Safety of Laparoscopic Ventral Hernia Repair in Octogenarians

Background and Objectives:

The recurrence rate after laparoscopic ventral hernia repair is lower than the rate of recurrence via the open approach in many series. Studies have demonstrated the safety and efficacy of this procedure but have had relatively young patient populations. We present our experience in a significantly older population.

Methods:

A retrospective chart review of all patients 80 to 89 years of age undergoing a laparoscopic ventral hernia repair at our institution from May 2000 to June 2007 was performed. Data collected included demographics, number and type of previous abdominal operations, number of previous hernia repairs, defect and mesh size, postoperative complications, and follow-up.

Results:

Twenty octogenarian patients underwent laparoscopic ventral hernia repair. Nine were men and 11 were women. The mean age was 82 years. Thirteen patients (65%) had one or more associated comorbidities at the time of surgery. Eighteen patients (90%) had undergone a mean of 1.7 prior abdominal operations. Six (30%) patients had undergone a mean of 1.1 previous open hernia repairs; 5 (83%) with mesh. Eight patients (40%) had an additional operative procedure at the time of laparoscopic hernia repair. Ten minor complications occurred in 10 patients (50%). Four major complications occurred in 4 patients (20%). One patient required reoperation for evacuation of hematoma at a trocar site. No patients complained of pain at a transabdominal suture site or persistent seromas by 6 weeks of follow-up. At mean follow-up of 3.1 months, no recurrences occurred and no patients required mesh removal in this series. No deaths occurred.

Conclusion:

Laparoscopic ventral hernia repair is becoming an accepted technique for hernia repair in the United States, with a well-documented low recurrence rate. Our series demonstrates that this approach is equally safe and effective for a significantly older segment of the population.     

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.     

Laparoscopic Transabdominal Preperitoneal Repair of Ventral Hernia: A Step Towards Physiological Repair

The laparoscopic ventral hernia repair with preperitoneal placement of mesh minimizes the complications related to the intraperitoneal position of mesh and fixating devices. It allows safe use of conventional and less expensive polypropylene mesh. The prospectively collected data of 68 patients who underwent laparoscopic transabdominal preperitoneal mesh hernioplasty, for different types of ventral hernias between January 2005 and December 2009 was retrospectively reviewed. The study included 68 patients, 16 males and 52 females with a mean age 51.1 ± 11.1 years (range 23–74 years). Most of the hernias (67.6%) were in the midline position. The mean size of the defect was 30.8 ± 24.4 cm2 (range, 4–144 cm2) and the mean mesh size was 237.8 ± 66.8 cm2 (range, 144–484 cm2). The mean operating time was 96.7 ± 16.7 min (range 70–150 min). All repairs were done with polypropylene mesh. The mean postoperative hospital stay was 1.5 ± 0.6 days (range, 1–4 days). Nineteen patients (27.9%) suffered from postoperative complications. Four patients (5.8%) were detected to have seroma formation. There were two recurrences (2.9%). The mean follow up was 22.7 ± 13.4 months (range, 6–48 months). The laparoscopic preperitoneal ventral hernia repair with polypropylene mesh is cheaper and has acceptable postoperative outcomes. Peritoneal coverage of the mesh not only acts as a barrier between mesh and bowel and thereby prevents adhesions, it also provides an additional security of fixation. This is a safe and feasible option of ventral hernia repair in expert hands. However, for proper validation of these conclusions a long term prospective clinical trial is required.     

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。     

Advanced Age: Is It an Indication or Contraindication for Laparoscopic Ventral Hernia Repair?

INTRODUCTION: Ventral hernias are common surgical problems in the geriatric population. Although ventral hernias are electively repaired in younger patients, the safety and efficacy of elective laparoscopic hernia repair in the geriatric age group is not well documented in the literature. METHODS: A review of 155 patients undergoing laparoscopic ventral hernia repair was undertaken. The patients were classified according to their age into 2 groups, Group A (n=126) for those who are 65 years old. The patient demographics, comorbidities, hernia characteristics, and operative and postoperative data were compared. RESULTS: Younger patients were found to have a significantly increased BMI, while the older group had an increased number of comorbidities. No difference was found in the complication or recurrence rates between the 2 groups. CONCLUSION: Elective laparoscopic ventral hernia repair in senior citizens is safe and feasible in our experience. We believe that the decision to perform an elective hernia repair in this patient population should be based on the general condition of the patient rather than the patient's chronological age.     

Robot-Assisted Transabdominal Preperitoneal Ventral Hernia Repair

Background and Objectives:

We believe that complications due to the mesh used in ventral hernia repairs can be reduced by using the natural barrier afforded by the peritoneum. This can be challenging to do laparoscopically, however we felt that the robot-assisted laparoscopic approach reduces the difficulty in placing the mesh in the preperitoneal space, and we want to share our early experiences with this approach. We describe the surgical technique used in robot-assisted laparoscopic transabdominal preperitoneal (TAPP) ventral hernia repair with mesh. In addition, we evaluate its feasibility and present preliminary perioperative results.

Methods:

We performed robot-assisted laparoscopic TAPP ventral hernia repairs in 3 patients in the spring of 2015. Demographic information and defect size were measured. Conversion from a laparoscopic to an open procedure was the primary outcome variable.

Results:

There were 3 cases of robot-assisted TAPP ventral hernia repair with mesh. The mean age of the patients was 49 years, the mean body mass index was 32.6 kg/m², and the mean operative time was 163.7 minutes. The mean defect size was 1219.0 mm². There were no conversions to open during this early learning phase. All patients were discharged home within the 24-hour postoperative period. No complications were noted during a mean follow-up of 3 months.

Conclusions:

We present our early experience with robot-assisted TAPP ventral hernia repair. We note that because of improved ergonomics and wristed instrumentation, the robotic platform enabled creation of peritoneal flaps and complete coverage of mesh with peritoneum after primary closure of the defect. The robotic approach is feasible and may provide a better environment for mesh integration and protection. Further investigations with long-term follow-up are needed to verify that this technique is effective in reducing mesh-related intra-abdominal complications.     

Laparoscopic Hernia Repair: a Two-Port Technique

Objective:

Various ventral and incisional hernia repair techniques exist and have largely replaced the open ones. The purpose of this study was to document the 2-port technique and demonstrate that it is feasible, efficient, and safe. To our knowledge, this is the largest report on this topic to date in the English-language literature.

Methods:

Forty patients with ventral hernias (VH) or incisional hernias (IH) underwent laparoscopic repair with a 2-port technique. The technique involves insertion of one 10-mm to 12-mm balloon port and one 5-mm port, usually on the left side as laterally as possible. A mesh is inserted through the balloon port site and secured to the abdominal wall by using either 4 peripheral or 1 central Prolene suture. Helical fasteners are used to attach the mesh to the abdominal wall.

Results:

Forty patients with 47 hernias underwent repair. Operating time ranged from 15 minutes to 70 minutes. Early complications were seen in 5 patients and included 1 small bowel enterotomy, 2 small bowel obstructions (SBO) with bowel adhering to the visceral side of the mesh, 1 wound infection, and 1 seroma. Late postoperative complications occurred in 8 patients (20%) who experienced persistent abdominal pain that resolved without any treatment. There was one recurrence during a mean follow-up of 23.5 months.

Conclusion:

Laparoscopic herniorrhaphy with the 2-port technique offers an efficient, safe, and effective repair for ventral and incisional hernias.     

The Use of Needlescopic Instruments in Laparoscopic Ventral Hernia Repair

A successful laparoscopic hernia repair requires complete covering of the hernia defect, adequate tension of the prosthesis, and secure stapling with a stapler. We describe herein our technique of performing laparoscopic hernia repair using a needlescopic instrument which results in minimal damage to the abdominal wall and has significant cosmetic benefits. Our technique is easy to perform and useful for achieving initial anchoring of the prosthesis before fixation to the abdominal wall with a laparoscopic stapler. Received: October 18, 2000 / Accepted: May 15, 2001     

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.     

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 incisional hernia repair in obese patients.

BACKGROUND AND OBJECTIVES: Laparoscopic incisional hernia repair is coming to the forefront as a preferred method of repair due to the advantages offered by minimally invasive techniques. To evaluate safety and feasibility of this approach in obese patients when performed by a general surgeon trained in basic laparoscopy with no prior experience in this technique, we reviewed our early experience in the first 18 patients. METHODS: All patients with incisional hernias presenting to a single surgeon from 2000 to 2002 were offered laparoscopic repair. Patients were informed about the limited experience of the surgeon in this particular field. Those who consented were repaired laparoscopically using a standard 4-port technique, one 12-mm port and three 5-mm ports. All patients with body mass index > or =30 were included in this review. A retrospective review of the data included demographics, operative time, blood loss, hospital stay, postoperative complications, and patient satisfaction. RESULTS: Nineteen laparoscopic repairs were completed in 18 patients. No conversions to open repair were necessary. All patients were females except for 2. All hernia sacs were left in place, some of which were empty while others required extensive lysis of adhesions to release sac contents. Mean fascial defect was 102.5 cm2. One defect was closed primarily without mesh, while the rest were closed using Composix mesh in 1 and Dual Plus Gore-Tex mesh in the rest. Three patients were discharged from the recovery room. Mean follow-up was 24 months. No wound or mesh infections occurred. Eight patients had no complications. Eight patients had asymptomatic seromas. Two patients had hematomas; none of them required drainage. One patient had nonspecific dizziness. One patient presented with bowel obstruction secondary to early recurrence (within a week). The repair was salvaged laparoscopically. Upon evaluation by telephone calls, all patients indicated extreme satisfaction with the results. CONCLUSIONS: A general surgeon with training in basic laparoscopy can safely perform laparoscopic incisional hernia repair on obese patients with minimal complications. The procedure requires a short leaning curve of no more than 3 cases and few extra materials to be feasible at any hospital in the US. Patient satisfaction with this technique is certainly gratifying.     

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 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.     

Laparoscopic Repair of Perineal Hernia

Perineal hernia is a rare but known complication following major pelvic surgery. It may occur spontaneously or following abdominoperineal resection, sacrectomy, or pelvic exenteration. Very little is known about spontaneous perineal hernia. Surgical repair via open transabdominal and transperineal approaches has been previously described. We report laparoscopic repair of spontaneous and postoperative perineal hernia in 2 patients.     

Current considerations in laparoscopic incisional and ventral herniorrhaphy.

Laparoscopic ventral and incisional herniorrhaphy is gaining popularity among both surgeons and patients. The key to the success of this procedure is avoidance of complications. In this article, important considerations in the preoperative, intraoperative, and postoperative aspects of this procedure are reviewed, with a particular focus on the repair of incisional defects. Surgical considerations to assist in the prevention of certain pitfalls associated with laparoscopic repair of ventral and incisional hernias are described.     

Ventral Hernia Repair: Outcomes Change with Long-Term Follow-Up

Background and Objectives:

Ventral hernia repairs continue to have high recurrence rates. The surgical literature is lacking data assessing the time trend to hernia recurrence after ventral hernia repairs and whether over time the recurrence rates change with laparoscopic technique compared to open repairs. Our aim was to carry out a long-term comparative analysis of ventral hernia repairs performed at our hospital over the last 10-y period to assess if outcomes change during the follow-up period.

Methods:

We conducted a retrospective observational study analyzing electronic medical records of all consecutive patients who had a ventral hernia repair from January 2001 to February 2010 at our hospital.

Results:

During the study period, 436 ventral hernia repairs were performed: laparoscopic repairs (n=156; 36%), laparoscopic converted to open (n=8; 2%), and open repairs (n=272; 62%). We analyzed the time distribution to hernia recurrence after surgery and found that 85% of recurrences after laparoscopic repairs and 77% of recurrences after open repairs occurred within 2 y of surgery. We did a Kaplan-Meier analysis for the subgroup of patients for whom we had a minimum 4-y follow-up and found that there continued to be a low subsequent yearly recurrence rate for open repairs after the initial 2-y follow-up.

Conclusion:

Most hernia recurrences occur within 2 y after surgery for ventral hernias. There appears to be a continued although low subsequent yearly rate of recurrence for open repairs.     

Evaluation of the Rebound Hernia Repair Device for Laparoscopic Hernia Repair

Background:

The characteristics of the ideal type of mesh are still being debated. Mesh shrinkage and fixation have been associated with complications. Avoiding shrinkage and fixation would improve hernia recurrence rates and complications. To our knowledge, this is the first study of a device with a self-expanding frame for laparoscopic hernia repair.

Methods:

Six Rebound Hernia Repair Devices were placed laparoscopically in pigs. This device is a condensed polypropylene, super-thin, lightweight, macro-porous mesh with a self-expanding Nitinol frame. The devices were assessed for adhesions, shrinkage, and histological examination. Laboratory and radiologic evaluations were also performed.

Results:

The handling properties of the devices facilitated their laparoscopic placement. They were easily identified with simple x-rays. The mesh was firmly integrated within the surrounding tissue. One device was associated with 3 small adhesions. The other 5 HRDs had no adhesions. We noted no shrinkage or folding. All devices preserved their original size and shape.

Conclusions:

At this evaluation stage, we found that the Rebound Hernia Repair Device may serve for laparoscopic hernia repair and has favorable handling properties. It prevents folding and shrinkage of the mesh. It may eliminate the need for fixation, thus preventing chronic pain. The Nitinol frame also allowed radiologic evaluation for gross movement. Further studies will be needed to evaluate its clinical application.