Adhesion formation after laparoscopic ventral incisional hernia repair with polypropylene mesh: a study using abdominal ultrasound.

OBJECTIVE: Laparoscopic repair of ventral incisional hernias is feasible and safe. Polypropylene mesh is often preferred because of its ease of handling and lower cost. Complications like adhesion and fistula formation can occur. The goal of this study was to determine whether bowel adhesions and their attendant complications could be prevented by interposition of omentum. METHODS: Thirty patients underwent laparoscopic ventral incisional hernias repair with polypropylene mesh. Omentum was always positioned over the loops of bowel for protection. At a mean follow-up of 14 months, 20 patients underwent ultrasonic examination using the previously described visceral slide technique to detect adhesions. RESULTS: The mean size of the hernias in the study was 50.3 cm2, and the mean size of the mesh applied was 275 cm2. Thirteen patents (65%) had no sonographically detectable adhesions. Five patients demonstrated adhesions between the mesh and omentum, 1 patient developed adhesions between the left lobe of the liver and the mesh, and only 1 case of bowel adhesion to the edge of the mesh was found. CONCLUSION: Laparoscopic ventral incisional hernias repair with polypropylene mesh and omental interposition is not associated with visceral adhesions in the majority of patients. Polypropylene mesh can be used safely when adequate omental coverage is available.     

Logistic regression analysis of risk factors for intra-abdominal hypertension after giant ventral hernia repair: a retrospective cohort study

Hernia - Intra-abdominal hypertension (IAH) is a classical complication after giant ventral hernia surgery and may lead to abdominal compartment syndrome (ACS). Assessment of risk factors and...     

Long-term pain and recurrence after repair of ventral incisional hernias by open mesh: clinical and MRI study

Background and aims Polypropylene mesh repair of large incisional ventral hernias has become increasingly popular. Long-term effects of the mesh on pain and abdominal muscles are not known.Patients/methods Retromuscular pre-peritoneal polypropylene mesh was placed by open technique in 84 consecutive patients with large ventral hernias (mean defect size 130 cm²). We re-examined the patients after a mean follow-up time of 3 years to find out the frequency of recurrence and chronic pain. We measured the thickness of abdominal muscles of eight patients preoperatively, and postoperatively after 1 year, using magnetic resonance imaging (MRI).Results Recurrent hernias had appeared in four patients (5%) at follow-up. Nine patients (13%) needed occasional pain-relieving drugs, but only three (4%) suffered persistent, severe, pain from the mesh. Some limitation during leisure-time physical activities was found in 10% of patients. Only ten patients (12%) were re-operated on because of wound complications or recurrence. MRI study indicated that abdominal muscles were postoperatively well preserved. Although wound infections (6%) and seroma (9%) were frequent complications, there was no need for meshes to be removed in the follow-up.Conclusion Open ventral herniorrhaphy with mesh is safe, effective and inexpensive. Small, recurrent hernias were infrequent and easy to re-operated on. Severe pain from the mesh was not common. Postoperative MRI study indicated no obvious damage of abdominal muscles after mesh placement.     

Laparoscopic versus open incisional hernia repair: a retrospective cohort study with costs analysis on 269 patients

Purpose

To compare clinical outcomes and institutional costs of elective laparoscopic and open incisional hernia mesh repairs and to identify independent predictors of prolonged operative time and hospital length of stay (LOS).

Methods

Retrospective observational cohort study on 269 consecutive patients who underwent elective incisional hernia mesh repair, laparoscopic group (N = 94) and open group (N = 175), between May 2004 and July 2014.

Results

Operative time was shorter in the laparoscopic versus open group (p < 0.0001). Perioperative morbidity and mortality were similar in the two groups. Patients in the laparoscopic group were discharged a median of 2 days earlier (p < 0.0001). At a median follow-up over 50 months, no difference in hernia recurrence was detected between the groups. In laparoscopic group total institutional costs were lower (p = 0.02). At Cox regression analysis adjusted for potential confounders, large wall defect (W3) and higher operative risk (ASA score 3–4) were associated with prolonged operative time, while midline hernia site was associated with increased hospital LOS. Open surgical approach was associated with prolongation of both operative time and LOS.

Conclusions

Laparoscopic approach may be considered safely to all patients for incisional hernia repair, regardless of patients’ characteristics (age, gender, BMI, ASA score, comorbidities) and size of the wall defect (W2-3), with the advantage of shorter operating time and hospital LOS that yields reduced total institutional costs. Patients with higher ASA score and large hernia defects are at risk of prolonged operative time, while an open approach is associated with longer duration of surgical operation and hospital LOS.

     

Long-term reoperation rate following primary ventral hernia repair: a register-based study

Hernia - The aim of this study was to analyse the risk for reoperation following primary ventral hernia repair. The study was based on umbilical hernia and epigastric hernia repairs registered in...     

Recurrences after laparoscopic repair of ventral and incisional hernia: lessons learned from 505 repairs

Background  All hernia recurrences in a series of 505 patients who underwent laparoscopic repair of a ventral hernia (n = 291) or incisional hernia (n = 214) were analyzed to identify factors responsible for the recurrence. Methods  In all laparoscopic repairs, an expanded polytetrafluoroethylene prosthesis overlapping the hernia margins by ≥3 cm was fixed with a double ring of tacks alone (n = 206) or with tacks as well as sutures (n = 299). During the mean follow-up time of 31.3 ± 18.4 months, nine patients (1.8%) had a recurrence, eight of which were repaired laparoscopically. Operative reports and videotapes of all initial repairs and repairs of recurrences were analyzed. Results  All recurrences followed an incisional hernia repair (p < 0.001). Five recurrences developed after mesh fixation with both tacks and sutures and four after mesh fixation with tacks alone (p = 1.0). All recurrences were at the site of the apparently sufficient original incision scar: in eight patients, the recurrent hernia was attached to the mesh; in one, it developed in another part of the scar. All initial repairs had been performed without technical errors. Upon repair of the recurrences, a new, larger mesh was placed over the entire incision, not just the hernia. There were no re-recurrences during follow-up (mean 19.8 ± 10.3 months). Conclusions  Recurrence after incisional hernia repair appears to be due primarily to disregard for the principle that the whole incision—not just the hernia—must be repaired. Our experience supports the idea that the entire incision has a potential for hernia development. Insufficient coverage of the incision scar is a risk factor for recurrence after laparoscopic repair of ventral and incisional hernia.     

One-year follow-up after incisional hernia treatment: results of a prospective randomized study

Background  

The incidence of incisional hernia after midline laparotomies ranges from 10 to 20%. The recurrence rate after this hernia surgery varies from 25 to 52% using autogenous tissue. The use of prosthetic meshes can decrease the postoperative hernia recurrence by up to 10%. The aim of this prospective randomized clinical study was to analyze and compare the results of three different incisional hernia surgical techniques.     

Massive incisional hernia of the bowel and urinary bladder: a case report

Abdominal hernias are not rare in women, but incisional bladder herniation is uncommon. Incisional hernias are an iatrogenic condition caused by protrusion of the abdominal viscera through the abdominal fascia. Omentum and small intestines are by far the most common viscera involved, and the condition is diagnosed on clinical examination either visually or by palpation of an abdominal bulge. We describe a case of bladder and bowel herniation through a lower transverse abdominal incision (Pfannenstiel), which followed emergent operative intervention for ectopic pregnancy.     

Long-term outcomes of 1326 laparoscopic incisional and ventral hernia repair with the routine suturing concept: a single institution experience

Purpose

This retrospective chart analysis reports and assesses the long-term (beyond 10 years) safety and efficiency of a single institution’s experience in 1326 laparoscopic incisional and ventral hernia repairs (LIVHR), defending the principle of the suturing defect (augmentation repair concept) prior to laparoscopic reinforcement with a composite mesh (IPOM Plus). This study aims to prove the feasibility and validity of IPOM Plus repair, among other concepts, as a well-justified treatment of incisional or ventral hernias, rendering a good long-term outcome result.

Methods

A single institution’s systematic retrospective review of 1326 LIVHR was conducted between the years 2000 and 2014. A standardized technique of routine closure of the defect prior to the intraperitoneal onlay mesh (IPOM) reinforcement was performed in all patients. The standardized technique of “defect closure” by laparoscopy approximating the linea alba under physiological tension was assigned by either the transparietal U reverse interrupted stitches or the extracorporeal closure in larger defects. All patients benefited from the implant Parietex composite^® mesh through an Intraperitoneal Onlay Mesh placement with transfacial suturing.

Results

LIVHR was performed on 1326 patients, 52.57 % female and 47.43 % male. The majority of our patients were young (mean age 52.19 years) and obese (average BMI 32.57 kg/m²). The mean operating time was 70 min and hospital stay 2 days, with a mean follow-up of 78 months. On the overall early complications of 5.78 %, we achieved over time the elimination of the dead space by routine closure of the defect, thus reducing seroma formation to 2.56 %, with a low risk of infection <1 %. Post-op sepsis occurred in only nine cases. Three secondary serosal breakdowns and two late perforations were re-operated, and three diabetic patients had infected hematomas, necessitating mesh removal. Through technical improvement in the suturing concept and our growing experience, we managed to reduce the incidence of transient pain to a low acceptable rate of 3.24 % (VAS 5–7) that decreased to 2.56 % on a chronic pain stage, which is comparable to the literature. On the overall rate of late complications of 10.74 %, we noticed also that by reducing the dead space, the chronic pain, skin bulging, and rate of recurrence were reduced to, respectively, 2.56, 1.50, and 4.72 %. One case of mortality was due to a tracheal stenosis, responsible for an acute respiratory syndrome. On a second-look follow-up of 126 patients (9.5 %), 45.23 % were adhesion free, 42.06 % had minor adhesions classified as Müller I, and 12.69 % had serosal adhesions classified as Müller II.

Conclusion

Our long series confirms the unexpected high rate of feasibility in the suturing concept or augmentation technique, and confers additional benefits to the conventional advantages of LIVHR in terms of reducing the overall morbidity, with a low rate of recurrences. Based on our experience and study, the current best indications for a successful LIVHR procedure should be tailored upon the limitations of the defect’s width and proper patient selection, to restore adequately the optimal functionality of the abdominal muscles and provide better functional and cosmetic outcomes.

     

Postoperative surgical site infections after ventral/incisional hernia repair: a comparison of open and laparoscopic outcomes

Background

The purpose of this study was to compare the incidence of postoperative surgical site infections (SSIs), operative times (OTs), and length of hospital stay (LOS) after open and laparoscopic ventral/incisional hernia repair (VIHR) using multicenter, prospectively collected data.

Methods

The incidence of postoperative SSIs, OTs, and LOS was determined for cases of VIHR in the American College of Surgeons’ National Surgical Quality Improvement Program database in 2009 and 2010. Open and laparoscopic techniques were compared using a propensity score model to adjust for differences in patient demographics, characteristics, comorbidities, and laboratory values.

Results

A total of 26,766 cases met the inclusion criteria; 21,463 cases were open procedures (reducible, n = 15,520 [72 %]; incarcerated/strangulated, n = 5,943 [28 %]), and 5,303 cases were laparoscopic procedures (reducible, n = 3,883 [73 %]; incarcerated/strangulated, n = 1,420 [27 %]). Propensity score adjusted odds ratios (ORs) were significantly different between open and laparoscopic VIHR for reducible and incarcerated/strangulated hernias with regard to superficial SSI (OR 5.5, p < 0.01 and OR 3.1, p < 0.01, respectively), deep SSI (OR 6.9, p < 0.01, and OR 8.0, p < 0.01, respectively) and wound disruption (OR 4.6, p < 0.01 and OR 9.3, p = 0.03, respectively). The risk for organ/space SSI was significantly greater for open operations among reducible hernias (OR 1.9, p = 0.02), but there was no significant difference between the open and laparoscopic repair groups for incarcerated/strangulated hernias (OR 0.8, p = 0.41). The OT was significantly longer for laparoscopic procedures, both for reducible (98.5 vs. 84.9 min, p < 0.01) and incarcerated/strangulated hernias (96.4 vs. 81.2 min, p < 0.01). LOS (mean, 95 % confidence interval) was significantly longer for open repairs for both reducible (open = 2.79, 2.59–3.00; laparoscopic = 2.39, 2.20–2.60; p < 0.01) and incarcerated/strangulated (open = 2.64, 2.55–2.73; laparoscopic = 2.17, 2.02–2.33; p < 0.01) hernias.

Conclusions

Laparoscopic VIHR for reducible and incarcerated/strangulated hernias is associated with shorter LOS and decreased risk for superficial SSI, deep SSI, and wound disruption, but longer OTs when compared to open repair.     

Long-term clinical and radiological outcomes of anterior uncoforaminotomy for unilateral single-level cervical radiculopathy: retrospective cohort study

BACKGROUND CONTEXTAnterior cervical discectomy and fusion is a common procedure for degenerative cervical radiculopathy. In 1996, Dr. H.D. Jho reported an operative technique allowing nerve root decompression via anterior uncoforaminotomy whereas avoiding fusion.PURPOSETo assess long-term clinical and radiological outcomes of anterior uncoforaminotomy in patients with degenerative cervical spine pathology.STUDY DESIGNA single clinic, retrospective cohort study.PATIENT SAMPLEAdult patients who underwent anterior uncoforaminotomy from 2013 to 2018.OUTCOME MEASURESClinical outcomes were assessed using VAS, NDI, SF-36 criteria. Radiological parameters included sagittal balance, disc height and White anPanjabi criterion.MATERIALS AND METHODSAll patients underwent unilateral single-level anterior uncoforaminotomy, and long-term clinical and radiologic follow up was carried out. Clinical outcomes were assessed using VAS, NDI, SF-36 criteria. Radiological parameters evaluated included sagittal balance, disc height and White and Panjabi criteria (3.5 mm of translation, 11 degrees of kyphosis). The mean follow-up period was 33.3 ± 10.6 months (range 12–57 months).RESULTSAll measures of clinical outcome improved. VAS (neck) and VAS (arm) decreased 3 [2; 4] and 5 [3; 5.2] points (median [interquartile range]), respectively (p<0.001); NDI improved from 0.38 [0.36; 0.4], to 0.29 [0.22; 0.34] (p<0.001). Two patients (6%) required additional surgery one year after operation. There were no complications in the perioperative period. Disc height decreased 0.8 mm [0.1; 2.1] (p<0.001). All patients retained stability of the cervical spine based on White and Panjabi criteria. Sagittal balance parameters did not change significantly.CONCLUSIONUncoforaminotomy is an effective and safe method to decompress a unilateral single-level nerve root in degenerative cervical radiculopathy whereas preserving anatomy and motion of the cervical spine.     

Paraileostomy hernia: a clinical and radiological study

Forty-six patients who underwent colectomy with end ileostomy for ulcerative colitis (n = 33) or Crohn's disease (n = 13) have been reviewed for paraileostomy hernia (PIH) formation 1-16 years after surgery. PIH developed in 13 of these patients (28 per cent) and was not related to the original disease or excessive weight gain. Twenty-eight patients underwent limited computed tomography (CT) scanning of the stomal region. Eight of these had a clinically detectable PIH, which was demonstrated on CT. A further two patients had PIH demonstrated on CT which was not detected by clinical examination. The rate of PIH was similar where the stoma emerged lateral to the rectus abdominis muscle (six out of 16 patients, 37 per cent) to where the stoma emerged through the rectus (four out of 12 patients, 33 per cent). Recurrence following operative repair of PIH was common. PIH occurs more frequently than previously supposed. CT can detect PIH and may be useful in evaluating a patient with stoma-related symptoms for occult PIH formation.     

No enterocutaneous fistula development in a cohort of 695 patients after incisional hernia repair using intraperitoneal uncoated polyproylene mesh

Hernia - To determine the incidence of enterocutaneous fistulas (ECFs) developed after elective incisional hernia (IH) repair using intraperitoneal uncoated polypropylene (PPE) mesh. This is a...     

Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study

Background Incisional hernia is an important complication of abdominal surgery. Its repair has progressed from a primary suture repair to various mesh repairs and laparoscopic repair. Laparoscopic mesh repair is a promising alternative, and in the absence of consensus, needs prospective randomized controlled trials. Methods Between April 2003 and April 2005, 66 patients with incisional, primary ventral and recurrent hernias were randomized to receive either open retrorectus mesh repair or laparoscopic mesh repair. These patients were followed up at 1-, 3-, and 6-month intervals thereafter for a mean of 12.17 months (open repair group) and 13.73 months (laparoscopic repair group). Results Lower abdominal hernias after gynecologic operations constituted the majority of the hernias (∼50%) in both groups. There was no significant injury to viscera or vessel in either group and no conversions. The defect size was 42.12 cm² in the open (group 1) and 65.66 cm² in the laparoscopic group (group 2), and the prosthesis sizes were, respectively, 152.67 cm² and 203.83 cm². The hospital stay was 3.43 days in open group and 1.47 days in laparoscopic group (p = 0.007). There was no significant difference in the pain scores between the two groups. More wound-related infectious complications occurred in the open group (33%) than in the laparoscopic group (6%) (p = 0.013). There was one recurrence in the open repair group (3%) and two recurrences in laparoscopic group (6%) (p = 0.55). Conclusions Laparoscopic repair of incisional and ventral hernias is superior to open mesh repair in terms of significantly less blood loss, fewer complications, shorter hospital stay, and excellent cosmetic outcome.     

Comparison of laparoscopic hernia repair and open herniotomy in children: a retrospective cohort study

Background

Laparoscopic hernia repair in infancy and childhood is still debatable. The objective of this study is to compare laparoscopic-assisted hernia repair (LH) versus open herniotomy (OH) as regards operative time, postoperative complications, recurrence rate, and contralateral metachronous hernia rate.

Methods

We analyzed all the patients with inguinal hernia who underwent surgery in our hospital from January 1, 2015 to December 31, 2015. There were 1125 patients, of which 202 patients received laparoscopic inguinal hernia repair (group A) and 923 patients received open herniotomy (group B). We recalled all the patients’ records to identify operative time, postoperative hydrocele formation, and contralateral patent processus vaginalis (CPP) detection; we recalled all the patients’ parents to identify the ipsilateral and contralateral recurrence and the testis position.

Results

During the study period, the lost to follow-up rate is 9.9% in group A and 14.1% in group B. The mean follow-up period was about 10.1 months. The mean operative time for females with bilateral hernia in group A was much shorter than that for those in group B (P = 0.001). The postoperative hydrocele formation rate in group A was 1.5%, compared with 8.2% in group B (P = 0.001). The recurrence rate was 0.64% in group A, whereas in group B the recurrence rate was 0.46%. Of patients with unilateral hernia, none in group A experienced a contralateral metachronous hernia (MH) compared with 10.1% in group B (P < 0.001) and 65% MH appeared in 3 months after the first hernia repair. Females and patients with initial left-sided hernia tended to have a contralateral MH after the first open hernia repair.

Conclusion

Laparoscopic hernia repair in children is safe and effective, especially for female patients and patients with initial left-sided hernia. We recommend repairing the CPP simultaneously when performing laparoscopic procedures.

     

Successful repair of a bladder herniation after old traumatic pubic symphysis diastasis using bone graft and hernia mesh

Bladder herniation associated with pubic symphysis diastasis is a very rare condition. We report a case with bladder herniation after traumatic pubic symphysis disruption. The patient was treated with open reduction of the bladder and definitive internal fixation of the pubis. We used a bone allograft for closure of the diastasis and a prolene mesh graft for supporting the abdominal wall. We obtained a successful outcome during a 12-month follow-up period.     

Long-term follow-up after umbilical hernia repair: are there risk factors for recurrence after simple and mesh repair

Adult umbilical hernia is a common surgical condition mainly encountered in the fifth and sixth decade of life. Despite the high frequency of the umbilical hernia repair procedure, disappointingly high recurrence rates, up to 54% for simple suture repair, are reported. Since both mesh and suture techniques are used in our clinic we set out to investigate the respective recurrence rates and associated complications, retrospectively. Patients who were treated between January 1998 and December 2002 were identified from our hospital database and invited to attend the outpatient department for an extra follow-up, history taking and physical examination. The use of prosthetic material, occurrence of surgical site infection, body mass and height as well as recurrence were recorded at the time of this survey. In total, 131 consecutive patients underwent operative repair of an umbilical hernia. Twenty-eight percent of the patients were female (n=37). In 12 patients (11%) umbilical hernia repair was achieved with mesh implantation. Fourteen umbilical hernia recurrences were noted (13%); none had been repaired using mesh. No relationship was found between wound infection or obesity and umbilical hernia recurrence. In the light of these results it is necessary to re-evaluate our clinical “guidelines” on mesh placement in umbilical hernia repair: apparently not every umbilical fascial defect needs mesh repair. Research should focus on establishing risk factors for hernia recurrence.