Small bowel lesion due to spiral tacks after laparoscopic intraperitoneal onlay mesh repair for incisional hernia

INTRODUCTIONLaparoscopic intraperitoneal onlay mesh (IPOM) repair has become a widely accepted operative technique for incisional hernias. However, tack fixation poses the risk of adhesions and injury to the intestine. We report the case of spiral tacks adherent to the small bowel after IPOM repair for incisional hernia.PRESENTATION OF CASE64 years old male patient who underwent laparoscopic IPOM repair for incisional hernia 1 year after open sigmoid resection. A laminated polypropylene mesh was fixed with titanium spiral tacks. 4 years later, elective open cholecystectomy was performed. Two spiral tacks integrated in the seromusular layer of the small bowel were encountered. Tacks were removed and bowel lesions oversewn with interrupted seromuscular stitches.DISCUSSIONAccording to the current literature, complications related to metal spiral tacks in IPOM mesh repair such as intestinal perforation or strangulation ileus seem to be rare. To our knowledge, spiral tacks adherent to the intestine have not yet been published to date. Alternative techniques for mesh fixation are transfascial sutures with single stitches, continuous sutures or fibrin glue, as already used in TAPP and TEP procedures for inguinal hernia repair. The ideal and safest technique for mesh fixation in IPOM repair for incisional hernias remains controversial.CONCLUSIONSpiral tacks used for intraperitoneal mesh fixation can lead to adhesions and bowel lesions. Sutures, absorbable tacks or fibrin glue are alternatives for mesh fixation. Further clinical trials are needed to evaluate the safest technique of laparoscopic IPOM incisional hernia repair.     

不同补片放置层次治疗外科手术切口疝的疗效

目的对不同补片放置层次（肌后修补术与腹腔内修补术）治疗外科手术切口疝的疗效及并发症发生情况进行比较。 方法回顾分析2015年1月至2018年1月,江苏省宜兴市人民医院普外科收治的切口疝72例患者的临床资料,其中采用腹腔内修补术35例（腹腔组）,肌后修补术37例（肌后组）,观察2组手术基本情况（手术时间、术后住院时间、住院总费用、术中出血量）、并发症（肠管损伤、肠梗阻、肠瘘、切口感染、切口脂肪液化）;术后第1天、第3天疼痛视觉模拟评分（VAS）及随访1年的复发情况。 结果腹腔组手术时间、术后住院时间均较肌后组短,而腹腔组术中出血量低于肌后组,但腹腔组住院总费用高于肌后组,差异有统计学意义（P<0.05）;腹腔组肠管损伤、肠梗阻、切口感染及切口脂肪液化等发生率低于肌后组,腹腔组见1例（2.86%）肠瘘并发症,肌后组未有肠瘘并发症出现,2组组间差异无统计学意义（P>0.05）;2组患者术后第1天、术后第3天VAS评分比较,差异无统计学意义（P>0.05）;随访1年后腹腔组复发0例,肌后组在术后7个月时有2例（5.71%）复发,2组复发率无统计学意义（P>0.05）。 结论两种术式不同补片放置层次方法治疗切口疝均有效,但腹腔内修补术治疗效果更佳,安全性高。     

切口疝腹腔镜IPOM修补七步法操作指南（2022版）

切口疝修补手术近年来逐步得到推广，多年来的经验及临床研究显示腹腔镜下腹腔内网片修补术（IPOM）能有效关闭缺损、减少复发，是治疗切口疝的理想方法。规范化腹腔镜下切口疝的IPOM修补术操作势在必行。本团队经过多年培训实践及临床对比研究，发现七步法遵循学习规律、适合操作者掌握，同时可减少手术并发症。因此，广东省医师协会疝与腹壁外科医师分会组织编写了第1版《切口疝腹腔镜IPOM修补七步法操作指南》，旨在针对疝和腹壁外科领域腹腔镜切口疝IPOM修补手术操作进行规范化和标准化，为疝和腹壁外科医生们规范修补操作、缩短学习曲线、减少术后并发症提供帮助。     

开放式完全腹腔内修补治疗巨大腹壁切口疝10例

目的探讨用Gore—Tex补片开放式完全腹腔内修补治疗巨大腹壁切口疝的疗效。方法用Gore．Tex补片开放式完全腹腔内修补治疗巨大腹壁切口疝10例，其中初发切口疝9例，复发切口疝1例。结果9例一期愈合，1例发生创面局限性积液，经穿刺负压引流处理后治愈，随访10个月至2年，无复发病例。结论用Gore—Tex补片开放式完全腹腔内修补治疗巨大腹壁切口疝经济，安全，有效，感染风险降低。     

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。     

应用合成补片修补腹壁切口疝的经验总结

目的:探讨腹壁切口疝病人的无张力手术治疗方法和疗效.方法:回顾性分析我院2000年7月至2008年6月间收治的215例应用合成补片修补腹壁切口疝病人的临床资料.结果:215例中101例采用IPOM方法,有1例复发,复发率0.99%;97例采用Stoppa方法,有3例复发,复发率3.09%;17例采用肌前修补法,有3例复发,复发率17.6%.在21例复发疝病人中,16例采用了IPOM方法,无再复发病例;5例采用了Stoppa方法,有1例再复发,复发率20%.结论:IPOM方法和Stoppa方法的手术适应症宽、复发率低.IPOM方法对于复发的切口疝病人有更好的治疗效果.术者的经验和方法的正确性对修补的成功均有重要意义.     

Open intraperitoneal hernia repair for treatment of abdominal wall defects--early results by placement of a polypropylene-ePTFE-mesh

BACKGROUND: Large incisional hernias are mainly repaired today by tension free implantations of prosthetic meshes using various placement methods. The advantages of the intraperitoneal open technique (IPOM) using a polypropylene mesh that is coated with ePTFE on the side facing the intestine, are described. METHODS AND RESULTS: 62 patients underwent an incisional hernia operation with the intraperitoneal positioning of a prosthetic mesh. The follow-up examinations after a range of 16.1 months showed a hernial recurrence rate of 6.4 %. A part of the resulting mesh infections (11.2 %) healed without surgical removal of the mesh. Clinical complications due to adhesion formation were not observed. CONCLUSION: The tissue sparing intraabdominal positioning technique simplifies the necessary overlap using healthy tissue as a prerequisite for a sufficient hernia repair exploiting the intraabdominal pressure.     

Operative Therapie der Narbenhernie

Secondary ventral hernia or incisional hernia occurs in at least 20?% of cases after laparotomy and most patients are symptomatic. The pathogenesis of incisional hernia is believed to be based on a defect in collagen synthesis indicating the necessity of covering the whole original incision with a non-resorbable, macroporous mesh. These meshes can be used on top of the fascia (onlay), in a retromuscular fashion (sublay) or intraperitoneally (IPOM). The IPOM technique is the preferred procedure during laparoscopic repair of ventral hernias. The clear advantage of the laparoscopic approach is the dramatically reduced rate of wound complications, especially infections. Major defects of the abdominal wall require plastic reconstruction with the component separation technique in both anterior and posterior approaches. The component separation technique must be combined with retromuscular mesh augmentation enabling a recurrence rate of less than 10 % and an acceptable morbidity to be achieved.     

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??Therapeutic effect of open incisional hernia mesh repair: A report of 636 cases HU Xing-chen??LI Shao-jie??TANG Jian-xiong, et al. Center of Treatment and Training for Hernia and Abdominal Wall Surgery??Huadong Hospital Affiliated to Fudan University??Shanghai 200040??China
Corresponding author??TANG Jian-xiong??E-mail??johnxiong@china.com
Abstract Objective To analyze the clinical efficacy of open incisional hernia mesh repair. Methods The clinical data of 636 cases of open incisional hernia mesh repair performed from December 2002 to September 2013 in Huadong Hospital Affiliated to Fudan University were analyzed retrospectively. According to the different types of incisional hernia??different patch and different surgical method were used. Recurrence??wound infection??chronic pain??patch infections??intestinal fistula, seroma and other complications were observed and analyzed. Results There were 5 cases of death (0.8%) after operation. There were 26 cases (4.1%) of recurrence??41 cases (6.4%) of wound infection or fat liquefaction??5 cases (0.8%) of chronic pain??10 cases (1.6%) of patch infection??12 cases (1.9%) of intestinal fistula and 6 cases (0.9%) of seroma. Recurrence rate of IPOM was lower than that of Sublay. Compared with Proceed??GORE-TEX DualMesh Composix or Kugel patch had high incidence of wound infection (P<0.01)??while using Composix E / X Mesh patch had no difference in incidence of wound infection (P>0.05). Incidence of patch infection of GORE-TEX DualMesh was significantly higher than that of Proceed (P<0.01). Conclusion Open incisional hernia mesh repair is a safe and effective technique. It would like to use different operations for different patients.     

生物补片一期修复污染状态下的腹壁疝和腹壁缺损

目的：评价生物补片用于污染或感染状态下腹壁缺损一期修复的安全性和有效性。方法 2010年4月以来17例腹壁缺损手术均因肠外瘘或肠造口、切口感染或同时肠道手术等原因而处于感染或污染状态：切口疝6例,腹股沟嵌顿疝1例,肠外瘘8例、直肠癌柱状切除术2例。腹壁缺损范围在(3 cm ×2 cm)～(6 cm×17 cm),均采用...     

Übersicht und aktuelle Trends in der Narbenhernienchirurgie

Incisional hernias occur in 5-10% of patients who have undergone laparotomy and are associated with high morbidity and significant socioeconomic costs. Techniques for reinforcing and/or replacing the abdominal wall with alloplastic meshes have reduced the recurrence rate in comparison to suture techniques from about 40% to less than 10%. A number of mesh types and surgical repair procedures are available, namely the onlay, inlay, sublay, underlay, and intraperitoneal onlay mesh (IPOM) techniques. Evolving strategies include precise criteria for incorporating patient body type, risk factors for recurrence, hernia morphology, and the available biomaterials into the planning of the surgical approach. The authors herein present an overview of the current surgical trends, focusing on mesh reinforcement (sublay technique) and mesh replacement (IPOM technique). Additionally, they review a classification of incisional hernias that is self-explanatory, practicable in routine clinical practice, and based on the cornerstones of morphology, hernia size, and risk factors for recurrence. Evidence for the indications and limitations of the main surgical repair techniques are illustrated and discussed.     

Laparoscopic ventral hernia meshplasty with "double-breasted" fascial closure of hernial defect: a new technique

BACKGROUND: Absence of recurrence, seroma, and pain eludes the laparoscopic surgeon managing ventral and incisional hernias. Multifactorial etiology (i.e., obesity, comorbidity, and dyscollagenemia) is a challenge. Surgeons have risen to this challenge by providing laparoscopic ventral hernia repair (LVHR). Stability of mesh in a standard LVHR is attributed to Pascal's Principle (PP). PP, based upon concentration of forces at the point of least resistance, has been classically applied in hydraulic jacks to move large masses. Application of PP in LVHR is thus misplaced where the hernial defect becomes a point of concentration of intra-abdominal forces. This makes the mesh inherently unstable. For a stable mesh aided by PP, benefits of defect closure needed to be explored. METHODS: Between January 2000 and December 2004, 30 nonsmoker patients with incisional, primary ventral, and recurrent ventral hernias were operated on. Laparoscopic closure of the defect augmented with intraperitoneal onlay mesh (IPOM), as done in standard LVHR, was preformed. RESULTS: Thirty patients with 34 defects of a mean "closed defect" length of 5.7 cm (range, 3-10) were operated on. Mean operative time was 90 minutes (range, 75-110). There were no conversions, visceral injury, postoperative visible bulge, or seroma. No painkiller except Paracetamol was required. There was no recurrence in a mean follow-up of 58 months (range, 26-84). Restored abdominal contour was achieved by all the patients. CONCLUSION: Closure of hernial defect augmented with IPOM is a safe, patient friendly, and scientific way of doing LVHR.     

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.     

A Randomised Prospective Study to Evaluate Preperitoneal Mesh Repair Versus Onlay Mesh Repair and Laparoscopic IPOM in Incisional Hernia Surgery

Incisional hernia remains a very common postoperative complication. These are encountered with an incidence of up to 20 % following laparotomy. These hernias enlarge over time, making the repair difficult, and serious complications like bowel obstruction, strangulation and enterocutaneous fistula can occur. Hence, elective repair is indicated to avoid these complications. Implantation of a prosthetic mesh is nowadays considered as the standard treatment due to low hernia recurrence. The most common mesh repair techniques used are the onlay repair, sublay repair and laparoscopic intraperitoneal onlay mesh (IPOM). However, it is still not clear which technique among the three is superior. A study consisting of 30 patients who underwent incisional hernia repair by onlay, laparoscopic and preperitoneal mesh repair with abdominoplasty was conducted in the Coimbatore Medical College and Hospital. Of the three groups, the preperitoneal repair with abdominoplasty was found to have better patient compliance and satisfaction with regard to occurrence of complications and appearance of the abdominal wall without laxity in a single sitting.     

Polyvinylidene fluoride: a suitable mesh material for laparoscopic incisional and parastomal hernia repair!

Background

Today, the laparoscopic approach is a standard procedure for the repair of incisional hernias. However, the direct contact of visceral organs with mesh material is a major issue.

Patients and methods

This prospective observational study presents the data of 344 patients treated for incisional and parastomal hernias with a new mesh made of polyvinylidene fluoride (PVDF; Dynamesh IPOM^®) between May 2004 and January 2008 with a minimum follow-up of 6 months. The median follow-up of 297 patients after incisional hernias totaled 24 months and 20 months for 47 patients with parastomal hernias. Incisional hernias were repaired using an IPOM technique. For parastomal hernias, a recently described sandwich technique was used with two meshes implanted in an intraperitoneal onlay position.

Results

The recurrence rate for incisional hernias was 2/297 = 0.6% and 1/47 = 2% for parastomal hernias. Three patients developed a secondary infection after surgical revision or puncture of a seroma. One patient had a bowel fistula through the mesh, with an abscess in the hernia sac. In all cases, the infection healed and the mesh could be preserved. No long-term mesh-related complications have been observed.

Conclusion

The laparoscopic repair of incisional and parastomal hernias with meshes made of PVDF (Dynamesh IPOM^®) revealed low recurrence and, overall, low complication rates. Especially in cases of infection, the material proved to be resistant without clinical signs of persistent bacterial contamination. Mesh-related complications did not occur during the follow-up.     

Laparoscopic transabdominal preperitoneal approach to place a polypropylene mesh on the abdominal wall: an experimental swine model of a technique that can be used for incisional hernia repair

Background The placement of intraabdominal polypropylene mesh entails risks of adhesions and fistulas that can be avoided by preperitoneal placement.Methods This comparative, open, experimental, prospective, randomized, and transversal study randomized pigs into two groups of 11 each for intraperitoneal (IPOM) or preperitoneal (TAPP) polypropylene mesh placement by laparoscopy. Diagnostic laparoscopy and tissue en-bloc resection was performed 28 days postoperatively for histopathologic analysis.Results The following data were observed for the two study groups: surgical time (IPOM: 35.73 ± 4.22 min; TAPP: 58.09 ± 6.28 min; p = <0.0001); adhesions (IPOM: 81.81%; TAPP: 27.27%; p = 0.032), grade III for IPOM and grade II for TAPP (p = 0.001); and interloop adhesions (IPOM: 81.81%; TAPP: 9.09%; p = 0.003). No fistulas were found in either group. The TAPP procedure showed better integration of mesh, without lesion to abdominal organs. Two complications, occurred with IPOM, and one with TAPP (p = 1.0, not significant).Conclusions The perperitoneal technique requires more time, but has fewer adhesions and less intraabdominal inflammatory response. It is a feasible technique that may diminish risks in the laparoscopic treatment of incisional hernias with polypropylene mesh.     

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??Comtemporary isssues, controversies and solutions of laparoscopic treatment for incisional hernia YUE Fei,LI Jian-wen. Gastrointestinal Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, and Shanghai Minimally Invasive Surgery Centre, Shanghai 200025,China
Corresponding author: LI Jian-wen, E-mail??ljw5@yeah.net
Abstract Laparoscopic inicisional hernia repair has witnessed a quarter century’s develeopment since its debut in 1993. The representative procedure IPOM has being expanded across the world rapidly due to simpler technique and less complications. With the optimization of defect closure and mesh fixation, and the breakthrough in boundary incisional hernias, laparoscopic incisional hernia repair become a well-acknowledged solution. As the consequences of material limitaions, intraperitoneal mesh related complications emerged with time goes by. Hernia specialists adjust the therapeutic strategy from intraperitoneal to extraperitoneal. However, the new techniques, such as MILOS and etc., are also encountering challenges and controversies. More clinical practice are still required for further evaluation.     

不同修补方式对切口疝患者围手术期肺功能影响的研究

目的分析不同修补方式对切口疝患者肺功能的影响。方法选择2004年3月至2007年3月在我院手术的切口疝患者72例，按手术方式不同分为3组（Onlay组、SubLay组和IPOM组），分别于围手术期不同时间（术前、术后24h、术后48h、术后72h、术后7d）采集动脉血进行血气分析，术前、术后7d行肺功能测试。结果IPOM组术后7d肺功能较Onlay组、SubLay组明显改善（P〈0．05）；术后24h各组PaO2较术前均有显著降低（P〈0．05），IPOM、SubLay组Pa02下降较Onlay更明显（P〈0．05），但术后7d，与Onlay组相比，IPOM、SubLay组PaO2较前者明显改善（P〈0．05）。结论善愈不同修补方式对切口疝患者围手术期肺功能的影响显著，IPOM可显著改变患者肺功能。