Magnetic Resonance–Visible Meshes for Laparoscopic Ventral Hernia Repair

Methods:Ten patients were surgically treated with intraperitoneally positioned superparamagnetic flat meshes. A magnetic resonance investigation with a qualified protocol was performed on postoperative day 1 and at 3 months postoperatively to assess mesh appearance and demarcation. The total magnetic resonance–visible mesh surface area of each implant was calculated and compared with the original physical mesh size to evaluate potential reduction of the functional mesh surfaces.Results:We were able to show a precise mesh demarcation, as well as accurate assessment of the surrounding tissue, in all 10 cases. We documented a significant decrease in the magnetic resonance–visualized total mesh surface area after release of the pneumoperitoneum compared with the original mesh size (mean, 190 cm² vs 225 cm²; mean reduction of mesh area, 35 cm²; P < .001). At 3 months postoperatively, a further reduction of the surface area due to significant mesh shrinkage could be observed (mean, 182 cm² vs 190 cm²; mean reduction of mesh area, 8 cm²; P < .001).Conclusion:The new method of combining magnetic resonance imaging and meshes that provide enhanced signal capacity through direct integration of iron particles into the polyvinylidene fluoride base material allows for detailed mesh depiction and quantification of structural changes. In addition to a significant early postoperative decrease in effective mesh surface area, a further considerable reduction in size occurred within 3 months after implantation.     

Laparoscopic Hernia Repair—When Is a Hernia Not a Hernia?

A wide range of diagnoses can present as inguinal hernia. Laparoscopic techniques are being increasingly used in the repair of inguinal hernias and offer the potential benefit of identifying additional pathology. The authors present the first reported case of a hydrocele of the canal of Nuck diagnosed laparoscopically. We review the incidence of identifying additional pathology through laparoscopy for inguinal hernia repair. We suggest that in patients with atypical presenting features of a hernia, the transabdominal preperitoneal, rather than a totally extraperitoneal, approach to groin hernia repair should be considered because of its greater diagnostic potential.     

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.     

Laparoscopic Hernia Repair-The Best Option ?

For 100 years the Bassini-type repair for inguinal hernia was the standard method.

The Lichtenstein “tension free” mesh repair replaced it on the grounds of much lower recurrence rates, < 5% vs 15%. However, open procedures all have significant long-term discomfort rates of up to 53%. Laparoscopic repair has become a genuine option in the last 15 years and offers low recurrence (< 1%) and minimal long-term discomfort. However, it has not been widely taken up. There is a common misconception that it takes longer to perform, has more complications and is much more expensive. None of these caveats stand up under objective scrutiny. It is time that laparoscopic repair became the method of choice for most elective inguinal hernia repairs.     

Elective Inguinal Hernia Repair with Mesh: Is there a Need for Antibiotic Prophylaxis? — A Review

Although it is widely accepted that antibiotic prophylaxis is indicated in elective mesh repair of inguinal hernia, the evidence for its value has been controversial. A recent Cochrane meta-analysis showed that there is insufficient data overall to demonstrate a clear advantage of prophylaxis and illustrated the classic problem in evidence-based medicine where a lack of evidence in support of an intervention may be interpreted as a reason not to implement it. This review of the literature evaluates the evidence for the effectiveness of intravenous antibiotics as prophylaxis in inguinal hernia repair with mesh. Pubmed and Embase searches revealed seven trials of antibiotic prophylaxis in mesh repair of inguinal hernia. The quality of the evidence and the limitations of the seven trials are discussed. Analysis of these seven trials adds to the Cochrane meta-analysis of Sanchez-Manuel and Seco-Gil. Only two of the trials support the use of antibiotic prophylaxis, and those were the only double-blind randomized controlled trials reviewed. In evidence-based medicine the absence of evidence in clear support of an intervention (as in this review, where only two of the seven trials support the use of antibiotic prophylaxis) may be taken as reason not to implement the intervention. It is possible, however, that what is needed to clarify the issue are further randomized controlled trials, rigorously performed and recruiting significantly larger numbers of patients. This review was prepared as part of the MSc in Surgical Practice programme developed by the Kent Institute of Medicine and Health Sciences, University of Kent     

Long-Term Outcome of Rives–Stoppa Technique in Complex Ventral Incisional Hernia Repair

Background  

Use of the Rives–Stoppa procedure for ventral incisional hernia repair (RS-VIHR), in which the prosthesis is placed between the rectus abdominis muscle and the posterior sheath, has diminished reherniation markedly and is the most promising open technique.     

Simultaneous Panniculectomy and Ventral Hernia Repair Following Weight Reduction after Gastric Bypass Surgery: Is it Safe?

Background Successful obesity surgery often results months later in redundant abdominal skin and subcutaneous tissue. Following open obesity surgery, ventral hernias are also common, yet little has been written about the safety of combining panniculectomy with ventral hernia repair. We performed a retrospective analysis of a single plastic surgeon’s experience with panniculectomy following gastric bypass surgery including both patients undergoing and those not undergoing simultaneous ventral hernia repair. Methods We reviewed the hospital and office records of patients undergoing panniculectomy at two university-affiliated community hospitals from March 2002 to February 2005 following gastric bypass surgery. Results The records of 100 patients (91 women) were available for review. Median age was 48 (range 25–65) and median interval between bypass surgery and panniculectomy was 23 months (range 6–286). Median decrease in BMI was 19 (range 13–47). Eighty-three patients underwent panniculectomy combined with at least one other procedure, most commonly ventral hernia repair (70) and buttock lift (9). Forty hernia repairs were performed with mesh. No patient required mesh removal in the postoperative period. Median length of hospital stay was 3 days (range 1–7). Twenty-nine patients required outpatient sharp debridement. Ten patients were readmitted for management of wound complications. No patients sustained a stroke, myocardial infarction, or pulmonary embolus. There was no mortality. Conclusions Following obesity surgery, simultaneous ventral hernia repair and panniculectomy can be accomplished safely with short hospital stays and few in-hospital complications. Postoperative wound problems are not infrequent but can be managed in the outpatient setting.     

Outcomes Following Placement of Non–Cross-Linked Porcine-Derived Acellular Dermal Matrix in Complex Ventral Hernia Repair

Repair of complex ventral hernias frequently results in postoperative complications. This study assessed postoperative outcomes in a consecutive cohort of patients with ventral hernias who underwent herniorrhaphy using components separation techniques and reinforcement with non–cross-linked intact porcine-derived acellular dermal matrix (PADM) performed by a single surgeon between 2008 and 2012. Postoperative outcomes of interest included incidence of seroma, wound infection, deep-vein thrombosis, bleeding, and hernia recurrence determined via clinical examination. Of the 47 patients included in the study, 25% were classified as having Ventral Hernia Working Group grade 1 risk, 62% as grade 2, 2% as grade 3, and 11% as grade 4; 49% had undergone previous ventral hernia repair. During a mean follow-up of 31 months, 3 patients experienced hernia recurrence, and 9 experienced other postoperative complications: 4 (9%) experienced deep-vein thrombosis; 3 (6%), seroma; 2 (4%), wound infection; and 2 (4%), bleeding. The use of PADM reinforcement following components separation resulted in low rates of postoperative complications and hernia recurrence in this cohort of patients undergoing ventral hernia repair.Key words: Ventral hernia repair, Biologic tissue matrix, Components separation, Synthetic meshAbdominal wall repair (AWR) for hernia is a common procedure, with an estimated 1 million or more procedures performed each year in the United States.¹ Incisional hernias are a common complication of AWR, with reported incidences ranging from 9% to 20% in prospective studies of patients undergoing abdominal surgery.^2–7 Significant advances have been made in surgical repair of abdominal hernias in recent decades, including the use of components separation techniques^8,9 and prosthetic mesh and biologic tissue matrix materials to facilitate closure of abdominal wall defects.⁹ Nevertheless, data from several retrospective studies have shown hernia recurrence remains a significant problem following AWR using components separation techniques, with recurrence rates ranging from 14% to 22%.^10–13 Synthetic mesh or biologic tissue matrix materials can be used to provide additional reinforcement in AWR with or without components separation. Reported recurrence rates following repair with prosthetic materials are highly variable^14–17 and can be impacted by the complexity of the individual patient case, number of previous hernia repairs, and surgeon''s technique.^9,18 While there is lack of consensus regarding which mesh or matrix type to use for reinforcement in AWR, according to the Ventral Hernia Working Group (VHWG), synthetic mesh should be avoided in patients classified as having grade 2 risk (e.g., those who are smokers, obese, diabetic, immunosuppressed or have chronic obstructive pulmonary disease) owing to the increased risk of postoperative infection associated with comorbidities.⁹Biologic tissue matrices may offer advantages over synthetic mesh for AWR in high-risk patients (e.g., better revascularization, less infection).^9,19,20 Non–cross-linked intact porcine-derived acellular dermal matrix (PADM; Strattice Reconstructive Tissue Matrix, LifeCell Corp, Branchburg, New Jersey) is designed to perform as a surgical matrix for soft-tissue repair while serving as a scaffold for the rapid ingrowth of host cells, collagen, and blood vessels.^21,22 In our practice, we have observed high complication rates following complex AWR with synthetic mesh in patients who have multiple risk factors with or without potentially contaminated or infected surgical fields. The objective of this study was to assess and describe postoperative outcomes in a consecutive cohort of patients who underwent ventral hernia repair using components separation techniques and reinforcement with PADM.