularly incisional hernias, has obvious attractions. We present complications encountered in the use of prolene mesh in the repair of three very large abdominal hernias.     

Improved outcomes with the Prolene Hernia System mesh compared with the time-honored Lichtenstein onlay mesh repair for inguinal hernia repair

BACKGROUND: Inguinal hernia repairs are commonly performed operations. Recently, Neumayer et al examined the gold standard Lichtenstein onlay mesh repair (LMR) against laparoscopic inguinal hernia repair and showed that the recurrence rates are higher for laparoscopic mesh repairs when compared with the open onlay mesh repair (laparoscopic = 10.1% versus open = 4.9%). In 1998, the Prolene Hernia System (PHS) mesh, consisting of an onlay and an underlay patch attached with a connector, was introduced as an option for tension-free open repair of inguinal hernias combining the benefits of a posterior and anterior repair from an open approach. Our objective was to evaluate the PHS mesh repair versus the LMR for inguinal hernias. We hypothesized that the recurrence rate of PHS mesh would be lower compared with the LMR with overall similar complication rates. METHODS: PHS mesh hernia repairs performed from January 2003 to July 2005 and LMR repairs from January 2000 to July 2002 were included. Demographic data such as age, race, and gender as well as comorbid conditions such as chronic obstructive pulmonary disease, congestive heart failure, previous myocardial infarction, diabetes, hypertension, prostatism, and chronic cough were collected. Complications such as cord injury, seroma, hematoma, urinary retention, urinary tract infection, orchitis, and wound infection were recorded. Recurrences in each group were also recorded. A student t test and chi-square analysis were used for statistical analysis. RESULTS: Six hundred twenty-two charts were reviewed during the 2 time periods (PHS mesh = 321, LMR = 302). The median follow-up for the study was 17 months. There was no significant difference with regards to age, race, gender, or comorbidities between the 2 groups. Overall, there was a trend toward decreased complications in the PHS mesh group compared with the LMR group (PHS mesh = 17%, LMR = 23%, P = .07), with a significant difference in the hematoma/seroma rates (PHS mesh = 6.9%, LMR = 12.6%, P = .015). Finally, there was a significant decrease in the recurrence rate for the PHS mesh group when compared with the LMR group (PHS mesh = 0.6%, LMR = 2.7%, P = .04). CONCLUSION: Our study shows, during a median follow-up of 17 months, improved outcomes by using the PHS mesh compared with the gold standard Lichtenstein onlay mesh for inguinal hernias with significantly lower recurrence rates. Additionally, in the PHS mesh group, there was a trend toward decreased overall complication rates with significantly less seroma/hematoma rates. Therefore, the PHS mesh repair may represent a superior alternative for the repair of inguinal hernias.     

Ubiquitous use of prosthetic mesh in inguinal hernia repair: the dilemma

Summary The omnipresence of prosthetic materials (mesh) used in hernia repairs throughout the world deserves careful review. The propensity to develop operative techniques wherein prosthetic mesh is used routinely, regardless of type hernia, has reached an unacceptable level of practice. Being foreign bodies, postoperative complications occur which directly can be traced to the implanted meshes. Recent interest in mesh complications, i.e., infection, mesh shrinkage, migration and fistula formation, has escalated. Although mesh foreign body tumorigenesis has not been seen in humans following hernia repair, there is sufficient animal data to cause concern. Similarly, neural complications following use of mesh, particularly after the open anterior notension repair methods, are being reported at alarming rates. Many types of inguinal hernias do not need mesh repairs. It is our premise that these hernias must be identified preoperatively. Certainly, type I, II and III C inguinal hernias of our classification, should not receive a prosthetic mesh repair. If prosthetic mesh is to be used, it should be placed to buttress the inguinal wall posteriorly so that advantage of Pascal's law may be assured.