Laparoscopic Ventral Hernia Repair

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Laparoscopic Ventral Hernia Repair

  1. 1. LAPAROSCOPIC Ventral Hernia Repair George S. Ferzli, MD, FACS Professor of Surgery, State University of New York
  2. 2. General Information: <ul><li>100,000 ventral hernia surgeries per year </li></ul><ul><li>3-20% of laparotomy incisions </li></ul><ul><li>10-15% of all hernia repairs </li></ul><ul><li>17% will develop </li></ul><ul><li>incarceration or strangulation </li></ul><ul><li>Mortality 0.3% </li></ul><ul><li>Elective repair, 1.1 % </li></ul><ul><li>Emergency repair </li></ul>
  3. 3. Primary repair of ventral hernia without mesh: <ul><li>Recurrence rate 25%-45% after first repair </li></ul><ul><li>58% recurrence after second attempt </li></ul>Hessilink VJ et al. An evaluation of the risk factors in incisional hernia recurrence. Surg Gyn Obst 1993 March;176(3) 228-34.
  4. 4. Primary repair of ventral hernia with mesh: <ul><ul><li> 10-20% recurrence </li></ul></ul><ul><ul><li> 12 % infection rate and wound complications </li></ul></ul>Luijendijk R W et al. A comparison of suture repair with mesh repair for incisional hernia N Engl J Med 2000; 343;392-8
  5. 5. <ul><li>Components separation technique </li></ul><ul><li>resulted in 32% recurrence </li></ul><ul><li>Devries Raleigh TS et al. Component separation technique for the repair of large abdominal wall hernia. JACS 2003 Jan 196(1) 32-7 </li></ul>Methods to decrease hernia occurrence and facilitate primary repair: <ul><li>Vacuum assisted closure </li></ul><ul><li>Prospective evaluation of vacuum assisted facial closure after open abdomen: Planned Ventral Hernia Rate is Substantially Reduced. Miller PR et al. Ann Surg 2004 May 239(5) 608-617 </li></ul>
  6. 6. <ul><li>Large incision </li></ul><ul><li>Extensive dissection </li></ul><ul><li>Drains </li></ul><ul><li>Mesh </li></ul><ul><li>Co-morbidities </li></ul>The increase in rate of wound complications in open incisional hernias repair is related to:
  7. 7. Laparoscopic Repair of Incisional Hernias <ul><ul><li> wound complications </li></ul></ul><ul><ul><li> recurrence rate </li></ul></ul><ul><ul><li> LOS </li></ul></ul><ul><ul><li> pain </li></ul></ul><ul><ul><li>coverage of “Swiss cheese” abdomen </li></ul></ul>
  8. 8. Preparing the patient <ul><ul><li>Consider bowel prep </li></ul></ul><ul><ul><li>Pre-operative antibiotic prophylaxis </li></ul></ul><ul><ul><li>Foley catheter </li></ul></ul><ul><ul><li>Nasogastric tube </li></ul></ul><ul><ul><li>SCDs/DVT prophylaxis </li></ul></ul>
  9. 9. Preparing the patient <ul><ul><li>Tuck arms at side </li></ul></ul><ul><ul><li>Secure patient to table </li></ul></ul><ul><ul><li>Consider footboard </li></ul></ul><ul><ul><li>Consider Ioban drape </li></ul></ul>
  10. 10. Equipment <ul><ul><li>Instrumentation </li></ul></ul><ul><ul><li>Atraumatic graspers </li></ul></ul><ul><ul><li>Ultrasonic shears </li></ul></ul><ul><ul><li>5 mm tacker </li></ul></ul><ul><ul><li>Suture passer </li></ul></ul>
  11. 11. <ul><li>Identify approximate size of defect </li></ul>
  12. 12. <ul><li>Determine sites for placement of ports </li></ul>
  13. 13. Sizing the mesh <ul><li>What is the best way to measure the mesh? </li></ul><ul><li>3 options: Intracorporeal with pneumoperitoneum, extracorporeal with pneumoperitoneum, extracorporeal desufflated </li></ul><ul><li>With extracorporeal measurement, the diameter of the outer (skin) circle is larger than the inner (peritoneal) circle. </li></ul><ul><li>This difference is proportional to the size of the patient. </li></ul><ul><li>Result is overestimation of hernia size and mesh by 1.7 to 3.1 cm </li></ul>Jin, J, Rosen MJ. Laparoscopic versus open ventral hernia repair. Surg Clin N Am 2008;88:1083-1100
  14. 14. Sizing the mesh LeBlanc KA. Incisional hernia repair; Laparoscopic Techniques. World J Surg , 2005 29 1073-1079
  15. 15. <ul><li>Access to abdomen </li></ul><ul><ul><li>Blunt trocar with open technique </li></ul></ul><ul><ul><li>Veress needle </li></ul></ul><ul><ul><li>Remote from </li></ul></ul><ul><ul><li>hernia site </li></ul></ul><ul><li>Trocar </li></ul><ul><li>Requirements </li></ul><ul><li>depend on hernia size </li></ul><ul><ul><li>11 mm or 12 mm </li></ul></ul><ul><ul><li>and 5 mm trocars </li></ul></ul>
  16. 16. <ul><li>Begin careful adhesiolysis </li></ul><ul><li>Blunt and </li></ul><ul><li>sharp dissection </li></ul><ul><li>Avoid use of </li></ul><ul><li>cautery </li></ul>
  17. 17. <ul><li>Full extent of defect identified </li></ul><ul><li>Beware of the presence of multiple defects </li></ul>
  18. 18. <ul><li>Once the defect is measured a mesh is selected that provides at least 3 cm of overlap around the defect. </li></ul><ul><li>Some surgeons use a 4 – 6 cm overlap. </li></ul><ul><li>This may be particularly important in the recurrent hernia or in the morbidly obese patient. </li></ul>LeBlanc KA. Incisional hernia repair: Laparoscopic techniques. World J Surg . 2005, 29; 1073-1079
  19. 19. <ul><li>Ensure proper mesh surface orientation </li></ul><ul><li>Place anchoring sutures </li></ul><ul><li>trans-abdominally </li></ul>
  20. 20. <ul><li>Secure periphery of mesh with tacker </li></ul><ul><li>Approximately 1cm apart </li></ul>
  21. 21. <ul><li>The tensile strength of the transabdominal suture is 2.5 times greater than that of the tacker </li></ul><ul><li>Cadaveric pig studies have shown that the optimal distance between fixation points is about 1.8 cm </li></ul><ul><li>Or the ideal number of fixation points can be derived by the formula: (2pi r)/7) x 3 = 2.7r </li></ul>Placement of sutures or tacks Riet M, Steenwijk PJ, Kleinrensink GJ , Steyerberg EW, Bojer HG. Tensile strength of mesh fixation methods in laparoscopic incisional hernia repair. Surg Endosc 2002 Dec; 16(12): 1713-6.
  22. 22. <ul><ul><li>Multicenter trial 11/1993-2/2003 </li></ul></ul><ul><ul><li>850 patients (85% evaluated </li></ul></ul><ul><ul><li>prospectively) </li></ul></ul><ul><ul><li>422 men and 428 women </li></ul></ul><ul><ul><li>Age 54 (13-94) </li></ul></ul><ul><ul><li>BMI 32.1 (22-67) </li></ul></ul><ul><ul><li>Defect size cm 2 118 (1-1600) </li></ul></ul><ul><ul><li>Mesh size cm 2 344 (24-2500) </li></ul></ul>Heniford BT, Park A, Ramshaw B, Veoller G: Laparoscopic repair of ventral hernias in nine years’ experience with 850 consecutive hernias. Ann Surg Vol. 238, Number 3, September 2003; 391-400
  23. 23. <ul><li>850 patients: </li></ul><ul><ul><li>Defect > 4 cm 2 </li></ul></ul><ul><ul><li>Elective procedure </li></ul></ul><ul><ul><li>Tension free PTFE (Gortex dual mesh) </li></ul></ul><ul><ul><li>>3 cm overlap of defect </li></ul></ul><ul><ul><li>Sac left in situ </li></ul></ul><ul><ul><li>Heniford BT, Park A, Ramshaw B, Veoller G: Laparoscopic repair of ventral hernias in nine years’ experience with 850 consecutive hernias. Ann Surg Vol. 238, Number 3, September 2003;391-400 </li></ul></ul>
  24. 24. <ul><li>850 Patients </li></ul><ul><ul><li>OR time 120 (110-420) </li></ul></ul><ul><ul><li>Conversion to open 31 (3.6%) </li></ul></ul><ul><ul><li>Mean hospital stay 2.3 (0-33) </li></ul></ul>Heniford BT, Park A, Ramshaw B, Veoller G: Laparoscopic repair of ventral hernias in nine years’ experience with 850 consecutive hernias. Ann Surg Vol. 238, Number 3, September 2003; 391-400
  25. 25. <ul><li>850 patients </li></ul><ul><ul><li>Recurrence 35 (4.7%) </li></ul></ul><ul><ul><li>Mean follow-up 20 months (1-96 months) </li></ul></ul>Heniford BT, Park A, Ramshaw B, Veoller G: Laparoscopic repair of ventral hernias in nine years’ experience with 850 consecutive hernias. Ann Surg Vol. 238, Number 3, September 2003; 391-400
  26. 26. Heniford BT, Park A, Ramshaw B, Veoller G: Laparoscopic repair of ventral hernias in nine years’ experience with 850 consecutive hernias. Ann Surg Volume 238, Number 3, September 2003; 391-400 Variable Patients with Complications Patients without Complications Mean defect size (cm) 202 105 Mean operating time (min) 142 116 Mean LOS (d) 4.7 1.8 Previous hernia repair (% of patients) 47 32 Hernia recurrence rate (%) 10.6 3.2
  27. 27. Heniford BT, Park A, Ramshaw B, Veoller G: Laparoscopic repair of ventral hernias in nine years’ experience with 850 consecutive hernias. Ann Surg Vol. 238, Number 3, September 2003; 391-400 Variable Patients with Hernia Recurrence Patients without Hernia Recurrence Mean defeat size (cm 2 ) 184 124 Mean operating time (min) 149 118 Previous hernia repair (% of patients) 63 35 Complication rate (%) 32 12
  28. 28. Heniford BT, Park A, Ramshaw B, Veoller G: Laparoscopic repair of ventral hernias in nine years’ experience with 850 consecutive hernias. Ann Surg Vol. 238, Number 3, September 2003; 391-400 Complication No. (%) of Patients Prolonged ileus 25 (3.0) Seroma > 6 wk 21 (2.6) Suture site pain > 8 wk 13 (1.6) Intestinal/bladder injury 14 (1.7) Cellulitis of trocar site 9 (1.1) Mesh infection 6 (0.7) Hematoma or post-op bleeding 3 (0.4) Urinary retention 10 (1.2) Fever of unknown origin 3 (0.4) Respiratory distress 8 (1.0) Cardiac event 6 (0.7) Trocar site herniation 7 (0.9) Clostridium difficile infection 3 (0.4) Total 112 (13.2)
  29. 29. What to do when an enterotomy occurs? <ul><ul><li>Contamination  repair injury and delay hernia repair </li></ul></ul><ul><ul><li>No spillage  repair hernia </li></ul></ul><ul><ul><li>Bladder injury  repair hernia </li></ul></ul><ul><ul><li>Delayed bowel injury  remove mesh and delay repair </li></ul></ul>
  30. 30. What to do with seroma? <ul><ul><li>Observation: most of them will resolve without intervention </li></ul></ul><ul><ul><li>Repetitive sterile aspiration </li></ul></ul><ul><ul><li>When persistent beyond 8 weeks or longer: removal of mesh and excision of hypertrophic mesothelium </li></ul></ul>
  31. 31. Can seroma formation be decreased? <ul><li>78 patients underwent 80 laparoscopic LVHR </li></ul><ul><li>Separated into 2 groups </li></ul><ul><li>Both groups repaired with ePTFE dual mesh secured by full-thickness stitches and endoscopic tacks </li></ul><ul><li>Group A (n=28) </li></ul><ul><ul><li>subgroup A1; n=17 - overlap of 2.5 cm </li></ul></ul><ul><ul><li>subgroup A2; n=11 - overlap of 4 cm and a full-thickness suture placed in the center of the hernia defect to reduce the &quot;dead space.&quot; </li></ul></ul><ul><li>Group B (n=52) Hernia sac cauterized by monopolar cautery or Harmonic scalpel </li></ul><ul><ul><li>subgroup B1; n=16 - overlap of 2.5 cm </li></ul></ul><ul><ul><li>subgroup B2; n=36 - overlap of 4 cm and a full-thickness suture placed in the center of the hernia defect to reduce the &quot;dead space.&quot; </li></ul></ul>Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Nikas K, Karfis E, Sioziou H. Seroma and recurrence in laparoscopic ventral hernioplasty. JSLS. 2008 Jan-Mar;12(1): 51-7
  32. 32. Postoperative complications <ul><li>A1 A2 B1 B2 </li></ul><ul><li> (n = 17) (n = 11) (n = 16) (n = 36) </li></ul><ul><li>Seroma 5 2 1 0* * p = 0.004 vs A1 </li></ul><ul><li>Clinical 4 0 1 0 * p = 0.009 vs A2 </li></ul><ul><li>Subclinical 1 2 1 0 </li></ul><ul><li>Hematoma 2 1 0 1 </li></ul><ul><li>Infection 2 0 0 0 </li></ul><ul><li>Recurrence 2 1 1 0** ** p = 0.036 vs A1 </li></ul><ul><li>Total Seroma A1 + A2 B1 + B2*** *** p = 0.004 </li></ul>Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G, Nikas K, Karfis E, Sioziou H. Seroma and recurrence in laparoscopic ventral hernioplasty. JSLS. 2008 Jan-Mar; 12(1):51-7
  33. 33. What to do for pain at transabdominal suture site? <ul><li>Nonsteroidal anti-inflammatory agents/oral narcotics </li></ul><ul><li>Subfascial injection of combination lidocaine and bupivacaine </li></ul>
  34. 34. <ul><li>103 patients underwent LVHR </li></ul><ul><li>24 patients (23%) had prolonged discomfort at a transabdominal suture site </li></ul><ul><li>Treatment consisted of injection around the suture site with 0.25 % bupivacaine with epinephrine and 1 % lidocaine </li></ul><ul><ul><li>20 patients required a single injection </li></ul></ul><ul><ul><li>2 patients required two injections </li></ul></ul><ul><ul><li>2 patients failed local injection and were referred to an anesthesia pain service </li></ul></ul><ul><ul><li>One underwent intercostal nerve block with resolution of pain </li></ul></ul><ul><ul><li>The other is currently in treatment </li></ul></ul>Carbonell AM, Harold KL, Mahmutovic AJ, Hassan R, Matthews BD, Kercher KW, Sing RF, Heniford BT. Local injection for the treatment of suture site pain after laparoscopic ventral hernia repair. Am Surg . 2003 Aug;69(8):688-91
  35. 35. Lap vs Open Non-Randomized   Number of Patients Mean LOS (Days) Complication Rate Recurrence Rate Holzman 1997 21 Lap 16 Open 1.6 v. 4.9* 23% v. 31%* 9.5% v. 12.5% Park 1998 56 Lap 49 Open 3.4 v. 6.5* 18% v. 37%* 10.7% v. 34.7%* Ramshaw 1999 79 Lap 174 Open 1.7 v. 2.8* 19% v. 31%* 2.5% v. 19.5%* Chari 2000 14 Lap 14 Open 5 v. 5.5 NA NA DeMaria 2000 21 Lap 18 Open 0.8 v. 4.4* 19% v. 50%* 5% v. 0%
  36. 36. Lap vs Open Prospective Randomized   Number of Patients Mean LOS (Days) Complication Rate Recurrence Rate Carbajo 1999 30 Lap 30 Open 2.2 v. 9.1* 6.7% v. 57%* 0% v. 5%* McGreevy 2003 65 Lap 71 Open 1.1 v. 1.5 8% v. 21% NA
  37. 37. <ul><li>n = 85 open anterior repair (OG) </li></ul><ul><li>n = 85 laparoscopic repair (LG) </li></ul><ul><li>OG LG </li></ul><ul><li>OR time 150.9min 61 min (p < 0.005) </li></ul><ul><li>Hospital days 9.9 days 2.7 days (p < 0.005) </li></ul><ul><li>Return to work 25 days 13 days (p < 0.005) </li></ul><ul><li>Complications 29.4% 16.4% (p < 0.005) </li></ul><ul><li>Relapse 1.1% 2.3% </li></ul>Olmi S, Scaini A, Cesana GC, Erba L, Croce E. Laparoscopic versus open incisional hernia repair; An open randomized controlled study. Surg Endosc 2007; 21; 555-559
  38. 38. Metanalysis of Lap v. Open Goodney et al. Archives Surgery 2002 October 137 (10): 114   322 Lap 390 Open P Value Complications 14% 27 % .003* LOS 2 days 4 days 0.02* OR Time 99 minutes 96 minutes 0.38
  39. 39. Cost comparison   Lap Open P-value Carbajo (1999) 12461 8273 NA McGreevy (2003) 9316 5858 0.01
  40. 40. Laparoscopic ventral hernia repair in the obese patient <ul><li>Group A (n = 134) Group B (n = 767) </li></ul><ul><li>BMI >/=40 (mean 46 BMI < 40 (mean 30) </li></ul><ul><li>OR time 154 min 119 min p < 0.01 </li></ul><ul><li>Hospital stay 3.6 days 2.4 days p = 0.03 </li></ul><ul><li>Mesh size 449 cm2 349 cm2 p = 002 </li></ul><ul><li>Recurrence 8.3% 2.9% p = 0.003 </li></ul><ul><li>Complications 19.7% 15.3% p = 0.46 </li></ul>Tsereteli Z, Pror BA, Heniford BT, Park A, Voeller G, Ramshaw BJ. Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia . 2008 Jun; 12(3): 233-8.
  41. 41. Laparoscopic ventral hernia repair in the obese patient <ul><li>LVHR in the morbidly obese population is safe and feasible, however, there is a higher, but acceptable recurrence rate. </li></ul><ul><li>LVHR in morbidly obese minimizes the potential wound and mesh complications that frequently occur for open mesh repair in this group of patients. </li></ul>Tsereteli Z, Pror BA, Heniford BT, Park A, Voeller G, Ramshaw BJ. Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia. 2008 Jun; 12(3): 233-8.
  42. 42. Laparoscopic ventral hernia repair for the recurrent hernia <ul><li>Advantages include: </li></ul><ul><ul><li>Avoiding dissection through previous operative sites </li></ul></ul><ul><ul><li>Avoiding disruption of prior mesh </li></ul></ul><ul><ul><li>Discovery of multiple small fascial defects </li></ul></ul><ul><li>Disadvantages include: </li></ul><ul><ul><li>Learning curve </li></ul></ul><ul><ul><li>Prior intra-abdominal mesh </li></ul></ul><ul><ul><li>Difficulty identifying entertomy </li></ul></ul><ul><ul><li>Adhesions </li></ul></ul><ul><ul><li>In-growth into mesh </li></ul></ul>
  43. 43. Laparoscopic ventral hernia repair for the recurrent hernia <ul><li>Study of recurrent incisional hernia and the effect of laparoscopic repair on: </li></ul><ul><ul><li>Adverse events </li></ul></ul><ul><ul><li>Quality of life </li></ul></ul><ul><ul><li>Recurrence rates </li></ul></ul><ul><li>Prospective study </li></ul><ul><li>n = 85 </li></ul><ul><li>Median follow up – 41 months </li></ul>Uranues S, Salhi B, Bergamaschi R. Adverse events, quality of life and recurrence rates after laparoscopic adhesiolysis and recurrent incisional hernia mesh repair in patients with previous failed repairs. J Am Col Surg. 2008, 207(5): 663-669.
  44. 44. Laparoscopic ventral hernia repair for the recurrent hernia <ul><li>Outcomes after operations </li></ul><ul><li>Length of stay, days (range) 2 (1 -9) </li></ul><ul><li>Port site cellulites, n (%) 1 (1.1) </li></ul><ul><li>Seroma, n (%) </li></ul><ul><ul><li>• No intervention 3 (3.5%) </li></ul></ul><ul><ul><li>• Fine-needle aspiration 3 (3.5%) </li></ul></ul><ul><li>Persistent pain, n (%) </li></ul><ul><ul><li>• No injection 4 (4.7) </li></ul></ul><ul><ul><li>• Local anesthetic 2 (2.3) </li></ul></ul><ul><li>Reoperations (SBO), n (%) 1 (1.1) </li></ul><ul><li>Recurrences </li></ul><ul><ul><li>• No intervention 1 (1.1) </li></ul></ul><ul><ul><li>• Reoperation 2 (2.3) </li></ul></ul>Uranues S, Salhi B, Bergamaschi R. Adverse events, quality of life and recurrence rates after laparoscopic adhesiolysis and recurrent incisional hernia mesh repair in patients with previous failed repairs. J Am Col Surg. 2008, 207(5): 663-669.
  45. 45. Laparoscopic ventral hernia repair for the recurrent hernia <ul><li>Gastroinestinal quality of life index scores (GIQLI) </li></ul><ul><li>Pre-op Follow up </li></ul><ul><li>GIQLI GIQLI </li></ul><ul><li>Symptoms 54 (22 - 57) 63 (41 - 77) p < 0.001 </li></ul><ul><li>Emotional function 12 (2 – 15) 16 (5 – 20) p < 0.001 </li></ul><ul><li>Physical function 15 (3 -20) 21 (7 – 27) p < 0.001 </li></ul><ul><li>Social function 14 (4 – 16) 13 (4 – 16) NS </li></ul><ul><li>Subjective </li></ul><ul><li>treatment assessment 3 (0 – 4) 3 (1 – 3) NS </li></ul><ul><li>Scores reported as medians (range) </li></ul><ul><li>Quality of life assessment performed at 24 months </li></ul>Uranues S, Salhi B, Bergamaschi R. Adverse events, quality of life and recurrence rates after laparoscopic adhesiolysis and recurrent incisional hernia mesh repair in patients with previous failed repairs. J Am Col Surg. 2008, 207(5):663-669.
  46. 46. Laparoscopic ventral hernia repair for the recurrent hernia <ul><li>Laparoscopic adhesiolysis and recurrent </li></ul><ul><li>hernia mesh repair results in: </li></ul><ul><ul><li>Low rate of adverse events </li></ul></ul><ul><ul><li>Improved health-related quality of life </li></ul></ul><ul><ul><li>A risk of recurrence similar to that of first time hernia repair </li></ul></ul>Uranues S, Salhi B, Bergamaschi R. Adverse events, quality of life and recurrence rates after laparoscopic adhesiolysis and recurrent incisional hernia mesh repair in patients with previous failed repairs. J Am Col Surg. 2008, 207(5): 663-669.
  47. 47. Conclusions <ul><li>In experienced hands, laparoscopic </li></ul><ul><li>repair of ventral hernias has: </li></ul><ul><li>low recurrence rate </li></ul><ul><li>low incidence of complications </li></ul><ul><li>short hospital stay </li></ul>

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