4
INTRODUCTION Incisional hernia is a common complication of most abdominal surgery. 1 Until recently, ventral incisional hernia has been repaired with an open technique with or without prosthetic mesh. The recurrence rate for open repair using conventional suturing techniques has been reported to be as high as 46%. 2 Although the recurrence rate has decreased to 5–15% with the use of a prosthetic mesh repair, 3–7 the morbidity associated with postoperative pain, wound haematoma, infection and long hos- pital stay remains a problem. 5–7 With the advances in laparo- scopic surgery, there is an opportunity to reduce such morbidity and save cost. Laparoscopic ventral incisional hernioplasty using intraperi- toneal onlay mesh was first reported in 1993. 8 Since then there have been sporadic case reports and small series published. 9–12 Fears of excessive adhesions to intraperitoneal mesh seem to have prevented widespread acceptance of the procedure. Manufacturers of mesh are helping to counter these fears with the development of prosthetic materials more suitable for intraperitoneal use, and there are encouraging early reports about the use of a composite mesh (Bard Composix mesh, Cranston, RI, USA). 13 METHODS We retrospectively reviewed and reported 30 cases of laparo- scopic ventral incisional hernia repairs mostly performed by two of the senior authors (NO’R and IM). Laparoscopic repairs were performed under general anaesthesia via a 10-mm camera port and usually two 5-mm working ports. A 30 degree scope was used. The specific placement of these ports was dependent on the location of the incisional hernia and the body habitus. For midline incisional hernia, a 10-mm camera port was inserted laterally via the open technique and two 5 mm ports were inserted as shown in Figs 1, 2. For non-midline incisional hernia, a 10-mm camera port was inserted sub- or supra-umbilically or laterally on the opposite side of the abdomen, and two 5-mm ports were inserted laterally away from the hernia (Figs 3, 4). Once the peritoneal cavity had been entered, intra-abdominal adhesions, if present, were divided. The margins of the hernia defect were identified and omentum, and bowel adherent to it were taken down. In this study, there was no inadvertent enter- otomy of the small or large bowel. The hernia sac was not routinely dissected. Primary suture repair was used for single defect < 1 cm in diameter. Otherwise, a mesh was used if the defect ANZ J. Surg. 2002; 72: 296–299 SURGICAL TECHNIQUE LAPAROSCOPIC REPAIR OF VENTRAL INCISIONAL HERNIA KEITH B. KUA,* MARK COLEMAN,* IAN MARTIN AND NICHOLAS O’ROURKE* Department of Surgery, * Royal Brisbane Hospital and Princess Alexandra Hospital, Brisbane, Queensland, Australia Background: Laparoscopic repair of ventral incisional hernias was first reported in 1993. Since then, there have been sporadic case reports and small series published about this procedure, but it has not been widely adopted. Newer types of composite prosthetic mesh may reduce the potential problem of bowel adhesion. Methods: Thirty cases of laparoscopic ventral incisional hernia repairs (carried out by two surgeons or their senior registrars) have been retrospectively reviewed and reported in this article. The data were obtained from patient records and subsequent phone surveys. Results: Thirty patients between 29 and 82 years (mean: 58 years) underwent this procedure. There were 14 men and 16 women. The average weight of the patients was 81 kg. The hernias were up to 6 or 7 cm in diameter. Mesh was used in 28 cases (polypropylene in 25 cases, expanded polytetrafluoroethylene in two cases and composite mesh in one case). Most meshes were laid intraperitoneally and fixed into position with laparoscopic spiral tacks. Twenty-nine cases were completed laparoscopically. One oper- ation (3.3%) was converted to an open procedure because of severe bowel adherence to the hernia sac. The mean operating time was 52 min for laparoscopic ventral incisional hernia repairs only. All but two patients tolerated an oral diet within 24 h. The postoperative hospital stay ranged from 0 to 11 days, with 17 patients (57%) staying overnight and eight patients (27%) staying another day. Over 80% of the patients returned to house duties within a week. There was no mortality, and minor complications occurred in four patients (14%). One patient had a small bowel obstruction treated successfully by repeat laparoscopy with division of fibrinous adhesions to polypropylene mesh on day four. Follow up ranged from 1 to 69 months (mean: 12 months). One patient did not attend follow-up appointments. There were three cases of hernia recurrence (10%). Conclusion: The results suggest that laparoscopic repair of ventral incisional hernias is a safe, effective and technically feasible oper- ation for small- to medium-sized hernias allowing shorter hospital stay, early recovery and resumption of normal activities. However, recurrence rates are comparable to open mesh hernioplasty especially for larger hernias. Key words: laparoscopy, incisional hernia, mesh repair. Abbreviations: BMI, body mass index; EPTFE, expanded polytetrafluroethylene; PPM, polyproylene mesh. Keith B. Kua MB BS; M. Coleman MB BS; I. Martin MB BS, FRACS; N. O’Rourke MB BS, FRACS. Correspondence: Dr K. B. Kua, Department of Surgery, Royal Brisbane Hospital, Corner of Herston and Bowen Bridge Roads, Brisbane, Qld 4029, Australia. Email: [email protected] Accepted for publication 22 October 2001.

Laparoscopic repair of ventral incisional hernia

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Page 1: Laparoscopic repair of ventral incisional hernia

INTRODUCTION

Incisional hernia is a common complication of most abdominalsurgery.1 Until recently, ventral incisional hernia has beenrepaired with an open technique with or without prostheticmesh. The recurrence rate for open repair using conventionalsuturing techniques has been reported to be as high as 46%.2Although the recurrence rate has decreased to 5–15% with the useof a prosthetic mesh repair,3–7 the morbidity associated withpostoperative pain, wound haematoma, infection and long hos-pital stay remains a problem.5–7 With the advances in laparo-scopic surgery, there is an opportunity to reduce such morbidity andsave cost.

Laparoscopic ventral incisional hernioplasty using intraperi-toneal onlay mesh was first reported in 1993.8 Since then there havebeen sporadic case reports and small series published.9–12 Fears of excessive adhesions to intraperitoneal mesh seem to haveprevented widespread acceptance of the procedure. Manufacturers

of mesh are helping to counter these fears with the development of prosthetic materials more suitable for intraperitoneal use, andthere are encouraging early reports about the use of a compositemesh (Bard Composix mesh, Cranston, RI, USA).13

METHODS

We retrospectively reviewed and reported 30 cases of laparo-scopic ventral incisional hernia repairs mostly performed by two ofthe senior authors (NO’R and IM).

Laparoscopic repairs were performed under general anaesthesiavia a 10-mm camera port and usually two 5-mm working ports. A30 degree scope was used. The specific placement of these portswas dependent on the location of the incisional hernia and the bodyhabitus. For midline incisional hernia, a 10-mm camera port wasinserted laterally via the open technique and two 5 mm portswere inserted as shown in Figs 1, 2. For non-midline incisionalhernia, a 10-mm camera port was inserted sub- or supra-umbilicallyor laterally on the opposite side of the abdomen, and two 5-mmports were inserted laterally away from the hernia (Figs 3, 4).Once the peritoneal cavity had been entered, intra-abdominaladhesions, if present, were divided. The margins of the herniadefect were identified and omentum, and bowel adherent to itwere taken down. In this study, there was no inadvertent enter-otomy of the small or large bowel. The hernia sac was not routinelydissected. Primary suture repair was used for single defect < 1 cm in diameter. Otherwise, a mesh was used if the defect

ANZ J. Surg. 2002; 72: 296–299

SURGICAL TECHNIQUE

LAPAROSCOPIC REPAIR OF VENTRAL INCISIONAL HERNIA

KEITH B. KUA,* MARK COLEMAN,* IAN MARTIN† AND NICHOLAS O’ROURKE*

Department of Surgery, *Royal Brisbane Hospital and †Princess Alexandra Hospital, Brisbane, Queensland, Australia

Background: Laparoscopic repair of ventral incisional hernias was first reported in 1993. Since then, there have been sporadic casereports and small series published about this procedure, but it has not been widely adopted. Newer types of composite prosthetic meshmay reduce the potential problem of bowel adhesion.Methods: Thirty cases of laparoscopic ventral incisional hernia repairs (carried out by two surgeons or their senior registrars) have been retrospectively reviewed and reported in this article. The data were obtained from patient records and subsequent phonesurveys.Results: Thirty patients between 29 and 82 years (mean: 58 years) underwent this procedure. There were 14 men and 16women. The average weight of the patients was 81 kg. The hernias were up to 6 or 7 cm in diameter. Mesh was used in 28 cases(polypropylene in 25 cases, expanded polytetrafluoroethylene in two cases and composite mesh in one case). Most meshes were laidintraperitoneally and fixed into position with laparoscopic spiral tacks. Twenty-nine cases were completed laparoscopically. One oper-ation (3.3%) was converted to an open procedure because of severe bowel adherence to the hernia sac. The mean operating time was52 min for laparoscopic ventral incisional hernia repairs only. All but two patients tolerated an oral diet within 24 h. The postoperativehospital stay ranged from 0 to 11 days, with 17 patients (57%) staying overnight and eight patients (27%) staying another day. Over80% of the patients returned to house duties within a week. There was no mortality, and minor complications occurred in four patients(14%). One patient had a small bowel obstruction treated successfully by repeat laparoscopy with division of fibrinous adhesions topolypropylene mesh on day four. Follow up ranged from 1 to 69 months (mean: 12 months). One patient did not attend follow-upappointments. There were three cases of hernia recurrence (10%).Conclusion: The results suggest that laparoscopic repair of ventral incisional hernias is a safe, effective and technically feasible oper-ation for small- to medium-sized hernias allowing shorter hospital stay, early recovery and resumption of normal activities.However, recurrence rates are comparable to open mesh hernioplasty especially for larger hernias.

Key words: laparoscopy, incisional hernia, mesh repair.Abbreviations: BMI, body mass index; EPTFE, expanded polytetrafluroethylene; PPM, polyproylene mesh.

Keith B. Kua MB BS; M. Coleman MB BS; I. Martin MB BS, FRACS; N. O’Rourke MB BS, FRACS.

Correspondence: Dr K. B. Kua, Department of Surgery, Royal BrisbaneHospital, Corner of Herston and Bowen Bridge Roads, Brisbane, Qld 4029,Australia.Email: [email protected]

Accepted for publication 22 October 2001.

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was > 1 cm in diameter, if there were multiple defects, or if thehernia was deemed too large to be closed primarily with sutureswithout causing unacceptable tension. The mesh was fashionedaccording to the size of the defect and introduced into theabdominal cavity either by pushing or, occasionally, rolling itup and pushing it down the 10-mm camera port. Larger pieces ofmesh were rolled up and pushed through the 10-mm port site byremoving the port and the telescope and reintroducing them.The mesh was then grasped by the laparoscopic forceps and laidintraperitoneally. It was attached to the abdominal wall usinglaparoscopic spiral tacks with a minimum of 2–3 cm of healthytissue surrounding the defect.11 Where possible, omentum wasinterposed between the mesh and underlying bowel. The 10-mmport site defect was closed with 0-nylon sutures.

In 21 cases, mesh was laid intraperitoneally and held in placewith laparoscopic spiral tacks (Origin Medsystems, MenloPark, CA, USA). The number of tacks used varied according to the surgeon and the size of the defects. It ranged from 10 tacks for small hernia defects, to 60 tacks for larger defects. Thetacks were stapled into the periphery and the centre of themesh. The security of the fixation was judged by the mobility ofthe mesh at the end of the procedure. In the remaining patients,mesh was placed extraperitoneally by creating an extraperi-toneal space with an Origin balloon (Origin Medsystems,Menlo Park, CA, USA) or transperitoneally by incising the

peritoneum to make a pocket to cover the mesh. Only twopatients with small defects < 1 cm were closed laparoscopicallywith 3/0 Novafil sutures.

All hospital charts were reviewed and follow up was con-ducted via hospital and clinic charts and phone interviews. Onlyone patient was lost to follow up.

RESULTS

There were 14 men and 16 women involved in the study. Theaverage age was 58 years (men: 64 years; women: 53 years) and the average weight was 81 kg (men: 87 kg; women: 78 kg). At least17 patients (57%) had significant comorbidities that includedobesity (BMI > 30), age > 70 years, cardiopulmonary diseases,steroid-dependent illnesses, diabetes mellitus, hepatic or renalinsufficiency. Nine patients (30%) had had previous herniarepairs at the same site, five of these patients had had more than onerepair. The sites of the ventral incisional hernias are outlined inTable 1.

Twenty-nine of 30 operations (97%) were completed laparo-scopically. One operation was converted to an open procedurebecause of severe omental and bowel adherence to the herniasac. In analysis, adhesions requiring more than 15–20 min dis-section to define the hernia were present in 19 of 29 cases(66%). The hernias were up to 6 or 7 cm in diameter. Omentum

Fig. 1. Operating theatre positioning for upper-midline hernias.Fig. 2. Operating theatre positioning for lower-midline hernias.

Fig. 3. Operating theatre positioning for right iliac fossa hernias. Note the different positions of the 10-mm camera port.

Fig. 4. Operating theatre positioning for left-upper-quadranthernias.

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298 KUA ET AL.

was adherent to the hernia sac in 12 cases altogether, three ofwhich had bowel adhered to it as well.

Thirteen patients (45%) had more than one hernia defectpresent on laparoscopy with some patients having multipledefects clustered together. These clustered defects were consideredas one defect. Mesh was used in 27 cases (93%).

Eleven patients had other procedures carried out at the time ofthe laparoscopic hernia repair (Table 2). Operative time rangedfrom 20 to 260 min (including those with other procedures) with amean of 52 min for laparoscopic incisional hernia repairs only.Postoperative stay ranged from 0 to 11 days, with 17 patients(57%) staying overnight and 8 patients (27%) staying 2 days.The rest of the patients stayed longer because of medical problems(one with congestive cardiac failure, one with discharging legwound from a split skin graft, one with prolonged ileus and painfrom a reversal of a Hartmann’s procedure and the one sufferingfrom poor mobility).

All except two patients tolerated an oral diet within the first 24 h. Postoperative analgesic requirements were not specificallymeasured but 20 of the 29 patients (69%) required only simple non-narcotic analgesia. Twenty-three of the 28 (82%) patientsfollowed up, had returned to household duties within a week.Most returned to normal activity within 2 weeks postoperatively.

Early minor complications occurred in four patients. Twopatients developed small wound haematomas which settledwithout treatment. Two patients had infection of the 10-mm portsite which responded to a short course of oral antibiotic. One of theabove patients developed a small bowel obstruction from fibrinousadhesions of the small bowel to the polypropylene mesh. Thiswas successfully treated by repeat laparoscopy and division ofadhesions on day four postoperatively. No further problemsensued in the patient. The same patient had had three previous openincisional hernia repairs at the same site and had significantadhesions present. There was only one late complication where thepatient complained of persistent pain at the operative site and

the mesh was removed 2 months later. As the patient was unable tobe contacted for follow up, we were unable to assess if her pain hadsubsided and whether it was related to the mesh.

Follow up of the patients ranged from 1 to 69 months (mean: 12 months). There were three hernia recurrences at 4, 8 and 11 months. Two of three patients had had past hernia repairs at thesame site. Their hernia recurrences may be related to weakabdominal wall. Two of three patients also had hernia defectslarger than 5 cm. Two patients elected not to have further opera-tions on their hernia. One patient went on to have an openrepair.

DISCUSSION

Incisional hernia is a common complication of all abdominalsurgery.1 George and Ellis, in their 12-year review of 81 inci-sional hernias repaired via the open-suture technique, reported arecurrence rate of 46%.2 Similar results were published byHorton and Smith earlier.14 The high recurrence rate was attributedto either the excessive tension used in approximating the edges of the defect, or postoperative wound infection and haematoma. As a result, prosthetic mesh was introduced to help close largerdefects without tension. Usher used Marlex mesh in his series of 541 patients and he reported a recurrence rate of 10%.4 Sub-sequent studies using prosthetic mesh performed by Larson andHarrower in 1978, Lewis in 1984 and Molloy et al. in 1991reported recurrence rates of 6–11%, average hospital stays of up to10 days and morbidity up to 34%.5–7

These problems of postoperative wound infection, haema-toma, pain and relatively long hospital stay led some surgeons totry a laparoscopic approach. This was first reported by LeBlanc andBooth who used expanded polytetrafluoroethylene (EPTFE)mesh placed laparoscopically in 30 patients, 27 of whom weretreated as day cases.9 In our series, 17 patients had significantcomorbidities and as a result were unsuitable to be treated asday cases. Furthermore, 11 patients had other procedures carriedout at the same time. Nevertheless, 59% returned home the fol-lowing day and 83% within 48 h, reflecting a faster recoveryand shorter hospital stay when compared to the open repair.This was recently confirmed in a comparison study betweenlaparoscopic and open incisional hernia repair carried out byPark et al.15

In the majority of cases in our series, an intraperitoneal prostheticmesh was used. The type of mesh used varied according to thesurgeon, but mainly consisted of the polypropylene mesh (PPM) or the EPTFE. Each has its advantages and disadvantages.Polypropylene mesh has good tensile strength but leads to greater

Table 1. Sites of incisional hernias

No. patients

Midline laparotomy incision 12Pfannensteil incision 5Appendectomy (McBurney/Lanz) incision 5Others (Horizontal, Kochers, Paramedian,

Umbilical, Right loin, Epigastric) 8Total (n) 30

Table 2. Associated procedures during or after laparoscopic hernia repair (n = 11)

Other procedures apart from laparoscopic ventral incisional hernioplasty No. of patients Time for the entire operation (min)

Laparoscopic reversal of Hartmann’s procedure 1 260Laparoscopic cholecystectomy 2 112 and 60Laparoscopic oophorectomy and open umbilical hernia repair 1 60Umbilical hernia repair 2 90 and 70Haemorrhoidectomy 1 90Lateral sphincterotomy 1 80Laparoscopic inguinal herniorrhaphy 1 90Excision of squamous cell carcinoma and split skin graft on leg 1 64Dilatation and curettage 1 45

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tissue reactivity and adhesions which are important in securingthe mesh in place. However, this has led to isolated cases ofbowel erosion and fistula formation in open hernia repairs.16,17

While this complication is of concern, it may be reduced if theomentum can be interposed between the bowel and the mesh.18 Inthis study, there were no reports of bowel erosion or fistula.

Expanded Polytetrafluoroethylene (EPTFE) mesh incites lessforeign body reaction,19 thus fewer adhesions and potentially a lower risk of bowel erosion or fistula formation. However, it maybe less secure for these very reasons as it incorporates less than thePPM mesh. Expanded PTFE mesh has also been reported to be lesseasily infected than PPM.19

Concerns about bowel adhesions to the intraperitoneal meshhave led researchers to try interpositioning an absorbable (Poly-glactin) mesh between the bowel and the nonabsorbable (PPM)mesh, but so far no significant benefit has been demonstrated.

We have also tried a new type of composite mesh – BardComposix Mesh – in one patient. It consists of two layers ofmesh, an outer polypropylene and an inner EPTFE boundtogether. A recent Canadian series of 30 patients suggests thecomposite mesh may be the choice of prosthetic material for useintraperitoneally.13

Our experience also demonstrated that laparoscopic repairallows repair of multiple incisional hernias at different sitesusing the same ports and, therefore, limits the number of incisions.This reduces postoperative pain, wound complications andlessens morbidity. It also allows direct visualization of early,small and clinically undetectable hernia which can be repaired atthe same time. In this series, eight patients (28%) had clinicallyundetectable hernias found at laparoscopy.

The complication rate in our series is comparable to moststudies using the laparoscopic technique and most were minorand easily treated.10,18 Haematoma in the space formerly filledby the hernia sac is not uncommon, but as port sites are placedaway from the repair, secondary infection of these collectionsand/or the mesh should be less. The argument that the operation istime-consuming and expensive is no longer valid as recent trials byCarbajo et al. and Holzman et al. demonstrate that the operativetime and the overall hospital costs of laparoscopic hernia repairsare, in fact, lower than open herniorrhaphies.18,20

Recurrence rate of 10% is high but may reflect our initialenthusiasm when hernias larger than 5 cm were tackled laparo-scopically. The follow up in this study is relatively short and thetrue rate of recurrence may be higher if the follow up is longer.From this study, we believe laparoscopy remains a usefulmethod of assessing and repairing most small- to medium-sizedhernias, but larger hernias may still require an open meshhernioplasty.

CONCLUSION

Our preliminary results with laparoscopic repair of ventral inci-sional hernias suggest that this is a safe, effective and techni-cally feasible operation for small- to medium-sized hernias withreduced morbidity, earlier recovery and shorter hospital stay

than the open repair. Longer follow up is required to confirm itsefficacy and safety. More prospective, randomized trials areneeded.

REFERENCES1. Mudge M, Hughes LE. Incisional hernia: A 10-year prospective

study of incidence & attitudes. Br. J. Surg. 1985; 72: 70–1.2. George CD, Ellis H. The results of incisional hernia repair:

A twelve year review. Ann. R. Coll Surg. Egl. 1986; 68: 185–7.3. Balen EM, Diez-Caballero A, Hernandez-Lizoain JL et al.

Repair of ventral hernias with expanded polytetrafluoroethylenepatch. Br. J. Surg. 1998; 85: 1415–18.

4. Usher FC. Hernia Repair with Marlex mesh. An analysis of 541 cases. Arch. Surg. 1962; 84: 325–8.

5. Larson GM, Harrower HW. Plastic mesh repair of incisionalhernias. Am. J. Surg. 1978; 135: 559–63.

6. Lewis RT. Knitted polypropylene (Marlex) mesh in the repair ofincisional hernias. Can. J. Surg. 1984; 27: 155–7.

7. Molloy RG, Moran KT, Waldron RP, Brady MP, Kirwan WO.Massive incisional hernia: Abdominal wall replacement withMarlex mesh. Br. J. Surg. 1991; 78: 242–4.

8. LeBlanc KA, Booth WV. Laparoscopic Repair of IncisionalAbdominal Hernias using Expanded Polytetrafluoroethylene:Preliminary findings. Surg. Laparosc. Endosc. 1993; 3: 39–41.

9. LeBlanc KA, Booth WV. Laparoscopic Repair of VentralHernias Using an Intraperitoneal Onlay Patch: Report CurrentResults. Contemp. Surg. 1994; 45: 211–14.

10. Park A, Gagner M, Pomp A. Laparoscopic Repair of LargeIncisional Hernias. Surg. Laparosc. Endosc. 1996; 6: 123–8.

11. Franklin M, Dorman J, Glass J, Balli J, Gonzales J. Laparo-scopic Ventral & Incisional Hernia Repair. Surg. Laparosc.Endosc. 1998; 8: 294–9.

12. Sanders LM, Flint LM, Ferrara JJ. Initial experience withlaparoscopic repair of incisional hernias. Am. J. Surg. 1999;177: 227–31.

13. Bendavid R. Composite mesh (polypropylene-E-PTFE) in theintra peritoneal position. A report of 30 cases. Hernia 1997; 1: 5–8.

14. Horton RE, Smith PC. Incisional hernias. Proc. Roy. Soc. Med.1969; 62: 513–15.

15. Park A, Birch D, Lovrics P, Lexington KY, Hamilton. Laparo-scopic and open incisional hernia repair: A comparison study.Surgery 1998; 124: 816–22.

16. Kaufman Z, Engelberg M, Zager M. Fecal fistula: A late com-plication of Marlex mesh repair. Dis. Colon Rectum 1981; 24:543–4.

17. Schneider R, Herrington JL Jr, Granda AM. Marlex mesh inrepair of a diaphragmatic defect later eroding into the distaloesophagus and stomach. Am. Surg. 1970; 45: 337–9.

18. Holzman MD, Purut CM, Reintgen K, Eubanks S, Pappas TN.Laparoscopic ventral and incisional hernioplasty. Surg. Endosc.1997; 11: 32–5.

19. Law NW. A comparison of polypropylene mesh, expandedpolytetrafluoroethylene patch and polyglycolic acid mesh forthe repair of experimental abdominal wall defects. Acta. Chir.Scand. 1990; 56: 759–62.

20. Carbajo MA, del Olmo JC, Blanco JI et al. Laparoscopic treat-ment vs open surgery in the solution of major incisional andabdominal wall hernias with mesh. Surg. Endosc. 1999; 13:250–2.