eTEP inferior access with tailored retromuscular dissection for small to mid-sized umbilical hernia repair with or without inguinal hernia: early experience

Hernia - The minimally invasive surgical repair of combined inguinal and ventral hernias often requires shifting from one approach or plane to another. The traditional enhanced-view totally...     

Short-term outcomes of minimally invasive retromuscular ventral hernia repair using an enhanced view totally extraperitoneal (eTEP) approach: systematic review and meta-analysis

Background

The enhanced view totally extraperitoneal (eTEP) approach is becoming increasingly more widely accepted as a promising technique in the treatment of ventral hernia. However, evidence is still lacking regarding the perioperative, postoperative and long-term outcomes of this technique. The aim of this meta-analysis is to summarize the current available evidence regarding the perioperative and short-term outcomes of ventral hernia repair using eTEP.

Study design

A systematic search was performed of PubMed, EMBASE, Cochrane Library and Web of Science electronic databases to identify studies on the laparoscopic or robotic-enhanced view totally extraperitoneal (eTEP) approach for the treatment of ventral hernia. A pooled meta-analysis was performed. The primary end point was focused on short-term outcomes regarding perioperative characteristics and postoperative parameters.

Results

A total of 13 studies were identified involving 918 patients. Minimally invasive eTEP resulted in a rate of surgical site infection of 0% [95% CI 0.0–1.0%], a rate of seroma of 5% [95% CI 2.0–8.0%] and a rate of major complications (Clavien–Dindo III–IV) of 1% [95% CI 0.0–3.0%]. The rate of intraoperative complications was 2% [95% CI 0.0–4.0%] with a conversion rate of 1.0% [95% CI 0.0–3.0%]. Mean hospital length of stay was 1.77 days [95% CI 1.21–2.24]. After a median follow-up of 6.6 months (1–24), the rate of recurrence was 1% [95% CI 0.0–1.0%].

Conclusion

Minimally invasive eTEP is a safe and effective approach for ventral hernia repair, with low reported intraoperative complications and good outcomes.

     

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.     

补片修补腹壁切口疝126例

目的探讨应用肌腱膜上补片置人手术（premuscular positioning of prosthesis Onlay，ONLAY）修补术治疗腹壁切口疝的治疗。方法1999年9月至2007年6月应用复合补片修补腹壁切口疝126例。其中男性60例，占47．5％，女性66例，占52．5％，年龄28—89岁，平均58．5岁。上腹部切口疝占36％，下腹部切口疝占64％。按中华医学会外科学会疝和腹壁外科学组分类，大切口疝（疝环缺损5—10cm）67例，巨大切口疝（疝环缺损≥10cm）59例。均采用肌腱膜上补片置人手术（ONLAY）修补法。结果全部患者顺利完成手术，无死亡病例及严重并发症。平均手术时间95min（70—120min），术中平均出血80na（60—250m1），术后住院14．5d（10—28d）。术后随访3个月至8年，复发3例，手术复发率为2．38％。结论ONLAY手术安全可靠，复发率低，是可以接受的切口疝修补方法。     

Traumatic abdominal wall hernia: same-admission laparoscopic repair

Traumatic abdominal wall hernias are uncommon. They are traditionally treated with open surgery. We report a case repaired using laparoscopic technique and prosthetic reinforcement.     

Musculature tissue engineering to repair abdominal wall hernia

Hernia repair is one of the most frequently performed operations in surgical clinics. Tissue engineering provides insights for the treatment of abdominal wall hernias and other disorders involving deficiencies in the musculature. The present review summarizes the mechanisms of muscle development and regeneration and provides an overview of tissue engineering strategies for the construction of muscles.     

Effect of hernia size on operative repair and post-operative outcomes after open ventral hernia repair

Background

Ventral hernia repair (VHR) is a commonly performed operation, but analysis of patient outcomes based upon hernia size is lacking. We sought to identify differences in operative repair and post-operative morbidity and mortality after open VHR based on hernia defect size.

Methods

Patient and operative data were retrospectively reviewed on all patients undergoing open incisional VHR between January 2008 and February 2015 by a single surgeon at the Johns Hopkins Hospital. Patient variables were described by means for continuous variables and percentages for discrete variables, with differences between groups calculated by Chi-squared analysis.

Results

During the study period, 228 patients underwent open VHR during which intraoperative defect size was measured. Patients were split into four groups based upon defect size: less than 200 cm², 200–300 cm², 301–400 cm², and over 400 cm². Patients with large defects were more likely to present with a recurrent hernia (P = 0.007) and trended towards a history of wound infections (P = 0.07). Operative time was significantly longer as defect size increased (P < 0.001). Component separation was most frequently used in patients with defects 200–300 cm² in size (P = 0.001), in whom primary closure was most likely to occur. While mesh was used in almost all patients, the specific location (overlay only, underlay only, or overlay with underlay) depended on hernia size (P < 0.001). Mean length of stay increased with defect size (P < 0.001). Larger defect size was associated with increased 30-day morbidity (P = 0.03) but not readmission (P = 0.53), recurrence (P = 0.99), or mortality (P = 0.99).

Conclusion

Hernia defect size affects operative time and surgical technique for repair of a ventral hernia. Larger defect size is associated with increased post-operative morbidity and length of stay but not readmission, recurrence, or mortality. Hernia size greater than 400 cm² should not be a limitation to operative repair.

     

Reconstruction of the abdominal wall for incisional hernia repair

BACKGROUND: Abdominal wall reconstruction with mobilization of autologous tissue has evolved as a reliable option for patients with incisional hernias. METHODS: With the aim of evaluating morbidity and recurrence rates in patients who underwent abdominal wall reconstruction for incisional hernia repair, we retrospectively reviewed the charts of 188 patients treated between 1996 and 2003. RESULTS: Primary approximation of the fascial defect was achieved in 77% and was reinforced by either mesh placement or rectus muscle advancement. The remaining 23% were reconstructed either by mesh placement, components separation, or distant flap mobilization. Median follow-up was 15 months. Overall morbidity rate was 38%; recurrence rate was 13%. Dimensions of the hernia and intraoperative enterotomies were associated with postoperative complications. Lack of complete restoration of the myofascial abdominal wall continuity was associated with recurrence. CONCLUSIONS: In patients with incisional hernias, techniques involving autologous tissue mobilization are safe and associated with low recurrence rates.     

腹壁切口疝无张力修补术及围手术期处理

【摘要】 目的 总结采用人工材料无张力修补腹壁切口疝的临床经验和方法,探讨人工材料置于腹壁不同的层次对疗效的影响及围手术期处理。方法 回顾性分析90例腹壁切口疝的手术方法、 围手术期处理、术后并发症、引流的放置及随访结果。结果 90例患者疝补术后恢复顺利,无严重并发症, 无术后死亡。1例发生切口红肿伴脂肪液化,1例因脂肪液化再次复发。结论 采用人工材料行无张力疝修补是合适的治疗腹壁切口疝的方法,人工材料置于腹壁不同层次均可取得良好疗效,良好的围手术期处理是疗效的重要保证。     

Open versus robotic-assisted transabdominal preperitoneal (R-TAPP) inguinal hernia repair: a multicenter matched analysis of clinical outcomes

Purpose

To compare the perioperative outcomes of initial, consecutive robotic-assisted transabdominal preperitoneal (R-TAPP) inguinal hernia repair (IHR) cases with consecutive open cases completed by the same surgeons.

Methods

Multicenter, retrospective, comparative study of perioperative results from open and robotic IHR using standard univariate and multivariate regression analyses for propensity score matched (1:1) cohorts.

Results

Seven general surgeons at six institutions contributed 602 consecutive open IHR and 652 consecutive R-TAPP IHR cases. Baseline patient characteristics in the unmatched groups were similar with the exception of previous abdominal surgery and all baseline characteristics were comparable in the matched cohorts. In matched analyses, postoperative complications prior to discharge were comparable. However, from post discharge through 30 days, fewer patients experienced complications in the R-TAPP group than in the open group [4.3% vs 7.7% (p?=?0.047)]. The R-TAPP group had no reoperations post discharge through 30 days of follow-up compared with five patients (1.1%) in the open group (p?=?0.062), respectively. Multivariate logistic regression analysis which demonstrated patient age >?65 years and the open approach were risk factors for complications within 30 days post discharge in the matched group [age?>?65 years: odds ratio (OR)?=?3.33 (95% CI 1.89, 5.87; p?<?0.0001); open approach: OR?=?1.89 (95% CI 1.05, 3.38; p?=?0.031)].

Conclusions

In this matched analysis, R-TAPP provides similar postoperative complications prior to discharge and a lower rate of postoperative complications through 30 days compared to open repair. R-TAPP is a promising and reproducible approach, and may facilitate adoption of minimally invasive repairs of inguinal hernias.

     

Incisional hernia repair techniques for the abdominal wall]

Incisional hernia repair has been the subject many publications over the last century. Suture techniques in one plane (Judd, 1912) or in several planes (Quenu, 1896) were described first. They remain suitable for the closure of small incisional hernias. Rectus abdominis sheath dissection techniques, also known as fascioplasties, then reinforced hernia repair by prolonging the anterior (Welti-Eudel, 1941) or posterior leaflet (Gibson, 1920) of the sheath. These plasties are still widely used, either alone, to repair medium-sized hernial orifices, or in combination with a prosthesis to repair large hernial orifices. Autologous tissues, such as fascia graft (Mac Arthur, 1901) or skin graft (Gossec, 1949) are now used because of the marked capacity of prostheses for secondary distension and their sensitivity to infection. Flaps, especially the tensor fasciae latae flap (Nahai, 1974), are indicated in infraumbilical incisional hernias in a septic context. Currently, only reinforcement prostheses can achieve lasting repair of large incisional hernias. Some teams still use intraperitoneal mesh implantation, but most teams prefer extraperitoneal implantation, generally associated with fascioplasty. Extraperitoneal mesh may be placed in a pre-musculo-aponeurotic or retromuscular position. Based on their experience, the authors opted for a pre-fascio-aponeurotic retromuscular prosthesis. They describe in detail the technique used and the results obtained based on the analysis of a series of 252 patients.     

Long term outcomes of robotic-assisted abdominal wall reconstruction: a single surgeon experience

Hernia - Robotic abdominal wall reconstruction (RAWR) is one of the most significant advances in the management of complex abdominal wall hernias. The objective of this study was to evaluate long...     

The influence of a multidisciplinary team meeting and prehabilitation on complex abdominal wall hernia repair outcomes

Hernia - Surgical site occurrences after transversus abdominis release in ventral hernia repair are still reported up to 15%. Evidence is rising that preoperative improvement of risk factors might...     

Totally extraperitoneal endoscopic inguinal hernia repair (TEP)

Background: This report reviews our experience with 5,203 totally extraperitoneal (TEP) endoscopic hernia repairs performed in 3,868 patients over the 7.5-year period between May 1994 and December 2001, 34.5% of whom had bilateral hernias and 13% recurrent hernias. Methods: We performed TEP as the method of choice in more than 92% of all the patients presenting with inguinal hernia, including those with incarcerated, strangulated, or inguinoscrotal hernias. After reduction of the hernial sac and appropriate dissection of the preperitoneal space, we placed a slit-free 10 × 15-cm polypropylene mesh without the use of staple fixation. Results: Altogether, 29 recurrent hernias (0.6%) were observed, more than 50% of which occurred during the first 2 years after the technique was introduced (1.8%). During subsequent years, the recurrence rate settled to approximately 0.3%. Regarding intraoperative complications, we observed eight injuries to the bladder. At this writing, no bowel injuries or damage to iliac vessels has been seen. Postoperatively, we noted only a single case of mesh infection. In 14 cases (0.4%), postoperative hemorrhage necessitated either inguinal or endoscopic reoperation. As a further major complication, a small bowel obstruction caused by inadequate closure of a peritoneal lesion occurred in two patients (0.05%). The overall reoperation rate for the 3,868 patients was 0.6%. Conclusions: We consider TEP to be a procedure that carries an acceptably low complication rate, combining the advantages of minor access surgery and mesh reinforcement of the groin. This approach is associated with early postoperative return to usual activities and a very low recurrence rate.     

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 repair of blunt traumatic anterior abdominal wall hernia.

Traumatic abdominal wall hernia is a relatively uncommon finding secondary to blunt trauma. We report a unique case of laparoscopic diagnosis and immediate repair of a traumatic anterior abdominal wall hernia after blunt abdominal trauma.     

Laparoscopic repair of traumatic abdominal wall hernia from handlebar injury

A 14-year-old boy was seen at an outside hospital after falling over the handlebar of his bicycle and was discharged home. He was subsequently seen in our emergency department with complaints of persistent abdominal pain. A computed tomography scan of the abdomen revealed disruption of the muscles of the upper right abdominal wall containing the hepatic flexure of the colon, with a small amount of intraperitoneal free fluid noted. The patient underwent laparoscopic exploration using 3 ports (2-5 mm and 1-12 mm) and 2 separate stab incisions. The traumatic abdominal wall hernia was repaired with interrupted sutures placed with an ENDO CLOSE (Covidien, Mansfield, MA) device, and a mesenteric defect in the colon was approximated with intracorporeal sutures. The trocar sites were sutured closed. The patient recovered well and was discharged home. Follow-up examination revealed no abdominal wall defect and resolution of his symptoms.Laparoscopic repair of a traumatic abdominal wall defect and exploratory laparoscopy after trauma is feasible and safe in the pediatric patient. It should be considered as an alternative approach with potentially less morbidity than an exploratory laparotomy for handlebar injuries in a stable patient.