Initial experience with transvaginal incisional hernia repair

Introduction

Natural orifice surgery has evolved from a preclinical setting into a common occurrence at the University of California San Diego (UCSD). With close to 40 transvaginal cases, we have become comfortable with this technique and are exploring other indications. One of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation. Patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites. In addition, patients with recurrent incisional hernias may, likewise, be at increased risk. We believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias. Here, we describe what we believe to be the first natural orifice transluminal endoscopic surgical (NOTES) approach to the repair of an abdominal wall hernia.

Methods

The patient is a 38-year-old female with a painful recurrent umbilical hernia, previously repaired 8 years prior with a polypropylene-based mesh. The patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.

Results

The patient had no intraoperative or postoperative complications. At 5 months follow up, the patient had no complaints, no evidence of hernia recurrence, and was very pleased with her result.

Conclusions

The repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible, and the result of our initial case was exceptional. However, there are still significant obstacles which must be addressed before this approach can be widely utilized. These obstacles include safe entrance into the abdominal cavity via a transvaginal approach, the proper mesh to be placed during the repair, and the risk of infection.     

腹腔镜下脐疝无张力修补术

目的 探讨腹腔镜下应用补片行脐疝修补的临床效果.方法 2006年8月至2009年4月在腹腔镜下对26例脐疝患者进行修补治疗.手术方法为用超声刀进行脐孔周围组织分离后,应用腔内缝合器将补片钉合疝孔边缘完成脐疝修补术.分析总结腹腔镜下应用补片行脐疝修补的临床效果.结果 26例患者均成功地在腹腔镜下行脐疝无张力修补术.手术时间30～45 min,平均35min.术中出血5～15 ml,平均8 ml.所有患者术后疼痛轻微,排气、排便时间20～32 h,平均26 h.术后住院3～7 d,平均住院5 d.住院期间未发生脂肪液化及感染,无手术死亡病例.所有患者均获得随访,时间3～25个月,平均14个月,未发现脐疝复发,所有患者对治疗效果较满意.结论 腹腔镜下脐疝无张力修补术具有创伤小、恢复快、并发症少等特点,符合疝无张力修补原则.     

Laparoscopic versus open umbilical hernia repair.

BACKGROUND: The use of prosthetic material for open umbilical hernia repair has been reported to reduce recurrence rates. The aim of this study was to compare outcomes after laparoscopic versus open umbilical hernia repair. METHODS: We reviewed all umbilical hernia repairs performed from November 1995 to October 2000. Demographic data, hernia characteristics, and outcomes were compared. RESULTS: Of the 76 patients identified, 32 underwent laparoscopic repair (LR), 24 primary suture repairs (PSR), and 20 open repairs with mesh (ORWM). Preoperative characteristics were similar between groups. Hernia size was similar between LR and ORWM groups, and both were larger than that in the PSR group. ORWM compared with the other techniques resulted in longer operating time, more frequent use of drains, higher complication rates, and prolonged return to normal activities (RTNA). The length of stay (LOS) was longer in the ORWM than in the PSR group. When compared with ORWM, LR resulted in lower recurrence rates. LR resulted in fewer recurrences in patients with previous repairs and hernias larger than 3 cm than in both open techniques. CONCLUSIONS: LR results in faster RTNA, and lower complication and recurrence rates compared with those in ORWM. Patients with larger hernias and previous repairs benefit from LR.     

Plug-technique for umbilical hernia repair in the adult

BACKGROUND: Umbilical hernia represents 6% of all abdominal wall hernias in the adult. Surgical repair should always be carried out due to possible occurrence of complications. Aim of this paper is to evaluate the efficacy of the plug-technique. METHODS: From October 1995 to April 2000, the authors performed 21 operations for acquired umbilical hernia with a defect smaller than 4 cm. Local anesthesia was used and a light intravenous sedation added in particularly anxious patients. The repair was achieved by insertion of a polypropylene dart plug sutured to the margins of the hernial defect. RESULTS: All patients were up and about straightaway and were discharged within 24 hours of surgery. Postoperative pain was mild and required hospital analgesia in only 19% of cases and domiciliary analgesia in 24%. During a follow-up ranging from 6 to 60 months (mean 30), only one recurrence has been recorded. CONCLUSIONS: This tension-free technique allows immediate rehabilitation, with few complications and a low recurrence rate.     

肝硬化腹水合并脐疝的Onlay和腹膜前疝修补术对比研究

目的探讨在肝硬化腹水合并脐疝患者的外科治疗中Onlay术式和腹膜前疝修补术式治疗效果的差异。 方法回顾性分析2010年1月至2018年1月,上海交通大学医学院附属第一人民医院收治的肝硬化腹水合并脐疝25例患者的临床资料。根据术式不同分为2组,对照组患者13例行Onlay术式,试验组患者12例行腹膜前疝修补术。比较2组手术时间、排气时间、住院时间、伤口愈合情况及术后复发等观察指标,并进行统计学分析。 结果对照组平均手术时间（56.9±16.3）min,住院时间（8.7±5.8）d,排气时间（2.6±0.7）d。试验组平均手术时间（49.4±17.1）min,住院时间（10.8±4.7）d,排气时间（2.7±0.6）d。2组术后疼痛评分、伤口愈合情况等比较,差异均无统计学意义（P>0.05）。观察期内对照组出现轻微伤口感染患者1例,2组患者均未出现复发情况。 结论对于肝硬化腹水合并脐疝患者,Onlay和腹膜前疝修补两种术式在治疗效果可能无明显差异。     

Concomitant sublay mesh repair of umbilical hernia and abdominoplasty

Concomitant mesh repair of large umbilical hernias and abdominoplasty pose a serious risk of devascularizing the umbilical stalk. A technique of placing mesh in a sublay manner, deep to the fascial defect, for an umbilical herniorrhaphy to avoid damage to the deep umbilical perforators during an abdominoplasty is described.     

Laparoscopic incisional and umbilical hernia repair in cirrhotic patients

BACKGROUND: Traditional approach to incisional hernias (IHs) in cirrhotic patients is plagued by a significant recurrence rate and frequent wound infections. The laparoscopic repair of IHs was designed to offer a minimally invasive and tension-free technique that yields less morbidity and fewer recurrences than the standard open repair. In cirrhotic patients there are additional reasons for the benefits of laparoscopy. First, preservation of the abdominal wall avoids interruption of large collateral veins. Second, nonexposure of viscera restricts electrolytic and protein losses, and improves absorption of ascites. Finally, the laparoscopic approach is associated with a lower perioperative blood loss (smaller abdominal incision). METHODS: A retrospective review was performed for 14 consecutive patients with ventral hernias and affected by chronic hepatitis or cirrhosis related to hepatitis C-B virus, who underwent laparoscopic repair at our institution between September 2002 and October 2004. All patients were in class A of Child-Pugh classification. RESULTS: There was no conversion to open operation. The mean size of the defects was 87 cm (range 1 to 480); incarceration was present in 2 patients and multiple (Swiss-cheese) defects in 1. In all cases, the mesh (average, 287 cm) was secured with transabdominal sutures and metal tacks or staples leaving the sac in situ. Operative time and estimated blood loss averaged 88 min (range 18 to 270) and 30 mL (range 10 to 150). Length of hospital stay averaged 2.6 days (range 1 to 6). There were 11 minor complications: seroma lasting >4 weeks (5), postoperative ileus (2), suture site pain >2 weeks (2), urinary retention (1), and skin breakdown (1). We experienced no recurrences with an average follow-up of 8 months (range 3 to 24). CONCLUSIONS: Laparoscopic IH repair is technically feasible and safe even in cirrhotic patients with fascial defects. This operation decreases postoperative pain, shortens the recovery period, and seems to reduce postoperative morbidity and recurrence. To the best of our knowledge, this is the first report in which a series of cirrhotic patients affected by incisional and umbilical hernias is treated with a laparoscopic approach.     

腹腔镜下生物补片修补成人脐疝

目的 探讨腹腔镜下生物补片修补成人脐疝的方法及效果.方法 2003年1月至2008年10月在腹腔镜下用生物补片修补脐疝21例,其中男6例,女15例,年龄36～73岁,平均56岁.疝环直径3～7.5 cm,平均5.2 cm.手术均采用全麻,术前1 d行清洁肠道准备,术前30 min预防性静脉应用抗生素1次.选用巴德Composix E/X复合补片,根据疝环大小选取适当规格补片,要求其边缘超过疝环缺损3～5 cm.将补片置入腹腔后平铺,聚丙烯而朝向腹壁,其中心点对准疝环中心点,用钉枪将补片固定于腹壁上,内外2圈,内圈沿疝环,外圈沿补片边缘.结果 所有手术均在腹腔镜下顺利完成,无中转开腹.手术时间30～96 min,平均52 min.术后出现明显腹胀2例,术后2～3 d自行缓解;1例术后出现修补区域腹壁的明显疼痛不适感,给予对症处理,1周后疼痛逐渐缓解消失.无浆液肿.无切口及补片感染.术后住院时间3～8 d,平均4.2 d.随访3个月至5年,平均32个月,无肠梗阻,无复发病例.结论 腹腔镜下生物补片修补成人脐疝是安全有效的.     

Laparoscopic femoral hernia repair using umbilical ligament as plug

A novel technique for the laparoscopic repair of femoral hernia is described. An 11-year-old boy who had undergone previous open inguinal herniorrhaphy presented with a persistent bulge in the ipsilateral groin. At laparoscopic exploration, a small femoral hernia was discovered. It was reduced with extrinsic compression and the defect closed laparoscopically using a permanent purse-string suture. The ipsilateral umbilical ligament was dissected off the abdominal wall and secured (plugged) over the internal opening, providing a tension-free repair. The immediate postoperative result was satisfactory and there was minimal postoperative pain. Two-year follow-up confirmed adequate repair, without recurrence. This laparoscopic technique enabled diagnostic precision, contralateral evaluation, and a novel means of patching and buttressing the peritoneal closure with umbilical ligament. The procedure is safe, simple, and provides excellent functional and cosmetic results.     

改良Kugel和CK补片修补成人脐疝23例报告

目的 总结改良Kugel和CK补片修补成人脐疝的经验.方法 回顾性分析成人脐疝23例,男5例,女18例,平均62(43～83)岁.采用改良Kugel手术17例,采用CK补片手术6例.结果 23例患者随访6个月～5年无复发.改良Kugel适于5 cm以下脐疝,脐疝直径大于5cm,使用CK补片修补.结论 使用这两种材料修补脐疝的优点是操作简便,手术时间短,修补可靠.     

脐外侧襞在腹股沟嵌顿疝修补术中应用的临床研究

目的探讨脐外侧襞疝修补手术在腹股沟嵌顿疝中的应用价值。方法选择腹股沟嵌顿疝并肠梗阻65例患者实施经腹疝内容物还纳，缝合疝囊颈口腹横肌，利用脐外侧襞对疝内口腹壁薄弱区域进行修补。结果62例患者成功进行手术，3例因肥胖脐外侧襞不明显，游离疝囊，缝合封闭内环口及周围腹；手术时间35～90min，平均56min；术后8～12h患者能下床活动，腹腔引流管均在术后2～4d内拔除，平均住院时间6．8d；所有患者无切口感染、肠漏、腹腔脓肿、腹膜炎、肠梗阻等并发症发生，康复出院。所有病例术后随访3～36个月，复查无复发。结论根据患者情况有选择经腹利用脐外侧襞修补腹股沟嵌顿疝是一种安全、有效、可行的方法，值得推广。     

Pure transvaginal laparoscopic appendectomy

Background

Natural orifice transluminal endoscopic surgery has been at the forefront of minimally invasive surgery. Benefits include no visible scars, less pain, and shorter recovery time. We describe a video of a 37-year-old female who underwent a pure transvaginal appendectomy (TVA) for acute appendicitis. This is 1 of 18 successfully performed TVAs at Yale-New Haven Hospital. Appropriate Institutional Review Board was obtained preoperatively.

Methods

The patient was positioned in steep Trendelenburg and then a weighted speculum was introduced into the vagina allowing exposure of the posterior vaginal fornix. The cervix was grasped with a single-toothed tenaculum on the posterior cervical lip and the posterior vaginal fornix was visualized. Access to the peritoneum was achieved by electrocautery and then sharp dissection. A SILS? port (Covidien, Mansfield, MA, USA) was introduced and pneumoperitoneum up to 15?mmHg was achieved. Two 5-mm trocars and one 12-mm trocar were used. A 5-mm 30° angled endoscope, a flexible reticulating endograsper, and straight standard instruments were used. The identified appendix was dissected and a stapler was used to divide the mesoappendix from the appendix. Following confirmation of good hemostasis and no spillage of bowel contents, the appendix was removed from the abdomen within a retrieval bag and the culdotomy was closed with a running absorbable suture. The patient tolerated the 27?min procedure well and was discharged home in good condition on postoperative day 1.     

Small bowel obstruction by mesh migration after umbilical hernia repair

A case of intestinal obstruction due to mesh migration is described. A 61 year old patient affected by BPCO and chronic atrial fibrillation is admitted for mechanical intestinal obstruction. He underwent a umbilical hernia repair with mesh and omphalectomy 6 years before. Laparotomy revealed the obstruction due to an inflammatory block including polypropylene mesh penetrating an ileal loop. Intestinal resection and mechanical isoperistaltic L-L anastomosis is performed. The post-operative period is complicated by cardiorespiratory problems and the patient comes discharged in XVII day. The prosthesis migration after umbilical hernia repair is an event never described in the literature; instead rare cases of migration after inguinal hernia repair are reported. The pathophysiological mechanisms of this complication are not still cleared and that makes necessary a careful technique in the use of the hernia mesh.     

Management of the sac during umbilical hernia repair in children

The umbilical hernial sac need not be removed completely during umbilical herniorrhaphy in children. This simplifies and shortens the procedure. The use of the pressure dressing as an important adjunct in the postoperative management of these patients is emphasized.     

Total transvaginal endoscopic abdominal wall hernia repair: a NOTES survival study

Hypothesis Natural orifice transluminal endoscopic surgery (NOTES) has gained widespread interest as a potentially less invasive alternative to laparoscopic surgery or, else, an evolution as the next-generation surgery. The main objective of this study was to assess the safety of transluminal abdominal wall hernia repair for potential human application by specifically investigating the feasibility and challenges of using a transvaginal approach. Design NOTES ventral hernia repair via a transvaginal approach. Setting University Hospital (National University Health System, Singapore). Participants The study utilized five female pigs (30–40 kg) between 5 and 7 months of age, which underwent abdominal wall hernia repair using a transvaginal approach. Intervention The procedures were performed using a double-channel endoscope under general endotracheal anesthesia. A mesh was placed and fixed to the abdominal wall using standard laparoscopic and endoscopic equipment. The animals survived for 2 weeks and were then euthanized and a necropsy performed. Main outcome measures To assess the safety and feasibility of NOTES ventral hernia repair in a survival experimental model. Results All of the procedures could be safely performed using the standard equipment. At the necropsy, all meshes were well in place and mild adhesions were recorded in one animal with a small abscess in the subcutaneous area. Conclusion This novel approach seems technically challenging but feasible using equipment and accessories currently available for conventional laparoscopic and interventional endoscopy with low intra-abdominal contamination and sepsis. New procedure-specific instruments and equipment need to be developed to allow the surgeon safer access and more degrees of instrument freedom.     

无张力疝修补术在治疗成人脐疝中的应用

目的:探讨无张力疝修补术在治疗成人脐疝中的临床应用价值。方法:应用无张力疝修补术治疗成人脐疝45例，其中应用网塞补片29例，三合一双层补片16例。观察手术时间、伤口疼痛、术后自主功能的恢复、并发症及复发率。 结果:手术全部成功。平均手术时间60min。4例术后出现皮下积液。随访6～48个月未见复发病例。结论:无张力疝修补术是治疗成人脐疝较好的术式，具有手术安全、术后恢复快、近期疗效满意和复发率低等优点。