“Component separation” technique and panniculectomy for repair of incisional hernia

Background

Primary incisional hernia repair is rarely successful, with recurrence rates ranging from 18% to 62%. We describe the integration of “components separation” herniorrhaphy with panniculectomy.

Methods

Twenty-two patients were treated. Standard panniculectomies and component separation were performed. Intravesical pressure was measured preoperatively, intraoperatively, and postoperatively. Measurement variations were compared using the Wilcoxon test. Complications or hernia recurrence were evaluated. The clinical appearance of the abdomen was subjectively evaluated by patients.

Results

Secure abdominal defect closure with midline approximation of the fascia was achieved in all patients. No major early complications occurred. Hernia recurred in 1 patient (4.5%). Intra-abdominal pressure increased in all the patients in our series but remained well below the danger level. Fifteen patients were fully satisfied with the appearance of their abdomen, whereas 7 were satisfied.

Conclusions

Abdominal component separation provides a reliable autologous reconstructive option. Hernia repair combined with abdominoplasty provides functional and esthetic benefits.     

杂交技术在切口疝修补术中的应用

自LeBlanc和Both开创腹腔镜修补切口疝以来,该技术已得到了广泛的应用,前瞻性临床资料Meta分析表明,与开腹切口疝修补相比,腹腔镜下修补能明显降低术后并发症,缩短住院时间。然而,也有报告表明,两种手术方法优、缺点无明显差别。同时有人认为,腹腔镜下修补增加了肠损伤的风险,甚至导致严重并发症。鉴于上述两种方法的优缺点,近年来有人将开放手术和腹腔镜技术相结合（亦称杂交技术,     

切口疝的杂交修补技术

目的 探讨杂交手术在切口疝修补术中的优缺点和手术技巧。方法 对2011年5月至2013年10月绍兴市人民医院进行的11例切口疝杂交修补术临床资料进行回顾分析。结果 11例切口疝杂交修补术全部成功。杂交手术原因：腹腔镜下粘连分离出现肠破裂1例,8例因粘连严重,分离困难而中转;2例因疝囊巨大,需要整形转为杂交手术。手术时间平均（170±42）min,术中出血量平均（46±30）m1;患者术后24、48和72h疼痛视觉评估评分为（5．9±1．8）分、（5．1±2．O）分和（3．4±1．3）分。术后住院3—9d,平均（5．3±1．8）d。11例患者均获随访,随访（14±8）个月,术后浆液肿1例,无切口疝复发,无血肿、感染、肠漏及术后腹壁慢性疼痛等并发症发生。结论 合理运用杂交修补手术能缩短手术时间,减少并发症,是安全可行的。     

Recommended technique for repair of incisional flank hernia

Described herein is a technique that has proved successful in repairing a flank fascial defect with a synthetic monofilament mesh (Marlex).     

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.     

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组织结构分离技术应用于腹壁缺损或者切口疝治疗中,通常在开放式或腹腔镜下联合补片应用,对复杂腹壁缺损或切口疝的治疗有着较好的治愈率,可能成为治疗复杂腹壁切口疝的主流术式之一。     

Comparative study of wound complications: Isolated panniculectomy versus panniculectomy combined with ventral hernia repair

BackgroundThe resection of an abdominal pannus carries the risk of wound-related morbidity in obese patients. Surgeons often perform a panniculectomy (PAN) to gain better access to the abdomen to perform other operations. We evaluated the incidence of wound complications after PAN with and without a concomitant procedure (i.e., ventral hernia repair [VHR]).MethodsWe reviewed the prospective data from all patients who underwent PAN alone and PAN combined with VHR from 2007 to 2011 at a single institution. The demographic data, operative information, and postoperative wound complications and interventions were recorded and analyzed using standard statistical methods. Multivariate logistic regression analysis was performed to control for confounding factors.ResultsAfter excluding the patients who had undergone concomitant procedures involving the gastrointestinal or genitourinary tract, 185 patients were included in the present study (143 patients in the PAN-VHR group and 42 in the PAN group). The average patient age was 55.4 and 47.6 years in the two groups (P = 0.001). The average body mass index was 38.0 and 41.1 kg/m² (P = 0.69). Of the 143 patients in the PAN-VHR group, 81.1% were women. In the PAN group, 92.9% were women (P = 0.09). The mean length of follow-up was 6.5 and 3.3 mo in the PAN-VHR and PAN groups, respectively (P = 0.04). In the PAN-VHR group, 96.5% underwent hernia repair with mesh and 29% underwent component separation. Subcutaneous talc was used in 58.6% of the PAN-VHR patients and 38.1% of the PAN patients (P = 0.02). Wound pulse-a-vac irrigation with bacitracin solution was used in 37.1% of PAN-VHR patients and 19.1% of the PAN patients (P = 0.03). The rate of wound complications and interventions for the PAN-VHR and PAN groups were not significantly different statistically (P < 0.05) and included seroma, seroma drainage, wound breakdown or necrosis, cellulitis, wound interventions, including bedside debridement and vac placement, and reoperation. After controlling for age, gender, body mass index, talc use, and pulse-a-vac irrigation use in the multivariate logistic regression analysis, the PAN-VHR group were more likely to develop cellulitis than the PAN-alone group (P = 0.004). The rates of all other wound complications were not significantly different statistically between the two groups after adjusting for confounding factors.ConclusionsPAN is associated with a significant risk of wound-related complications. The risk of postoperative cellulitis is increased further in patients who undergo concomitant VHR. However, the risk of all other wound complications and the need for interventions was not increased by performing concomitant VHR.     

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.     

Modifications to Rives technique for midline incisional hernia repair

Between 1990 and 1997, 284 patients were treated in our hospital for abdominal hernias. In the original group, 239 patients (84.15%) had midline hernia, and 45 (15.8%) had lateral hernia. A total of 152 midline hernia patients (63.5%) were treated using our variant of Rives technique. In all these cases, preperitoneal and retromuscular polypropylene mesh was used as a reinforcement and was subsequently attached by means of absorbable sutures to the external border of the rectus muscles. There were no deaths. A total of 42 of all patients operated on (27.6%) suffered from long-term postoperative pain. In seven cases (4.6%) it was necessary to remove the prosthesis because of chronic infection, and there were two recurrences in patients in whom the prosthesis had to be removed. In our experience, the Rives technique is a suitable and safe treatment for the repair of midline incisional hernias. The use of absorbable sutures and fixation of the mesh to the external oblique aponeurosis can reduce the original problems of abdominal pain and unaesthetic skin scars. Electronic Publication     

Laparoscopically assisted components separation technique for ventral incisional hernia repair

Reconstruction of the abdominal wall to repair ventral hernias continues to pose a challenge to surgeons due to relatively high rates of recurrence and morbidity. In 1990, Ramirez pioneered a technique of components separation of the abdominal wall for ventral hernia repair. Although an effective hernia repair, the mobilization of skin and subcutaneous tissue endangers the blood supply and predisposes midline skin to necrosis. The goal of this study is to determine whether releasing incisions in the transversus abdominis fascia and posterior rectus sheath provide adequate mobilization of the abdominal wall necessary for ventral hernia repair, thus paving the way for a laparoscopic component separation technique. Ten fresh cadavers were used and one side of the abdomen underwent the conventional Ramirez components separation: midline incision, dissection of skin and subcutaneous tissue off the anterior abdominal wall, and incisions in the external oblique aponeurosis and posterior rectus sheath, while the other side received incisions in the transversus abdominis fascia and the posterior rectus sheath with no undermining of the skin. The amount of fascial translation was measured after each incision. Incising only the external oblique aponeurosis produced greater mobilization of the abdominal wall at the level of the umbilicus (P = 0.02) and anterior superior iliac spine (ASIS, P = 0.029) than releasing only transversus abdominis fascia. More importantly, there was no statistically significant difference in the amount of release produced by the complete internal-release components separation versus the conventional technique. In order to test the feasibility of performing the procedure laparoscopically, one additional cadaver underwent a laparoscopic transversus abdominis fascia release. The procedure was successful and resulted in comparable amounts of fascial release as the other 10 cadavers. From this study, it appears technically feasible to perform a laparoscopic components separation to repair a ventral hernia and the procedure produces the same amount of release as the conventional open component separation technique.     

Concomitant bariatric and ventral/incisional hernia surgery in morbidly obese patients

Introduction

Ventral hernias are not uncommon in the bariatric population. Their management is technically demanding and remains controversial. Hernia complications can be lethal after bariatric surgery (BS). We herein report our experience with concomitant BS and ventral hernia repair (VHR).

Methods

We performed a retrospective analysis of a prospectively maintained database queried for combined procedures. Hernias were repaired after complete reduction (when the defect was not empty) using a dual mesh fixed to the abdominal wall with absorbable tackers. Data collected included demographics, anthropometrics, co-morbidities, peri-operative course, and intermediate weight loss and co-morbidity status.

Results

Between 2007 and 2012, a total of 54 patients (34 females, mean body mass index 44.2 kg/m²) underwent concomitant BS and VHR. The vast majority of procedures were laparoscopic sleeve gastrectomies (N = 48; 89 %). Others included laparoscopic Roux-en-y gastric bypass (RYGB), open RYGB, and laparoscopic gastric banding (two each). Six patients had complications (11 %): three leaks, two abdominal wall hematomas, and one pulmonary embolism. Hernia recurrence was noted in one patient (1.8 %). Average excess weight loss post-surgery was 49.9 ± 10.3 and 57.7 ± 9.2 % at 6 and 12 months, respectively. The total number of pre-operative co-morbidities was 110. At 12-month follow-up, 50 % (N = 56) were completely resolved and 38 % (N = 42) were improved.

Conclusion

Concomitant BS and VHR is feasible and safe, obviating the need for two separate procedures while not hampering the outcome of either. Complication rates for the combined surgery do not seem to be adversely affected.     

腹壁切口疝的腹腔镜修补与开放式手术的比较

<正>腹壁切口疝是腹内组织或器官经由手术切口的潜在间隙或薄弱区域突出于体表所形成的腹壁包块。其为手术造成的医源性疝,而手术修补是其唯一的治疗方法。直接修补     

Nuttall technique: A method for subumbilical incisional hernia repair revised

Background Large ventral incisional hernias are frequently repaired either by open or by laparoscopic mesh technique. The technique recommended by Nuttall has been used for the repair of large subumbilical incisional hernias but has not been popularized. Materials and methods From 1991 to 2005, 21 patients, mean age 64.6 ± 13 (44–86) years, underwent repair of large subumbilical incisional hernia with the Nuttall technique by which the rectus muscles are detached from the symphysis pubis and transposed to the opposite side. The exerted tension is minimal to the underlying tissues, and no prosthetic material is required to reinforce the abdominal wall. Results Morbidity was recorded in five patients (23.8%). The median follow-up time was 84 months, and the recurrence rate was 4.8% (one patient). Conclusions Although a small number of patients have undergone repair with the Nuttall technique, the long-term results of the method seem to be encouraging for the repair of large subumbulical incisional hernias.     

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??Objective:To investigate the security and the operative experiences of laparoscopic ventral incisional herniorrhaphy. Methods:The laparoscopic mesh repair was performed for 79 patients with abdominal ventral incisional hernias from March 2004 to May 2006 in Hua Shan Affiliated Hospital of Fu Dan University. Results:Laparoscopic incisional herniorrhaphy with meshes was successfully performed in 98.7% (78/79) of patients.One case (1.3%) was converted to an open procedure because of extensive adhesion intraperitoneally. The mean operating time was 88 minutes and postoperative hospital stay averaged 4.6 days.Eighteen (22.8%) patients were found to have more than one hernial defect intraoperatively.Postoperative complications included severe pain in operative area temporary (n=58,73.4%),prolonged pain in suture site (n=6,7.6%),seroma (n=14,17.7%),intestinal fistula (n=1,1.3%) and recurrence (n=1,1.3%). Conclusion:Laparoscopic ventral incisional herniorrhaphy with meshes can be performed in most of incisional hernias after complete dissection of adhesions,through the laparoscopy it may find others defects.But the postoperative pain is severe in repair area.If extensive dense adhesion will interfere with the manipulation and lysis,the patients should be converted to open operation.     

腹腔镜腹壁切口疝修补术的现状和展望

开放腹膜前修补术（sublay）和腹腔镜腹腔内修补术（IPOM）是治疗腹壁切口疝的主要术式，各类腔镜非腹腔内修补术（MINIM）目前处于探索阶段，未来有较大的进展空间。IPOM和MINIM术式具有不同的修补理念、技术特点和适应人群，严格把握手术指证，可以最大程度体现各自的优势。现代疝外科更注重“微创”和“腹壁功能重建”，在修复腹壁缺损、恢复腹壁功能的同时，尽可能减少腹壁的过度分离。随着新材料的研发、新技术的探索和腔镜平台的升级换代，基于微创理念的腹腔切口疝修补术会拥有更广阔的前景。