Complications of laparoscopic incisional–ventral hernia repair: the experience of a single institution

Background Laparoscopic incisional–ventral hernia repair (LIVH) is used with increasing frequency for the morbidly obese and for complex and recurrent hernias. The experience of a single institution with this technique is reviewed and the findings and complications are presented.Methods Data were collected retrospectively for a single surgeons series of patients undergoing LIVH at the institution described in this report.Results The review showed a complication rate of 15.2%, a recurrence rate of 2%, and a prosthetic infection rate of 2%. Patients with a body mass index greater than 30 cm/m² accounted for 73% of the complications and made up 62.2% of the patients.Conclusions The LIVH procedure may be safely performed with low complication and recurrence rates even for the obese, allowing ventral hernia repair to be performed safely with good results. The LIVH technique should be considered for the repair of all incisional and ventral hernias requiring repair with a mesh prosthesis.     

Laparoscopic ventral hernia repair in the elderly: does the type of hernia matter?

Purpose

Assess the impact of age and type of hernia on the outcomes of laparoscopic ventral hernia repair (LVHR).

Methods

Operating room database of all laparoscopic ventral hernias performed from April 2001 to July 2010 was analyzed retrospectively. Patients were divided into two groups: primary hernias (Group 1) and incisional hernias (Group 2). These groups were further stratified into patients <65?years of age (Groups 1A and 2A) and patients >65?years of age (Groups 1B and 2B). Patient demographics, hernia characteristics, perioperative outcomes, and disposition at discharge were compared. p-values <0.05 were considered significant.

Results

325 patients, with a mean age of 56.6?years (24–93?years) underwent LVHR. The mean length of stay (LOS) was longer (2.7?days vs 1.7?days, p value?=?0.02), and the rate of same day discharge was also significantly lower (12 vs. 25?%, p?=?0.02) for Group 2B when compared to Group 2A. Three patients in Group 2B, who had been living independently, were discharged to a skilled nursing facility, which proved significantly different when compared with Group 2A. There was no statistically significant difference in perioperative outcomes between younger and older subgroups with primary hernias.

Conclusions

LVHR in the elderly with incisional hernias have longer LOS and have a higher need for post-discharge nursing care unlike their counterparts with primary hernias. Identifying this cohort of patients early on helps the health-care providers to optimize the outcomes.     

Thirty-day readmission after ventral hernia repair: predictable or preventable?

Introduction  

Thirty-day readmission has become an increasingly scrutinized event in the field of surgery, especially in light of projected cuts in reimbursement. Although studies have evaluated large populations, little work has been done on procedure-specific populations. Our objective is to determine if any factors are predictive of 30-day readmission in patients undergoing ventral hernia repair.     

DynaMesh® in the repair of laparoscopic ventral hernia: a prospective trial

Purpose

To investigate mesh-related complications in patients undergoing laparoscopic ventral hernia repair using DynaMesh^®.

Methods

In the period 1 January 2005 through 31 December 2010, 181 consecutive patients undergoing laparoscopic ventral hernia repair in our day surgery unit using DynaMesh^® were entered prospectively in the National Danish Hernia Database. Data concerning abdominal reoperations after hernia repair were later collected on all 181 patients from the National Danish Health Registry. Postoperative telephone interviews were conducted estimating postoperative pain and patient satisfaction.

Results

Six % (11 patients) were reoperated because of mesh-related complications. Three had small bowel obstruction and one had a colonic fistula with mesh infection, all causing bowel resection and mesh removal. Mesh-related cutaneous fistula was seen in one patient. Six patients had a symptomatic recurrence requiring reoperation. Abdominal wall hematomas were seen in two cases, while two other patients had symptomatic large seromas, of which one was drained surgically. After a median follow-up of 34 months (range 12–63) in 140 patients, 66 % were pain free (0 on the Numeric Rating Scale (NRS)). Of 26 patients with moderate to severe pain (NRS > 3) at follow-up, only 4 regretted the operation. Sixteen patients thought they had a recurrence, of these only 3 regretted the operation.

Conclusion

The use of DynaMesh^® in laparoscopic ventral hernia repair was associated with a 6 % risk of mesh-related reoperation in a high volume setting. Despite chronic pain in 19 %, after 34 months follow-up patient satisfaction was high.     

Laparoscopic ventral hernia repair: are there comparative advantages over traditional methods of repair?

Recent studies have noted advantages of laparoscopic over open repair of ventral hernias. Because few reports have involved comparison with traditional repair we report a comparison between laparoscopic and open approaches. We retrospectively reviewed the records of patients undergoing ventral hernia repair over a 28-month period. Patients were grouped into three categories: laparoscopic repair with mesh, open repair with mesh, and open repair without mesh. There were 295 ventral hernia repairs and there was no difference in age, gender, operative complications, or hospital stay between the groups. Mesh and defect size was greater in the laparoscopic group. The overall postoperative complication rate was greater in the open group with mesh. Yet when specific wound complications were analyzed there was no difference between the groups. Furthermore a death occurred in the laparoscopic group from an unrecognized bowel injury. The recurrence rate was greatest in the open repair without mesh group. Finally hospital cost was greatest in the laparoscopic group and third-party reimbursement was better for the open techniques. We were unable to demonstrate a significant advantage to laparoscopic ventral hernia repair. Although many patients with large fascial defects were well served with this approach it may not be a better option for these patients.     

Validation of a questionnaire for the assessment of pain following ventral hernia repair—the VHPQ

Purpose

The aim of this study was to create and evaluate the validity and reliability of a novel ventral hernia pain questionnaire (VHPQ) to assess pain following surgery for ventral hernia.

Methods

The questionnaire was constructed using focus groups and patient interviews. Validity was tested on 51 patients who responded to the VHPQ and brief pain inventory (BPI) 1 and 4?weeks following surgery. Reliability and internal consistency was tested on 74 patients who had surgery 3?years earlier and received the VHPQ and BPI on two separate occasions. Pain not related to surgery was examined on one occasion using the VHPQ on 100 non-operated people.

Results

For pain intensity items, a significant decrease was seen from week 1 to week 4 postoperative (p?<?0.05). Spearman rank correlations were significant between the pain intensity items of the VHPQ and the BPI, tested 1?week postoperative (p?<?0.05). Kappa levels for test?Cretest of items for interference with daily activities were higher than 0.5 for all items except one. Intra-class correlation was significant for pain intensity items (p?<?0.05) in the test?Cretest group. Three years after surgery, the operated group stated more pain in the pain intensity items (p?<?0.05) and more interference with daily activities (p?<?0.05) than a non-operated group from the general population.

Conclusion

The validity and reliability of the VHPQ make it a useful tool in assessing postoperative pain and patient satisfaction.     

Variation in mesh placement for ventral hernia repair: an opportunity for process improvement?

BACKGROUND: Incisional hernia repair (IHR) with mesh has been associated with decreased hernia recurrence. We analyzed variation in mesh use for IHR. METHODS: A cohort undergoing IHR from 16 Veterans' Administration (VA) Hospitals was identified. Patient-specific variables were obtained from National Surgical Quality Improvement Program (NSQIP) data. Operative variables were obtained from physician-abstracted operative notes. Univariate and multivariable logistic regression analyses were used to model mesh implantation predictors. RESULTS: A total of 1,123 IHR cases were analyzed; Mesh was implanted in 69.6% (n = 781). Regression models demonstrated repair at a high performing facility was associated with a nearly 4-fold increase in mesh utilization. Other significant predictors include repair of recurrent hernia, chronic steroid use, and multiple fascial defects. CONCLUSIONS: There is variation in the rate of mesh placement for IHR by VA facility, even after accounting for key explanatory variables. Patterns of mesh placement in IHR appear to be based on practice style.     

Does a history of wound infection predict postoperative surgical site infection after ventral hernia repair?

BackgroundStratification of risks of postoperative wound/mesh infection after hernia repair remains a challenge. We aimed to determine the role of a previous wound infection on surgical site infection in patients undergoing open ventral hernia repair.MethodsAll patients undergoing open ventral hernia repair in a clean setting were evaluated from a prospectively maintained database. The primary end point was the development of a postoperative surgical site infection.ResultsA total of 146 patients were included in the analysis, and 22 patients had a history of previous wound infection. The rate of surgical site infection did not differ between those with or without a history of wound infection (14% vs 9%; P = .444). Patients with a history of chronic obstructive pulmonary disease or smoking were at an increased risk of developing a surgical site infection.ConclusionsFor patients undergoing open ventral hernia repair, a history of previous wound infection is not predictive of postoperative surgical site infection.     

Laparoscopic ventral hernia repair: Does primary repair in addition to placement of mesh decrease recurrence?

Background  

The advent of laparoscopic ventral hernia repair (LVHR) not only reduced the morbidity associated with open repair but also led to a decrease in the hernia recurrence rate. However, the rate continues to remain significant.     

Morbid obesity with ventral hernia: is concomitant bariatric surgery with laparoscopic ventral hernia mesh repair the best approach? An experience of over 150 cases

BackgroundObesity has been consistently associated with a higher incidence of ventral hernia. It is preferable to treat both obesity and hernia in such patients because, with weight loss, the risk of recurrence of hernia is reduced. Bariatric surgery offers the best treatment for obesity and its associated co-morbidities and in combination with intraperitoneal onlay mesh repair (IPOM) provides the best treatment in such patients. The bariatric surgical team often faces the dilemma of whether to offer concomitant bariatric surgery with IPOM or a staged procedure in such patients because the safety of a concomitant procedure still creates doubt.ObjectivesIn this study we present our long-term results of the concomitant approach in such patients to analyze its long-term safety and efficacy.SettingTertiary care teaching hospital, India.MethodsWe have performed a retrospective evaluation of all patients who underwent concomitant bariatric surgery with IPOM for primary or recurrent ventral hernia from January 2003 to July 2017 who completed a minimum follow-up of 12 months.ResultsA total of 156 patients of underwent concomitant bariatric surgery with IPOM, 120 patients (body mass index : 43.64 ± 6.8) underwent sleeve gastrectomy, and 36 patients (body mass index: 42.49 ± 8.57) underwent Roux-en-Y gastric bypass. One-hundred and seventeen patients were operated for primary hernia and 39 for recurrent hernia. There were no postoperative mesh infections and only 1 patient had recurrence.ConclusionBariatric surgery with IPOM provides the patient with a 1-stage treatment for both obesity and ventral hernia along with reduced risk of recurrence as a result of weight loss. It is safe to do a combined procedure in high volume centers with adequate expertise.     

Laparoscopic ventral hernia repair: is there an optimal mesh fixation technique? A systematic review

Purpose

The purpose of this study is to distinguish the optimal mesh fixation technique used in laparoscopic ventral hernia repair (LVHR). A particular fixation technique of the mesh to the abdominal wall is required, which should be strong enough to prevent migration of the mesh and, at the same time, keep injury to the abdominal wall minimal to prevent postoperative discomfort and pain.

Methods

An extensive literature search was performed in the PubMed database from its onset until November 2012. All series of at least 30 patients operated by laparoscopy for a ventral hernia, with the use of a standardized surgical technique well-defined in the “Methods” section, and with a follow-up of at least 12 months were included. The series were categorized according to the technique of mesh fixation described: “tacks and sutures,” “tacks only,” and “sutures only.” For each treatment group, the recurrence rate was adjusted to the number of patients treated and the 95 % confidence interval was calculated. No overlap between two intervals was defined as a significant difference in recurrence rate.

Results

A total of 25 series were included for statistical evaluation. Thirteen trials used both tacks and sutures, ten used only tacks, and two used only sutures. Overall recurrence rate was 2.7 % (95 % CI [1.9–3.4 %]).

Conclusion

None of the currently available mesh fixation techniques used for LVHR was found to be superior in preventing hernia recurrence as well as in reducing abdominal wall pain. The pain reported was remarkably high with all different fixation devices. Further research to develop solid and atraumatic fixation devices is warranted.     

Should laparoscopic paraesophageal hernia repair be abandoned in favor of the open approach?

Background The most appropriate approach to the repair of large paraesophageal hernias remains controversial. Despite early results of excellent outcomes after laparoscopic repair, recent reports of high recurrence require that this approach be reevaluated.Methods For this study, 60 primary paraesophageal hernias consecutively repaired at one institution from 1990 to 2002 were reviewed. These 25 open transabdominal and 35 laparoscopic repairs were compared for operative, short-, and long-term outcomes on the basis of quality-of -life questionnaires and radiographs.Results No difference in patient characteristics was detected. Laparoscopic repair resulted in lower blood loss, fewer intraoperative complications, and a shorter length of hospital stay. No difference in general or disease-specific quality-of-life was documented. Radiographic follow-up was available for 78% open and 91% laparoscopic repairs, showing anatomic recurrence rates of 44% and 23%, respectively (p = 0.11).Conclusions Laparoscopic repair should remain in the forefront for the management of paraesophageal hernias. However, there is considerable room for improvement in reducing the incidence of recurrence.Supported by an unrestricted educational grant from Tyco Healthcare Canada     

Acute surgical admissions at the end of life–an analysis of non-operative hospital deaths

BackgroundPatients with advanced illnesses are often admitted with acute surgical emergencies. There is currently no evidence characterising such admissions. We aimed to evaluate emergency patients, managed non-operatively, who died during the same admission.MethodsThis single-centre retrospective, observational study collected data points for a 12 month period including age, prior documented do not resuscitate order (DNAR), existing cancer, Charlson Comorbidity Index, frailty, surgical diagnosis, interval from admission to death and care given. Patients who underwent surgical intervention were excluded. Non-parametric tests were used for statistical analysis.ResultsA total of 72 patients were included in this study, of which 68.1% died within 6 days of admission (median 4.0 days). Patients with visceral perforation, obstruction, bowel ischaemia or known malignancy were more likely to die within 6 days than those with pancreatitis, sepsis or new malignancy (median 2 vs 7 days, p < 0.001). Patients with frailty (2 vs 4 days, p = 0.017) and existing DNAR (3 vs 4 days, p = 0.048) died more rapidly than those without. Age and comorbidity index did not impact time to death.ConclusionFrailty, surgical diagnosis and existing DNAR were predictors of shorter admission to death interval, while age and comorbidity index were not. This has implications on inpatient palliative care service planning.