Laparoscopic paraesophageal hernia repair with acellular dermal matrix cruroplasty

Background:

Laparoscopic paraesophageal hernia repair (LPEHR) has been shown to be both safe and efficacious. Compulsory operative steps include reduction of the stomach from the mediastinum, resection of the mediastinal hernia sac, ensuring an appropriate intraabdominal esophageal length, and crural closure. The use of mesh materials in the repair of hiatal hernias remains controversial. Synthetic mesh may reduce hernia recurrences, but may increase postoperative dysphagia and result in esophageal erosion. Human acellular dermal matrix (HADM) may reduce the incidence of hernia recurrence with reduced complications compared with synthetic mesh.

Methods:

A retrospective review of all cases of laparoscopic hiatal hernia repair using HADM from December 2008 through March 2010 at a single institution was performed evaluating demographic information, BMI, operative times, length of stay, and complications.

Discussion:

Forty-six LPEHRs with HADM were identified. The mean age of patients was 60.3 years (±13.9); BMI 30.3 (±5.3); operative time 182 minutes (±56); and length of stay 2.6 days (±1.9). Nine of 46 (19.6%) patients experienced perioperative complications, including subcutaneous emphysema without pneumothorax (n=2), urinary retention (n=1), COPD exacerbation (n=2), early dysphagia resolving before discharge (n=1), esophageal perforation (n=1), delayed gastric perforation occurring 30 days postoperatively associated with gas bloat syndrome (n=1), and PEG site abscess (n=1). There were 2 clinically recurrent hernias (4.3%). Radiographic recurrences occurred in 2 of 26 patients (7.7%). Six of 46 (13%) patients reported persistent dysphagia.

Conclusion:

LPEHR with HADM crural reinforcement is an effective method of repairing symptomatic paraesophageal hernias with low perioperative morbidity. Recurrences occur infrequently with this technique. No mesh-related complications were seen in this series.     

Prosthetic Bioabsorbable Mesh for Hiatal Hernia Repair During Sleeve Gastrectomy

Background and Objectives:

Laparoscopic sleeve gastrectomy has become a valuable primary bariatric operation. It has an acceptable complication profile and amount of weight loss. However, one of the most distressing complications to the patient is reflux postoperatively. There is thought to be a relationship between a hiatal hernia and postoperative reflux. There is disagreement on how to address a hiatal hernia intraoperatively, and the use of mesh is controversial. Our objectives were to examine the use of a prosthetic bioabsorbable mesh for repair of a large hiatal hernia during a sleeve gastrectomy and to examine the incidence of reflux and mesh-related complications in the near term.

Methods:

This is a case series of patients with hiatal hernia undergoing a primary sleeve gastrectomy. None of the patients had a previous hiatal hernia repair. Three patients with large hiatal hernias diagnosed preoperatively or intraoperatively were included. The hiatus of the diaphragm was repaired with a posterior crural closure, and a piece of prosthetic bioabsorbable mesh was placed posteriorly to reinforce the repair.

Results:

There were 3 patients. The mean follow-up period was 12 months. There were no mesh-related complications. One of the patients needed to resume proton pump inhibitors to control reflux.

Conclusion:

The use of a prosthetic bioabsorbable mesh to repair a hiatal hernia simultaneously with a sleeve gastrectomy is safe. There were no mesh-related complications at 1 year.     

Laparoscopic Incisional Hernia Repair With Fibrin Glue in Select Patients

Background and Objective:

Laparoscopic treatment of incisional hernias can be performed using different types of fixation devices and prosthesis. We present a case series of 19 patients with incisional hernias with a diameter of <6cm, who underwent laparoscopic repair using Hi-tex dual-side mesh, positioned intraperitoneally, fixed to the abdominal wall by fibrin glue (Tissucol).

Methods:

Nineteen patients with incisional hernias <6cm in diameter were enrolled in this study and treated laparoscopically with Hi-tex and Tissucol. Surgical complications and patient outcomes were assessed with a clinical follow-up.

Results:

Laparoscopic repair of incisional hernias by using Hi-tex mesh affixed to the parietal wall with fibrin glue was feasible and easy in patients with parietal defects <6cm in diameter. Mean operating time was 30 minutes. Mean hospital stay was 1.5 days. Almost no postoperative pain, major surgical complications, seroma formation, relapses, or prosthesis infection occurred during a mean follow-up of 20 months.

Conclusions:

In select patients, Hi-tex mesh affixed using fibrin glue allows laparoscopic repair of incisional hernias with very good patient outcomes, especially in terms of postoperative pain and seroma formation.     

Laparoscopic Hiatal Hernia Repair in 221 Patients: Outcomes and Experience

Background and Objectives:

Hiatal hernia is a common condition often associated with symptomatic gastroesophageal reflux disease (GERD). The objectives of this study were to examine the efficacy and safety of laparoscopic hiatal hernia repair (LHHR) with biologic mesh to reduce and/or alleviate GERD symptoms and associated hiatal hernia recurrence.

Methods:

We retrospectively reviewed consecutive LHHR procedures with biologic mesh performed by a single surgeon from July 2009 to October 2014. The primary efficacy outcome measures were relief from GERD symptoms, as measured according to the GERD–health-related quality-of-life (GERD-HRQL) scale and hiatal hernia recurrence. A secondary outcome measure was overall safety of the procedure.

Results:

A total of 221 patients underwent LHHR with biologic mesh during the study period, and pre- and postoperative GERD-HRQL studies were available for 172 of them. At baseline (preoperative), the mean GERD-HRQL score for all procedures was 18.5 ± 14.4. At follow-up (mean, 14.5 ± 11.0 months [range, 2.0–56.0]), the score showed a statistically significant decline to a mean of 4.4 ± 7.5 (P < .0001). To date, 8 patients (3.6%, 8/221) have had a documented anatomic hiatal hernia recurrence. However, a secondary hiatal hernia repair reoperation was necessary in only 1 patient. Most complications were minor (dysphagia, nausea and vomiting). However, there was 1 death caused by a hemorrhage that occurred 1 week after surgery.

Conclusions:

Laparoscopic hiatal hernia repair using biologic mesh, both with and without a simultaneous bariatric or antireflux procedure, is an efficacious and safe therapeutic option for management of hiatal hernia, prevention of recurrence, and relief of symptomatic GERD.     

Gallbladder perforation by absorbable spiral tacker

Introduction

Mesh fixation with tacker systems is common in laparoscopic and open hernia repair. Complications due to absorbable tackers are rare and have not been described in the literature. However, we report a case of gallbladder erosion due to tacker dislocation.

Methods

An open hernia repair was performed using an intraperitoneal onlay mesh for a recurrent parastomal hernia after two previous mesh repairs in a 67-year-old patient.

Results

On postoperative day 2, the patient was reoperated because of a dislocated tacker that eroded and perforated the fundus region of the gallbladder. Putatively, tacker dislocation occurred owing to imbalanced traction forces. Initially, the mesh was fixed with absorbable tackers around the stoma on the right and transmuscular suture fixation was carried out on the left abdominal side. On revision surgery, tension forces to the right were therefore neutralised by additional transmuscular sutures on the right side.

Conclusions

Absorbable tackers in open hernia repair provide a safe and effective mesh fixation if tension forces are carefully avoided.     

Revisional Laparoscopic Parastomal Hernia Repair

Background:

We herein report a laparoscopically performed re-do operation on a patient who had previously undergone a laparoscopic parastomal hernia repair.

Case Report:

We describe the case of a 71-year-old patient who presented within 3 months of her primary laparoscopic parastomal hernia repair with recurrence. On relaparoscopy, dense adhesions to the mesh were found, and the mesh had migrated into the hernia sac. This had allowed loops of small bowel to herniate into the sac. The initial part of the procedure involved the lysis of adhesions. A piece of Gore-Tex DualMesh with a central keyhole and a radial slit was cut so that it could provide at least 3 cm to 5 cm of overlap of the fascial defect. The tails of the mesh were wrapped around the bowel, and the mesh was secured to the margins of the hernia with circumferential metal tacking and 4 transfascial sutures. The patient remains in satisfactory condition and no recurrence or any surgery-related problem has been observed during 8 months of follow-up.

Conclusion:

Revisional laparoscopic repair of parastomal hernias seems feasible and has been shown to be safe and effective in this case. The success of this approach depends on longer follow-up reports and standardization of the technical elements.     

Minimally Invasive Spigelian Hernia Repair

Introduction:

Spigelian hernia is an uncommon ventral hernia characterized by a defect in the linea semilunaris. Repair of spigelian hernia has traditionally been accomplished via an open transverse incision and primary repair. The purpose of this article is to present 2 case reports of incarcerated spigelian hernia that were successfully repaired laparoscopically using Gortex mesh and to present a review of the literature regarding laparoscopic repair of spigelian hernias.

Methods:

Retrospective chart review and Medline literature search.

Results:

Two patients underwent laparoscopic mesh repair of incarcerated spigelian hernias. Both were started on a regular diet on postoperative day 1 and discharged on postoperative days 2 and 3. One patient developed a seroma that resolved without intervention. There was complete resolution of preoperative symptoms at the 12-month follow-up.

Conclusion:

Minimally invasive repair of spigelian hernias is an alternative to the traditional open surgical technique. Further studies are needed to directly compare the open and the laparoscopic repair.     

Bulging of the Mesh After Laparoscopic Repair of Ventral and Incisional Hernias

Background and Objectives:

To investigate the prevalence, diagnosis, clinical significance, and treatment strategies for bulging in the area of laparoscopic repair of ventral hernia that is caused by mesh protrusion through the hernia opening, but with intact peripheral fixation of the mesh and actually a still sufficient repair.

Methods:

Medical records of all 765 patients who underwent laparoscopic ventral hernia repair were reviewed, and all patients with a swelling in the repaired area were identified and analyzed.

Results:

Twenty-nine patients were identified. They all underwent a computed tomography assessment. Seventeen patients (2.2% of the total group) had a hernia recurrence; in an additional 12 patients (1.6%), radiologic examinations indicated only bulging of the mesh but no recurrence. Bulging was associated with pain in 4 patients who underwent relaparoscopy and got a new, larger mesh tightly stretched over the entire previous repair. Eight asymptomatic patients decided on “watchful waiting.” All patients remained symptom free during a median follow-up of 22 months.

Conclusion:

Symptomatic bulging, though not a recurrence, requires a new repair and must be considered as an important negative outcome of laparoscopic ventral hernia repair. In asymptomatic patients, “watchful waiting” seems justified.     

Combined treatment of symptomatic massive paraesophageal hernia in the morbidly obese

Introduction:

Repair of large paraesophageal hernias by itself is associated with high failure rates in the morbidly obese. A surgical approach addressing both giant paraesophageal hernia and morbid obesity has, to our knowledge, not been explored in the surgical literature.

Methods:

A retrospective review of a bariatric surgery database identified patients who underwent simultaneous repair of large type 3 paraesophageal hernias with primary crus closure and Roux-en-Y gastric bypass (RYGB). Operative time, intraoperative and 30-day morbidity, weight loss, resolution of comorbid conditions and use of anti-reflux medication were outcome measures. Integrity of crural closure was studied with a barium swallow.

Results:

Three patients with a mean body mass index of 46kg/m² and mean age of 46 years underwent repair of a large paraesophageal hernia, primary crus closure, and RYGB. Mean operative time was 241 minutes and length of stay was 4 days. There was no intraoperative or 30-day morbidity. One patient required endoscopic balloon dilatation of the gastrojejunostomy. At 12 months, all patients were asymptomatic with excellent weight loss and resolution of comorbidities. Contrast studies showed no recurrence of the hiatal hernia.

Conclusion:

Simultaneous laparoscopic repair of large paraesophageal hernias in the morbidly obese is safe and effective.     

Laparoscopic repair of complicated umbilical hernia with Strattice Laparoscopic™ reconstructive tissue matrix

INTRODUCTION

Complex hernias continue to present a challenge. Surgical techniques for repair are carefully considered to reduce risk for complications. Laparoscopic repairs improve postoperative infection rates, and placement of biologic mesh decreases mesh infection rates. However, laparoscopic repairs using biologic mesh is generally challenging due to difficulty with maneuverability.

PRESENTATION OF CASE

We present a case of a complex ventral hernia that was laparoscopically repaired using a new FDA cleared laparoscopic biologic graft. The patient had multiple comorbidities, including obesity, hepatitis C, endocarditis secondary to IV drug use, tobacco smoking, bilateral inguinal hernia, and recurrent umbilical hernia. The recurrent hernia was larger, irreducible, and discolored compared to original defect. The patient underwent laparoscopic repair with primary closure and reinforcement with Strattice™ Tissue Matrix Laparoscopic (LifeCell Corporation, Branchburg, NJ). At nine months postoperative, the patient had no evidence of recurrence, infection, or chronic pain, demonstrating early success from the surgical management.

DISCUSSION

Presence of multiple comorbidities and incarcerated recurrent hernia increase risk for complications during and/or after hernia repair. Considering these factors, laparoscopic repair with Strattice Laparoscopic and defect closure was a reasonable technique for repair.

CONCLUSION

Laparoscopic suture repair reinforced with biologic dermal tissue matrix was successfully performed during a complex hernia repair.     

Long-Term Durability and Comfort of Laparoscopic Ventral Hernia Repair

Background:

Repair of ventral hernias, including primary ventral hernias and incisional ventral hernias, is performed in the United States 90,000 times per year. Open or traditional ventral hernia repairs involve the significant morbidity and expense of a laparotomy and a significant risk of recurrent herniation. Laparoscopic ventral hernia repair (LVHR) may offer a less-invasive alternative with shorter length of hospital stay, fewer cardiopulmonary complications, and low recurrence rates.

Methods:

225 patients underwent laparoscopic ventral hernia repairs in which carboxymethylcellulose-sodium hyaluronate coating (Sepramesh, Davol, Providence, RI) was used primarily. All cases were included prospectively from the study period of 2002 through 2009. Patient characteristics were recorded, and follow-up analysis was performed over a period of 42 mo following surgery. Recurrence, reoperations, and all complications were recorded. Mesh awareness and mesh-related pain were assessed using the hernia-specific Carolinas Comfort Scale (CCS) instrument, completed by 72 patients.

Results:

Over 42 mo of follow-up, 2 ventral hernias have recurred, and no long-term bowel erosion or fistulization has occurred. Little or no mesh-related symptoms were reported, and mean scores for mesh awareness and mesh pain were 3.6 and 3.2, respectively, on a scale from 0–40 (lower scores signify less pain or awareness). Two serious early complications occurred related to intestinal ileus and metal tacks producing intestinal perforation, and this led to a change in the tacking devices used.

Conclusions:

LVHR with carboxymethylcellulose-sodium hyaluronate coating (Sepramesh) is safe and effective. Complications are rare, the repair is durable, and long-term results are good with rare recurrences, low awareness of mesh, and little pain. Technical lessons include use of at least one transfascial suture and the avoidance of metal tacks for fixation.     

Safety and Efficacy of Laparoendoscopic Single-Site Surgery for Abdominal Wall Hernias

Background:

Laparoendoscopic single-site surgery has rapidly progressed from the animal laboratory to clinical use since mass production of multichannel ports began in 2007. Indeed, it has now been shown to be feasible and safe for many commonly performed operations.

Methods:

This study cohort comprised 22 unselected patients with abdominal wall hernias of varying types: multiply recurrent inguinal (n=2), suprapubic (n=1), ventral/incisional (n=17), and parastomal hernias (n=2), who underwent laparoendoscopic single-site ventral hernia repair between December 2009 and February 2011. Standard dissecting instruments and a 52cm/5.5mm/30^°angle laparoscope were used.

Results:

Patients included 14 men and 8 women, with a median age of 56 (range, 32 to 78) years and a mean body mass index of 31.5±4.7kg/m². The mean mesh size was 460cm² (range, 225 to 884cm²). Mean operation time was 125 minutes for ventral/incisional hernias and 270 minutes for parastomal hernias. No conversions to multiport or open surgeries were necessary. There was no mortality or morbidity, and no recurrence at 6- to 18-month follow-up. The mean satisfaction score was 2.7 (range, 2 to 3) with no patients reporting dissatisfaction with the procedure.

Conclusion:

This series, though relatively small, represents a diverse group of patients with varying abdominal wall hernias, including parastomal hernias. These successful laparoendoscopic single-site surgeries, with no complications, demonstrate safety and efficacy, albeit in a specialized hernia center. This study is a prelude to the eventual validation of laparoendoscopic single-site hernia surgery with prospective randomized controlled trials.     

Sutureless laparoscopic ventral hernia repair in obese patients

Background and Objective:

Transfascial sutures (TFS) are a standard component of laparoscopic ventral herniorrhaphy (LVHR) that contribute to the durability of repair, but also pain and, resultantly, hospital stay. We sought to examine LVHR without TFS in obese patients with small abdominal wall hernias.

Methods:

Between September 2002 and December 2007, 174 patients underwent LVHR at Yale-New Haven Hospital. Patients with BMI >30kg/m² and small primary abdominal wall hernias were eligible for repair without TFS. Correlation between BMI, defect surface area, operative time, and postoperative stay was assessed.

Results:

Fourteen patients underwent LVHR with no TFS, 2 with normal BMI and recurrent hernia after open repair and 12 with BMI>30 kg/m² and primary small hernia. Mean age was 38.8 years. The average defect size was 5.3cm²; mean operative time (OT) was 42 minutes. Eleven patients (92%) were discharged home the day of surgery. No infectious or bleeding complications occurred. One patient required chronic pain management, and 8 patients (67%) developed seromas that resorbed spontaneously. There was no hernia recurrence at 7-month follow-up.

Conclusion:

LVHR is feasible without TFS provided the hernia defect is small. Surgery can be performed on an outpatient basis in obese individuals with minimal postoperative morbidity.     

Evaluation of composite mesh for ventral hernia repair

Introduction:

Composite mesh prostheses incorporate the properties of multiple materials for ventral hernia repair. This study evaluated a polypropylene/ePTFE composite mesh with a novel internal polydioxanone (PDO) absorbable ring.

Methods:

Composite mesh was placed intraperitoneally in 16 pigs through an open laparotomy and explanted at 2, 4, 8, and 12 weeks. Intraabdominal adhesions were measured laparoscopically. Host tissue in-growth was assessed histologically and tensiometrically. Degradation of the internal PDO ring component was also measured tensiometrically. Appropriate statistical tests were used, and P≤.05 indicated significance.

Results:

No adhesions were formed in 50% of the grafts explanted at 8 weeks and 25% of grafts explanted at 12 weeks. There were significantly more vascular structures at 8 weeks, 73.5±28, compared with 2 weeks, 6.75±2 (P≤.01). The T-peel force at the mesh-host tissue interface was not significantly different among time points. The absorbable PDO ring underwent complete degradation by 12 weeks.

Conclusions:

This composite mesh was associated with minimal intraabdominal adhesions, progressive in-growth of host tissues, and complete degradation of a novel internal PDO ring that aided mesh positioning. This composite hernia mesh showed a favorable performance in a porcine model of open ventral hernia repair.     

Incidental Non-Inguinals Hernias in Totally Extra-Peritoneal Hernia Repair

Introduction

Totally extra-peritoneal (TEP) inguinal hernia repair allows identification and repair of incidental non-inguinal groin hernias. We assessed the prevalence of incidental hernias during TEP inguinal hernia repair and identified the risk factors for incidental hernias.

Materials and Methods

Consecutive patients undergoing TEP repair from May 2005 to November 2012 were the study cohort. Inspection for ipsilateral femoral, obturator and rarer varieties of hernia was undertaken during TEP repair. Patient characteristics and operative findings were recorded on a prospectively collected database.

Results

A total of 1,532 TEP repairs were undertaken in 1,196 patients. Ninety-three patients were excluded due to incomplete data, leaving 1,103 patients and 1,404 hernias for analyses (1,380 male; 802 unilateral and 301 bilateral repairs; median age, 59 years). Among the 37 incidental hernias identified (2.6% of cases), the most common type of incidental hernia was femoral (n=32, 2.3%) followed by obturator (n=2, 0.1%). Increasing age was associated with an increased risk of incidental hernia, with a significant linear trend (p<0.01). The risk for patients >60 years of age was 4.0% vs 1.4% for those aged <60 years (p<0.01). Incidental hernias were found in 29.2% of females vs 2.2% of males, (p<0.0001). Risk of incidental hernia in those with a recurrent inguinal hernia was 3.0% vs 2.6% for primary repair (p=0.79).

Conclusions

Incidental hernias during TEP inguinal hernia repair were found in 2.6% of cases and, though infrequent, could cause complications if left untreated. The risk of incidental hernia increased with age and was significantly higher in patients aged >60 years and in females.     

Laparoscopic Hernia: Umbilical-Pubis Length Versus Technical Difficulty

Laparoscopic hernia repair is more difficult than open hernia repair. The totally extraperitoneal procedure with 3 trocars on the midline is more comfortable for the surgeon. We studied the impact of the length between the umbilicus and the pubis on the totally extraperitoneal procedure (95 hernias operated on in 70 patients). This length did not influence the totally extraperitoneal procedure in this study.

Background:

The laparoscopic repair of hernias is considered to be difficult especially for the totally extra-peritoneal technique (TEP) due to a limited working space and different appreciation of the usual anatomical landmarks seen through an anterior approach. The aim of our study has been to answer a question: does the umbilical-pubic distance, which influences the size of the mesh, affect the TEP technique used in the treatment of inguinal hernias?

Methods:

From January 2001 to May 2011, the umbilical-pubic (UP) distance was measured with a sterile ruler graduated in centimeters in all patients who underwent a symptomatic inguinal hernia by the TEP technique in two hernia surgery centers. The sex, age, BMI, hernia type, UP distance, operation time, hospital stay and complications were prospectively examined based on the medical records.

Results:

Seventy patients underwent 95 inguinal hernia repairs by the TEP technique. The umbilical-pubic distance average was 14 cm (10 to 22) and a 25 kg/m2 (16–30) average concerning the body mass index (BMI). Seventy percent of patients were treated on an outpatient basis. The postoperative course was very simple. There was no recurrence of hernia within this early postoperative period.

Conclusion:

The umbilical-pubic distance had no influence on the production of TEP with 3 trocars on the midline in this study.     

Mini-mesh repair for femoral hernia

INTRODUCTION

Femoral hernia consists only 4% of all primary groin hernias. It is described as “the Bête Noire of Hernias” because of its nature and anatomy which is difficult to understand for the surgeons and tendency to recurrence. Although there is some large series of femoral hernia in the literature, few studies prospectively comparing repair techniques especially for this type of hernia has been published. A new technique named mini-mesh repair is described here.

PRESENTATION OF CASE

After hernia sac is dissected completely and sent back into the preperitoneal space, femoral canal is exposed. A round or oval shaped patch is prepared in 1.5–2.5 cm in diameter according to the size of the femoral canal. Mesh is secured to the Cooper''s ligament with 2/0 polypropylene suture. Eight femoral hernias in 8 patients were repaired with this new technique. Patient satisfaction is very good. One seroma and one limited ecchymosis were recorded. No recurrence was observed in a mean follow-up of 22.4 months. No chronic pain was recorded.

DISCUSSION

Many techniques for femoral hernia repair have been described to date with a variety of clinical outcomes. Each technique has its own advantages and disadvantages. Mesh repairs without tension seems to be better choices. When the transversalis fascia is healthy and strong in a patient with femoral hernia a large piece of mesh may be unnecessary. The simple technique described in this paper can be a good alternative. It is totally problem-oriented, and the burden of prosthetic material is very limited.

CONCLUSION

Mini mesh repair may be a good solution for selected patients with femoral hernia.     

Laparoscopic Total Extraperitoneal Repair in Femoral Hernia Without Fixation of the Mesh

Background & Objectives:

We report on laparoscopic total extraperitoneal repair without fixation of mesh for femoral hernia in 6 patients.

Methods:

During a 3-year period, laparoscopic total extraperitoneal repair of femoral hernia was performed without mesh fixation in 6 patients. The recurrence rate, pain scores, hospital stay, and other morbidity parameters were noted. Pain scores were 1=no pain, 2=mild pain, 3=moderate pain, 4=severe pain, and 5=intolerable pain.

Results:

All 6 patients were females and had unilateral hernias. Mean age was 33.8±18.6 years, and follow-up ranged from 12 months to 36 months. Four patients were operated on while under spinal anesthesia, and 2 patients were operated on while under general anesthesia. Mean operating time was 29.2±10.7 minutes. The mean pain scores 24 hours and the first week after operation were, respectively, 2.33±0.52 and 1.33±0.52. Mean hospital stay was 1.17±0.41 days, and mean days to resumption of normal activities were 8.5±2.1 days. No patient had urinary retention or seroma formation in the postoperative period. At follow-up, no hernia had recurred.

Conclusions:

Laparoscopic femoral hernia repair without fixing the mesh is safe, feasible, and associated with minimal morbidity and recurrence rates.