Early Experience with Laparoscopic Incisional Hernia Repair

Objective To explore the clinical efficacy of laparoscopic hiatal hernia repair in combination of fundoplication in treating patients with reflux esophagitis and hiatal hernia. Methods Retrospective analysis ofthe clinical data of 54 patients with reflux esophagitis and hiatal hernia under laparoscopic hiatal hernia repair in combination of fundoplication admitted from January 2012 to January 2016.In aspects of the operation time, intraoperative blood loss, postoperative hospitalization days and complications to evaluate the treatment effect of laparoscopic hiatal hernia repair combined fundoplication. Results There were 53(98%)patients underwent the laparoscopic hiatal hernia repair and fundoplication.One case converted tolaparotomy.47(87%)patients used mesh repair while others did not.The number of patients who did the operation of Toupet, Nissen, Dor(gastric folding degree were 270°, 360°, 180°respectively)were 32(59.3%), 19(35.2%)and 3(5.5%). Operation time was 95~355 minutes, average time(193.6±87.6)minutes.Intra-operative blood loss was 10~600 ml, average blood loss(72.5±21.3)ml; the average postoperative hospitalization stay was(8.1±7.4)days, 53 patients′postoperative hospitalization stay were 3~18 days, one was 62 days.The extubation time was 3 days after operation.The complication included: One case with digestive fistula(Nissen), who recovered in 10 days after the continuous gastrointestinal decompression and peritoneal drainage.One case had the symptom of difficulty swallowing and 2 cases(Toupet)with sickness and reflux, with conservative treatment, they recovered in 1 week.In 3 years following up, 12 patients lost access and 42 patients had complete remission. Conclusion For reflux esophagitis and hiatal hernia patients, laparoscopic hiatal hernia repair and fundoplication is a safe and effective treatment method. Key words: Hernia, hiatal; Fundoplication; Laparoscopic; Esophagitis, peptic

Objective To investigate the clinical effect and safety of laparoscopic extraperitoneal tension-free hernia repair in the treatment of inguinal hernia. Methods The patients with inguinal hernia who were treated in Nanjing First Hospital from January 2016 to December 2017 were randomly divided into the study group (laparoscopic extraperitoneal tension-free hernia repair, n=84) and the control group (open tension-free hernia repair, n=84). The operation time, bleeding volume and hospitalization time of the two groups were compared and analyzed. The time of first ambulation (h), complications (wound infection, urinary retention, hematoma) and pain (VAS) scores on the 1st and 3rd day after operation. Results The operation time, hospitalization time and first time out of bed activity time of the study group were shorter than those of the control group, and the differences were statistically significant (P<0.05). The amount of intraoperative bleeding of the study group was less than that of the control group, and the difference was statistically significant (P<0.05). The incidences of incision infection, hematoma and urinary retention in the study group were lower than those in the control group, and the overall incidence was lower than that in the control group (P<0.05). The VAS scores of the study group on the 1st and 3rd day after operation were significantly lower than those in the control group (P<0.05). Conclusion Laparoscopic extraperitoneal tension-free hernia repair has a good clinical effect in the treatment of inguinal hernia, and it can reduce the incidence of postoperative complications, which is worthy of clinical application. Key words: Hernia, inguinal; Herniorrhaphy; Laparoscopes

Laparoscopic ventral incisional hernia repair: a more effective alternative to conventional repair of recurrent incisional hernia.

Incisional hernia is a common long-term complication of abdominal surgery. Historically the open repair with or without mesh was the mainstay of treatment. However, many recently published laparoscopic repair studies have challenged surgeons to re-evaluate which technique provides the best short and long-term outcomes. A Medline search of all English-language literature was performed using the keywords 'incisional', 'ventral', 'hernia', 'laparoscopic', and 'open'. Further references were obtained by cross-referencing the bibliography in each paper. Current evidence suggests that the laparoscopic incisional hernia repair is the optimal surgical treatment. A laparoscopic repair appears to shorten hospital stay, decrease perioperative complication rates, and decrease recurrence rates. However, there is no randomized trial utilizing a standardized complication grading system making it difficult to draw a definitive conclusion as to which repair is best.

I appreciate the comments of Sabuncuoglu et al. [1] about my article [2]. They raised several important issues regarding indications for laparoscopic hernia repair, primary end points of hernia surgery, and the difficulties of urologic surgery after laparoscopic and endoscopic hernia repair. The historical studies on laparoscopic and open hernia repair techniques presented by Sabuncuoglu et al. do not analyze the different hernia types (e.g., medial and lateral inguinal hernias, scrotal hernias, incarcerated hernias, hernias after radical prostatectomy and recurrences following TAPP and TEP). Therefore, the statements of the Hernia Trialists Collaboration study are restricted [3]. Nevertheless, the data suggested less persistent postoperative pain and numbness following laparoscopic repair and the patients were able to return to their usual activities more quickly. According to the study, there was no apparent difference in recurrence rate between laparoscopic and open mesh methods of hernia repair. However, the transferability of the results is limited. The European Hernia Society (EHS) has recommended TAPP and TEP as standard procedures for repairing bilateral and recurrent hernias after anterior repair, and inguinal hernias in females [4]. In addition, the International Endohernia Society (IEHS) recommended TAPP and TEP as treatment options for complicated hernias (scrotal hernias, incarcerated hernias, hernias after radical prostatectomy, and recurrent hernias after TAPP and TEP procedures), if the repair is performed by a surgeon experienced in laparoscopic and endoscopic hernia repair [5]. Besides the recurrence rate, a high level of patient satisfaction with the outcome of their repair is an important primary end point in hernia surgery. According to my retrospective study, 96.9 % of all patients were satisfied with the result of their modified TAPP. Only 1.5 % was dissatisfied due to hernia recurrence, persistent pain, or postoperative complications. A radical prostatectomy after a bilateral laparoscopic or endoscopic hernia repair and a TAPP or TEP after a radical prostatectomy are challenging and time-consuming interventions. A modification of the surgical repair technique is necessary. There is necessarily a steep learning curve for these procedures. The repair should be done only by surgeons who have extensive experience in laparoscopic and endoscopic hernia repair [5]. According to single-case reports [6, 7], the fibrotic reaction of the implanted mesh after endoscopic and laparoscopic hernia repair makes urologic cancer surgery complicated. According to these reports, the preparation of the preperitoneal space should be nearly impossible [1]. In contrast, Stolzenburg et al. [8] presented a large series of 2,000 endoscopic extraperitoneal radical prostatectomy (EERPE) procedures, including 50 patients who had had a prior endoscopic/laparoscopic hernioplasty, with no conversions to an open procedure and the rates of intraand postoperative complications were not increased. We agree with these authors that EERPE after TAPP and TEP is a safe and effective procedure when port placement and the preparation of the retropubic space are modified. For this procedure, a surgeon experienced not only in laparoscopic hernia repair but also in laparoscopic radical prostatectomy is needed. Replying to the question of how to manage hernia repair in patients with risk factors for pelvic surgery, to our W. K. J. Peitsch (&) Klinik fur Allgemeinund Viszeralchirurgie, Katholisches Krankenhaus St. Josef, Kliniken Essen Sud, Propsteistr. 2, 45239 Essen, Germany e-mail: wkjpeitsch@t-online.de

Objective To explore the feasibility, clinical application value and safety of laparoscopic surgery in treating patients with esophageal hiatal hernia. Methods The clinical data of 20 cases of esophageal hiatal hernia who were enrolled to undertake laparoscopic hiatal hernia repair and fundoplication at our hospital were retrospectively analyzed from March 2012 to September 2017, then we value their clinical results and prognosis. Results All 20 cases of laparoscopic operations were accomplished successfully and no conversions were needed, including 16 cases of Nissen operation, 4 cases of Toupet operation,20 cases of hernia repaired with non-absorbable suture, 7 cases repaired with U Soft Mesh.Mean operation time was 150 minutes (range: 95~180 minutes). Mean intraoperative blood lose was 40ml (range: 30~70 ml).Liquid diets were taken in after 24~48 hours of surgery. Clinical symptoms were effectively relieved in all cases and no mortality and severe complications were noted. Mean postoperative hospital stay were 4.1 days (range: 3~7days). 20 cases were all followed up, and mean follow up period was 2.6 years (range: 3 months to 5 years), there were no cases who dead and with anatomic recurrence, the rate of satisfaction for operation was 95.0%. Conclusion Minimally invasive laparoscopic surgery for esophageal hiatal hernia has the obviously advantages of minimal trauma, fast recovery, safe, high reliability and generalizable value. Key words: Esophageal hiatal hernia; Laparoscopy; herniorrhaphy; Fundoplication; Clinical analysis

Background: The main purpose of this study was to analyze patient-related factors that may influence the risk of hernia recurrence following laparoscopic incisional hernia repair (LIHR), including the potential role of chosen materials. Materials and Methods: A multicenter, retrospective cohort study was conducted on all patients who were aged >18 years and who underwent elective laparoscopic incisional hernia mesh repair at the Departments of Surgery of the S. Anna University Hospital in Ferrara and Sassuolo Hospital in Modena, Italy. Exclusion criteria were as follows: patients undergoing an open or emergency incisional hernia repair or with primary ventral hernia. All hernia and operative variables that may favor hernia recurrence were collected and analyzed. Follow-up was conducted through a standardized telephone interview, followed by an outpatient visit and diagnostic imaging if needed. Results: From September 2002 to September 2017, 312 consecutive patients underwent elective laparoscopic incisional hernia mesh repair. At a mean 22-month follow-up, 273 patients presented no recurrence of incisional hernia and 39 had relapsed. Intra- and postoperative complications were similar between groups. Unadjusted Cox regression analysis showed a statistically significant association between both the partially absorbable mesh (P < .0001) and absorbable tacks (P = .001) and recurrence, while after adjusting for potential confounders, only the partially absorbable mesh was significantly associated with recurrence (P = .007). Conclusions: The laparoscopic approach may be considered safe for incisional hernia mesh repair. In this multicenter, retrospective cohort study, the use of a partially absorbable mesh in LIHR was the only predictor of hernia recurrence. The partially absorbable mesh that was investigated, however, has been withdrawn from the market.

Objective:High recurrence rates have been documented after primary repair of incisional hernias. Laparoscopic ventral and incisional hernia repairs have been performed with very low rates of recurrence. We have modified the standard technique of laparoscopic repair in patients with small incisional and ventral hernias. The purpose of this study was to document the technique utilizing only two 5-mm ports and demonstrate that it is safe, effective, and feasible.Methods:Three patients with small incisional or ventral hernias were examined. The standard laparoscopic ventral hernia repair technique was modified as follows: two 5-mm ports were inserted on opposite sides of the defect. The defects ranged from 2.5 cm to 4 cm in size. Expanded polytetrafluoroethylene mesh (DualMesh, WL Gore, Flagstaff, AZ) was used to cover the hernia defect, overlapping the defect margins circumferentially by 3 cm. The mesh diameter ranged from 8.5 cm to 10 cm. The mesh was inserted through a 5-mm skin incision site and affixed into position with transfascial sutures and spiral tacks.Results:The operative time ranged from 53 minutes to 57 minutes. All patients were discharged home the day of surgery and reported minimal postoperative pain. Follow-up ranged from 6 months to 1 year; all patients were doing well without recurrence.Conclusion:Laparoscopic repair of ventral or incisional hernias can be performed using only two 5-mm ports. This technique can be done on an outpatient basis in a safe, timely fashion.

Objective: To ruleout whether there was a difference in, recurrence rate, morbidity, and duration of hospital stay between patients undergoing open or laparoscopic ventral hernia surgery. Materials and methods: Cohort study in single-institution was compared prospectively collected from patient cohorts undergoing laparoscopic or open intraperitoneal onlay mesh repair. Literature search was performed using search engine Google and our online facility of Springer Link. The following search terms were used. Laparoscopic versus ventral hernia repair, ‘laparoscopic repair of ventral hernia, controversies in laparoscopic ventral hernia repair, comparison of laparoscopic and open (Ventral Hernia) repair, Laparoscopic Repair of Ventral Hernia during obesity. About 143 citations found in total. Data collected from 360 consecutive patients who had undergone laparoscopic or open intraperitoneal onlay mesh repair of a ventral hernia were prospectively collected from October 1995 and December 2005 are recorded . Main outcome of the study: Hernia recurrence and duration of hospital stay and morbidity. Postoperative complications of Clavien grade 2 or more than grade 2 were considered as major complications. Results: Intraperitoneal onlay mesh surgery was performed in 233 patients by open approach and in 127 patients by laparoscopic approach. Groups were similar for sex and body mass index and it is calculated by weight in kilograms divided by the height in meters squared and the mean age for the laparoscopic group was 3 years younger; and the mesh was selected larger for the laparoscopic group. Mean follow-up for both laparoscopic and open groups was 30 and 36 months; and the conversion rates are 4%. Major morbidities were 15% in the open group and 7% in the laparoscopic group. Recurrence rates were 9% in the open group and 12% in the laparoscopic group. Postoperative inpatient admission was more frequent after the open procedure than after the laparoscopic procedure (28% and 16%, respectively). Conclusions: Outcomes of the study shows not much difference with respect to recurrence rates after long-term follow-up; however, lower rate of major morbidity and increased outpatient-based procedure rates favor laparoscopic repair in this study.

Findings have shown that laparoscopic incisional hernia repair is superior to conventional open techniques. The objective of the current study was to evaluate the results of laparoscopic surgery on incisional hernias in an outpatient surgery unit in a university hospital. Data were gathered prospectively for all laparoscopic incisional hernia repairs from January 1997 to December 2006. A total of 127 patients were operated in an outpatient surgery unit. The patients' clinical features, hernia type, intraoperative and postoperative complications, and reasons for hospital admission are studied. None of the patients required readmission to hospital, 15 had no need for analgesic treatment (11.8%) and the mean requirement was 6 days. The mean time of return to normal activity was less than 10 days and all the patients expressed their satisfaction with the procedure they received. During follow-up we detected 5 recurrences (4.4%). The statistical study showed no significant differences between the hospitalized patients and those treated on an ambulatory basis with regard to morbidity and recurrence rate (P<0.05). We do find a lower intraoperative and early postoperative (<30 d) complication rate in favor of the ambulatory patients (P<0.001). Laparoscopic repair of incisional hernias can be performed as a highly efficient ambulatory procedure with igual morbidity and recurrences than hospitalized patients.

Performance of simulated laparoscopic incisional hernia repair correlates with operating room performance

Laparoscopic and open incisional hernia repair: A comparison study

Background: Incisional hernia and primary ventral hernia are among the most common surgical problems that general surgeons face annually in the United States (U.S.). Over 2 million laparotomies are performed in the US and the subsequent incisional hernia rate is 3–20%. At our institution, over the last several years, one surgeon has been performing a unique repair of intermediate-sized hernias by combining open and laparoscopic approaches. We hypothesized that, through a minimal incision, lysis of adhesions and primary repair can be performed, which can then be buttressed with a laparoscopically placed mesh that provides a generous underlay reinforcement that cannot be achieved in open repair. Furthermore, this technique provides the additional benefit of apposition of the rectus muscles and decreased seroma formation compared to laparoscopic hernia repair. Methods: Patients that underwent ventral hernia repair with laparoscopic assistance at NYU Lutheran Medical Center between October of 2012 and January 2015 form this study population. Each patient’s demographic, intra-operative, and postoperative data were collected and analyzed. Patient demographics included gender, age, BMI, prior abdominal surgery, co morbidities, and anticoagulation use. Intra-operative data included defect size, mesh size, and operative time. Postoperative data included complications, length of hospitalization, re-currences, seroma formation, surgical site infections (SSI), and mesh explantation. The surgical technique was as follows: a minimal incision was used over the defect which was only big enough to allow dissection down to the hernia borders. The hernia was reduced and lysis of adhesions of surrounding tissue performed. The hernia was sized and a mesh chosen to provide at least 3 to 5 cm of underlay around the defect. A series of one to four stay sutures were placed in the midline of the mesh and the mesh was placed intra-corporeally. The defect was closed primarily using the Smead-Jones technique (in 17 of 19 patients) to provide a tension-free double layer closure. The abdomen was in-sufflated, the mesh visualized, fixed to the midline via the stay sutures, and tacked circumferentially. The subcutaneous tissue and the skin were closed with absorbable suture. Results: A total of 19 patients (12 females, 7 males) underwent the hybrid hernia repair from October 2012 through January 2015. Only 1 (5%) was admitted postoperatively due to severe underlying co morbidities. The average size of the hernia defect was 5.94 cm 2 (2.5–15 cm 2 ) with an average mesh size of 16×16 cm 2 (9×9–25×20 cm 2 ) being used. Average operative time was 153 minutes with a range of 69–281 minutes. One (5%) had an early (within the first three months post-surgery) recurrence of the hernia. One patient (5%) had an early superficial SSI noticed during the 1 week follow-up appointment and was treated with oral antibiotics. None of the patients required re-hospitalization. None of the patients developed any seroma or any deep tissue infections requiring mesh explantation. Fourteen (74%) of the 19 patients were reached via telephone for further follow-up. All 14 patients were satisfied with the results of their surgery with only 1 complaint of pre-existing gastritis unrelated to the surgery. All of the patients that were employed prior to the surgery were able to return to work post-operatively. None of the patients reported any residual incisional or back pain. Conclusions: Hybrid ventral hernia repair has the physiological benefit of fascial continuity by re-approximating the hernia edges. This technique also maximizes the benefit of laparoscopic repair while mini-mizing associated complications. Patients had no severe wound complications. This surgical technique resulted in a low recurrence rate, and minimal pain after the procedure, making the hybrid technique a safe alternative method when repairing intermediate sized ventral hernias.

Laparoscopic incisional hernia repair has become widely accepted in the management of incisional hernias. There has been recent interest in combining fascial closure along with mesh placement to improve outcomes. We report our experience with this technique. Cases were evaluated retrospectively from 2012 to 2015. There were no exclusions. Cases were included which involved laparoscopic ventral hernia repair with fascial closure and mesh placement. Fascial closure was performed using non-absorbable sutures passed with a suture passage device percutaneously. A 5-cm overlap was performed using intra-peritoneal mesh. Fixation was performed using absorbable tacks in a double crown technique. One hundred and twelve cases were included. The mean age was 57years old (range 33-81years). Fifty-nine were females and 53 were males. The median post-operative stay for the non-fascial closure group was 0days (range 0-12days). The median post-operative stay for the fascial closure group was 0days (range 0-12days). All cases were followed up clinically at 6weeks. In the non-fascial closure group, five patients developed a seroma (12%). One patient developed a wound infection (3%). Six patients presented with a recurrence over the study period (15%). In the fascial closure group, four patients had a seroma, which was managed conservatively (5%). One patient developed a wound infection (1%). Five patients developed a recurrence over the study period (7%). We have shown comparable rates for seroma and recurrence to other series. Laparoscopic incisional hernia repair with defect closure is feasible and reduces seroma rate and recurrence.

BackgroundVentral incisional hernia is a common problem after abdominal surgery. Most patients with these hernias present with greater omentum and gastrointestinal prolapse. However, hepatic herniation through a ventral incisional hernia is a rare phenomenon that has been seldom reported in the literature. We report the case of a ventral incisional hernia with hepatic herniation treated with laparoscopic repair.Case presentationA 68-year-old Japanese women with a history of myocardial resection for hypertrophic cardiomyopathy 1 year earlier was admitted to our hospital with symptoms of vomiting and epigastric pain. Physical examination showed a 4-cm epigastric mass. Abdominal computed tomography revealed left hepatic lobe herniation through the lower edge of a mid-sternal incision. We diagnosed the patient with a ventral incisional hernia with hepatic herniation. The patient underwent laparoscopic hernia repair. During an 18-month follow-up, no recurrence or symptoms have been observed.ConclusionsTo the best of our knowledge, this is the first case report of laparoscopic repair of ventral incisional hernias with hepatic herniation. Laparoscopic repair was useful and suitable for this rare herniation due to its minimally invasive nature and ability to achieve sufficient visibility of the surgical field. Laparoscopic repair could be a potential treatment option for elective surgery for this disease, which is often treated conservatively.