Use of a new type of PTFE mesh in laparoscopic incisional hernia repair: the continuing evolution of technique and surgical expertise

We present the results of our first 44 laparoscopic incisional hernia repairs. This study examines the effectiveness of this technique in patients presenting with a first-time or recurrent incisional hernia. From October 2001 to November 2002, a total of 45 consecutive patients underwent laparoscopic incisional hernia repair with a new form of expanded polytetrafluoroethylene (ePTFE) mesh. Patient data, preoperative, intraoperative, and postoperative records, were recorded and analyzed. Mean defect size was 84 cm2, mean mesh size was 311 cm2, mean surgical time was 65 minutes, and mean hospital stay was 2.25 days. Postoperative complications occurred in four patients (9.1%). The laparoscopic approach is a safe, effective, and relatively complication-free option in the management of first-time and recurrent incisional hernias. The use of modified ePTFE mesh with a dual surface in incisional hernia repair enables early tissue attachment, reduces adhesions, and could reduce the incidence of recurrences.     

Laparoscopic Incisional Hernia Repair in Liver Transplant and Other Immunosuppressed Patients

We report the early results of laparoscopic incisional hernia repair in a small group of immunosuppressed patients and compare these results with a cohort of patients with open repair. We describe a modification used to secure the cephalad portion of the Gore-Tex mesh in high epigastric incisional hernias often encountered after liver transplantation. Data were gathered retrospectively for all incisional hernia repairs by our group from March 1996 to January 2001. Twelve of 13 attempted patients had successful completion of their laparoscopic hernia repairs with no reported recurrences to date. Two of these procedures were performed for recurrent hernias. We completed nine of nine attempted laparoscopic hernia repairs in liver transplant patients with epigastric incisional hernias. We repaired two of three attempted lower midline incisional hernias in renal disease patients. One of these patients was soon able to reuse his peritoneal dialysis catheter. A total of 15 patients, 12 with liver transplants, underwent open repair of their incisional hernias. These patients had seven recurrences and/or serious mesh infections with five patients electing repeated operations. In our initial series, laparoscopic mesh repair of incisional hernias is practical and safe in the abdominal organ transplant population with a low incidence of early recurrence and serious infections.     

Concurrent Gastric Bypass and Repair of Anterior Abdominal Wall Hernias

Background: Many patients seeking surgical treatment for morbid obesity present with anterior abdominal wall hernias. Although principles of hernia repair involve a tension-free repair with the use of prosthetic mesh, there is concern about the use of mesh in gastric bypass surgery due to potential contamination with the contents of the gastrointestinal tract and resultant mesh infection. We report our series of patients undergoing Roux-en-Y gastric bypass (RYGBP) and simultaneous anterior abdominal wall hernia repair. Methods: All patients who underwent simultaneous RYGBP surgery and anterior abdominal wall hernia repair were reviewed. Results: 12 patients underwent concurrent RYGBP and anterior wall hernia repair. There were 5 women and 7 men with average age 54.9 ± 8.5 years (range 35 to 64) and average body mass index (BMI) 50.4 ± 10.3 kg/m² (range 38 to 70). Two open and 10 laparoscopic RYGBP operations were performed. Nine patients (75%) underwent incisional hernia repairs and 3 patients (25%) underwent umbilical hernia repair concurrent with gastric bypass. Average size of defect was 14.7 ± 13.4 cm². One patient had primary repair and 11 patients had prosthetic mesh repair: polypropylene in 3 patients (25%) and polyester in 8 patients (67%). With a 14.1 ± 9.3 month follow-up, there have been no mesh infections and 2 recurrences, one in the patient who underwent primary repair and one in a patient repaired with polyester mesh but with two previous failed incisional hernia repairs. Conclusion: Concurrent RYGBP and repair of anterior abdominal wall hernias is safe and feasible. In order to optimize success, tension-free principles of hernia repair with the use of prosthetic mesh should be followed since no mesh infections occurred in our series.     

Ventralex mesh in umbilical/epigastric hernia repairs: clinical outcomes and complications

BACKGROUND: Umbilical and epigastric hernias have historically been repaired without mesh resulting in recurrence rates in some series of up to 40%. Recent data suggests mesh repair of these hernias may decrease recurrent hernia rates. Ideal placement of the mesh is behind the defect, which is difficult to do without a large incision in these hernias unless done laparoscopically. The Ventralex hernia patch is a composite PTFE/polypropylene patch allowing intraperitoneal placement behind the hernia defect through a small incision, and without the cost of laparoscopy. To date, only one study exists evaluating this new prosthesis. METHODS: This study is a retrospective chart review of all umbilical and epigastric hernias repaired with the Ventralex hernia patch by a single surgeon. Patient characteristics and operative and post-operative data were collected. Hernia recurrence is the primary outcome. Secondary outcomes include complication rates. RESULTS: Eighty-eight patients from 2003-2006 were evaluated. The population included patients aged 25-86 (mean 52) with nineteen females (22%). The average BMI was 32 (range 18-68). Eighteen patients were smokers, five patients were diabetic, and two patients were chronic steroid users. The size of patches used were small (72%), medium (27%), and unknown (1%). Average operating room time was 52 min (range 19-194). The different types of hernias repaired were umbilical (68%), epigastric (30%), and incisional (2%). Follow-up visits ranged from 8 days to 3.1 years in all but five patients (6%). No hernia recurrences were found in follow-up. Complications included two patients (2.2%) with mesh infection requiring removal of the patch, one patient with post-operative urinary retention, and seroma formation in another patient. CONCLUSIONS: The composite PTFE/polypropylene hernia patch is effective in preventing hernia recurrence in umbilical, epigastric, and small ventral hernia repairs and can be accomplished with a low rate of complications.     

Rives-Stoppa procedure for repair of large incisional hernias: experience with 57 patients

Abstract Background. The use of prosthetic materials in tension-free incisional hernia repairs has diminished reherniation rates markedly; however, infection, intestinal fistulization, and seroma formation have been reported after repairs. Use of the Rives-Stoppa procedure for incisional hernia repair, in which the prosthesis is placed between the rectus abdominis muscle and the posterior sheath, may reduce occurrence of these problems. Methods and materials. Over a 6-year period 57 open abdominal wall incisional hernia repairs were performed using the Rives-Stoppa technique; 15 (26.3%) had previously undergone incisional hernia repair. The prosthetic materials used were polypropylene, expanded polytetrafluoroethylene (ePTFE), and ePTFE with perforations. The prosthesis size ranged from 8×8 cm to 20×28 cm (mean area 199.6 cm²). Follow-up consisted of an office visit 12 months postoperatively and at least one subsequent office visit or telephone interview; mean follow-up time was 34.9 months (range 11.7–81.9). Results. There were no hernia recurrences (except in one patient whose prosthesis was removed), gastrointestinal complications, fistulas, or deaths. Seromas occurred postoperatively in seven patients (12.3%). Two patients (3.5%) had wound infections that required removal of the prosthesis. Conclusions. In this series the Rives-Stoppa technique had excellent long-term results, with minimal morbidity, in patients with large primary or recurrent incisional hernias. The absence of serious complications and hernia recurrences in patients with grafts in place suggests that the Rives-Stoppa procedure is the repair of choice in such patients. Electronic Publication     

Laparoscopic tension-free repair of anterior abdominal wall incisional and ventral hernias with an intraperitoneal Gore-Tex mesh: prospective study and review of the literature

BACKGROUND: Recurrence rates after repair of incisional and ventral hernias range from 18% to 52%. Prosthetic open repair has decreased this rate, but the wide fascial dissection it requires increases the complication rate. Laparoscopic repair is a safe and effective alternative. PATIENTS AND METHODS: A prospective study was performed including 86 patients (63 women and 23 men) with a mean age of 54 years (range 29-79 years) having incisional or ventral hernias who underwent laparoscopic repair in our institution between July 1994 and October 2001. The majority of the patients were obese with a mean body mass index of 31.7 kg/m2. The abdominal wall defect size ranged from 2 X 1 cm to 20 X 13 cm. In all cases, a Gore-Tex mesh (Dual Mesh, W.L. Gore & Associates, Flagstaff, AZ, USA) was used in sizes ranging from 10 X 15 cm to 20 X 30 cm. RESULTS: Nineteen repairs were performed for recurrent hernias (12 incisional and 7 ventral). The mean operative time was 110.3 minutes (range 50-240 minutes). There was one open conversion (1.2%), one intraoperative complication (1.2%), and no deaths. There were no wound or mesh infections. Immediate postoperative complications occurred in 9 patients (10.6%) and late complications occurred in 16 patients (18.8%). The average hospital stay was 4.8 days (range 2-19 days). During a mean follow-up of 37 months (range 6-73 months), there were 6 hernia recurrences (7%). CONCLUSION: Laparoscopic repair of incisional hernia and ventral hernia appears to be safe, especially with the use of Gore-Tex mesh, and is proving to be effective as it decreases pain, complications, hospital stay, and recurrences.     

Preliminary results of a two-layered prosthetic repair for recurrent inguinal and ventral hernias combining open and laparoscopic techniques

The use of prosthetic mesh has become the standard of care in the management of hernias because of its association with a low rate of recurrence. However, despite its use, recurrence rates of 1% have been reported in primary inguinal repair and rates as high as 15% with ventral hernia repair. When dealing with difficult recurrent hernias, the two-layer prosthetic repair technique is a good option. In the event of incarcerated or strangulated hernias, however; placement of prosthetic material is controversial due to the increased risk of infection. The same is true when hernia repairs are performed concurrently with potentially contaminated procedures such as cholecystectomy, appendectomy, or colectomy. The purpose of this study is to report our preliminary results on the treatment of recurrent hernias by combining laparoscopic and open techniques to construct a two-layered prosthetic repair using a four ply mesh of porcine small intestine submucosa (Surgisis®, Cook Surgical, Bloomington, IN, USA) in a potentially infected field and a combination of polypropylene and ePTFE (Gore-Tex®, W.L. Gore and Associates, Flagstaff, AZ, USA) in a clean field. From September 2002 to January 2004, nine patients (three males and six females) underwent laparoscopic and open placement of surgisis mesh in a two layered fashion for either recurrent incisional or inguinal hernias in a contaminated field. A total of eight recurrent hernia repairs were performed (five incisional, three inguinal) and one abdominal wall repair after resection of a metastatic tumor following open colectomy for colon carcinoma. Six procedures were performed in a potentially contaminated field (incarcerated or strangulated bowel within the hernia), two procedures were performed in a contaminated field because of infected polypropylene mesh, and one was in a clean field. Mean patient age was 56.4 years. The average operating time was 156.8 min. Operative findings included seven incarcerated hernias (four incisional and three inguinal), one strangulated inguinal hernia, and one ventral defect after resection of an abdominal wall metastasis for a previous colon cancer resection. In two of the cases, there was an abscess of a previously placed polypropylene mesh. All procedures were completed with two layers of mesh (eight cases with surgisis and one with combination of polypropylene/ePTFE). Median follow up was 10 months. Complications included two seromas, one urinary tract infection, two cases of atelectasis and one prolonged ileus. There were no wound infections. The average postoperative length of stay was 7.8 days. There have been no mesh-related complications or recurrent hernias in our early postoperative follow-up period. The use of a new prosthetic device in infected or potentially infected fields, and the two-layered approach shows promising results. This is encouraging and provides an alternative approach for the management of difficult, recurrent hernias.     

Laparoscopic incisional hernia repair as a day surgery procedure: audit of 127 consecutive cases in a university hospital

BACKGROUND: Findings have shown that laparoscopic incisional hernia repair is superior to conventional open techniques. The objective of the current study was to evaluate the results of laparoscopic surgery on incisional hernias in an outpatient surgery unit in a university hospital. METHODS: Data were gathered prospectively for all laparoscopic incisional hernia repairs from January 1997 to December 2006. A total of 127 patients were operated in an outpatient surgery unit. The patients' clinical features, hernia type, intraoperative and postoperative complications, and reasons for hospital admission are studied. RESULTS: None of the patients required readmission to hospital, 15 had no need for analgesic treatment (11.8%) and the mean requirement was 6 days. The mean time of return to normal activity was less than 10 days and all the patients expressed their satisfaction with the procedure they received. During follow-up we detected 5 recurrences (4.4%). The statistical study showed no significant differences between the hospitalized patients and those treated on an ambulatory basis with regard to morbidity and recurrence rate (P<0.05). We do find a lower intraoperative and early postoperative (<30 d) complication rate in favor of the ambulatory patients (P<0.001). CONCLUSIONS: Laparoscopic repair of incisional hernias can be performed as a highly efficient ambulatory procedure with igual morbidity and recurrences than hospitalized patients.     

Is laparoscopic umbilical hernia repair with mesh a reasonable alternative to conventional repair?

BACKGROUND: Laparoscopic mesh repair has been advocated as treatment of choice for ventral hernias. The term "ventral hernia" refers to a variety of abdominal wall defects and laparoscopic papers have not reported defect specific analysis. The purpose of this study was to determine any advantages to laparoscopic mesh repair of umbilical hernias. METHODS: A retrospective review (January 1998 to April 2001) was made of patients undergoing umbilical hernia repair. Patients were categorized into three groups: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. Comparative analysis was performed. RESULTS: One-hundred and sixteen umbilical hernia repairs were performed in 112 patients: 30 laparoscopic mesh repairs, 20 open mesh repairs, and 66 open nonmesh repairs. The laparoscopic technique was used for larger defects and took more time with a trend toward fewer postoperative complications and recurrences. CONCLUSIONS: Laparoscopic umbilical hernia repair with mesh presents a reasonable alternative to conventional methods of repair.     

Deep prosthesis infection in incisional hernia repair: predictive factors and clinical outcome.

OBJECTIVE: To evaluate the incidence of prosthetic infection in incisional hernia repairs, to determine whether there are any factors associated with prosthetic infection and to describe the clinical outcome. DESIGN: Retrospective clinical study. SETTING: Teaching hospital, Germany. SUBJECTS: 121 consecutive patients who underwent incisional hernia repair in our department from December 1994 to December 1999. INTERVENTION: Hernia repair by implantation of an alloplastic prosthesis by the Stoppa-Rives technique. MAIN OUTCOME MEASURES: Postoperative deep prosthetic infection and associated factors. RESULTS: All 121 patients had the mesh implanted in the subfascial plane, 77 had a polypropylene mesh (Prolene) (64%), 7 had a polyester mesh (Mersilene) (6%), and 37 patients had a expanded polytetrafluoroethylene patch (ePTFE, Gore-Tex) (31%). Postoperatively the mesh became infected in 8 patients (7%), a mean of 4.5 months (range 0.5-16) after hernia repair. All three infected ePTFE patches had to be removed whereas drainage was sufficient treatment for the infected polypropylene and polyester meshes. CONCLUSION: Once a mesh infection is verified adequate drainage seems to be sufficient for polypropylene and polyester meshes but ePTFE patches should be removed.     

Intraperitoneal modification of the Rives-Stoppa repair for large incisional hernias

Introduction Recurrence rates for open repair of ventral/incisonal hernias historically range from 6% for the classic Rives-Stoppa repair to 35–45% for some of the techniques more commonly used in the United States. We report a modification to the classic Rives-Stoppa repair that allows intraperitoneal placement of the prosthetic, secured with a running suture. The abdominal muscles are closed over the mesh to protect it from any superficial wound problems that might develop and to restore normal architecture of the abdominal wall. Method A chart review was undertaken on all patients undergoing open ventral incisional hernia repair by a single surgeon from 2000 to 2006. All hernias were repaired with the intraperitoneal modification mimicking the principles of the Rives-Stoppa repair. Patient characteristics and operative and postoperative data were collected. Primary outcome was recurrence of hernia. Secondary outcomes were complications and rate of mesh infection. Results One hundred and fifteen patients were evaluated. Thirty-four patients had repair of recurrent ventral hernias. The average patient was obese, female, and 59 years old. Twenty-five patients used tobacco, eleven were diabetic, and seven used chronic corticosteroids. Meshes utilized included ePTFE, coated polyester, coated polypropylene, and biologic mesh. Average size of mesh was 465.4 cm². There were four recurrences (3.4%), three of which were due to mesh infection requiring mesh removal. Recurrence rate not secondary to mesh removal was 0.9%. Complications occurred in 26% with seroma formation being the most frequent (16%). Conclusion The intraperitoneal modification to the original Rives-Stoppa repair leads to a very low recurrence rate for large ventral hernia repairs with minimal complications and low rate of mesh infection. Presented at the 2007 American Hernia Society Meeting, Hollywood, FL, USA.     

Laparoscopic repair of large incisional hernias

Incisional hernias after abdominal operations are a significant cause of long-term morbidity and have been reported to occur in 3 to 20 per cent of laparotomy incisions. Traditional primary suture closure repair is plagued with up to a 50 per cent recurrence rate. With the introduction of prosthetic mesh repair recurrence decreased, but complications with mesh placement emerged ushering in the development of laparoscopic incisional herniorrhaphy. The records of patients who underwent laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001 were reviewed. Patient demographics, hernia defect size, recurrence, operative time, and procedure-related complications were evaluated. Fifty patients (22 male and 28 female, mean age 57 years with range of 24-83) were scheduled for laparoscopic incisional hernia repair between June 1, 1995 and September 1, 2001. The average patient was obese with a mean body mass index of 35.8 kg/m2 (range 16-57 kg/m2). Two patients (4%) had primary ventral hernias. Forty-eight patients (96%) had incisional hernias with 22 (46%) of these previously repaired with prosthetic mesh. Mean defect size was 206.1 cm2 (range 48-594 cm2). The average mesh size was 510.2 cm2 (range 224-1050 cm2). Gore-Tex DualMesh and Bard Composite Mesh were used in 84 and 16 per cent of the repairs, respectively. Mean operating time was 97 minutes. There were no deaths. Complications were seen in 12 per cent patients (six occurrences) and included two small bowel enterotomies, a symptomatic seroma requiring aspirate, a mesh reaction requiring a short course of intravenous antibiotics, and trocar site pain (two patients). There were no recurrences during a mean follow-up of 41 months (range 3-74 months). We conclude that laparoscopic incisional herniorrhaphy offers a safe and effective repair for large primary and recurrent ventral hernia with low morbidity.     

Longterm results of a prospective study of 225 femoral hernia repairs: indications for tissue and mesh repair

BACKGROUND: Femoral hernias are uncommon, and there are relatively few clinical studies of longterm outcomes after repair. Although the McVay repair has been classically described, the infrainguinal plug technique has gained popularity in recent years. Evidence supporting these repairs is sparse. STUDY DESIGN: A prospective study of elective femoral hernia repairs was done at the Shouldice Hospital from June 1999 until June 2003. The tissue-based complete groin repair (CGR) and a preperitoneal mesh repair were performed for specific indications. Patients were followed annually for 5 years to examine for recurrences and complications. RESULTS: Two hundred fifty-six patients were enrolled, with 225 completing 5 years of followup. Median age was 55 years, and hernias on the right side were more common (63.1%). Concurrent inguinal hernias were found in 115 patients (51%), and 41 (18.2%) had a previous inguinal hernia repair. A complete groin repair was performed in 120 patients and a preperitoneal mesh repair in 78. The remaining had an infrainguinal mesh repair. The overall recurrence rate was 3.1%, with a median time to recurrence of 12 months. There was no significant difference between mesh and suture repairs. Chronic postoperative pain was experienced by 20 patients (8.9%). CONCLUSIONS: Femoral hernias can be repaired electively with a tissue-based or a preperitoneal mesh technique, with durable longterm results. Mesh repair is indicated for recurrent femoral hernias, inguinofemoral hernias, prevascular hernias, association with concurrent direct hernias, and, if tension is anticipated, with complete groin repair. Infrainguinal mesh repair is used only when there has been a successful previous inguinal hernia repair.     

Rezidivleistenhernienreparation nach vorangegangener Netzimplantation

INTRODUCTION: Since the use of prosthetic mesh for the surgical repair of inguinal hernias has become increasingly popular, mesh material introduced during a previous operation is being detected in a growing number of patients undergoing surgery for recurrent hernia. This applies to at least 10% of recurrences. Needed is a therapeutic algorithm for the surgical management of recurrent hernias after previous mesh repair. MATERIAL AND METHODS: A total of 672 recurrent hernia repairs performed in hospitals in the German cities Aachen and Koblenz were analysed in order to review clinical practice. In 92 patients (13.7%) who underwent surgery for recurrent hernia, mesh had been used in the previous hernia repairs. Attention was focused on the location of the recurrence in relation to the site of mesh implantation and on the advantages and disadvantages of the various surgical procedures for repairing recurrent hernias. Re-examination was performed with a mean follow-up of 3 years. RESULTS: Surgeons mostly decided during operation which procedure to use. A transinguinal approach was preferred for patients presenting with recurrent hernia and pain, and mesh material introduced during a previous operation was then explanted. In the case of multiple recurrences, a minimal direct suture repair was used for small defects or a preperitoneal approach for inserting a new, large mesh. The majority of recurrences were medial or suprapubic, especially those occurring after a Lichtenstein repair. After re-examining 87 of 92 patients, nine recurrences (10.3%) were found. Mesh-free suturing methods were affected most frequently. Moderate complaints were reported by 39.1%, and 4.6% suffered from medical chronic pain. CONCLUSION: The surgical management of recurrent hernias after previous mesh repair is a particular challenge for surgeons. We introduce a therapeutic algorithm for recurrent hernia surgery after previous mesh implantation based on analysis of clinical practice.     

Laparoscopic ventral hernia repair: an initial institutional experience

BACKGROUND: Ventral and incisional hernias remain a problem for surgeons with reported recurrence rates of 25-50% for open repairs. Laparoscopic approaches offer several theoretical advantages over open repairs. MATERIALS AND METHODS: All patients undergoing a laparoscopic ventral hernia repair from April to December 2000 were prospectively entered in a database. Patients underwent repair with expanded polytetrafluoroethylene dual mesh. Full-thickness abdominal wall nonabsorbable sutures and 5-mm tacks were placed circumferentially. RESULTS: Of 32 patients, 15 underwent incisional repair, 13 had repair of a recurrent incisional hernia, and 4 had repair of a primary abdominal wall defect. Two procedures [2/32; 6.3%] were converted to open, one for loss of abdominal domain and one for neovascularization due to cirrhosis. There were two early recurrences [2/30; 6.7%]. Both of these failures occurred in patients with hernia defects extending to the inguinal ligament, preventing placement of full-thickness abdominal wall sutures inferiorly. Average operating time was 128 +/- 42 min (range 37-225 min). Average length of stay was 1.8 days [range 0-7 days]. There were no transfusion requirements or wound infections. One patient underwent a small bowel resection after completion of repair. One patient required drainage of a seroma 4 weeks after the procedure. CONCLUSIONS: Laparoscopic ventral hernia repair can be safely performed with an acceptable early recurrence rate, operative time, length of stay, and morbidity. Securing the mesh with full-thickness abdominal wall sutures in at least four quadrants remains a key factor in preventing early recurrence.     

Incisional hernia repair in Sweden 2002

Incisional hernia is a common problem after abdominal surgery. The complication and recurrence rates following the different repair techniques are a matter of great concern. Our aim was to study the results of incisional hernia repair in Sweden. A questionnaire was sent to all surgical departments in Sweden requesting data concerning incisional hernia repair performed during the year 2002. Eight hundred and sixty-nine incisional hernia repairs were reported from 40 hospitals. Specialist surgeons performed the repair in 782 (83.8%) patients. The incisional hernia was a recurrence in 148 (17.0%) patients. Thirty-three per cent of the hernias were subsequent to transverse, subcostal or muscle-splitting incisions or laparoscopic procedures. Suture repair was performed in 349 (40.2%) hernias. Onlay mesh repair was more common than a sublay technique. The rate of wound infection was 9.6% after suture repair and 8.1% after mesh repair. The recurrence rate was 29.1% with suture repair, 19.3% with onlay mesh repair, and 7.3% with sublay mesh repair. This survey revealed that there is room for improvement regarding the incisional hernia surgery in Sweden. Suture repair, with its unacceptable results, is common and mesh techniques employed may not be optimal. This study has led to the instigation of a national incisional hernia register.     

Repair of giant incisional abdominal wall hernias using open intraperitoneal mesh

Background Very large and complex incisional hernias, especially those involving loss of abdominal wall, present a particular challenge to the surgeon. Aims The open intraperitoneal technique was used prospectively for the repair of incisional hernias in a selected group of patients with large defects, often those with major loss of abdominal wall, overweight patients, and previous failures of incisional repair. Materials and methods Between 1 January 1999 and 31 December 2005, out of 275 patients operated on for incisional hernia repair, 61 of them, most of whom were obese with multiorificial recurrent or giant hernias and contraindicated for laparoscopy, were treated using an open intraperitoneal mesh technique. There were 50 females and 11 males, with a mean age of 61. The median ASA score of the group was 2.3, with a mean BMI of 34 kg/m² and a mean hernia surface of 182 cm². Sixty-four percent of the patients had undergone one or more previous incisional hernia repairs. Results Mean operating time was 130 min, with an average hospital stay of 13 days. None of the patients died. Postoperative complications occurred in 21% of the patients; most of which were minor, but two cases (3.3%) developed deep abscesses requiring surgery and removal of the mesh. A recurrence rate of 5% was found after a mean follow-up of 35 months (8–88). Conclusion Open intraperitoneal mesh repair appears to be a good option for the treatment of complex incisional hernia (at least 10 cm in diameter or multiorificial) in obese patients contraindicated for laparoscopy.     

Laparoscopic incisional hernia repair: our experience with 105 consecutive cases

Conventional repair of incisional hernia is associated with significant complications and a high recurrence rate (30-50%). The laparoscopic approach offers an effective alternative and reduces the recurrences to less than 5%. The aim of this study was to review our experience with laparoscopic incisional hernia repair. Medical records of all patients who underwent laparoscopic incisional hernia repair from January 2002 to December 2006 were reviewed. Demographic and postoperative data were recorded. The study population consisted of 105 patients, 72 females (68.5%) and 33 males (31.5%); the mean age was 56 years (range: 17-83 years). The mean fascial defect size was 116.9 cm2 and the average mesh size used was 256 cm2. Operative time was 118 min and the average hospital stay was 5 days. An expanded polytetrafluoroethylene (ePTFE) prosthesis was used In all patients. Perioperative complications occurred in 33 patients (31.4%) including seroma, cellulitis at the trocar site and prolonged ileus. During the follow-up there were 3 hernia recurrences (2.8%). Our study shows that laparoscopic incisional hernia repair resulted in a moderate rate of perioperative complications, a short hospital stay and a low recurrence rate. Hence the laparoscopic technique should be considered an effective and safe alternative to conventional incisional hernia repair.     

Reasons for early recurrence following laparoscopic hernioplasty

The incidence and reasons for early recurrences following laparoscopic hernioplasty have not been studied. Because the incidence is small and the follow up is short, a multi-institutional study was performed among the pioneers in the field. The incidence figures were obtained by survey of surgeons who had significant experience (over 100 cases) and kept concurrent records.Fifty-four recurrences (1.7%) occurred after 3229 laparoscopic hernia repairs. There were 1944 transabdominal preperitoneal (TAPP) repairs with 19 recurrences (1%) and 578 preperitoneal repairs with no recurrences. There were 345 onlay mesh (IPOM) repairs with seven recurrences (2%), and 286 plug and patch repairs with 26 recurrences (9%). Simple closures were performed 76 times with two recurrences (2.6%).Fifty-seven patients (three cases were referred to the author without incidence data but complete records for analysis) had 60 recurrent hernias. Recurrences were noted, on average, 5.1 months postoperatively (range 0–30 months). The most common reason for recurrence was that the mesh was too small — 36 (60%). The mesh was never stapled in 19 instances (32%), and the hernia was never repaired in three cases (20%). The clips pulled through the tissue in six cases (8%), and in 10 cases (15%) the repair has not yet been undertaken because the etiology was unclear. There was more than one reason in 19 patients. Technical factors were responsible for nearly all recurrences.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, Tennessee, USA, 18–19 April 1994     

A review of incisional hernia repairs: preoperative weight loss and selective use of the mesh repair

At the Shouldice Clinic pre-operative weight loss is used prior to incisional hernia repairs. Mesh repair is selectively used, based on specific hernia characteristics. A series of 236 patients were reviewed and followed up for 36 months. Data were available on 188 patients (80%). There were 15 recurrences (8%). The number of obese patients was reduced from 67 (35.6%) to 25 (13.3%) through the weight loss program. The hernia diameter, gastrointestinal complications, and surgical site infection were significantly related to recurrence but not the type of repair, obesity, location, or previous recurrences. The risk factors of incisional hernias include size, intestinal complications and infections. A selective use has a comparable result to the exclusive use of mesh repair. Weight reduction has yet to be shown to affect the rate of recurrence, and further prospective studies are required.