Laparoscopic Repair of Recurrent Ventral Hernias
By Costanza, Michael J; Heniford, B Todd; Arca, Marjorie J; Mayes,
James T; Gagner, Michel The American Surgeon
Available on MerckMedicus December 01, 1998
INCISIONAL HERNIAS REPRESENT an important element of morbidity after
abdominal surgery. Three to 13 per cent of patients undergoing a
laparotomy will develop a fascial defect in their abdominal scar,
which necessitates approximately 90,000 ventral hernia
operations/year.1 Lasting surgical repair of these hernias continues
to be elusive. Eighteen to 41 per cent of ventral hernias recur after
initial repair. When those hernias that have recurred are repaired,
the incidence of a second recurrence can exceed 50 per cent.2
An effective ventral hernia repair should be achieved with the goals
of minimal perioperative morbidity and low recurrence rate. A variety
of surgical techniques have been described in attempts to meet these
goals. Relaxing incisions have been used to decrease suture line
tension for primary hernia repairs. Other surgical techniques include
the Keel procedure, internal retention sutures, and muscle rotation
flaps. The use of prosthetic mesh has resulted in a lower recurrence
rate when compared with a primary repair.3 The disadvantage of a
herniorraphy involving mesh is the need for an extensive surgical
dissection and a slight increase in the rate of infection. Patients
undergoing open repair usually spend several days in the hospital
postoperatively, frequently require abdominal drains, and often need a
long recovery period.4
The laparoscopic approach to ventral hernias can minimize the
disadvantages of open herniorraphy without compromising the ability to
implement a tension-free, mesh repair. Using laparoscopy, an extension
adhesiolysis with placement of a large prosthesis can typically be
accomplished through three or four small incisions. Patients
undergoing laparoscopic ventral hernia repairs generally have shorter
postoperative stays, require less narcotics, and return to their
normal activity level quickly. The rate of recurrence seems low, but
is presently under investigation.
Our group has performed laparoscopic ventral herniorraphy for 2.5
years. All patients who present with ventral hernias larger than 4 cm
are considered candidates for this approach. This study examines the
effectiveness of laparoscopic ventral herniorraphy in patients with
recurrent hernias after conventional hernia repairs.
Methods
A retrospective review of all patients with recurrent ventral hernias
who underwent laparoscopic repair at the Cleveland Clinic Foundation
was conducted. Patient records were reviewed for number of previous
hernia repairs, number of previous abdominal operations, and body mass
index [BMI = patient weight (kg)/patient height (m)]. Operative
records documented the number and size of fascial defects, the size of
prosthetic mesh inserted, and the method in which the mesh was
secured. Postoperative use of pain medicine, time to return of bowel
function, and length of hospital stay were recorded. Follow-up
surveillance for recurrences and postoperative complications was
obtained on all patients at 2 weeks, 1 month, 6 months, 1 year, and
annually after surgery.
Operative Technique
The procedure is performed with the patient under general anesthesia.
A Foley catheter and orogastric tube are inserted for bladder and
gastric decompression. A first generation cephalosporin is
administered before incision, and the dose is repeated every 2 hours
during the procedure. Typically, an open technique is used to place
the first trocar away from the hernia defect.5 Pneumonperitoneum is
established by insufflating the abdomen to 15 mm Hg with carbon
dioxide. A 30- or 45-degree laparoscope is introduced through the
initial trocar, and the abdomen is explored. The hernia defect and any
associated adhesions are identified. Usually two or three additional
trocars are inserted under direct vision at least 5 cm from the
lateral edge of the hernia defect. The ultimate number and exact
placement of trocars depends on the individual case. An adhesiolysis
is performed to free the bowel from the anterior abdominal wall.
External manual palpation of the abdominal wall and hernia defect
changes the angles of vision and usually facilitates the dissection.
Attempts to remove the hernia sac are avoided.
After the hernia contents have been reduced, the edges of the defect
are identified and the size of the hernia is measured internally with
a laparoscopic instrument or by inserting a narrow plastic ruler via
one of the ports (Fig. 1). A piece of expanded polytetrafluoroethylene
(ePTFE) mesh (Dual Mesh; W.L. Gore and Assoc., Flagstaff, AZ) is then
cut so that it will overlap the edges of the defect by 4 cm in all
directions. The prosthetic mesh is then tightly rolled and inserted
into the abdominal cavity through one of the trocars. After the mesh
is opened and oriented inside the abdomen, a laparoscopic tacker is
used to secure the mesh in position, lateral to the edges of the
hernia defect by 4 cm in all directions.
The prosthetic mesh is sutured into position with full thickness
transabdominal stitches placed every 3 to 4 cm along the outer border
of the mesh. Through a 2-mm stab incision, one end of an
O-polypropylene suture is passed through the abdominal wall and mesh
and deposited intraperitoneally using a suture passer. Through the
same incision, the suture passer is reintroduced into the abdomen at a
different angle so that it penetrates the fascia and mesh at least 1
cm from the position in which the suture was originally introduced.
The intra-abdominal tail of the suture is then pulled to the outside
where the knot is tied and buried in the subcutaneous tissues (Fig.
2). This process is repeated at 3- to 4-cm intervals around the entire
circumference of the mesh. Laparoscopic staples or tacks are then used
between sutures to fix the mesh to the abdominal wall. This is done to
ensure that intra-abdominal viscera cannot slip between the mesh and
the abdominal wall in the gaps between sutures. Tacks and staples are
not used to increase the strength of the repair.
At the completion of the procedure, nonabsorbable sutures are used to
close the abdominal fascia at each trocar site. The trocar skin
incisions are closed with absorbable subcutaneous sutures. The 2-mm
incisions that were made for the suture passer are closed with
adhesive paper strips. No drains were used for any of the patients.
Postoperatively, patients are given intravenous or intramuscular
narcotics for analgesia. A diet is started on the 1st postoperative
day, and patients begin to ambulate as soon as possible. Most patients
are discharged on the 2nd postoperative day.
Results
From August 1995 to June 1997, 31 patients underwent attempted
laparoscopic ventral hernia repair; 16 were for recurrent hernias and
the subject of this study. Patients have been followed for an average
of 18 months and none have been lost to follow-up (Table 1).
Patient Characteristics
There were 10 males and 6 females. The average age of the patients was
56 years (range, 28- 83 years). Patients were typically obese with an
average body mass index of 30 kg/m2 (range, 22-34 kg/m2; normal, 20-25
kg/m2). All of the patients had undergone previous abdominal surgery
and at least one open ventral hernia repair; 10 of 16 patients had two
or more prior hernia operations. The average number of previous
ventral hernia repairs for the series was 2.4 (range, 1-7), and the
average number of previous abdominal procedures was 4 (range, 1-10).
Operative Results
Fifteen patients underwent successful laparoscopic repair of their
recurrent ventral hernia. One patient was converted to an open repair
because of dense adhesions and loss of abdominal domain. Multiple,
large hernias were frequently encountered at the time of surgery. The
average hernia measured 130 cm2 and the largest defect was 480 cm2. In
each case, a piece of a ePTFE mesh was placed to repair the hernia.
The average size of the mesh used was nearly 300 cm2 (range, 12-1470
cm2).
Postoperative Results
Patients generally had a short postoperative stay. All patients were
discharged on postoperative days 1 to 4; the mean and median length of
stay was 2 days. Patients required minimal amounts of postsurgical
analgesia. An average of 19 mg of narcotics (morphine equivalent) were
used postoperatively. Bowel function returned quickly in most
patients. All the patients in our series had flatus or a bowel
movement and were tolerating a regular diet in 2 days or less.
Patients were closely followed postoperatively for 7 to 23 months
(average, 18 months). There have been two complications. One patient
returned to the hospital with cellulitis, which resolved with 3 days
of intravenous antibiotics; he continues to do well 16 months
postoperatively. Another patient developed skin breakdown over the
area of the hernia repair. This resulted in an infection of the mesh
and subsequently necessitated removal. With an average follow-up of 18
months, this patient represents the only recurrence of the series.
Discussion
Incisional hernia is the most common long-term complication after
abdominal surgery, occurring in 3 to 13 per cent of cases.'
Predisposing factors to incisional hernia include: wound infection,
obesity, advanced age, pulmonary complications, male gender, and
hepatic insufficiency. Conventional primary repair of ventral hernias
is plagued with a high recurrence rate. Eighteen to 41 per cent of
ventral hernias recur after the initial repair, and recurrent ventral
herniorraphy can be associated with a 50 per cent failure rate.2
Repairing ventral hernias with mesh can decrease the recurrence rate.
The placement of the prosthesis by the conventional open technique
involves a large incision, an extensive subcutaneous and
intra-abdominal surgical dissection, and often necessitates the
placement of drains. A postoperative ileus, an extended hospital stay,
and a prolonged recovery period is frequently associated with this
type of operation. Complication rates range from 8 to 19 per cent
after open ventral hernia repair.2
Laparoscopic repair of ventral hernia uses a minimally invasive
approach to obtain the benefits of an open mesh herniorraphy while
attempting to minimize the postoperative morbidity. An extensive
intra-abdominal dissection can be accomplished through three or four
laparoscopic ports, which eliminates the need for a large incision and
expansive subcutaneous dissection. Despite the minimally invasive
technique, a large piece of prosthetic mesh can be inserted and a
tension-free repair can be obtained. Patients typically recover
quickly after a laparoscopic ventral herniorraphy, require relatively
little pain medication, and leave the hospital within a few days s
A laparoscopic approach to recurrent ventral hernias is technically
feasible. All of the patients in our series presented with recurrent
ventral hernias, and most patients had undergone multiple prior hernia
operations. Only one conversion from laparoscopic to open hernia
repair was required. In this case, there were dense adhesions and loss
of abdominal domain, and it was felt that the laparoscopic repair
could not be performed safely.
The principles necessary for a successful mesh hernia repair are not
sacrificed by using the laparoscopic approach. Dissection of viscera
from the abdominal wall is performed to define the hernia defects and
to identify healthy fascia to which the mesh should be secured. The
peritoneal onlay method that is used during laparoscopic ventral
herniorraphy is based on the Stoppa-Rives technique for open ventral
herniorraphy.9 They describe the placement of prosthetic mesh
posterior to the anterior fascia. This would seem to allow for the
intra-abdominal pressure to hold the mesh in the correct position over
a large surface area.
All patients in this series were managed with Gore-Tex Dual Mesh (W.L.
Gore and Assoc.). This ePTFE prosthetic was chosen over a standard
polypropylene mesh due to the fact that the mesh is often directly
exposed to the intestine. PTFE evokes a limited inflammatory and
foreign body response. This, along with its limited porocity, reduces
adhesions from the intra-abdominal viscera.10 Adhesions to the mesh,
which occur more frequently with polypropylene, can result in fistulas
and sepsis during early or long-term follow-up.lo The Dual Mesh offers
a second advantage by having larger pores on the side of the mesh that
is exposed to the abdominal wall. This feature allows for tissue
growth into the mesh, which aids in securing the mesh longterm.
A strong emphasis should be placed on the correct fixation of the mesh
to the abdominal wall. As described in "Methods", large nonabsorbable
sutures are used in full-thickness transabdominal bites to secure the
mesh. Laparoscopic tacks or staples are used only to initially hold
the mesh in position and to fill in the gaps between sutures. Strong
and reliable fixation is important when using ePTFE mesh because it
may be more slowly incorporated into the abdominal wall lo but this is
controversial.11
Patients in our series fared well postoperatively. The short duration
of the patients' hospital stays can be attributed to several factors.
After a laparoscopic procedure, the patients' ileus is frequently
limited; they can usually tolerate a diet on the 1 st postoperative
day and generally regain bowel function quickly. Parenteral narcotic
requirements are less after a minimally invasive procedure; thus,
their influence on recovery is also diminished.
We had two complications in our series of patients. One patient
returned to the hospital with cellulitis that resolved with
intravenous antibiotics. Another patient, in whom the mesh was sutured
directly to the skin, developed skin breakdown that resulted in an
infection of the mesh -that subsequently required its removal. This
patient represents our only hernia recurrence. The ultimate durability
of the laparoscopic ventral hernia repair can only be determined with
a longer follow-up. A prospective, randomized trial comparing the
postoperative course and rate of recurrence of laparoscopic and open
ventral hernia repairs would also help better define the role of the
laparoscopic approach for recurrent ventral hernias.
Conclusions
Laparoscopic repair can be an effective method of addressing the
difficult problem of recurrent ventral hernias. The laparoscopic
approach provides a means of obtaining a tension-free, mesh repair
with a low complication and recurrence rate. Previous open abdominal
herniorraphies, including those repaired with mesh, are not a
contraindication to attempting this approach. However, our one case of
conversion to an open repair demonstrates that loss of abdominal
domain may be a circumstance that prevents successful laparoscopic
repair.
The patients in our series put laparoscopic ventral herniorraphy to a
rigorous test. All of the patients had recurrent hernias and most of
the patients had multiple previous recurrences. Despite these
challenges, the hernias were effectively repaired with mesh that was
secured with transabdominal sutures. The laparoscopic approach offers
the typical advantages seen with other minimally invasive surgical
procedures including reduced hospital stay, decreased narcotic
requirements, and an early return of bowel function. |
