Experience of Laparoscopic Incisional Hernia Repair in Kidney and/or Pancreas Transplant Recipients

Despite the wide popularity of laparoscopic incisional hernia repair (LIHR) in the nontransplant population, there are very few reports of LIHR available in abdominal organ transplant patients and none exclusively on kidney and/or pancreas (KP) transplant patients. We retrospectively reviewed a consecutive series of LIHR in KP transplant recipients performed over a period of 4 years and compared the results with LIHR in non‐transplant patients during the same period. A total of 36 transplant patients were compared with 62 nontransplant patients. There were five patients converted to the open procedure in the transplant and four in nontransplant patients (p‐NS). There were three seromas and one patient had a bowel perforation in the transplant group versus eight seromas, one bowel perforation and one small bowel obstruction noted in the nontransplant group. One patient in each group had a mesh infection requiring explant. Patients were followed up for a mean period of 2.2 years in the transplant group and 3 years in the nontransplant group. Overall there were five recurrences in the transplant group and four in the nontransplant group (p = NS). These results suggest that that LIHR is a safe and effective alternative to open repair.     

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.     

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.     

Laparoscopic Repair of Left Lumbar Hernia After Laparoscopic Left Nephrectomy

Lumbar hernias, rarely seen in clinical practice, can be acquired after open or laparoscopic flank surgery. We describe a successful laparoscopic preperitoneal mesh repair of multiple trocar-site hernias after extraperitoneal nephrectomy. All the key steps including creating a peritoneal flap, reducing the hernia contents, and fixation of the mesh are described. A review of the literature on this infrequent operation is presented. Laparoscopic repair of lumbar hernias has all the advantages of laparoscopic ventral hernia repair.     

小切口辅助腹腔镜巨大腹壁切口疝修补术的探讨

目的总结小切口辅助腹腔镜巨大切口疝修补术的经验。方法 2008年6月-2009年12月,采用小切口辅助腹腔镜修补巨大切口疝15例,疝环（12.3±3.4）cm,采用小切口切除疝囊并进行腹壁塑形。结果 15例均顺利完成手术,手术时间100-150 min,（123.3±15.9）min。小切口长度5-8 cm,（6.0±0.9）cm。术中发现隐匿疝6例,一并予以修补。浆液肿1例。术后住院时间4-8 d,（5.3±1.2）d。1例术后疼痛持续〉3个月,无切口感染和肠道及腹腔脏器损伤。全组随访12-30个月,（19.9±4.7）月,无复发。结论小切口辅助腹腔镜修补巨大切口疝是一种安全可靠的手术方法,术后并发症少,达到了腹壁塑形的效果。     

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.     

改良完全腹膜外腹腔镜疝修补术31例报告

目的评价改良的完全腹膜外腹腔镜疝修补(totally extraperitoneal laparoscopic hernia repair,TEP)手术方法的可行性和安全性。方法2007年1月~8月,在全麻下行改良TEP31例。用一次性吸引器头的塑料外套管对手术区域的腹膜前间隙进行初步分离,再将国产单腔气囊导管小心置入腹膜外间隙,充气扩张建立腹膜外间隙。术中不固定补片。结果手术全部成功,手术时间(69.8±21.8)min,术中出血量(7.6±4.2)ml,术后住院时间(2.6±1.3)d。术中腹膜破裂5例,术后阴囊积液2例,无其他手术并发症。31例随访1~7个月,(4.2±2.4)月,未见复发及腹股沟区慢性疼痛等并发症。结论改良TEP是一种安全可行的无张力疝修补技术,腹股沟区慢性疼痛症状少。     

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.     

腹腔镜下复合补片修补耻骨上切口疝(附25例报道)

目的总结腹腔镜下耻骨上切口疝修补的手术方法及效果。方法回顾性分析2007年3月至2010年10月期间笔者所在科室25例行腹腔镜下耻骨上切口疝修补术患者的临床资料。男13例,女12例;年龄35～83岁,中位年龄52岁;其中2例是复发疝。疝缺损下缘距耻骨弓距离均小于5 cm。在直视下采用螺旋钉枪将补片固定到腹壁上,补片下边缘须低于耻骨弓2 cm并将其固定到耻骨弓及双侧的耻骨梳韧带上。结果 25例患者均成功完成腹腔镜下切口疝修补,无中转开腹。疝缺损最大径为6.1～12.5 cm,平均9.5 cm。手术时间为90～180 min,平均128 min。总并发症发生率为28%(7/25)。包括术中膀胱损伤1例;术后补片上方浆液肿4例,经局部穿刺抽吸后消失;术后修补区域腹壁疼痛2例,未行特殊处理于术后1个月内逐渐缓解并消失。22例患者获随访,随访率为88%,随访时间为6～48个月,平均30个月,1例于术后2个月复发,复发率为4%。结论腹腔镜下耻骨上切口疝修补是一种安全有效的方法,其网片重叠缺损边缘至少超过5 cm,网片下边缘必须在直视下固定到双侧耻骨梳韧带上,这样可以增加固定的强度并降低修补术后复发率。     

Female Gender and Diabetes Mellitus Increase the Risk of Recurrence after Laparoscopic Incisional Hernia Repair

Background

Laparoscopic hernia repair is used widely for the repair of incisional hernias. Few case studies have focussed on purely ‘incisional’ hernias. This multicentre series represents a collaborative effort and employed statistical analyses to provide insight into the factors predisposing to recurrence of incisional hernia after laparoscopic repair. A specific hypothesis (ie, laterality of hernias as well as proximity to the xyphoid process and pubic symphysis predisposes to recurrence) was also tested.

Methods

This was a retrospective study of all laparoscopic incisional hernias undertaken in six centres from 1 January 2004 to 31 December 2010. It comprised a comprehensive review of case notes and a follow-up using a structured telephone questionnaire. Patient demographics, previous medical/surgical history, surgical procedure, postoperative recovery, and perceived effect on quality of life were recorded. Repairs undertaken for primary ventral hernias were excluded. A logistic regression analysis was then fitted with recurrence as the primary outcome.

Results

A total of 186 cases (91 females) were identified. Median follow-up was 42 months. Telephone interviews were answered by 115/186 (62%) of subjects. Logistic regression analyses suggested that only female sex (odds ratio (OR) 3.53; 95% confidence interval (CI) 1.39–8.97) and diabetes mellitus (3.54; 1–12.56) significantly increased the risk of recurrence. Position of the defect had no statistical effect.

Conclusions

These data suggest an increased risk of recurrence after laparoscopic incisional hernia repair in females and subjects with diabetes mellitus. These data will help inform surgeons and patients when considering laparoscopic management of incisional hernias. We recommend a centrally hosted, prospectively maintained national/international database to carry out additional research.     

腹腔镜下修补70岁以上患者腹壁切口疝(附8例报道)

目的初步探讨并总结腹腔镜下腹腔内置补片法修补70岁以上老年患者腹壁切口疝的临床经验。方法回顾性分析了我院2005年7月至2008年7月期间实施的8例腹腔镜下腹腔内置补片法修补70岁以上老年患者腹壁切口疝的临床资料。结果8例中有1例因腹腔粘连严重而中转开腹手术,其余7例均成功完成腹腔镜下疝修补手术;手术时间50～180min,平均105min;术后1例发生高碳酸血症导致昏迷,经呼吸机辅助呼吸24h后好转;1例发生血清肿,1例术区明显疼痛超过1个月,均经保守治疗治愈;住院时间7～14d,平均9.5d。术后随访12～36个月(平均26.5个月)无复发,无局部不适。结论腹腔镜下腹腔内置补片法修补70岁以上患者的腹壁切口疝是安全、可行的,且具有微创、恢复快等优点,但必须注意围手术期处理及手术技巧。     

N-Butyl Cyanoacrylate Versus Conventional Suturing for Fixation of Meshes in an Incisional Hernia Model

ABSTRACT

Background: Chronic pain and related complications reported after the use of perforating fixation devices in hernia surgery have led to the use of tissue sealants. Fibrin sealant is a feasible option for mesh fixation; however data on cyanoacrylate glues are limited. Methods: 32 Sprague-Dawley rats were divided into two groups and a 1.5 cm abdominal wall defect was created on each animal. The lesions were then repaired with 2 × 2 cm polypropylene meshes, fixed with n-butyl-cyanoacrylate in the first group and with polypropylene sutures in the second group. The rats were sacrificed on the 21st and 42nd days. The presence of infection, recurrence, and abdominal adhesions were evaluated, followed by biomechanical testing and histological examination. Results: No mesh infection or hernia recurrences were recorded. There was no statistically significant difference between neither the adhesion scores nor the mean broken pressure of the two groups. Cyanoacrylate sealing was found equivalent to suturing in terms of tissue ingrowth, fibrosis, inflammatory infiltration, abscess formation, and necrosis. Furthermore, cyanoacrylate resulted in less foreign body reaction. Conclusions: Mesh fixation by cyanoacrylate may be considered as an alternative to suture fixation.     

Incisional Hernia Repair of Medium- and Large-Sized Defects: Laparoscopic IPOM Versus Open SUBLAY Technique

Background: Small incisional hernias can be repaired laparoscopically with low morbidity and reasonable recurrence rates. The aim of this study was to compare laparoscopic with open technique in medium- and large-sized defects regarding postoperative complications and recurrence rates.

Methods: Between 2012 and 2016, 102 patients with medium- or large-sized defects according to EHS classification underwent incisional hernia repair. Patients’ characteristics, hernia size and postoperative complications were prospectively recorded. In October 2016, eligible patients were assessed for recurrence.

Results: About 31 patients underwent laparoscopic IPOM and 71 patients open SUBLAY repair. Morbidity rate was significantly lower in IPOM group than in SUBLAY group (19% versus 41%; p?=?.028). Postoperative complications according to Clavien–Dindo classification were significantly lower in the IPOM group (p?=?.021). Duration of surgery (88 versus 114?min; p?=?.009) and length of hospital stay (five versus eight days; p?<?.001) were significantly shorter for IPOM than for SUBLAY. 71 patients were available for follow-up. Recurrence rates showed no significant difference between study groups (13% versus 7%, p?=?.508).

Conclusions: Laparoscopic repair in medium- and large-sized defects is a feasible and safe approach. IPOM compared to SUBLAY significantly reduces postoperative complications and hospital stay; recurrence rates are comparable.     

Incisional Hernia Repair in Renal Transplantation Patients

Introduction: Abdominal wall dehiscence in renal transplantation patients risks the survival of the transplanted organ. No clear treatment algorithm exists in the literature for this group of patients. Methods: Between 1992 and 2001, the Division of Plastic Surgery at the University of Maryland treated 41 of 2499 renal transplant patients. Based on a retrospective review of these patients, an algorithm was developed to guide the management of midline and lower quadrant abdominal wall defects. Results: Most lower quadrant defects were repaired with tensor fascia lata grafts. Most midline defects were repaired with the component separation technique. Use of a single- or multi-staged repair was based on the extent of infection. Hernia recurrence was 22% over 21 months. 80% of the transplant kidneys were functioning following repair. Conclusion: An algorithm for the repair of abdominal wall defects after kidney transplantation is presented taking into account the location and the extent of infection.     

Laparoscopic Intraperitoneal Repair of Incisional and Ventral Hernias

Background : After reports in the literature on the safety and feasibility of laparoscopic repair of ventral hernia, and with the potential advantages of the minimal invasive approach, we started to perform this technique in 2001. This study was done to evaluate the results of our initial experience.

Methods : From March 2001 to October 2003, all patients with a ventral hernia greater than 4 cm were planned to have a laparoscopic repair. Patients were studied retrospectively, collecting data on preoperative and intraoperative variables, complications and recurrences.

Results : In 49 patients, out of 52 patients planned, laparoscopic repair was performed. The indication was incisional hernia in 88% and recurrence after open hernia repair in 43%. The mean hernia surface area was 86,6 cm² and 43% had a width greater than 10 cm. There were no intraoperative complications and the mean operating time was 103 min. Postoperative complications were seen in 9 patients (18,4%). Mean hospital stay was 5,9 days. Mean follow-up was 14,3 months. Late complications were seen in three patients (6,1%). Recurrence was present in one patient (2,0%). Conclusions : Laparoscopic repair of incisional and ventral hernia is a safe alternative for open mesh repair. Further definition of indications is needed, based on the dimension and the localization of the hernia. If the omission of transabdominal wall sutures improves the postoperative course with no adverse effect on recurrence rate, will be the subject of a randomized trial we have started this year.     

Single-Port Onlay Mesh Repair of Recurrent Inguinal Hernias after Failed Anterior and Laparoscopic Repairs

Methods:Patients referred with two or more recurrences of inguinal hernia underwent SIL-IPOM from November 1, 2009, to June 24, 2014. A 2.5-cm infraumbilical incision was made, and an SIL port was placed intraperitoneally. Modified dissection techniques were used: chopstick and inline dissection, 5.5-mm/52-cm/30° angled laparoscope, and conventional straight dissecting instruments. The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.Results:Nine male patients underwent SIL-IPOM. Their mean age was 53 years and mean body mass index was 26.8 kg/m². Mean mesh size was 275 cm². Mean operation time was 125 minutes, with a hospital stay of 1 day. The umbilical scar length was 23 mm at the 6-week follow-up. There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.Conclusion:Inguinal hernias recurring after two or more failed conventional anterior and laparoscopic repairs can be safely and efficiently treated with SIL-IPOM.