5. Wantz, et al. Incisional hernia: the problem and the cure. J Am Coll Surg. 1999;188:429-431.

6. Adye B, Luna G. Incidence of abdominal wall hernia in aortic surgery. Am J Surg1998;175:400-402.

7. Graham DJ, Stevenson JT, McHenry CR. The association of intra-abdominalinfection and abdominal wound dehiscence. Am Surg. 1998; 64:600-665.

Abdomen and Its Contents

Review of Laparoscopic Incisional andVentral Hernia RepairsGuest Reviewers: James M. Nottingham, MD, and Raymond P.Bynoe, MD, University of South Carolina, Columbia, SouthCarolina

LAPAROSCOPIC REPAIR OF RECURRENT VENTRAL HERNIAS. Costanza MJ,Heniford BT, Arca MJ, Mayes JT, Gagner M. Am Surg 1998;64:1121-1127.

Objective: To evaluate the efficacy of laparoscopic ventral hernia repairs.

Design: A retrospective review.

Setting: The Department of Surgery, Cleveland Clinic Foundation in Cleveland,Ohio.

Participants: Thirty-one patients identified for attempted laparoscopic hernia re-pair, but only 15 had a completed laparoscopic hernia repair.

Results: Fifteen patients had successful completion of the laparoscopic hernia repair,and 1 was converted to an open mesh repair because of dense adhesions and loss ofabdominal domain. The polytetra fluoroethylene (e-PTFE) mesh was used to repaireach defect. Only 2 complications and only 1 short-term recurrence occurred. Thelength of stay averaged 2 days. Most of the patients were obese, with a body mass index(BMI) averaging 30 kg/m2. The 2 complications included a cellulitis, which respondedto antibiotics, and a patient with skin breakdown requiring mesh removal and repair ofthe recurrent hernia.

Conclusions: The laparoscopic ventral hernia repair technique can be an effectivemethod of repair. The technique allows tension-free mesh repair. The technique alsooffers advantages of reduced hospital stay (about 2 days), decreased narcotic require-ments, and earlier return of bowel function (�2 days).

RECURRENCE IN LAPAROSCOPIC INCISIONAL HERNIA REPAIRS: A PER-SONAL SERIES AND REVIEW OF THE LITERATURE. Koehler RH, Voeller G. JSoc Laparoendosc Surg 1999;3:293-304.

Objective: To assess the safety and efficacy of the laparoscopic incisional hernia in 34patients and to review factors associated with the 3 recurrences.

Design: Retrospective review and analysis of the patients and a review of the litera-ture.

REVIEWER COMMENTS

This is 1 of the first articles describing thetechnique of laparoscopic ventral herniarepair. Even though it is retrospectiveand a review, the authors have done anice job describing the technique andhave produced what may be termed a fea-sibility study. The study enrolls a limitednumber of patients, and it has a shortfollow-up period of only 18 months. Thetechnique is possible, contrary to the oldbelief that laparoscopy could not be per-formed in the operated abdomen. Safeaccess can be gained, the adhesions can betaken down, and an effective repair canbe based on Stoppa’s principles of the dif-ficult hernia repair. Even though the ar-ticle describes only 15 patients, it hasbeen the forerunner of increasing laparo-scopic ventral hernia repair reports.

REVIEWER COMMENTS

The laparoscopic repair of incisional her-nias is an excellent option. Koehler andVoeller show with this study that short-term results are very good. Extreme caremust take place with the adhesionolysisin order to avoid the enterotomies. Theincidental enterotomies were di-

CURRENT SURGERY • Volume 59/Number 5 • September/October 2002 441

Setting: Martha’s Vineyard Hospital in Martha’s Vineyard, Massachusetts.

Participants: Thirty-four consecutive laparoscopic incisional hernia repairs wereevaluated in a retrospective manner.

Results: Thirty-two patients underwent 34 laparoscopic incisional hernia repairswith equal male:female ratio. The average operative time was about 100 minutes, withan average length of stay at 1.9 days. Two patients developed cellulitis, which re-sponded to antibiotics, and 2 other patients had enterotomies, which required patchremoval. Three short-term recurrences (9%) occurred in this series.

Conclusions: Laparoscopic incisional hernia repair with the e-PTFE patch offersexcellent results with low morbidity compared with the open counterpart. Avoidingenterotomies, adequate mesh fixation with sutures and tacks, and mesh overlapping thedefect all seem to increase the success of the repair.

FIVE-YEAR EXPERIENCE WITH THE “FOUR-BEFORE” LAPAROSCOPIC VEN-TRAL HERNIA REPAIR. Reitter DR, Paulsen JK, Debord JR, Estes NC. Am Surg2000;66:465-469.

Objective: To describe the laparoscopic technique for laparoscopic ventral herniarepair and to evaluate this 5-year experience.

Design: A retrospective review of the 5-year experience.

Setting: Department of Surgery the University of Illinois College of Medicine atPeoria.

Participants: Forty-nine patients underwent a laparoscopic ventral hernia repair inthis 5-year period.

Results: Forty-nine patients underwent attempted laparoscopic ventral hernia re-pair, and successful completion occurred in 47. Two were converted to open becauseof adhesions and bleeding. Operative time averaged 152 minutes with a follow-upaverage of 27 months. Significant complications occurred in 3 patients. One hadseparation of the mesh from the fascia and was repaired laparoscopically. Another hada trocar site hernia, and the last had a mesh infection requiring mesh removal 12months after the combined cholecystectomy and hernia repair. Ninety percent of thepatients responding to the satisfaction questionnaire were “satisfied” with the results.

Conclusions: Laparoscopic ventral hernia repair must be well studied before it willbecome the standard of care.

LAPAROSCOPIC VENTRAL AND INCISIONAL HERNIA REPAIR IN 407 PA-TIENTS. Heniford BT, Park A, Ramshaw BJ, Voeller G. J Am Coll Surg 2000;190:645-650.

Objective: To assess the safety and efficacy of the laparoscopic ventral and incisionalhernia repair.

Design: Retrospective chart review.

Setting: Four academic centers: the Department of Surgery, Carolinas Medical Cen-ter in Charlotte, North Carolina; the Department of Surgery, University of Kentuckyin Lexington; the Department of Surgery, Georgia Baptist Hospital in Atlanta; and theDepartment of Surgery, University of Tennessee in Memphis.

Participants: Four hundred and seven patients were included in this multi-institu-tional study. The 4 principle surgeons used a similar operative technique.

REVIEWER COMMENTS (Con’t)

rectly involved with 1 of the recurrencesin this study. Fixation must include su-tures placed transabdominally and fullthickness about 5 cm away from the her-nia defect’s edge. The e-PTFE mesh wasthe prosthetic of choice for these reasons:less “adhesionogenic,” less infective, andless fistula formation. Overall, this is agood summary of the do’s and don’ts ofthis procedure as it has evolved in theexperience of others.

REVIEWER COMMENTS

The technique described in this paper isan excellent manner in which to get themesh oriented quickly when startingwith the laparoscopic ventral hernia re-pair. As reported in the other papers, thekey to a successful repair is adequate fix-ation with the suture about 4 cm apartwith a 4-cm overlap of the fascial defect.The overlap can be difficult to see withthe opaque mesh; so the initial orienta-tion is critical for adequate coverage andsuccess. The technique allows the meshto be held up against the abdominal wall,which allows easier access for placementof the rest of the sutures and tacks. Theresults are excellent and, as shown in theother papers, are better than the opentechnique in recurrence and morbidity inthe short term.

REVIEWER COMMENTS

This is an excellent paper by Heniford etal. This study is the largest on record atthis time. Even though it is retrospectiveand nonrandomized, the study shows abroad range of complications associatedwith the repair at almost a 2-year follow-up. The most common complications in-cluded paralytic ileus, seroma, and suturepain. Mesh infection occurred in 4 pa-tients (1%), and other complicationswere mostly minor, such as cellulitis atthe trocar site, trocar herniation, urinaryretention, and so on. Enterotomies oc-

442 CURRENT SURGERY • Volume 59/Number 5 • September/October 2002

Results: Four hundred and seven repairs were successful in an equal proportion ofmen and women. Most of the patients were obese with a mean BMI of 32. Most of thedefects were about 100 cm2, and the mesh size averaged 287 cm2. The mean operativetime was 97 minutes with minimal blood loss. The mean length of stay was 1.8 days.No deaths occurred, but 53 complications did occur (13%), most of which were minoror local. In many patients, small seromas developed around the mesh that seemed tospontaneously resolve. Suture site pain responded to repeated local injections of bu-pivacaine. The mean follow-up has been 23 months. Only 14 patients (3.4%) devel-oped a recurrence.

Conclusions: The surgeon with only initial experience should be careful in hispatient selection to obtain the skills necessary for the complicated cases. After an initialexperience that has not been quantified, surgeons may expand their patient selectioncriteria and broaden the included patients. With a larger number of patient procedures,the surgeon may feel comfortable and obtain excellent results like Heniford et al.

REVIEWER SUMMARY

About 2 million patients will undergo a celiotomy in the United States each year.1 Ofthese, about 2% to 12% will develop an incisional hernia.2-5 Furthermore, about 30%will develop a recurrent hernia if the mesh is not used at the initial repair.6,7 About 66%to 90% of the recurrences will be seen at 24 months; so studies should provide at leastthat much follow-up.8,9 Ideal incisional hernia repairs should be carried out with littleto no mortality, low morbidity, low local wound complications, and very low recur-rence rates of the initial repair. Laparoscopic surgery is evolving in the year 2000, andmany reports are now available for the use of the standardized laparoscopic incisionalhernia repair as the initial repair.10,11 The repair should be used for defects over 4 cmin diameter, and the repair should be based on the Stoppa12 principles and the elimi-nation of any undue tension.13,14

Laparoscopic techniques have been developed for the placement of the meshthrough lateral trocars and fixation of the e-PTFE mesh with either buried en massesutures or a series of helical tacks. All agree the mesh must overlap the defect by some4 cm to 5 cm at each edge. The technique begins with abdominal access through eitheropen or closed techniques at least 5 cm from the fascial edge defect. An extensiveabdominal wall adhesionolysis is performed with either “cold” scissors or ultrasoniccutter. It is critical to avoid any enterotomies during this step. Once the defect is clearedat least 5 cm from the defect, the e-PTFE mesh is cut and placed inside the abdomenand oriented inside the abdomen. Eight to 12 sutures are used to secure the mesh to theabdominal wall around the defect, and helical tacks are then used to secure the outermesh edge every 1 cm so that the bowel will not herniate above the mesh. A secondinner row of tacks is used to reduce seroma formation.15 Routine prophylactic antibi-otics are given before the procedure and every 2 hours during the procedure.

The four papers that have been offered here are the start of another new movementin laparoscopic surgery. The most successes are reported with the use of e-PTFE meshbecause lower incidences of problems are associated with intra-abdominal placementof the e-PTFE mesh.16-18 Initial reports by Costanza et al show that their experiencewith the laparoscopic repair seemed promising. The 18-month follow-up showed only1 recurrence in a 15-patient series. Patients had a shorter length of stay compared withhistorical open controls. In 1999, Reitter et al published a series of 47 patients withgood results, with a 7.1% recurrence rate and a high patient satisfaction rating at about24 months. Koehler and Voeller published another retrospective study of 32 patients,which showed excellent results from a e-PTFE laparoscopic repair with a 9% recur-rence rate, which falls much below the generally accepted figures of 30% for the openrepair. The largest cohort study by Heniford et al revealed 407 patients with only a3.4% recurrence rate as well as a low conversion rate of 1.9%. The paper also supportsa low threshold for reexploration for a missed enterotomy when a postoperative patient

REVIEWER COMMENTS (Con’t)

curred in 6 patients; 4 were repaired lapa-roscopically and mesh placed, 1 was con-verted to an open procedure, and 1 was adelayed diagnosis postoperative. Becausemost (66% to 90%) of the hernias recurwithin the first 24 months, I suspect thisnumber of recurrences may not changemuch as the group is followed. The pop-ulation shows a lower recurrence andmorbidity rate than is expected by thehistorical controls for open mesh repairs.The technique has been standardizedacross these 4 surgeons, and it probablywill become the “standard” laparoscopicventral and incisional hernia repair.

CURRENT SURGERY • Volume 59/Number 5 • September/October 2002 443

is not recovering as quickly as expected. All studies report a low incidence of meshinfection, local wound problems, and morbidities. Anesthetic risk has been low, asdiscussed by the papers. The papers are summarized in Table 1.

For incisional hernia, the laparoscopic e-PTFE repair is now challenging the best-reported recurrence rates from the open repairs. These laparoscopic incisional herniadata again lack the prospective design and the long-term follow-up desired by mostclinicians. In the short term, the data are promising, and this repair may be the futurefor skilled laparoscopists. In the largest study, a 3.4% recurrence rate exists at 23months. Because most of the recurrences (66% to 90%) occur by 24 months, anappreciable change in these numbers should not occur, although long-term follow-upof this group is necessary. Resident training should continue to give exposure to thistechnique, because the technique may become reality in the future.

PII S0149-7944(00)00484-0

REFERENCES

1. Read RC, Yoder G. Recent trends in the management of incisional herniation.Arch Surg. 1989;124:485-488.

2. Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am. 1993;73:557-571.

3. Mudge M, Hughes LE. Incisional hernia: a 10- year prospective study of inci-dence and attitudes. Br J Surg. 1985;72:70-71.

4. Leaper DJ, Pollack AV, Evans M. Abdominal wound closure: a trial of nylon,polyglycolic acid, and steel sutures. Br J Surg. 1977;64:603-606.

5. Pollock AV, Greenall MJ, Evans M. Single-layer mass closure of major laparot-omies by continuous suturing. J R Soc Med. 1979;72:889-893.

6. Langer S, Christiansen J. Long-term results after incisional hernia repair. ActaChir Scand. 1985;151:217-219.

7. Larson GM, Harrower HW. Plastic mesh repair of incisional hernia. Am J Surg.1978;135:559-563.

8. Hesselink VJ, Luijendijk RW, de Wilt JHW, et al. An evaluation of risk factors inincisional hernia recurrence. Surg Gyencol Obstet. 1993;176:228-234.

9. van der Linden FT, van Vroonhoven TJ. Long-term results after surgical correc-tion of incisional hernia. Neth J Surg. 1988;40:127-129.

10. Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional hernias. SurgLaparosc Endosc. 1996;6:123-128.

11. Le Blanc KA, Booth WV. Laparoscopic repair of incisional abdominal herniasusing expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc En-dosc. 1993;3:420-424.

12. Stoppa RE. The treatment of complicated groin and incisional hernias. WorldJ Surg. 1989;13:545-554.

TABLE 1. Summary of Table of Studies

Author#

Patients

#Open

conversion#

Recurrence#

Complications#

Mortality

Costanza et al 31 16 (52%) 1 (3.2%) 2 (6.5%) 0Koehler and

Voeller32 0 3 (9.4%) 11 (34.4%) 1 (3.1%)

Reitter et al 49 2 (4.1%) 3 (6.1%) 3 (6.1%) 0Heniford et al 407 8 (2%) 14 (3.4%) 53 (13%) 0

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13. Adamsons RJ, Enquist IF. The relative importance of sutures to the strength ofhealing wounds under normal and abnormal conditions. Surg Gynecol Obstet.1963;117:396-401.

14. Law NW. A comparison of polypropylene mesh, expanded polytetrafluoroethyl-ene patch and polyglycolic acid mesh for the repair of experimental abdominalwall defects. Acta Chir Scand. 1990;156:759-762.

15. Toy FK, Bailey RW, Carey S, et al. Multicenter prospective study of laparoscopicventral hernioplasty: preliminary results. Surg Endosc. 1998;12:955-959.

16. DeBord JR, Wyffels PL, Marshall JS, et al. Repair of large ventral incisionalhernias with expanded polytetrafluoroethylene prosthetic patches. Postgrad GenSurg. 1992;4:151-160.

17. Kennedy GM, Matyas JA. Use of expanded polytetrafluoroethylene in the repairof the difficult hernia. Am J Surg. 1994;168:304-306.

18. Deysine M. Hernia repair with expanded polytetrafluoroethylene. Am J Surg.1992;163:422-424.

Endocrine

Anaplastic Thyroid Carcinoma: AnUpdateGuest Reviewers: Ahmed M. Halal, MD, and Charles F. Cobb, MD,Department of Surgery, Allegheny General Hospital, Pittsburgh,Pennsylvania

ANAPLASTIC THYROID CARCINOMA SURVIVAL. Voutilainen PE, Multanen M,Haapianinen RK, Leppaniemi AK, Sivula AH. World J Surg 1999;23:975-979.

Objective: To detect a subgroup of patients with anaplastic thyroid carcinoma thatmay have a better prognosis or to detect any intervention that would be useful in themanagement of patients with anaplastic carcinoma.

Design: A retrospective study.

Setting: Helsinki University Central Hospital, Helsinki, Finland.

Participants: Thirty-three consecutive patients operated on for anaplastic carci-noma presenting to the university hospital from 1967 to 1994.

Results: The histologic specimens and records of 33 patients with anaplastic carci-noma were reviewed. All patients had locally advanced disease at presentation, and halfof the patients had distant metastases. The median age was 66.6 years for 26 womenand 63.6 years for 7 men. Total thyroidectomy was performed on 11 patients; asubtotal resection, a lobectomy, or a biopsy only was done to the rest. Tracheostomywas performed on 11 patients at the initial operation because of tracheal compression.All patients were treated postoperatively with levothyroxine substitution. Radiother-apy and chemotherapy were used on an individual basis.

Overall survival was 41.9% at 3 months, 23.2% at 6 months, and 9.7% at 1 year.The median survival was 2.5 months. Two patients survived for more than 1 year. Onewas cured after being operated on for follicular carcinoma with microscopic foci ofanaplastic carcinoma. A second patient with predominantly papillary carcinoma and

REVIEWER COMMENTS

The authors noted that the use of post-operative radiation, the absence of dis-tant metastases, local respectability, andthe use of radioactive iodine ablationproved to be independent prognostic fac-tors for improved survival. However, it isnot clear why a particular treatment wasused in the individual patient, how manypatients were treated in a certain way,and how much their survival improved.The authors did note that the chemo-therapy did not seem to improve survival.What is clear, however, is the overall sur-vival of anaplastic carcinoma patients isvery poor. The only 2 patients who sur-vived more than 1 year had either follic-ular or papillary carcinoma with only tinyincidental foci of anaplastic carcinomanoted on the final pathology report.

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