Laparoscopic repair of chronic traumatic diaphragmatic hernia using biologic mesh with cholecystectomy for intrathoracic gallbladder

Background and Objectives:

Diaphragmatic rupture is a serious complication of both blunt and penetrating abdominal trauma. In the acute setting, delay in diagnosis can lead to severe cardiovascular and respiratory compromise. Chronic cases can present years later with a plethora of clinical symptoms. Laparoscopic techniques are being increasingly utilized in the diagnosis and treatment of traumatic diaphragmatic hernias.

Method:

We describe a case of a 70-year-old female who presented with signs and symptoms of a small bowel obstruction. She was ultimately found to have an obstruction secondary to a chronic traumatic diaphragmatic hernia with an intrathoracic gallbladder and incarcerated small intestine. A cholecystectomy and diaphragmatic hernia repair were both performed laparoscopically. This case report presents an atypical cause of bowel obstruction and reviews the current literature on laparoscopic management of traumatic diaphragmatic hernias.

Results and Conclusion:

Laparoscopy is increasingly used in the diagnosis and treatment of traumatic diaphragmatic hernias with good results.     

Laparoscopic Repair of a Posttraumatic Left-Sided Diaphragmatic Hernia Complicated by Strangulation and Colon Obstruction

Background:

Posttraumatic diaphragmatic hernias (PDH) are serious complications of blunt and penetrating abdominal or thoracic trauma. Traditional thoracic or abdominal operations are usually performed in these cases.

Methods:

We present 2 cases of posttraumatic left-sided diaphragmatic hernia complicated by strangulation and colon obstruction. Both cases were successfully treated with laparoscopy.

Results:

We found that laparoscopy is a safe, successful, and gentle procedure not only for diagnosis but also for treatment of complicated PDH. Strangulation and colon obstruction were not contraindications to performing laparoscopic procedures. The postoperative course and long-term follow-up (range, 12 to 30 months) were uneventful and short. We expect the same good long-term results after laparoscopic repair as after open conventional surgery.

Conclusion:

We recommend the use a minimally invasive approach to treat posttraumatic diaphragmatic hernia complicated by strangulation and colon obstruction in hemodynamically stable patients.     

Abdominal wall hernia and aortic injury secondary to blunt trauma: Case report and review of the literature

INTRODUCTION

Traumatic abdominal wall hernia (TAWH) and traumatic abdominal aortic injury (TAAI) are two uncommon complications secondary to blunt trauma. In both TAWH and TAAI, reported cases are often associated with poly-trauma. TAWH may be initially missed if more pressing issues are identified during the patient''s primary survey. TAAI may be an incidental finding on imaging or, if severe, a cause of an acute abdomen and hemodynamic abnormality.

PRESENTATION OF CASE

A 54-year-old white male suffered a TAWH and TAAI (pseudoaneurysm) due to severe blunt trauma. TAWH was apparent on physical exam and the TAAI was suspected on computed tomography (CT). The patient''s TAWH was managed with a series of abdominal explorations and the TAAI was repaired with endovascular stenting.

DISCUSSION

TAWH and TAAI are commonly due to severe blunt trauma from motor vehicle collisions. Diagnosis is made through physical exam, imaging studies, or surgical exploration. A variety of surgical techniques achieve technical success.

CONCLUSION

The patient with blunt trauma to the abdomen is at risk for TAWH and TAAI, which are often associated with other injuries. Investigations should include thorough clinical exam through secondary survey and radiologic imaging in the hemodynamically normal patient.     

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.     

Laparoscopic 5-mm trocar site herniation and literature review

Objective:

To evaluate the evidence for fascial closure of 5-mm laparoscopic trocar sites.

Methods:

We conducted electronic database searches of PubMed and the Cochrane Library for articles published between November 2008 and December 2010. We used the keywords trocar hernia, trocar-site hernia, laparoscopic hernia, trocar port-site hernia, laparoscopic port-site hernia. Prospective and retrospective case series, randomized trials, literature reviews, and randomized animal studies of trocar hernias on abdominal wall defects from gynecologic, urologic, and general surgery literature were reviewed. The Cochrane Database was reviewed for pertinent studies. Metaanalysis was not possible due to the significant heterogeneity between studies and lack of randomized trials large enough to assess the incidence of this rare complication.

Results:

Trocar-site hernias are a rare but known complication of laparoscopic surgery. Trocar size ≥10mm is associated with an increased rate of hernia development. Currently, the accepted gynecologic surgical practice is closure of fascial incisions ≥10mm, while incisions <10mm do not require closure. However, large prospective and retrospective case series reports from general surgery and urology literature support nonclosure of blunt or radially dilating trocars in paramedian sites. Expert opinion and small case reports suggest that in cases of prolonged manipulation of 5-mm trocar sites the surgeon should consider fascial closure, because extension of the initial incision may have occurred.

Conclusion:

There is no evidence to recommend routine closure of 5-mm trocar incisions; the choice should continue to be left to the discretion of the individual surgeon.     

Symptomatic Right-Sided Diaphragmatic Hernia in the Third Trimester of Pregnancy

Background:

Laparoscopic repair of incarcerated diaphragmatic hernias is widely recognized as both safe and effective. However, symptomatic diaphragmatic hernias encountered in the setting of pregnancy, while rare, present a significant surgical challenge. Furthermore, right-sided diaphragmatic hernias account for only 13% of cases. Here, we present a case in which a symptomatic, posterior right-sided diaphragmatic hernia, presenting in the later stages of pregnancy, was successfully repaired using a laparoscopic approach.

Methods:

Our patient is a 42-y-old gravid woman who, at 27 wk gestation, was admitted to the gynecology service with a 2-d history of right upper quadrant abdominal pain, right shoulder pain, abdominal distension, and obstipation.

Results:

Computed tomography of the chest demonstrated an incarcerated right diaphragmatic hernia. Surgical consultation was obtained, and the patient was taken to the operating room urgently for repair. Intraoperatively, the cecum was reduced and the diaphragm repaired primarily using a laparoscopic approach. The patient recovered well and was discharged home on postoperative day 8 with no complications to the patient or the pregnancy.

Conclusion:

Laparoscopic reduction and repair of symptomatic incarcerated diaphragmatic hernia can be safely performed in the third trimester of pregnancy.     

Laparoscopic repair of incidentally found Spigelian hernia

Background and Objectives:

A Spigelian hernia is a rare type of hernia that occurs through a defect in the anterior abdominal wall adjacent to the linea semilunaris. Estimation of its incidence has been reported as 0.12% of all abdominal wall hernias. Traditionally, the method of repair has been an open approach. Herein, we discuss a series of laparoscopic repairs.

Methods:

Case series and review of the literature.

Cases:

Three patients are presented. All were evaluated and taken to surgery initially for a different disease process, and all were incidentally found to have a spigelian hernia. These patients underwent laparoscopic repair of their hernias; 2 were repaired intraperitoneally and one was repaired totally extraperitoneally. Two patients initially underwent a mesh repair, while the third had an attempted primary repair.

Conclusions:

There is evidence that supports the use of laparoscopy for both diagnosis and repair of spigelian hernias. There are also reports of successful repairs both primarily and with mesh. In our experience with the preceding 3 patients, we found that laparoscopic repair of incidentally discovered spigelian hernias is a viable option, and we also found that implantation of mesh, when possible, resulted in satisfactory results and no recurrence.     

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.     

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.     

Traumatic flank hernias: acute and chronic management

BACKGROUND: Traumatic flank hernias are increasingly recognized as occurring after severe blunt injury. To clarify the role and timing of operative therapy, we review here our recent experience. METHODS: A prospectively maintained database at Oklahoma's only level I trauma center was reviewed to identify all patients presenting with traumatic flank hernias. RESULTS: During the period from July 2001 through February 2007, 25 patients (.2% of all blunt trauma patients) had traumatic flank hernias. The average age was 36.4 years (range 13 to 66), and all cases but 1 were related to motor vehicle crashes. All patients had at least 1 associated injury. Repairs were done by standardized approach. Eleven patients underwent immediate surgery; 8 underwent delayed repair; and 3 underwent late repair (range 4.5 to 10 years after injury). The other 3 patients were managed expectantly. There was 1 mortality and 3 recurrences. Length of stay for acute trauma ranged from 5 to 49 days and was dependent on the severity of associated injuries. Follow-up of 21 patients ranged from 7 to 710 days. CONCLUSIONS: Traumatic flank hernias are rare but more common than previously recognized. Prompt recognition, proper timing, and technique are key to successful outcomes.     

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.     

Obturator Hernia: Laparoscopic Diagnosis and Repair

Objective:

Review of international literature reveals eight reported cases of laparoscopic obturator hernia repair. Non-specific signs and symptoms make the diagnosis of an obturator hernia difficult. Laparoscopic intervention provides a minimally invasive method to simultaneously diagnose and repair these hernias.

Methods and Procedures:

A 35 year old woman presented with lower abdominal pain, vaginal bleeding, and dyspareunia. During gynecological diagnostic laparoscopy, a pelvic floor hernia was suspected, and a general surgical evaluation was sought. At a subsequent laparoscopy, the diagnosis of a left direct inguinal and a right obturator hernia was made. Both were repaired laparoscopically with polypropylene mesh.

Results:

At follow-up at one and six weeks postoperatively, the patient''s complaints of pain had completely resolved.

Conclusion:

The diagnosis of obturator hernia is problematic. The usual presenting signs and symptoms are non-specific. Without conclusive historical or physical findings, laparoscopy is an excellent method for diagnosing obturator hernia. This entity, once diagnosed laparoscopically, can be repaired simultaneously via laparoscopic mesh technique.     

CRITICAL ANALYSIS OF EXPERIMENTAL MODEL FOR STUDY OF ADHESIONS AFTER INCISIONAL HERNIAS INDUCED IN RATS’ AND REPAIR OF ABDOMINAL WALL WITH DIFFERENT BIOMATERIALS

Background:

Adhesions induced by biomaterials experimentally implanted in the abdominal cavity are basically studied by primary repair of different abdominal wall defects or by the correction of incisional hernias previously performed with no precise definition of the most appropriate model.

Aim:

To describe the adhesions which occur after the development of incisional hernias, before the prosthesis implantation, in an experimental model to study the changes induced by different meshes.

Methods:

Incisional hernias were performed in 10 rats with hernia orifices of standardized dimensions, obtained by the median incision of the abdominal wall and eversion of the defect edges. Ten days after the procedure adhesions of abdominal structures were found when hernias were repaired with different meshes.

Results:

The results showed hernia sac well defined in all rats ten days after the initial procedure. Adhesions of the greater omentum occurred in five animals of which two also showed adhesions of small bowel loops besides the omentum, and another two showed liver adhesions as well as the greater omentum, numbers with statistical significance by Student''s t test (p<0.05).

Conclusion:

Although it reproduces the real clinical situation, the choice of experimental model of incisional hernia repair previously induced implies important adhesions, with possible repercussions in the evaluation of the second operation, when different implants of synthetic materials are used.     

Conversion to Stoppa Procedure in Laparoscopic Totally Extraperitoneal Inguinal Hernia Repair

Background and Objectives:

Conversion to open surgery is an important problem, especially during the learning curve of laparoscopic totally extraperitoneal (TEP) inguinal hernia repair.

Methods:

Here, we discuss conversion to the Stoppa procedure during laparoscopic TEP inguinal hernia repair. Outcomes of patients who underwent conversion to an open approach during laparoscopic TEP inguinal hernia repair between September 2004 and May 2010 were evaluated.

Results:

In total, 259 consecutive patients with 281 inguinal hernias underwent laparoscopic TEP inguinal hernia repair. Thirty-one hernia repairs (11%) were converted to open conventional surgical procedures. Twenty-eight of 31 laparoscopic TEP hernia repairs were converted to modified Stoppa procedures, because of technical difficulties. Three of these patients underwent Lichtenstein hernia repairs, because they had undergone previous surgeries.

Conclusion:

Stoppa is an easy and successful procedure used to solve problems during TEP hernia repair. The Lichtenstein procedure may be a suitable option in patients who have undergone previous operations, such as a radical prostatectomy.     

Incarcerated hernia in 11-mm nonbladed trocar site following laparoscopic appendectomy

Background:

Nonbladed trocars are considered less traumatic to the abdominal wall due to the lack of fascial incision. It has been suggested that closure of the abdominal fascia may be unnecessary when such nonbladed trocars are used.

Case Report:

We report on 2 patients who were diagnosed with trocar-site hernias 2 days after laparoscopic appendectomy performed using 11-mm nonbladed trocars.

Conclusion:

Although rare, trocar-site hernias after laparoscopic surgery with nonbladed trocars remain a cause of postoperative morbidity and require prompt intervention. Therefore, this report underscores the significance of performing meticulous closure of all trocar sites that are ≥10mm.     

QUALITY OF LIFE OF IN PATIENTS SUBMITTED TO ANTERIOR ABDOMINAL WALL LAPAROSCOPIC HERNIOPLASTY

Background

The laparoscopic ventral hernia repair technique made possible surgeries with smaller skin incisions and smaller dissection of the soft tissue around the hernia, therefore with a better wound, a quicker postoperative recovery and a lower complication rate.

Aim

To evaluate the applicability of a quality of life survey based on the molds of the American Hernia Society, European Hernia Society and Carolinas Equation for Quality of Life, through telephone in patients submitted to laparoscopic hernioplasty by IPOM technique.

Methods

A retrospective cohort study was made to evaluate the quality of life of 21 patients that underwent anterior abdominal wall laparoscopic hernioplasty by intraperitoneal onlay mesh technique. Questionnaire was applied through telephone.

Results

Of the 21 patients, 19% felt that the hernia recurred. Also 19% passed through another abdominal wall surgery, and among these, 75% was related to the previously hernia correction. Finally, 81% of patients did not undergo any other abdominal wall surgery.

Conclusion

It was possible to apply the quality of life questionnary by telephone on patients who underwent an anterior abdominal wall. The results, in its turn, were satisfactory and showed that patients, in general, were satisfied with the surgical procedure.     

The Role of Laparoscopy in the Management of Groin Hernia

Introduction:

The advantage of using minimally invasive techniques over open techniques in the repair of groin hernias is still debated. Despite its more widespread use, an apparent dichotomy exists. While some surgeons continue to believe that no advantage is gained using the laparoscopic technique, others argue laparoscopic hernia repair (LHR) offers a quicker recovery with the use of a tensionfree repair.

Methods:

A mailing to the general surgeon members of the Society of Laparoendoscopic Surgeons, an international multidisciplinary laparoendoscopic society, was performed (mailing size=l680).

Results:

Nine hundred and ninety-three surgeons responded (60%). Across all demographic variables, 60% of respondents performed approximately 27% of their hernia repairs laparoscopically (40% of respondents did not perform LHR). Surgeon age less than 45 was the only demographic characteristic that predicted the likelihood to perform LHR (p<0.0001) and the percentage of hernias repaired laparoscopically (p<0.005). Most respondents felt that the presence of bilateral hernias (73%) or a recurrent hernia (74%) were indications for LHR. Eighty-nine percent of respondents felt that LHR would still be performed 20 years from now. Surgeons expressed concerns regarding increased cost, the need for more anesthesia, and a lack of long-term follow-up for LHR.

Conclusions:

Only surgeon age predicted the likelihood of a surgeon performing LHR or the percentage of hernias that would be repaired laparoscopically.     

Radiological and clinical examination in the diagnosis of Spigelian hernias

Introduction

Spigelian hernia are rarely reported lateral abdominal wall hernias. Clinical diagnosis of a suspected hernia can be challenging owing to vague presenting symptoms and signs. This study aimed to investigate the accuracy of preoperative imaging and clinical examination in the diagnosis of Spigelian hernias.

Methods

A retrospective analysis was performed of patients who presented to North Tyneside and Wansbeck General Hospitals between 1998 and 2010. All patients were assessed by a consultant general surgeon in the outpatient clinic or on the surgical admissions ward. Patients were included who presented with a history suggestive of a Spigelian hernia and a palpable lump or equivocal clinical examination. All patients proceeded to surgery, which was used as the reference standard.

Results

Overall, correlation with operative findings showed computed tomography (CT) to have a sensitivity of 100% and a positive predictive value (PPV) of 100%. Ultrasonography had a sensitivity of 90% and a PPV of 100%. Clinical assessment alone had a sensitivity of 100% and a PPV of 36%.

Conclusions

This study shows that ultrasonography and CT have a high sensitivity and PPV in relation to occult Spigelian hernias. When no obvious Spigelian hernia is present, patients should be evaluated with radiological investigation to establish a diagnosis. Owing to diagnostic uncertainty, a laparoscopic approach should be favoured.     

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.