Strength of tissue attachment to mesh after ventral hernia repair with synthetic composite mesh in a porcine model

Background A prospective animal study involving 12 female swine aimed to measure the strength of tissue attachment to composite mesh at various time points after laparoscopic ventral hernia repair in a porcine model. Methods Each animal had two 10 × 16-cm sheets of polypropylene/expanded polytetrafluoroethylene (ePTFE) composite mesh laparoscopically affixed to the abdominal wall with a helical tacking device. No transfascial sutures were used. The animals were euthanized 2, 4, 6, and 12 weeks after surgery, and abdominal walls were resected en bloc with the patches. Each patch was cut into 2 × 7-cm strips, and each strip was independently analyzed. The strength of the tissue attachment to the mesh was measured using a servohydraulic tensile testing frame. The abdominal wall was peeled from the mesh, and the transverse, or “lap-shear” force was recorded. Data are reported as mean force in pounds. Results The mean lap-shear force was 0.83 ± 0.06 lbs at 2 weeks, 1.06 ± 0.07 lbs at 4 weeks, 0.88 ± 0.08 lbs at 6 weeks, and 1.13 ± 0.07 lbs at 12 weeks. The mean force was higher at 12 weeks than at 2 weeks (p < 0.05). No other periods were significantly different from any other. Conclusions The findings demonstrate that the majority of tissue ingrowth and strength has occurred by 2 weeks after laparoscopic placement of a composite hernia prosthesis. Strength very gradually increases until 12 weeks after surgery. This has clinical implications for human ventral hernia repair. Further study is needed to evaluate the necessity of transfascial sutures for securing polypropylene-based prostheses to the abdominal wall during ventral hernia repair. Presented at the 85th Annual Meeting of the New England Surgical Society, 2 October 2004, Montreal, Quebec, Canada     

Multicentric observational cohort study evaluating a composite mesh with incorporated oxidized regenerated cellulose in laparoscopic ventral hernia repair

Background

A variety of newly developed mesh products have recently become available to use inside the peritoneal cavity. This analysis reports the first clinical data evaluating the experience with the use of Proceed® mesh in laparoscopic ventral hernia repair.

Patients and methods

During a 6-month period, 114 adult patients underwent a laparoscopic ventral hernia repair using an intra-abdominal placement of a Proceed mesh. The operative procedure was stratified for all centers. Perioperatively, different parameters were evaluated considering the conversion rate to open procedure, complications such as seroma and hematoma, bowel lesions, urinary retention, acute, and chronic pain, mesh infection, and recurrences.

Results

The mean age of the patients was 45 years (range 19–84 years). There were no conversions to open repair and no mortality. Complications included 12 seromas/hematomas (four aspirated), chronic discomfort in two patients, and urinary retention in one patient. There have been four recurrences (3.5%), occurring 3, 4, 4, and 15 months after surgery, respectively. The mean follow-up period was 27 months (range 12–38 months). There have been no documented infections of the mesh.

Conclusions

This multicentric study documents a favorable experience using large-pore mesh in laparoscopic ventral hernia repair. There were no major complications related to the mesh. Technical advantages considering mesh handling and long-term advantages considering chronic pain might be of interest with the use of this lightweight mesh for minimally invasive ventral hernia repair.     

Evaluation of new prosthetic meshes for ventral hernia repair

Background In hernia repair, particularly laparoscopic hernia repair, direct contact between mesh and abdominal organs cannot always be avoided. Several mesh materials and composite meshes have been developed to decrease subsequent adhesion formation. Recently, new meshes have been introduced. In an experimental rat study, their value was established and compared with that of meshes already available on the market. Methods In 200 rats, eight different meshes were placed intraperitoneally and in direct contact with abdominal viscera. The following meshes were tested: polypropylene (Prolene), e-PTFE (Dualmesh), polypropylene– polyglecaprone composite (Ultrapro), titanium–polypropylene composite (Timesh), polypropylene with carboxymethylcellulose–sodium hyaluronate coating (Sepramesh), polyester with collagen-polyethylene glycol–glycerol coating (Parietex Composite), polypropylene–polydioxanone composite with oxidized cellulose coating (Proceed), and bovine pericardium (Tutomesh). At 7 and then at 30 days postoperatively, adhesion formation, mesh incorporation, tensile strength, shrinkage, and infection were scored by two independent observers. Results Parietex Composite, Sepramesh, and Tutomesh resulted in decreased surface coverage with adhesions, whereas Prolene, Dualmesh, Ultrapro, Timesh, and Proceed resulted in increased adhesion coverage. Parietex Composite, Prolene, Ultrapro, and Sepramesh resulted in the most mesh incorporation. Dualmesh and Tutomesh resulted in significantly increased shrinkage. There were no differences in mesh infection. Parietex Composite and Dualmesh resulted in a moderate inflammatory reaction, as compared with the mild reaction the other meshes exhibited. Conclusion Parietex Composite and Sepramesh combine minimal adhesion formation with maximum mesh incorporation and tensile strength. The authors recommend the use of these meshes for hernia repair in which direct contact with the abdominal viscera cannot be avoided.     

开放式补片修补术治疗腹壁切口疝（附210例报告）

目的 分析开放式补片修补术治疗腹壁切口疝的临床疗效。方法 回顾性分析我院于2013年10月至2018年3月行开放式补片修补术的210例腹壁切口疝病人的临床资料。分析不同术式和补片固定方式,术后血清肿、切口感染、补片感染、慢性疼痛、肠漏、复发以及死亡的发生。结果 术后血清肿25例（11.90%）,切口感染14例（6.67%）,补片感染3例（1.43%）,慢性疼痛7例（3.33%）,肠漏3例（1.43%）,复发7例（3.33%）,死亡2例（0.95%）。采用IPOM术式病人术后仅有血清肿并发症发生率低于Sublay术（P<0.05）,差异有统计学意义,其余并发症发生和复发率差异无统计学意义（P>0.05）。Sublay术式中加强法与桥接法术后并发症差异无统计学意义（P>0.05）。采用缝线+不可吸收疝钉组与缝线+可吸收疝钉组术后慢性疼痛和复发率无统计学差异（P>0.05）。结论 开放式补片修补术治疗腹壁切口疝安全有效。     

Laparoscopic versus open ventral hernia mesh repair: a prospective study

Background An incisional hernia develops in 3% to 13% of laparotomy incisions, with primary suture repair of ventral hernias yielding unsatisfactory results. The introduction of a prosthetic mesh to ensure abdominal wall strength without tension has decreased the recurrence rate, but open repair requires significant soft tissue dissection in tissues that are already of poor quality as well as flap creation, increasing complication rates and affecting the recurrence rate. A minimally invasive approach was applied to the repair pf ventral hernias, with the expectation of earlier recovery, fewer postoperative complications, and decreased recurrence rates. This prospective study was performed to objectively analyze and compare the outcomes after open and laparoscopic ventral hernia repair. Methods The outcomes for 50 unselected patients who underwent laparoscopic ventral hernia repair were compared with those for 50 consecutive unselected patients who underwent open repair. The open surgical operations were performed by the Rives and Stoppa technique using prosthetic mesh, whereas the laparoscopic repairs were performed using the intraperitoneal onlay mesh (IPOM) repair technique in all cases. Results The study group consisted of 100 patients (82 women and 18 men) with a mean age of 55.25 years (range, 30–83 years). The patients in the two groups were comparable at baseline in terms of sex, presenting complaints, and comorbid conditions. The patients in laparoscopic group had larger defects (93.96 vs 55.88 cm²; p = 0.0023). The mean follow-up time was 20.8 months (95% confidence interval [CI], 18.5640–23.0227 months). The mean surgery durations were 90.6 min for the laparoscopic repair and 93.3 min for the open repair (p = 0.769, nonsignificant difference). The mean postoperative stay was shorter for the laparoscopic group than for the open hernia group (2.7 vs 4.7 days; p = 0.044). The pain scores were similar in the two groups at 24 and 48 h, but significantly less at 72 h in the laparoscopic group (mean visual analog scale score, 2.9412 vs 4.1702; p = 0.001). There were fewer complications (24%) and recurrences (2%) among the patients who underwent laparoscopic repair than among those who had open repair (30% and 10%, respectively). Conclusions The findings demonstrate that laparoscopic ventral hernia repair in our experience was safe and resulted in shorter operative time, fewer complications, shorter hospital stays, and less recurrence. Hence, it should be considered as the procedure of choice for ventral hernia repair.     

The use of the Kugel mesh in ventral hernia repairs

BACKGROUND: The management of ventral hernias is a common problem. Goals of hernia repair include reduction of the contents, reperitonealization of the abdomen, repair of the fascial defect, and restoration of the normal abdominal wall contour. Repairs frequently require the use of mesh to reduce the incidence of recurrence. A variety of repair techniques have been described, often associated with significant pain, prolonged recovery, and complications. METHODS: We describe a technique using a partial component separation, reperitonealization of the abdominal cavity with the hernia sack, and insertion of the Kugel mesh for bridging the gap. RESULTS: We have used this technique on 65 ventral hernias. Fifty-two patients went home from the recovery room and 11 stayed less than 23 hours. One patient had a wound infection and 2 had seromas. There have been no recurrences to date. CONCLUSIONS: Repair of ventral hernias with the Kugel mesh using a partial component separation is safe, effective and durable.     

Open Rives-Stoppa ventral hernia repair made simple and successful but not for everyone

Background: The Rives-Stoppa (RS) repair of ventral incisional hernias (VIHR) is technically difficult. It involves the retromuscular placement of mesh anterior to the posterior fascia and the primary closure of the anterior fascia. Recurrence rates are 0–8%. We proposed that the operation could be done with equal success by placing the mesh in an intraperitoneal position and primarily closing the fascia anterior to the mesh. Methods: 81 patients who had undergone an open RS-VIHR with intraperitoneal mesh were evaluated for hernia recurrence and factors associated with recurrence. Results: 55 women and 26 men (mean BMI 38±9) underwent RS-VIHR (mean age 49±11 years). Of these patients, 44 (54%) had a prior VIHR, 30 (37%) had an incarcerated hernia and 34 (42%) had multiple fascial defects. PTFE was used in 83% and Prolene in 12%. Average LOS was 5.8±12 days. All received perioperative intravenous antibiotics and 28% were discharged on oral antibiotics. Follow-up averaged 30±24 months. Recurrent VIH developed in 12/81 (15%), with three occurring after removal of infected mesh and one after a laparotomy. Excluding these four, the recurrence rate was 10%. There was no correlation between hernia recurrence and age, BMI, hernia size, number of prior repairs, or LOS (t-test p>0.05). Hernia recurrence did not correlate with gender, prior peritoneal contamination, incarceration, multiple defects, adhesions, mesh type, oral antibiotics, cardiac disease, diabetes, tobacco use, or seroma (X² p>0.05). Those with a wound infection and/or abscess formation had a significantly higher recurrent hernia rate (60% vs. 8%, X² p<0.001). Patients with pulmonary disease had a significantly higher recurrence rate (50% vs. 12%, X² p=0.01). Conclusions: RS-VIHR with intraperitoneal mesh is a successful and less technically challenging method of repair than prior modifications. Aggressive efforts to identify infection and treat early may prevent abscess formation and subsequent recurrent hernia. Patients with chronic pulmonary disease have an unacceptably high recurrence rate and should not be considered as candidates for elective RS-VIHR.Presented at the Seventh Annual Scientific Meeting of the American Hernia Society, Orlando, FL, 24–28 February 2004     

Polyester composite versus PTFE in laparoscopic ventral hernia repair

Introduction:

Both polyester composite (POC) and polytetrafluoroethylene (PTFE) mesh are commonly used for laparoscopic ventral hernia repair. However, sparse information exists comparing perioperative and long-term outcome by mesh repair.

Methods:

A prospective database was utilized to identify 116 consecutive patients who underwent laparoscopic ventral hernia repair at The Mount Sinai Hospital from 2004-2009. Patients were grouped by type of mesh used, PTFE versus POC, and retrospectively compared. Follow-up at a mean of 12 months was achieved by telephone interview and office visit.

Results:

Of the 116 patients, 66 underwent ventral hernia repair with PTFE and 50 with POC mesh. Patients were well matched by patient demographics. No difference in mean body mass index (BMI) was demonstrated between the PTFE and POC group (31.8 vs. 32.5, respectively; P=NS). Operative time was significantly longer in the PTFE group (136 vs.106 minutes, P<.002). Two perioperative wound infections occurred in the PTFE group and none in the POC group (P=NS). No other major complications occurred in the immediate postoperative period (30 days). At a mean follow-up of 12 months, no significant difference was demonstrated between the PTFE and POC groups in hernia recurrence (3% vs. 2%), wound complications (1% vs. 0%), mesh infection, requiring removal (3% vs. 0%), bowel obstruction (3% vs. 2%), or persistent pain or discomfort (28% vs. 32%), respectively (P=NS).

Conclusion:

Our study demonstrated no significant association between types of mesh used and postoperative complications. In the 12-month follow-up, no differences were noted in hernia recurrence.     

复合补片和生物补片治疗食管裂孔疝的疗效对比研究

目的:对比应用复合补片和生物补片治疗反流性食管炎和食管裂孔疝的疗效。方法:21例应用Crurasoft誖复合补片组及20例应用BiodesignTM Surgisis誖生物补片组修补食管裂孔疝病人,对比分析术后复发率和补片相关并发症发生的差异。结果:两组病人一般情况、食管裂孔长径和手术时间等方面无统计学差异。应用复合补片和生物补片均能使术前反流性食管炎的症状显著缓解。复合补片组和生物补片组围手术期并发症发生率分别为9.5%和30.0%,两组间无统计学差异。术后6个月随访裂孔疝复发率均为0。复合补片组和生物补片组长期随访平均时间分别为(16.3±8.9)个月和(17.3±6.8)个月,解剖性复发率分别为4.8%和5.0%,无统计学差异。两组病人均未发生食管侵蚀的并发症。复合补片组病人术后吞咽困难发生率高于生物补片组(38.1%比20..0%),但无统计学差异。结论:应用新一代小肠黏膜下基质补片和复合补片修补食管裂孔疝后疗效满意,复发率低,补片相关的严重并发症发生率差异无统计学意义。     

Feasibility and outcome after laparoscopic ventral hernia repair using Proceed mesh

Background  There are many different meshes available for laparoscopic repair of ventral hernias. A relatively new product is the Proceed mesh with a bioresorbable layer against the bowels and a polypropylene layer against the abdominal wall. There are, however, no human data available. The aim of this study was to evaluate the feasibility and outcome after laparoscopic ventral hernia repair using the Proceed mesh in humans. Methods  Patients presenting for laparoscopic ventral hernia repair in our department from September 2004 to October 2006 were included in the study. All patients had a standard laparoscopic ventral hernia repair using the Proceed mesh secured with tackers with a double crown technique. Patients were discharged according to standard discharge criteria, and follow-up was performed with a search in the national patient database and with manual search in the patients’ files. Results  Our study included 49 patients with a median age of 64 years (range 30–89) and body mass index of 27.8 (19.4–50.5). The dimensions of the mesh varied from 4 × 4 cm to 30 × 40 cm (median 15 × 15 cm). One patient developed an uncomplicated wound infection and none of the 49 patients developed mesh infections or postoperative seroma requiring surgical intervention. Thus, there were no mesh-related complications. During the follow-up period of 17 months (3–27), we have not seen any postoperative recurrences. The median length of stay was 1 day (range 0–63), and there was no mortality. Conclusion  Laparoscopic ventral hernia repair in humans using the Proceed mesh is feasible and has a low complication rate even in obese patients or those with pulmonary disease.     

应用聚丙烯和e-PTFE复合补片修补腹壁巨大切口疝

目的回顾性分析应用聚丙烯和e鄄PTFE复合补片修补腹壁巨大切口疝的效果,介绍腹腔内应用复合补片的方法和经验。方法1999年5月至2003年12月应用复合补片修补腹膜难以对合的腹壁巨大缺损22例,其中补片置于皮下12例,腹腔内10例。平均随访期39个月。结果手术后切口并发症的发生率为41%(9/22),1例修补术后复发,占4.6%。应用皮下法发生切口感染3例,其中1例因严重感染而将补片取出;切口处皮下积液2例。应用腹腔内法者中仅2例发生切口皮下少量积液。结论腹壁巨大切口疝,特别是难以关闭腹膜的病例,可应用聚丙烯和e鄄PTFE复合补片进行修补。应用腹腔内置补片法并辅以正确的术后处理可使局部并发症明显减少。     

Pregnancy following laparoscopic mesh repair of ventral abdominal wall hernia

Background:

There are no data on laparoscopic repair of ventral and incisional hernias (LRVIH) in fertile women who intend to have further pregnancies. A unique series is described of 8 women who got pregnant and gave birth after LRVIH.

Methods:

Medical records of 875 consecutive patients who underwent LRVIH were reviewed. Women who gave birth after LRVIH were identified. At follow-up, patients answered a questionnaire on pain, discomfort, recurrence, and problems during pregnancy and delivery and underwent a physical examination.

Results:

Eight patients were identified; all agreed to inclusion. Four women received LRVIH for incisional hernia; 4 were operated on for primary ventral hernia. Median age at LRVIH was 29 years (range, 24 to 34). No postoperative complications occurred. Median time between LRVIH and delivery was 22.5 months (range, 12 to 44). Median follow-up after delivery was 23.5 months (range, 2 to 40). Five patients experienced a tearing pain in the area of hernia repair during the last months of pregnancy. This pain was not continually present and disappeared after delivery in all patients. All infants were born healthy at full term. Seven patients had a vaginal birth and one had a caesarean delivery. There were no major complications during pregnancy or delivery. At control examination, all patients were asymptomatic and, with one exception, without signs of recurrence. One patient had a swelling in the repaired area indicating either recurrence or mesh bulging. Being asymptomatic, she refused any further diagnostics.

Conclusion:

LRVIH in fertile women who intend to have further pregnancies is an acceptable therapeutical option that causes no significant problems during pregnancy or delivery.     

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.     

Large neomucosal space 25 years after mesh repair of ventral hernia

A 64-year-old, otherwise healthy, male patient presented with a malodorous abdominal wall fistula of recent onset. He gave a history of mesh repair of ventral hernia 25 years ago. Computed tomography scan of the abdomen revealed a 15 cm × 15 cm thick-walled cavity inside the abdomen adjacent to bowel loops and the prosthetic mesh. Resection of the mass included a 25-cm segment of small bowel. Histopathology revealed a thick-walled large cavity lined with mucosa, surrounding a large wrinkled sheet of permanent mesh.     

Simple technique for mesh placement during laparoscopic ventral hernia repair

Laparoscopic ventral hernia repair has many advantages over the open approach. Mesh placement and orientation to overlap the hernia defect is a crucial step. The current techniques for mesh placement are time-consuming. A simple technique for mesh placement during laparoscopic ventral hernia repair is described.     

A simplified laparoscopic technique for mesh placement in ventral hernia repair

The use of a large synthetic mesh for laparoscopic repair of significant ventral abdominal wall defects may be accompanied by technical difficulties resulting from improper orientation and positioning of the mesh over the defect. We suggest a technique based on initial fixation of the mesh center to the central point of the defect, and subsequent centrifugal attachment of the mesh to the abdominal wall. This technique is advantageous because it leads to precise orientation and positioning of the synthetic patch and to significant reduction of the time needed for its reinforcement over and around the defect. Received: 25 September 1998/Accepted: 27 November 1998     

Pregnancy and ventral hernia repair

Summary Reluctance to repair anterior abdominal wall hernias in women of childbearing age is probably unjustified. A unique series is described of 27 women who gave birth to 41 full-term babies following repair of an anterior abdominal wall hernia with no recurrence of the hernia. Nineteen had primary and recurrent umbilical hernias and an incisional hernia in a low transverse incision repaired by the onlay darn technique and have produced 29 babies. Eight had umbilical hernias, gross diastasis of the recti and post-cesarean section vertical incisional hernias repaired by the Shoelace technique followed by 12 full-term pregnancies. Little is written about the fate of the abdominal wall subjected to pregnancies following repair of ventral hernias, since the majority of women having these hernias repaired are past the child-bearing age or are warned off further pregnancies by their doctors or undergo tubal ligation with the hernia repair. The Shoelace repair is described, stressing its advantages over mesh hernioplasties in women who wish to have further pregnancies. There is apparently no reason to refuse to repair these hernias. There are even positive indications in view of serious complications associated with pregnancy in the presence of an anterior wall hernia. Prosthetic mesh tends to contract and harden and may seriously interfere with abdominal expansion in pregnancies so these hernias are probably best repaired by the Shoelace technique.     

Laparoscopic repair of ventral incisional hernia

Background : Laparoscopic repair of ventral incisional hernias was first reported in 1993. Since then, there have been sporadic case reports and small series published about this procedure, but it has not been widely adopted. Newer types of composite prosthetic mesh may reduce the potential problem of bowel adhesion. Methods : Thirty cases of laparoscopic ventral incisional hernia repairs (carried out by two surgeons or their senior registrars) have been retrospectively reviewed and reported in this article. The data were obtained from patient records and subsequent phone surveys. Results : Thirty patients between 29 and 82 years (mean: 58 years) underwent this procedure. There were 14 men and 16 women. The average weight of the patients was 81 kg. The hernias were up to 6 or 7 cm in diameter. Mesh was used in 28 cases (polypropylene in 25 cases, expanded polytetrafluoroethylene in two cases and composite mesh in one case). Most meshes were laid intraperitoneally and fixed into position with laparoscopic spiral tacks. Twenty‐nine cases were completed laparoscopically. One operation (3.3%) was converted to an open procedure because of severe bowel adherence to the hernia sac. The mean operating time was 52 min for laparoscopic ventral incisional hernia repairs only. All but two patients tolerated an oral diet within 24 h. The postoperative hospital stay ranged from 0 to 11 days, with 17 patients (57%) staying overnight and eight patients (27%) staying another day. Over 80% of the patients returned to house duties within a week. There was no mortality, and minor complications occurred in four patients (14%). One patient had a small bowel obstruction treated successfully by repeat laparoscopy with division of fibrinous adhesions to polypropylene mesh on day four. Follow up ranged from 1 to 69 months (mean: 12 months). One patient did not attend follow‐up appointments. There were three cases of hernia recurrence (10%). Conclusion : The results suggest that laparoscopic repair of ventral incisional hernias is a safe, effective and technically feasible operation for small‐ to medium‐sized hernias allowing shorter hospital stay, early recovery and resumption of normal activities. However, recurrence rates are comparable to open mesh hernioplasty especially for larger hernias.