Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20 th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.     

A novel technique of lumbar hernia repair using bone anchor fixation

Lumbar hernias are difficult to repair due to their proximity to bone and inadequate surrounding tissue to buttress the repair. We analyzed the outcome of patients undergoing a novel retromuscular lumbar hernia repair technique. The repair was performed in ten patients using a polypropylene or polytetrafluoroethylene mesh placed in an extraperitoneal, retromuscular position with at least 5 cm overlap of the hernia defect. The mesh was fixed with circumferential, transfascial, permanent sutures and inferiorly fixed to the iliac crest by suture bone anchors. Five hernias were recurrent, and five were incarcerated; seven were incisional hernias, and three were posttraumatic. Back and abdominal pain was the most common presenting symptom. Mean hernia size was 227 cm² (60–504) with a mesh size of 620 cm² (224–936). Mean operative time was 181 min (120-269), with a mean blood loss of 128 ml (50–200). Mean length of stay was 5.2 days (2–10), and morphine equivalent requirement was 200 mg (47–460). There were no postoperative complications or deaths. After a mean follow-up of 40 months (3–99) there have been no recurrences. Our sublay repair of lumbar hernias with permanent suture fixation is safe and to date has resulted in no recurrences. Suture bone anchors ensure secure fixation of the mesh to the iliac crest and may eliminate a common area of recurrence.     

Incisional hernia following appendectomy. Surgical experience

Summary Appendectomy is a very frequent cause of incisional hernia. In this paper the rate of recurrence after the hernia repair by simple suture and mesh repair was studied. 17 lateral incisional hernias secondary to appendectomy were repaired over a 9 year period. Prosthetic repair was carried out in 9 cases and primary closure in the remaining 8 cases. All the patients were followed over a period that ranged from 1 to 8 years (mean 5.6 years). There was one recurrence, though 2 patients (11.7%) with mesh repair complained about abdominal pain during the first postoperative year. The study concludes that both techniques can be successfully implemented if the correct indications based on the extent of the defect and the clinical characteristics of the patient are respected.     

腹壁切口疝的外科治疗(附53例临床分析)

目的总结治疗腹壁切口疝的临床经验.方法对1994年4月～2002年8月53例腹壁切口疝患者在年龄、手术方法、引流放置,抗生素应用及预后进行回顾性分析.结果53例患者采用人工合成材料或直接缝合修补.术后切口积液3例,无切口感染.随访时间3月～5年,治愈46例,复发7例.结论腹壁切口疝是腹部手术后常见的并发症之一,尤其是老年患者.合理使用人工合成材料及直接缝合修补法适可以获得良好的治疗效果.     

Primary incisional hernia repair with or without polypropylene mesh: a report on 384 patients with 5-year follow-up

Background and aim Several studies have claimed that mesh repair of incisional hernia lowers recurrence rates when compared to suture repair. We investigated the relative effectiveness of mesh and suture repair in a large homogeneous cohort of patients with primary incisional hernia.Patients and methods In a retrospective single-centre cohort study, a total of 446 consecutive patients were identified, of whom 86% could be followed up. Mean length of follow-up was 5 years. In 79 patients (22%), we implanted a mesh, usually polypropylene (Prolene).Results Compared to suture repair, mesh repair prolonged operating time by over 30 min and caused seroma in 12.7% of the patients (p<0.001). Only 4 of the 79 patients with mesh repair developed recurrence, compared to 55 of the 305 patients with suture repair (5 vs 18%, p=0.02 by log-rank test). In multivariate Cox regression, recurrence rates were fourfold higher after suture than after mesh repair (p=0.02). Interestingly, old age was associated with a decreased susceptibility for recurrence (p=0.01).Conclusion Our data confirms the long-term effectiveness of mesh repair under routine conditions. Suture repair should be restricted to small hernias in patients free of known risk factors.     

Laparoscopic sutured closure with mesh reinforcement of incisional hernias

Background This study reports medium-term outcomes of laparoscopic incisional hernia repair. Study Design Laparoscopic repair was performed on 721 patients with ventral hernia. After adhesiolysis the defect was closed with no. 1 polyamide suture or loop. This was followed by reinforcement with intraperitoneal onlay repair with a bilayered mesh. Results Laproscopic repair of ventral hernia was performed on 613 females and 108 males. Of these, 185 (25.7%) were recurrent incisional hernias of which 93 had undergone previous open hernioplasty. The remaining 92 patients had previously undergone sutured repair. The average operating time was 95 min (range 60–115 min). Conversion rate was 1%. The average hospital stay was 2 days (range 1–6 days). The commonest complication was seroma formation at the incisional hernia site. Full-thickness bowel injury occurred in two patients. The mean follow-up period was 4.2 years (range 3 months to 10 years). Recurrence was noted in four (0.55%) patients. Conclusion Laparoscopic repair is well-tolerated and can be accomplished with minimum morbidity in ventral hernias.     

Cost analysis of incisional hernia repair by suture or mesh

The objective was to make a cost analysis of incisional hernia repair by suture repair or prosthetic mesh repair. The study included 44 patients who underwent hernia repair between 1991 and 2000. The rate of recurrent incisional hernia after more than 1 year with associated costs was registered. In 1996, the technique of incisional hernia repair was changed from suture repair to mesh repair. With a mesh repair, zero out of 19 patients presented with a recurrence at follow-up, and with suture repair, five out of 13 had a recurrence (P<0.01). The duration of anaesthetic and operation was longer, but stay in the surgical ward, and sick leave was shorter for patients with a mesh repair than for those with a suture repair. For working patients, costs in the operating theatre were 4,095 Swedish kronor (SEK) higher with a mesh repair, and the costs for surgical ward, sick leave, and examination were 10,129 SEK lower than with a suture repair. Thus, with a mesh repair, the total costs were 6,034 SEK lower than with a suture repair. For retired patients, the total costs with a mesh repair were 1,898 SEK lower than with a suture repair. We conclude that in this setting, mesh repair of incisional hernias produced lower costs than suture repair.     

Intra Peritoneal Polypropylene Mesh and Newer Meshes in Ventral Hernia Repair: What EBM Says?

Incisional hernias and other ventral hernias are common surgical problems. It is estimated that incisional hernia complicates about 2 % to 10 % of laparotomies. Ventral and incisional hernia repairs are among the common surgeries done by a general surgeon. It is proven beyond any doubt that suture repair of these hernias should not be done as recurrence rates are unacceptably high, some series reporting as high as 54 % on long-term follow-up. A prosthetic mesh should always be used in ventral hernia repair (VHR). Now, the polypropylene mesh (PPM) has become the prosthetic mesh of choice in the repair of hernias, including inguinal hernia. However, with the advent of laparoscopic repair where the mesh is placed intraperitoneally, concerns regarding safety of PPM are raised. Newer meshes are introduced, claiming lesser complication rate. Many types of newer meshes are available now. Newer meshes are invariably costlier than PPM by 15–20 times. Is this extra cost worth? We looked in to available literature for an answer.     

Simplified technique for incisional hernia repair with mesh prosthesis

This paper describes a simplified technique for the repair of incisional hernias. The previous scar is resected, and the peritoneal sac is carefully dissected until it is completely exposed. The sac is opened to liberate structures adherent to the sac or to the area immediately surrounding the defect. The peritoneum is closed and invaginated to form a sac bed underlying the entire extent of the defect, and the mesh is laid on this sac bed. The mesh is then fixed with "U" stitches, reinforcing these by inserting a second line from the edge of the defect to the mesh. Suture material used is polypropylene 1/0 or 2/0. This procedure has been carried out on 15 patients, and after 1 year of follow-up, there has been no recurrence of the hernia. Operating time was reduced, and the surgical technique was found to be easier. Placing a mesh prosthesis inside the hernia sac and fixing it to the abdominal wall with two lines of suturing simplifies the repair procedure, reduces operating time, and is effective in the repair of all incisional hernias. A study is required to compare this outcome with the different mesh repair techniques.     

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。     

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.     

Combined fascia and mesh repair of incisional hernias

Incisional hernia is a relatively common complication following abdominal operations. Due to high recurrence rates following primary suture, a prosthetic mesh is now usually used to repair the hernia. Several different types of repair are described. A combined fascia and mesh technique avoids opening the peritoneal cavity and potential damage to bowel. This study describes results of this technique. Consecutive patients undergoing the operation were contacted to assess freedom from recurrence and satisfaction with results. Some 34 patients underwent 36 incisional repairs. Of the 34 patients 21 were men and 13 were women with a median age of 69 years (range 31–86 years). The causative incisions were midline (30), Kochers (2), Pfannesteil (2) and transverse (2). The median time spent in hospital was three nights (range 1–14 days). Two patients developed seromas, another complained of pain soon after operation, one patient developed a superficial wound infection another developed a tender drain site which required exploration. One patient with significant co-morbidity died 13 days postoperatively from multiorgan failure. Freedom from recurrence of the hernia was 91% at 5 years. However patient survival was only 70% at 5 years. This technique is associated with low postoperative morbidity and a low recurrence rate. Patients presenting with incisional hernias have a poor long-term prognosis which needs to be borne in mind when planning intervention.     

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.     

应用人工材料行腹肌后筋膜前修补治疗切口疝80例

目的:总结应用人工材料修补腹壁切口疝的经验。方法:回顾分析我院以单丝编织聚丙烯网片修补的80例腹部切口疝的临床资料。结果:全组无围手术期死亡,1例术后24h内出现急性左心功能衰竭,经对症处理后治愈。全组无切口感染,无血肿形成;拔除引流管后皮下血肿形成1例,无窦道形成。平均住院(14.3±6.5)d。获随访者73例,无复发病例。结论:人工材料腹肌后筋膜前修补术是治疗腹壁切口疝的优良术式;对于疝环横径>10cm或疝内容物多、突出时间较长的巨大切口疝病人应予充分的术前准备。     

Randomized clinical trial of suture repair, polypropylene mesh or autodermal hernioplasty for incisional hernia

BACKGROUND: Since conventional suture repair for incisional hernia is associated with high recurrence rates, alloplastic and autoplastic prosthetic techniques have been suggested. METHODS: In a randomized trial, 160 patients with simple or complex hernias underwent either suture repair, autodermal skin graft or onlay polypropylene mesh repair. Suture repair was not done in complex hernias. This report concerns a planned interim analysis. RESULTS: At mean follow-up of 16 months, there were 17 hernia recurrences that were distributed similarly between the surgical techniques. There were fewer infectious complications after suture repair (three of 33 patients) than after skin graft or mesh repair (seven of 39 and five of 28 for simple hernias; seven of 31 and ten of 29 respectively for complex hernias) (P not significant). The severity of infections after polypropylene mesh implantation prompted the trial committee to discontinue the study. No differences were noted in duration of stay in hospital and quality of life. However, pain was significantly more frequent after polypropylene mesh repair (pooled risk ratio 2.9 and 1.8 at 6 weeks and 1 year respectively). CONCLUSION: Suture repair was safe for small incisional hernias. Both autoplastic and alloplastic hernia repair yielded comparably low recurrence rates, but led to a high rate of wound infection.     

Factors affecting recurrence after incisional hernia repair

Incisional hernias occur primarily as a result of high tension and inadequate healing of a previous incision, the latter of which is frequently related to infection at the surgical site. Despite recent advances in operative techniques, the recurrence rate remains unacceptably high. To evaluate the impact of different predisposing factors for the recurrence of incisional hernia, we reviewed retrospectively the medical records of 297 patients who had undergone incisional herniorrhaphy (188 tissue repairs, 109 mesh repairs) in our hospital. Demographic data (age and gender), type of repair, body mass index, hernia size, presence of chronic illnesses and wound complications were evaluated in a univariate and multivariate manner analysis. The overall recurrence rate was 30.3%, with the recurrence rate in patients who underwent tissue repair being 39.4% and that in patients following prosthetic repair 14.6%. The recurrence rate was significantly influenced by type of repair, obesity, hernia size, wound healing disorders and some chronic comorbidities. We conclude that it is necessary to become familar with the risk factors for recurrence of incisional hernia in order to eliminate or decrease their effect on the positive outcome of incisional herniorrhaphy.     

Konventionelle Reparation der parastomalen Hernie

The reparation of parastomal hernias and their recurrence remain problematic although the implementation of mesh techniques has lowered recurrences rates. Conventional surgical techniques include suture repair, relocation of the stoma as well as diverse hernia repair procedures with mesh implantation. Suture repair has been abandoned due to its high recurrence rate. Simple relocation is not recommended because of high rates of recurrent parastomal hernias. Conventional hernia repair using mesh implants is classified according to the mesh position into epifascial (onlay), retromuscular (sublay) and intraperitoneal (IPOM) techniques. Furthermore, a combination of relocation with additional mesh enforcement is also possible. The value of the different mesh techniques and of new biological mesh prostheses must be evaluated in randomized controlled studies.     

Laparoscopic ventral and incisional hernia repair: An 11-year experience

Incisional hernias develop in 2%–20% of laparotomy incisions, necessitating approximately 90,000 ventral hernia repairs per year. Although a common general surgical problem, a "best" method for repair has yet to be identified, as evidenced by documented recurrence rates of 25%–52% with primary open repair. The aim of this study was to evaluate the efficacy and safety of laparoscopic ventral and incisional herniorrhaphy. From February 1991 through November 2002, a total of 384 patients were treated by laparoscopic technique for primary and recurrent umbilical hernias, ventral incisional hernias, and spigelian hernias. The technique was essentially the same for each procedure and involved lysis of adhesions, reduction of hernia contents, closure of the defect, and 3–5 cm circumferential mesh coverage of all hernias. Of the 384 patients in our study group, there were 212 females and 172 males with a mean age of 58.3 years (range 27–100 years). Ninety-six percent of the hernia repairs were completed laparoscopically. Mean operating time was 68 min (range 14–405 min), and estimated average blood loss was 25 mL (range 10–200 mL). The mean postoperative hospital stay was 2.9 days and ranged from same-day discharge to 36 days. The overall postoperative complication rate was 10.1%. There have been 11 recurrences (2.9%) during a mean follow-up time of 47.1 months (range 1–141 months). Laparoscopic ventral and incisional hernia repair, based on the Rives-Stoppa technique, is a safe, feasible, and effective alternative to open techniques. More long-term follow-up is still required to further evaluate the true effectiveness of this operation.     

Low recurrence rate of a two-layered closure repair for primary and recurrent midline incisional hernia without mesh

Background  Incisional hernia is a serious complication after abdominal surgery and occurs in 11–23% of laparotomies. Repair can be done, for instance, with a direct suture technique, but recurrence rates are high. Recent literature advises the use of mesh repair. In contrast to this development, we studied the use of a direct suture repair in a separate layer technique. The objective of this retrospective observational study is to assess the outcomes (recurrences and complications) of a two-layered open closure repair for primary and recurrent midline incisional hernia without the use of mesh. Methods  In an observational retrospective cohort study, we analysed the hospital and outpatient records of 77 consecutive patients who underwent surgery for a primary or recurrent incisional hernia between 1st May 2002 and 8th November 2006. The repair consisted of separate continuous suturing of the anterior and posterior fascia, including the rectus muscle, after extensive intra-abdominal adhesiolysis. Results  Forty-one men (53.2%) and 36 women (46.8%) underwent surgery. Sixty-three operations (81.8%) were primary repairs and 14 (18.2%) were repairs for a recurrent incisional hernia. Of the 66 patients, on physical examination, three had a recurrence (4.5%) after an average follow-up of 2.6 years. The 30-day postoperative mortality was 1.1%. Wound infection was seen in five patients (6.5%). Conclusions  A two-layered suture repair for primary and recurrent incisional hernia repair without mesh with extensive adhesiolysis was associated with a recurrence rate comparable to mesh repair and had an acceptable complication rate. D. den Hartog and A.H.M. Dur contributed equally to this article.     

Repair of lumbar incisional hernia using polypropylene mesh strip sutures – A case report

IntroductionLumbar hernias are considered rare and they constitute less than 1.5% of all abdominal wall hernias.Case reportHere we present a case of a 72-year-old female with a left flank swelling since 2-years diagnosed as a lumbar incisional hernia. This lumbar incisional hernia¹ was repaired successfully using polypropylene mesh strip sutures.²DiscussionMany surgical techniques have been described for repair of LIH. Suture repair, mesh repair and myofascial flaps have been described for lumbar hernias. Repairing a lumbar hernia can be surgically challenging because of its proximity to bony structures, which can limit proper dissection and mesh overlap. We performed defect closure with PMSS. Patient has no recurrence after 2 years of follow up.ConclusionIn our case of left lumbar incisional hernia, defect closure with PMSS was an effective operation. This technique may also be effective in potentially contaminated settings due to reduced implant load. Further studies are required to understand its biomechanics and long-term outcomes.