Laparoscopic treatment of ventral abdominal wall hernias: preliminary results in 100 patients.

OBJECTIVE: The laparoscopic treatment of eventrations and ventral hernias has been little used, although these hernias are well suited to a laparoscopic approach. The objective of this study was to investigate the usefulness of a laparoscopic approach in the surgical treatment of ventral hernias. METHODS: Between January 1994 and July 1998, a series of 100 patients suffering from major abdominal wall defects were operated on by means of laparoscopic techniques, with a mean postoperative follow-up of 30 months. The mean number of defects was 2.7 per patient, the wall defect was 93 cm2 on average. There were 10 minor hernias (<5 cm), 52 medium-size hernias (5-10 cm), and 38 large hernia (>10 cm). The origin of the wall defect was primary in 21 cases and postsurgical in 79. Three access ports were used, and the defects were covered with PTFE Dual Mesh measuring 19 x 15 cm in 54 cases, 10 x 15 cm in 36 cases, and 12 x 8 cm in 10 cases. An additional mesh had to be added in 21 cases. In the last 30 cases, PTFE Dual Mesh Plus with holes was employed. RESULTS: Average surgery time was 62 minutes. One procedure was converted to open surgery, and only one patient required a second operation in the early postoperative period. Minor complications included 2 patients with abdominal wall edema, 10 seromas, and 3 subcutaneous hematomas. There were no trocar site infections. Two patients developed hernia relapse (2%) in the first month after surgery and were reoperated with a similar laparoscopic technique. Oral intake and mobilization began a few hours after surgery. The mean stay in hospital was 28 hours. CONCLUSIONS: Laparoscopic technique makes it possible to avoid large incisions, the placement of drains, and produces a lower number of seromas, infections and relapses. Laparoscopic access considerably shortens the time spent in the hospital.     

腹腔镜下腹壁切口疝补片修补术的初步经验

目的:探讨腹腔镜下腹壁切口疝修补术的手术方法、安全性等问题。方法:对我院2004年3月～11月间收治的25例腹壁切口疝病人,进行腹腔镜下修补术。结果:24例(96%)手术成功,1例(4%)因腹腔内广泛粘连而中转为剖腹修补。平均手术时间为110min,平均术后住院6d,6例(24%)病人术中发现有一个以上的隐匿性缺损。术后并发症有:术后短期内修补区腹壁明显疼痛21例(84%),腹壁缝合点较长时间疼痛6例(24%),浆液肿3例(12%);无修补区感染,也未发现早期复发的病例。结论:对腹壁切口疝,多数病人是可以经腹腔镜进行粘连松解及补片修补术的,还可在术中发现其他隐性缺损。对腹腔内广泛粘连而影响操作器械的进入及分离者,应及时中转剖腹手术。     

Laparoscopic and open abdominal wall reconstruction using Parietex® meshes Clinical results in 2700 hernias

Summary The authors report a series of 2445 inguinal hernias and 272 incisional hernias treated between 1993 and 1997 by the insertion of a Parietex mesh via either a laparoscopic (1595 procedures) or an open approach (578 procedures). Pain scores and time to return to normal activity were lower in the laparoscopic group than in the open surgery group (p < 0.001). In all of the groups, the average incidence of the total reported events (complications) was around 10% with no statistical difference. This ratio seemed to compare favourably to previously published reports. Considering inguinal hernias in particular, chronic pain was extremely rare (0.6% in the laparoscopic group and 0.8% in the open surgery group). Whatever the approach, sepsis was also very rare (1/1526 laparoscopic procedures, 2/380 open operations). These findings illustrate the local tolerance of the mesh. Recurrence rates were below 1% with no statistical difference between groups. This retrospective study demonstrates the clinically apparent local tolerance of this type of mesh. Prospective and long term clinical results will be necessary to show whether the short term tolerance of Parietex mesh influences the long term functional results.     

比较腹腔镜腹腔内与开放腹膜前间隙补片置入术治疗腹壁切口疝的效果

目的比较腹腔镜腹腔内补片置入术(IPOM)与开放腹膜前间隙补片置入术(Sublay)治疗腹壁切口疝的效果。方法选取2016-01—2019-01间在郑州大学第一附属医院接受疝修补术治疗的76例腹壁切口疝患者,将36例行腹腔镜IPOM术的患者作为腔镜组。将40例行开放Sublay术的患者作为开放组。回顾性分析患者的临床资料。结果2组患者均成功完成手术。2组手术时间差异无统计学意义(P>0.05)。腔镜组术中出血量、术后肠蠕动恢复时间及住院时间均少于开放组,差异有统计学意义(P<0.05)。腔镜组术后近期疼痛发生率低于开放组,差异有统计学意义(P<0.05),其余并发症差异无统计学意义(P>0.05)。结论腹腔镜IPOM术具有创伤小、恢复快、疼痛轻、出血少、并发症少等优点,具有更广阔的应用前景。     

Laparoscopic transabdominal preperitoneal approach to place a polypropylene mesh on the abdominal wall: an experimental swine model of a technique that can be used for incisional hernia repair

Background The placement of intraabdominal polypropylene mesh entails risks of adhesions and fistulas that can be avoided by preperitoneal placement.Methods This comparative, open, experimental, prospective, randomized, and transversal study randomized pigs into two groups of 11 each for intraperitoneal (IPOM) or preperitoneal (TAPP) polypropylene mesh placement by laparoscopy. Diagnostic laparoscopy and tissue en-bloc resection was performed 28 days postoperatively for histopathologic analysis.Results The following data were observed for the two study groups: surgical time (IPOM: 35.73 ± 4.22 min; TAPP: 58.09 ± 6.28 min; p = <0.0001); adhesions (IPOM: 81.81%; TAPP: 27.27%; p = 0.032), grade III for IPOM and grade II for TAPP (p = 0.001); and interloop adhesions (IPOM: 81.81%; TAPP: 9.09%; p = 0.003). No fistulas were found in either group. The TAPP procedure showed better integration of mesh, without lesion to abdominal organs. Two complications, occurred with IPOM, and one with TAPP (p = 1.0, not significant).Conclusions The perperitoneal technique requires more time, but has fewer adhesions and less intraabdominal inflammatory response. It is a feasible technique that may diminish risks in the laparoscopic treatment of incisional hernias with polypropylene mesh.     

Repair of large midline incisional hernias with polypropylene mesh: Comparison of three operative techniques

Polypropylene mesh is widely used for the reconstruction of incisional hernias that cannot be closed primarily. Several techniques have been advocated to implant the mesh. The objective of this study was to evaluate, retrospectively, early and late results of three different techniques, onlay, inlay, and underlay. The records of 53 consecutive patients with a large midline incisional hernia — 25 women and 28 men, mean age 60.4 (range 28–94) — were reviewed. Polypropylene mesh was implanted using the onlay technique in 13 patients, inlay in 23 patients, and underlay in 17 patients. Either the greater omentum or a polyglactin mesh was interponated between the mesh and the viscera. The records of these 53 patients were reviewed with respect to: size and cause of the hernia, pre- and postoperative mortality and morbidity, with special attention to wound complications. Patients were invited to attend the outpatient clinic at least 12 months after implantation of the mesh for physical examination of the abdominal wall. Postoperative complications occurred in 14 (26.4%) patients. The onlay technique had significantly more complications, as compared to both other techniques. Reherniation occurred in 15 (28.3%) patients. The reherniation rate of the inlay technique was significantly higher than after the underlay technique (44% vs 12%, P=0.03) and tended to be higher than the onlay technique (44% vs 23%, P=0.22). Repair of large midline incisional hernias with the use of a polypropylene mesh carries a high risk of complications and has a high reherniation rate. The underlay technique seems to be the better technique.     

Classification of primary and incisional abdominal wall hernias

Purpose  A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. Methods  Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. Results  To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. Conclusions  A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

Laparoscopic sutured closure with mesh reinforcement of incisional hernias

Background This study reports medium-term outcomes of laparoscopic incisional hernia repair. Study Design Laparoscopic repair was performed on 721 patients with ventral hernia. After adhesiolysis the defect was closed with no. 1 polyamide suture or loop. This was followed by reinforcement with intraperitoneal onlay repair with a bilayered mesh. Results Laproscopic repair of ventral hernia was performed on 613 females and 108 males. Of these, 185 (25.7%) were recurrent incisional hernias of which 93 had undergone previous open hernioplasty. The remaining 92 patients had previously undergone sutured repair. The average operating time was 95 min (range 60–115 min). Conversion rate was 1%. The average hospital stay was 2 days (range 1–6 days). The commonest complication was seroma formation at the incisional hernia site. Full-thickness bowel injury occurred in two patients. The mean follow-up period was 4.2 years (range 3 months to 10 years). Recurrence was noted in four (0.55%) patients. Conclusion Laparoscopic repair is well-tolerated and can be accomplished with minimum morbidity in ventral hernias.     

Classification of incisional hernias of the abdominal wall

Summary Incisional hernias of the abdominal wall assume many clinical forms in terms of their site and size, the quality of the tissues of the abdominal wall and the number of previous recurrences, among many other factors. Any serious prospective and possibly comparative scientific study dealing with the results of treatment must begin by defining the type of incisional hernia studied. Hence, it seemed necessary to employ a classification allowing a study or comparison of homogeneous groups. The aim of this work was to propose a simple classification of predictive value, based on a statistical study of the relations between four parameters, i.e. the site of the incisional hernia, the width of the hernial orifice, the number of previous recurrences, and the results of treatment. A retrospective study dealing with a series of 435 abdominal incisional hernias was done to this end.This work was presented at the XXI EHS International Congress, Madrid, Spain, 3–6 November 1999     

Respiratory mechanics in abdominal compartment syndrome and large incisional hernias of the abdominal wall

Summary The abdominal compartment syndrome (ACS) is a clinical condition characterized by an increase of abdominal pressure which needs prompt abdominal decompression. The surgery of large abdominal hernias can present similar problems with an increased abdominal pressure at peritoneal closure which needs a prosthetic tension-free abdominal closure to correct the increased respiratory work-load. We undertook a study in order to compare the respiratory mechanical work-load changes during the surgery of large abdominal incisional hernias and the ACS. We measured the static compliance of the entire respiratory system (Crs), and its components-lung (CL) and chest-wall (Ccw)-during the acute phase of increased abdominal pressure and after decompressive treatment. In ACS the baseline measurements of Crs, CL, Ccw were 0.034, 0.049 and 0.115 L/cmH₂0 respectively; after decompression treatment we observed a great increase of Ccw (0.167 L/cmH₂O) whereas Cl remained the same (0.O49L/cmH₂O); Crs varied from 0.034 to 0.038 L/cmH₂O. In the surgery of large laparoceles, the Crs changed from 0.048 to 0.046 and the Ccw from 0.150 to 0.180, with an unchanged Cl. We conclude that the abdominal compartment syndrome is characterized by a well-defined alteration of respiratory work-load (decrease of chest-wall compliance), and that from a mechanical point of view there is only a quantitative difference if compared to large ventral hernia repair. The decrease of chest-wall compliance in the latter is less severe and statistically different (p = 0.002).This work was presented as a poster at the AHS EHS Joint Meeting Hernia in the 21st Century, Toronto, Canada, 15 18 June 2000     

肌后间隙修补法治疗腹壁切口疝患者的疗效

目的探讨肌后间隙修补法（Sublay）在腹壁切口疝患者治疗中的手术效果。 方法回顾性分析2015年1月至2017年8月,首都医科大学附属北京朝阳医院疝和腹壁外科107例行Sublay手术的腹壁切口疝患者的临床资料,分析患者的一般资料、手术方法、并发症及术后转归情况,随访其有无切口疝复发及补片相关并发症发生情况。 结果本组患者均顺利完成手术,平均手术时间（60.3±7.8）min,平均住院时间（17.6±5.3）d,所有患者术后恢复良好,2例患者出现脂肪液化,经换药后伤口愈合;1例患者出现皮下血肿,1例患者出现血清肿,经局部加压保守治疗后治愈,无伤口感染及局部异物感,无死亡患者。随访时间6～38个月,平均随访时间（22.7±10.8）个月,无切口疝复发,无死亡患者,无补片感染、慢性疼痛及局部异物感等补片相关并发症发生。 结论肌后间隙修补手术（Sublay）治疗腹壁切口疝结果满意,手术疗效较好。     

腹腔镜上腹部切口疝修补术45例临床应用

目的探讨腹腔镜上腹部切口疝修补术的方法改进与效果。方法回顾性分析我院自2008年8月至2013年7月完成的腹腔镜上腹部切口疝修补术45例的病例资料。结果本组45例患者,中转开腹手术2例。关闭缺损法腹腔镜切口疝修补术35例。手术时间45—190min,平均（105±34．6）min;术后24—48h下床活动;1～3d后肠排气。术后住院时间2～17d,平均（6．5±2．8）d。39例患者随访1～56个月,有1例复发,复发率为2．6％,未发现慢性疼痛性并发症。结论腹腔镜上腹部切口疝修补术微创、并发症的发生率低、具有良好的应用前景。     

Laparoscopic treatment of large paraesophageal hernias

Background: We set out to evaluate the results of the laparoscopic treatment of large paraesophageal hernias in 22 patients. Methods: Between 1993 and 1998, we operated on 22 consecutive patients. Preoperative assessment consisted of endoscopy, barium esophagogram, 24-h pH testing, manometry, and gastric emptying times. Results: In the first three patients, the sac was not excised and gastropexy was not performed. Because of recurrences, we decided to change the technique in an attempt to avoid further complications. During middle- to long-term follow-up, only three recurrences were seen in the subsequent 19 patients. There were no deaths in this series. Conclusions: Laparoscopic treatment of large paraesophageal hernias is feasible. Because recurrences may occur after successful laparoscopic treatment, both resection of the sac and some form of gastropexy are imperative. Received: 22 March 2000/Accepted: 30 April 2000/Online publication: 20 September 2000     

Dynamic patchplasty—a tension-free reconstruction of incisional hernias

Background and aims An anatomical and physiological reconstruction of the abdominal wall after incisional hernia must include reconstruction of the linea alba to restore the physiological function of the vertebral column and respiration. Against this background, a special reconstruction method employing a mesh, which is performed in our department, is presented.Materials and methods In the period between 1 January 2000 and 1 June 2004, a total of 106 patients with incisional hernias after median laparotomy of the upper and lower abdomen were operated on in our department using this tension-free technique with one or two meshes. We have now evaluated the outcomes after a median follow-up of 25.8 months (6.5–53.3).Results In one patient (0.9%), the peritoneal sac was inadvertently opened, resulting in injury to the small bowel serosa. Surgical complications were observed in 14 patients (13.2%) after dynamic patchplasty. In seven cases (6.6%), wound healing disorders were seen. Overall, 6 out of 106 (5.5%) patients needed revision surgery. In the follow-up period, 92 patients (follow-up 86.8%) could be contacted and re-examined. Four patients (3.8%) had died. There were four recurrences (4.3%), which had already been repaired, and one chronic seroma, which caused no symptoms and which was detected in ultrasound and computed tomography.Conclusion In view of the possibility of achieving physiological reconstruction and in the light of a tolerable morbidity rate, dynamic patchplasty is a suitable method for incisional hernias. Long-term results hold out promise of an acceptable low recurrence rate.A commentary on this paper is available at .     

Combined fascia and mesh repair of incisional hernias

Incisional hernia is a relatively common complication following abdominal operations. Due to high recurrence rates following primary suture, a prosthetic mesh is now usually used to repair the hernia. Several different types of repair are described. A combined fascia and mesh technique avoids opening the peritoneal cavity and potential damage to bowel. This study describes results of this technique. Consecutive patients undergoing the operation were contacted to assess freedom from recurrence and satisfaction with results. Some 34 patients underwent 36 incisional repairs. Of the 34 patients 21 were men and 13 were women with a median age of 69 years (range 31–86 years). The causative incisions were midline (30), Kochers (2), Pfannesteil (2) and transverse (2). The median time spent in hospital was three nights (range 1–14 days). Two patients developed seromas, another complained of pain soon after operation, one patient developed a superficial wound infection another developed a tender drain site which required exploration. One patient with significant co-morbidity died 13 days postoperatively from multiorgan failure. Freedom from recurrence of the hernia was 91% at 5 years. However patient survival was only 70% at 5 years. This technique is associated with low postoperative morbidity and a low recurrence rate. Patients presenting with incisional hernias have a poor long-term prognosis which needs to be borne in mind when planning intervention.     

Simplified technique for incisional hernia repair with mesh prosthesis

This paper describes a simplified technique for the repair of incisional hernias. The previous scar is resected, and the peritoneal sac is carefully dissected until it is completely exposed. The sac is opened to liberate structures adherent to the sac or to the area immediately surrounding the defect. The peritoneum is closed and invaginated to form a sac bed underlying the entire extent of the defect, and the mesh is laid on this sac bed. The mesh is then fixed with "U" stitches, reinforcing these by inserting a second line from the edge of the defect to the mesh. Suture material used is polypropylene 1/0 or 2/0. This procedure has been carried out on 15 patients, and after 1 year of follow-up, there has been no recurrence of the hernia. Operating time was reduced, and the surgical technique was found to be easier. Placing a mesh prosthesis inside the hernia sac and fixing it to the abdominal wall with two lines of suturing simplifies the repair procedure, reduces operating time, and is effective in the repair of all incisional hernias. A study is required to compare this outcome with the different mesh repair techniques.     

腹腔镜下切口疝补片修补术的临床应用

目的 探讨腹腔镜下腹壁切口疝修补术的手术方法、安全性等问题。方法对2004年3月至2006年5月79例行腹腔镜下补片修补术治疗腹壁切口疝病人的临床资料进行分析。结果 78例（98．7％）手术成功，1例因腹腔内广泛粘连而中转开放修补。平均手术时间为88min，平均术后住院4．6d，18例（22．8％）病人术中发现有1个以上的隐匿性缺损。术后并发症：术后短期内修补区腹壁明显疼痛58例（73．4％）。腹壁缝合点较长时间疼痛6例（7．6％），浆液肿14例（17．7％），无手术死亡，1例术后出现肠瘘，经保守治疗好转，1例腰部切口疝的病人术后复发。结论 多数病人腹壁切口疝可以经腹腔镜行粘连松解及补片修补术，并可在术中发现其他隐性缺损，手术安全性较高。对腹腔内广泛粘连而影响操作器械进入及粘连分离者，应及时中转开腹手术。     

Retrofascial mesh repair of ventral incisional hernias

BACKGROUND: Recurrence rates after ventral incisional hernia repair are reported to be as high as 33% and are associated with considerable morbidity and lost time. The purpose of this study was to determine if retrofascial mesh placement reduces the incidence of recurrence as well as the severity of wound infections. METHODS: A prospective database covering the period from January 1995 to June 2003 was maintained. All patients underwent a standardized technique by a single surgeon. Polypropylene mesh was placed between the fascia and the peritoneum with the fascia closed over the mesh. RESULTS: There were 150 patients (126 women, 24 men) with a mean age of 55 years. Their average weight was 88 kg, with an average body mass index of 32. Sixty-three (42%) of the hernias were recurrences of a previous repair. The average size of the hernia was 8 x 14 cm. There was 1 postoperative mortality. There was a 9% postoperative infection rate with 2 patients (1%) requiring mesh removal. Long-term follow-up evaluation has revealed 3 recurrences (2%) and 3 readmissions for bowel obstruction with 1 patient requiring surgical release. There were no fistulas noted. CONCLUSIONS: Incisional hernia repair with mesh placed in the retrofascial position decreases both the risk for recurrence and the severity of wound infection without significant problems from bowel obstruction or enteric fistula.     

腹腔镜下腹腔内网片植入法和开放式肌后筋膜前补片修补法治疗腹壁切口疝的疗效比较

【摘要】 目的〓比较腹腔镜下腹腔内网片植入法(IPOM)和开放式肌后筋膜前补片修补法(Sublay)治疗腹壁切口疝的疗效。方法〓回顾性分析30例腹腔镜应用IPOM法和28例开放式应用Sublay法治疗腹壁切口疝的病例,比较其手术疗效及术后患者生活质量。结果〓两组手术时间、平均住院时间、术中出血量及术后并发症比较,腹腔镜组均明显优于开放手术组,有统计学差异(P<0.05)。结论〓应用腹腔镜行IPOM治疗腹壁巨大切口疝安全可行,具有有创伤小,住院时间短,恢复快,术后并发症少的优点。     

Incisional hernias after laparoscopic vs open cholecystectomy

Background: The aim of this study was retrospectively to compare the incidence of incisional hernia formation at trocar sites in laparoscopic cholecystectomy with that after conventional open cholecystectomy. Methods: In all, 271 patients with cholelithiasis underwent either laparoscopic cholecystectomy (LC group, n= 142) or open cholecystectomy (OC group, n= 129). In the OC group, the surgical approach was to use a right subcostal incision in 20.2%, right transrectal laparotomy in 73.6%, and midlaparotomy in 6.2%. Laparotomy closure was performed by continuous absorbable suture for the peritoneum and discontinuous absorbable stitches for muscle and fascia. Laparoscopic access was achieved by use of four trocars (two 10 mm and two 5 mm). Umbilical port closure was performed by suture of fascia using discontinuous stitches. Closure of the remaining ports was performed by suture of the skin. Results: Both patient groups were statistically similar with respect to general risk factors. Follow-up was performed in 84 (65.1%) OC and 123 (86.6%) LC patients and ranged from 2 to 10 years (mean, 8 years) and 1 to 5 years (mean, 3 years) respectively. Five (5.9%) OC and two (1.6%) LC patients developed incisional hernias, although the difference between groups was not significant. All hernias in OC patients appeared after transrectal laparotomy. The LC hernias appeared at the umbilical port, and one of the patients developed an additional xiphoides port-associated hernia. Conclusions: The laparoscopic technique showed a lower (although not significantly) incidence of incisional hernias than the open procedure. Received: 16 July 1998/Accepted: 27 November 1998