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.     

A systematic review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia formation

Aim Despite advances in surgical technique, parastomal herniation is common. This systematic review aims to assess the efficacy of prophylactic mesh at primary operation in reducing the incidence of parastomal hernia. Method Medline, EMBASE and CENTRAL were searched for relevant publications between January 1980 and January 2010. The search strategy included text terms and MESH headings for parastomal hernia, mesh and prevention and/or prophylaxis of hernia. No language restrictions were applied. Bibliographies from the papers requested in full were manually checked. All randomized controlled trials were included regardless of the language of publication. Results were extracted from the papers by two observers independently on a predefined data sheet. Disagreements were resolved by discussion. REVMAN 5 was used for statistical analysis. Results Of 27 possible studies three randomized controlled trials fulfilled the criteria for systematic review, with a total of 128 patients (mesh 64, no mesh 64). The two study groups were well matched demographically. The incidence of parastomal hernia in the mesh group was 12.5% (8/64) compared with 53% (34/64) in the control group (P < 0.0001). There was no difference in mesh related morbidity in the two groups. Conclusion Although only three trials with 128 patients fulfilled the criteria for this systematic review, the data suggest that the use of prophylactic prosthetic mesh at the time of primary stoma formation reduces the incidence of parastomal hernia.     

Abdominal lipectomy and mesh repair of midline periumbilical hernia after bariatric surgery: How to spare the umbilicus

Background: Abdominal lipectomy is becoming an increasingly common surgical procedure in patients with esthetic deformities resulting from massive weight loss induced by bariatric surgery. Sometimes a midline incisional hernia coexists with the pendulus abdomen. Herein presented is a technique to perform a retromuscular mesh repair of the incisional hernia while sparing the umbilicus. Methods: The abdominal lipectomy with concomitant retro-muscular mesh repair of a midline incisional hernia is done sparing the vascular supply of the umbilicus on one side only. Results: 5 consecutive women with pendulus abdomen resulting from bariatric surgery-induced massive weight loss and concomitant midline incisional hernia underwent abdominal lipectomy and incisional hernia mesh repair. Mean BMI was 28.6 kg/m² (range 26–35), one patient was a smoker, and another had type 2 diabetes requiring oral hypoglycemic agents. Two patients had had a previous incisional hernia repair with intraperitoneal mesh. One patient had partial necrosis of the umbilicus and another experienced necrosis of only the epidermis that recovered fully. Conclusions: The umbilicus can be safely spared during abdominal lipectomy with concomitant midline incisional hernia mesh repair. Recurrent incisional hernia and common risk factors for wound healing such as diabetes and obesity increase the risk of umbilical necrosis.     

Suture versus staple for fixation of mesh in incisional hernia repair

The incidence of incisional hernia has been reported to be between 11 and 20% in patients post laparotomy and carries the risk of pain, incarceration and strangulation. Prosthetic mesh for incisional hernia repair has been shown to be superior to suture repair. The recurrence rate of primary mesh repair of incisional hernias has been reported to be as high as 38%. This experimental study in euthanised rats aims to compare the fixation strength of mesh using sutures and surgical staples. Forty euthanised adult male Sprague–Dawley rats were used for midline laparotomy incisions and repair of the abdominal wall carried out using polypropylene mesh anchored using either skin staples or Prolene sutures. An intra‐abdominal expander device was inserted into the abdomen and inflated to measure ‘burst pressure’. Pressure changes and surgical time were recorded. There was no statistically significant difference (P = 0.83) in the pressure required to disrupt the mesh fixation between the two groups, 101 ± 12 mmHg in the suture group versus 102 ± 14 mmHg in the staple group. Staple fixation was 9.7 times faster compared with suture fixation, 291 ± 42 s for suture versus 30 ± 8 s for staples (P < 0.001) (power = 94%). The immediate strength of fixation is equal using both sutures and staples, however staple fixation is faster. Mesh migration due to inadequate fixation using either method is unlikely to cause early failure, however suture and staple ‘cut out’ during early movement may explain this.     

Laparoscopic ePTFE mesh repair of incisional and ventral hernias

Incisional hernia is a relatively frequent complication of abdominal surgery. The use of mesh to repair incisional and ventral hernias results in lower recurrence rates compared with primary suture techniques. The laparoscopic approach may be associated with lower postoperative morbidity compared with open procedures. Long-term recurrence rates after laparoscopic ventral and incisional hernias are not well defined. A prospective study of the initial experience of a standardized technique of laparoscopic incisional and ventral hernia repair carried out in a tertiary referral hospital was undertaken between January 2003 and February 2007. Laparoscopic hernia repair was attempted in 71 patients and was successful in 68 (conversion rate 4%). The mean age of the patients identified was 63.1 years (39 men and 31 women). Multiple hernial defects were identified in 38 patients (56%), and the mean overall size of the fascial defects was 166 cm(2). The mean mesh size used was 403 cm(2). The mean operative time was 121 minutes. There were six (9%) major complications in this series, but there were no deaths. Hernia recurrence was noted in four patients (6%) at a mean follow up of 20 months. Our preliminary experience indicates that laparoscopic incisional and ventral hernia repair is technically feasible and has acceptable postoperative morbidity and low early recurrence rates.     

Abdominal wall compliance after Marlex® mesh implantation for incisional hernia repair

Summary In view of the poor results of suturing techniques, incisional hernias are often best repaired with biomaterials. Their use brings the recurrence rate to below 10%, but patients sometimes complain of discomfort and restricted abdominal mobility. We report our experience with 41 patients after implantation of a Marlex®-mesh in a preperitoneal, retromuscular position (mean follow-up period 16.7 months). The effect of implanted meshes on abdominal wall mobility was measured noninvasively with the aid of three dimensional stereography and compared with a non-operated healthy control group (n = 21). The commonest early postoperative complication was seroma in 32% of cases, usually relieved by aspiration. Infection and hematoma were less frequent at 4.9% and 12.2% respectively. Three patients developed a recurrent hernia. During follow-up 7.3% experienced pain during heavy activities, 29.3% during daily activities and 4.9% at rest. Three dimensional stereography showed a highly significant (p < 0.001) decrease in abdominal wall mobility following mesh implantation, compared to a non-operated control group. Improved composition of the mesh material involving a smaller proportion of polypropylene and greater elasticity, should be considered for the future, in order to reduce patient discomfort.The study was supported by BIOMAT (Interdisciplinary Centre of Clinical Investigation, RWTH Aachen).     

腹腔镜联合开腹补片修补术对巨大切口疝及肠黏连紧密腹壁切口疝患者临床研究

目的分析腹腔镜结合开腹补片修补术对腹部切口疝患者治疗效果。 方法回顾性分析湖北省肿瘤医院肝胆胰外科自2011年2月至2018年2月收治的腹壁切口疝患者133例,其中62例行开腹补片修补术为对照组,余71例行腹腔镜结合开腹补片修补术为观察组;观察患者手术状况、术后恢复状况,术后1 d采用ELISA法检测血清氧化应激指标,包含胰岛素（InS）、β-内啡肽（β-EP）、生长激素（GH）和总抗氧化能力（T-AOC）含量,术后对患者随访1年,记录患者术后并发症和复发率情况。 结果观察组患者术中失血量低于对照组,差异有统计学意义（P<0.05）;观察组患者术后下床活动时间、肠功能恢复时间、首次进食时间、肠鸣音恢复时间及住院时间均低于对照组,差异有统计学意义（P<0.05）;术后1 d观察组患者血清InS、GH及T-AOC含量高于对照组,β-EP含量低于对照组,差异有统计学意义（P<0.05）;观察组患者并发症发生率低于对照组,差异有统计学意义（P<0.05）。 结论腹腔镜联合开腹补片修补术对巨大切口疝及肠黏连紧密腹壁切口疝患者疗效显著,患者创伤小、术后恢复快,且术后并发症发生率和复发率降低。     

Abdominal wall defects: pathogenesis,prevention and repair

Abdominal wall defects occur in the postoperative course after abdominal surgery in the form of wound dehiscence in the short term and incisional hernia in the long term. Prevention and treatment remain a significant challenge to surgeons. This article provides an update regarding the most recent insights on the pathogenesis of these common abdominal wall defects. In the ‘How to’ sections, the best methods of opening and closing the abdomen are presented, with a focus on prevention of short- and long-term complications. Also, the various options and indications for mesh and autologous abdominal wall reconstructions are discussed. Finally, a treatment algorithm based on our extensive experience and the best available evidence in the literature is presented for the various forms of incisional hernias discussed.     

Abdominal wall defects: pathogenesis,prevention and repair

‘Abdominal wall defects’ is a collective term used to describe two distinct pathologies: primary ventral hernias and incisional hernias. This article describes the pathogenesis, risk factors and the management of each.     

剖腹腹腔内补片修补腹壁切口疝21例体会

目的 探讨、总结剖腹腹腔内补片修补腹壁切口疝的经验.方法 2007年2月至2010年3月收治的21例腹壁切口疝采用复合补片进行开放式完全腹腔内修补.结果 1例术后3d死于腹腔室间隔综合征,其余20例无并发症发生,随访 6个月～3年无复发.结论 腹壁切口疝采用复合补片进行开放式完全腹腔内修补方法安全、有效     

Transgastric placement of biologic mesh to the anterior abdominal wall

Background

Incisional hernia repairs have a risk of wound complications that may be decreased using a natural orifice transluminal endoscopic surgery (NOTES) approach. The aim of this study was to determine the feasibility and safety of transgastric mesh placement to the anterior abdominal wall in a porcine model as a precursor to future studies of NOTES ventral hernia repair.

Methods

The procedure was done under sterile conditions with a double lumen endoscope using a plastic overtube. The endoscope was placed in the stomach preloaded with an overtube. Entrance of the endoscope and overtube into the peritoneal cavity was performed with the percutaneous endoscopic gastrostomy (PEG) technique. A 13 × 15 cm Surgisis^® Gold? mesh with four corner sutures was delivered through the overtube. Transfascial suture passer and endoscopic grasper were used to externalize the sutures and attach the mesh to the anterior abdominal wall. The gastrotomy was closed with a transabdominal gastropexy. The pigs were sacrificed at 2 weeks.

Results

Mesh placement was performed in five pigs. Operative time was 215 min (standard deviation, SD 99 min). The most difficult portion of the procedure involved manipulating the gastric overtube, likely exposing the mesh to bacteria in the stomach. Culture-positive abscesses were present at the mesh in 3/5 animals. The mesh appeared intact in 4/5 animals; one of the infected meshes had delamination of 50% of the mesh. Adhesions to the mesh surface varied from 2% to 100%. At 2 weeks, median mesh size was 116 cm² (range 96–166 cm²) and median contraction was 41% (range 15–51%). Histologic evaluations demonstrated marked inflammation and fibrosis progressing into the mesh material.

Conclusions

Totally endoscopic transgastric delivery and fixation of a biologic mesh to the anterior abdominal wall is feasible. Challenges remain in designing systems for mesh delivery that exclude gastric content. Once these problems can be surmounted NOTES ventral hernia repair may become an option in man.     

复合补片和生物补片治疗食管裂孔疝的疗效对比研究

目的:对比应用复合补片和生物补片治疗反流性食管炎和食管裂孔疝的疗效。方法:21例应用Crurasoft誖复合补片组及20例应用BiodesignTM Surgisis誖生物补片组修补食管裂孔疝病人,对比分析术后复发率和补片相关并发症发生的差异。结果:两组病人一般情况、食管裂孔长径和手术时间等方面无统计学差异。应用复合补片和生物补片均能使术前反流性食管炎的症状显著缓解。复合补片组和生物补片组围手术期并发症发生率分别为9.5%和30.0%,两组间无统计学差异。术后6个月随访裂孔疝复发率均为0。复合补片组和生物补片组长期随访平均时间分别为(16.3±8.9)个月和(17.3±6.8)个月,解剖性复发率分别为4.8%和5.0%,无统计学差异。两组病人均未发生食管侵蚀的并发症。复合补片组病人术后吞咽困难发生率高于生物补片组(38.1%比20..0%),但无统计学差异。结论:应用新一代小肠黏膜下基质补片和复合补片修补食管裂孔疝后疗效满意,复发率低,补片相关的严重并发症发生率差异无统计学意义。     

Primary inguinal hernia: The held-in mesh repair

Summary In the last 10 years, in Italy a rapid evolution has occurred from the “traditional” herniorraphies (Bassini, Shouldice) toward prosthetic techniques and outpatient procedures under local anesthesia are now most commonly preferred. Since october 1992 we have adopted a personal modification of the sutureless mesh repair, which we call held in mesh repair. Basic steps of this technique are: the placement of a plug in the deep ring for direct and indirect hernias; the linking of the medial edge of the prosthesis to the suture flattening the trasversalis fascia; the closure of the gap for the spermatic cord. With this technique 930 primary groin hernias were operated on in 798 patients (132 were bilateral); outpatient surgery was performed in 486 patients (60.9%). Anesthesia was local in 761 patients (95.4%). The mesh, generally sized 4.5×10 cm, in all cases was composed of polypropylene (Marlex^? or Prolene^?). 682 patients (85.5%) required analgesics. One hernia recurred (0.1%) after two years; one femoral pseudorelapse (0.1%) occurred at the 6th postoperative month. Nine complications occurred, for a rate of 0.9%. They were: one hemorrhage; 2 hematomas; one testicular atrophy; one lymphorrea; 2 ilioinguinal neuralgias; 2 seromas. No wound infections occurred; in none was it necessary to remove the mesh. The favorable results of the held in mesh repair and the simplicity of the procedure suggest that it can be considered a safe and reliable technique for most primary inguinal hernias. The negligible rates of femoral pseudorelapse and of indirect recurrences do not justify the employment in primary hernias of more complex preperitoneal techniques implying more complex anesthesia procedures and a higher C/B ratio.     

Quadrapod mesh for posterior wall reconstruction in adult inguinal hernias

Inguinal hernia repairs are the most frequently carried out operations worldwide, and open-mesh herniorrhaphies have gained wide acceptance for advantages of little tension, less pain and lower recurrence rates. Even so, potential drawbacks of original open-mesh repairs exist, and we accordingly make some modifications, suggesting a new 'quadrapod' marlex mesh as an alternative. From July 2002 to March 2004, we carried out 288 consecutive inguinal hernia repairs using quadrapod mesh in 273 patients, all of them were male and aged older than 35 years. Patient demographics, operative parameters, morbidity and outcomes were collected in detail. After surgery, patients were followed up every 6 months at one surgeon's clinic and any major abnormality was recorded. Mean age of the 273 patients was 58.7 years. Twenty-eight patients had recurrent hernias and 15 bilateral hernias. Mean surgical duration was 50.7 min. One patient suffered from major wound infection and needed prolonged hospitalization for parenteral antibiotics. Owing to old age and benign prostatic hyperplasia, 11 patients receiving spinal anaesthesia had temporary postoperative urine retention and needed short-term urinary catheter insertion. Most patients were discharged 1 day following surgery. Acute wound pain generally improved within days, and no patients complained of chronic pain or debility necessitating special interventions. With a mean follow up of 40.7 months, no case of recurrent herniation was detected to date. Open-mesh herniorrhaphy using quadrapod mesh provides a cheap, feasible and effective alternative choice in centres with limited resources. Preliminary results are encouraging, and a formal prospective study may be warranted.     

切口疝缝合修补和补片修补的术后复发

判断切口疝修补方法优劣的最重要标准是术后复发率。有关组织修补和补片修补术后复发情况,以及各种组织修补方法和补片修补方法与复发的关系有许多不同的报道和争论。以下就上述问题做一论述。