LAPAROSCOPIC Ventral Hernia Repair

LAPAROSCOPIC Ventral Hernia Repair

George S. Ferzli, MD, FACSProfessor of Surgery, State University of New York

George S. Ferzli, MD, FACSProfessor of Surgery, State University of New York

General Information:General Information:• 100,000 ventral hernia surgeries per year

• 3-20% of laparotomy incisions

• 10-15% of all hernia repairs

• 17% will develop incarceration or strangulation

• Mortality 0.3% • Elective repair, 1.1 %• Emergency repair

Primary repair of ventral hernia without mesh:Primary repair of ventral hernia without mesh:

• Recurrence rate 25%-45% after first repair

• 58% recurrence after second attempt

Hessilink VJ et al. An evaluation of the risk factors in incisional hernia recurrence. Surg Gyn Obst 1993 March;176(3) 228-34.

Primary repair of ventral hernia with mesh:Primary repair of ventral hernia with mesh:

10-20% recurrence

12 % infection rate and wound complications

Luijendijk R W et al. A comparison of suture repair with mesh repair for incisional hernia N Engl J Med 2000; 343;392-8

• Components separation technique

resulted in 32% recurrence

Devries Raleigh TS et al. Component separation technique for the repair of large abdominal wall hernia. JACS 2003 Jan 196(1) 32-7

• Vacuum assisted closureProspective 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

Methods to decrease hernia occurrence and facilitate primary repair:

Methods to decrease hernia occurrence and facilitate primary repair:

• Large incision

• Extensive dissection

• Drains

• Mesh

• Co-morbidities

The increase in rate of wound complications in open incisional hernias repair is related to:

Laparoscopic Repair of Incisional HerniasLaparoscopic Repair of Incisional Hernias

• wound complications

• recurrence rate

• LOS

• pain

• coverage of “Swiss cheese” abdomen

Preparing the patientPreparing the patient

• Consider bowel prep

• Pre-operative antibiotic prophylaxis

• Foley catheter

• Nasogastric tube

• SCDs/DVT prophylaxis

Preparing the patientPreparing the patient

• Tuck arms at side

• Secure patient to table

• Consider footboard

• Consider Ioban drape

EquipmentEquipment

Instrumentation

• Atraumatic graspers

• Ultrasonic shears

• 5 mm tacker

• Suture passer

• Identify approximate size of defect

• Determine sites for placement of ports

Sizing the meshSizing the mesh• What is the best way to measure the mesh?• 3 options: Intracorporeal with pneumoperitoneum,

extracorporeal with pneumoperitoneum, extracorporeal desufflated

• With extracorporeal measurement, the diameter of the outer (skin) circle is larger than the inner (peritoneal) circle.

• This difference is proportional to the size of the patient.

• Result is overestimation of hernia size and mesh by 1.7 to 3.1 cm

Jin, J, Rosen MJ. Laparoscopic versus open ventral hernia repair. Surg Clin N Am 2008;88:1083-1100

Sizing the meshSizing the mesh

LeBlanc KA. Incisional hernia repair; Laparoscopic Techniques. World J Surg, 2005 29 1073-1079

Access to abdomen• Blunt trocar with open technique

• Veress needle

• Remote from

hernia site

Trocar

Requirements depend on hernia size

• 11 mm or 12 mm

and 5 mm trocars

• Begin careful adhesiolysis

• Blunt and

sharp dissection

• Avoid use of

cautery

• Full extent of defect identified

• Beware of the presence of multiple defects

• Once the defect is measured a mesh is selected that provides at least 3 cm of overlap around the defect.

• Some surgeons use a 4 – 6 cm overlap.• This may be particularly important in

the recurrent hernia or in the morbidly obese patient.

LeBlanc KA. Incisional hernia repair: Laparoscopic techniques. World J Surg. 2005, 29; 1073-1079

• Ensure proper mesh surface

orientation

• Place anchoring sutures trans-abdominally

• Secure periphery of mesh with tacker

• Approximately 1cm apart

• The tensile strength of the transabdominal suture is 2.5 times greater than that of the tacker

• Cadaveric pig studies have shown that the optimal distance between fixation points is about 1.8 cm

• Or the ideal number of fixation points can be derived by the formula: (2pi r)/7) x 3 = 2.7r

Placement of sutures or tacksPlacement 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.

•Multicenter trial 11/1993-2/2003•850 patients (85% evaluated

prospectively)•422 men and 428 women•Age 54 (13-94)•BMI 32.1 (22-67)•Defect size cm2 118 (1-1600)•Mesh size cm2 344 (24-2500)

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

850 patients:• Defect > 4 cm2

• Elective procedure• Tension free PTFE (Gortex dual mesh)• >3 cm overlap of defect

• Sac left in situ

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

850 Patients• OR time 120 (110-420)• Conversion to open 31 (3.6%)• Mean hospital stay 2.3 (0-33)

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

850 patients• Recurrence 35 (4.7%)

• Mean follow-up 20 months (1-96 months)

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 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

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 Hernia Recurrence

Patients without Hernia Recurrence

Mean defeat size (cm2)

184 124

Mean operating time (min)

149 118

Previous hernia repair (% of patients)

63 35

Complication rate (%)

32 12

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 PatientsProlonged 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)

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

What to do when an enterotomy occurs?What to do when an enterotomy occurs?

• Contamination repair injury and delay hernia repair

• No spillage repair hernia

• Bladder injury repair hernia

• Delayed bowel injury remove mesh and delay repair

What to do with seroma?What to do with seroma?

• Observation: most of them will resolve without intervention

• Repetitive sterile aspiration

• When persistent beyond 8 weeks or longer: removal of mesh and excision of hypertrophic mesothelium

Can seroma formation be decreased?Can seroma formation be decreased?

• 78 patients underwent 80 laparoscopic LVHR • Separated into 2 groups• Both groups repaired with ePTFE dual mesh secured by full-

thickness stitches and endoscopic tacks • Group A (n=28)

•subgroup A1; n=17 - overlap of 2.5 cm•subgroup A2; n=11 - overlap of 4 cm and a full-thickness suture

placed in the center of the hernia defect to reduce the "dead space." • Group B (n=52) Hernia sac cauterized by monopolar cautery or

Harmonic scalpel •subgroup B1; n=16 - overlap of 2.5 cm •subgroup B2; n=36 - overlap of 4 cm and a full-thickness suture

placed in the center of the hernia defect to reduce the "dead space."

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

Postoperative complicationsPostoperative complications

A1 A2 B1 B2

(n = 17) (n = 11) (n = 16) (n = 36)

• Seroma 5 2 1 0* * p = 0.004 vs A1

• Clinical 4 0 1 0 * p = 0.009 vs A2

• Subclinical 1 2 1 0

• Hematoma 2 1 0 1

• Infection 2 0 0 0

• Recurrence 2 1 1 0** ** p = 0.036 vs A1

• Total Seroma A1 + A2 B1 + B2*** *** p = 0.004

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

What to do for pain at transabdominal suture site?What to do for pain at transabdominal suture site?

• Nonsteroidal anti-inflammatory agents/oral narcotics

• Subfascial injection of combination lidocaine and bupivacaine

• 103 patients underwent LVHR• 24 patients (23%) had prolonged discomfort at a

transabdominal suture site• Treatment consisted of injection around the suture

site with 0.25 % bupivacaine with epinephrine and 1 % lidocaine

• 20 patients required a single injection• 2 patients required two injections • 2 patients failed local injection and were referred to an

anesthesia pain service • One underwent intercostal nerve block with resolution of

pain• The other is currently in treatment

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

Lap vs Open Non-RandomizedLap vs Open Non-Randomized

  Number of Patients

Mean LOS (Days)

Complication Rate

Recurrence Rate

Holzman1997

21 Lap16 Open

1.6 v. 4.9* 23% v. 31%*

9.5% v. 12.5%

Park1998

56 Lap49 Open

3.4 v. 6.5* 18% v. 37%*

10.7% v. 34.7%*

Ramshaw1999

79 Lap174 Open

1.7 v. 2.8* 19% v. 31%*

2.5% v. 19.5%*

Chari2000

14 Lap14 Open

5 v. 5.5 NA NA

DeMaria2000

21 Lap18 Open

0.8 v. 4.4* 19% v. 50%*

5% v. 0%

Lap vs Open Prospective RandomizedLap vs Open Prospective Randomized

  Number of Patients

Mean LOS (Days)

Complication Rate

Recurrence Rate

Carbajo1999

30 Lap30 Open

2.2 v. 9.1* 6.7% v. 57%*

0% v. 5%*

McGreevy2003

65 Lap71 Open

1.1 v. 1.5 8% v. 21%

NA

n = 85 open anterior repair (OG) n = 85 laparoscopic repair (LG)

OG LG• OR time 150.9min 61 min (p <

0.005)• Hospital days 9.9 days 2.7 days (p < 0.005)• Return to work 25 days 13 days (p < 0.005)• Complications 29.4% 16.4% (p < 0.005)• Relapse 1.1% 2.3%

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

Metanalysis of Lap v. OpenMetanalysis of Lap v. Open

  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

Goodney et al. Archives Surgery 2002 October 137 (10): 114

Cost comparisonCost comparison

  Lap Open P-value

Carbajo(1999)

12461 8273 NA

McGreevy

(2003)9316 5858 0.01

Laparoscopic ventral hernia repair in the obese patientLaparoscopic ventral hernia repair in the obese patient

Group A (n = 134) Group B (n = 767)BMI >/=40 (mean 46 BMI < 40 (mean 30)

• OR time 154 min 119 min p < 0.01• Hospital stay 3.6 days 2.4 days p = 0.03• Mesh size 449 cm2 349 cm2 p = 002• Recurrence 8.3% 2.9% p = 0.003• Complications 19.7% 15.3% p = 0.46

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.

Laparoscopic ventral hernia repair in the obese patientLaparoscopic ventral hernia repair in the obese patient

• LVHR in the morbidly obese population is safe and feasible, however, there is a higher, but acceptable recurrence rate.

• LVHR in morbidly obese minimizes the potential wound and mesh complications that frequently occur for open mesh repair in this group of patients.

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.

Laparoscopic ventral hernia repair for the recurrent herniaLaparoscopic ventral hernia repair for the recurrent hernia

• Advantages include:• Avoiding dissection through previous operative sites• Avoiding disruption of prior mesh • Discovery of multiple small fascial defects

• Disadvantages include:• Learning curve• Prior intra-abdominal mesh• Difficulty identifying entertomy• Adhesions• In-growth into mesh

Laparoscopic ventral hernia repair for the recurrent herniaLaparoscopic ventral hernia repair for the recurrent hernia

• Study of recurrent incisional hernia and the effect of laparoscopic repair on:

• Adverse events• Quality of life• Recurrence rates

• Prospective study• n = 85• Median follow up – 41 months

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.

Laparoscopic ventral hernia repair for the recurrent herniaLaparoscopic ventral hernia repair for the recurrent herniaOutcomes after operationsLength of stay, days (range) 2 (1 -9)Port site cellulites, n (%) 1 (1.1)Seroma, n (%)

• No intervention 3 (3.5%)• Fine-needle aspiration 3 (3.5%)

Persistent pain, n (%)• No injection 4 (4.7)• Local anesthetic 2 (2.3)

Reoperations (SBO), n (%) 1 (1.1)Recurrences

• No intervention 1 (1.1)• Reoperation 2 (2.3)

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.

Laparoscopic ventral hernia repair for the recurrent herniaLaparoscopic ventral hernia repair for the recurrent herniaGastroinestinal quality of life index scores (GIQLI) Pre-op Follow up

GIQLI GIQLI Symptoms 54 (22 - 57) 63 (41 - 77) p < 0.001Emotional function 12 (2 – 15) 16 (5 – 20) p < 0.001Physical function 15 (3 -20) 21 (7 – 27) p < 0.001Social function 14 (4 – 16) 13 (4 – 16) NSSubjective treatment assessment 3 (0 – 4) 3 (1 – 3) NS

Scores reported as medians (range)Quality of life assessment performed at 24 months

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.

Laparoscopic ventral hernia repair for the recurrent herniaLaparoscopic ventral hernia repair for the recurrent hernia

Laparoscopic adhesiolysis and recurrent

hernia mesh repair results in:• Low rate of adverse events

• Improved health-related quality of life

• A risk of recurrence similar to that of first time hernia repair

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.

ConclusionsConclusions

In experienced hands, laparoscopic

repair of ventral hernias has:

• low recurrence rate

• low incidence of complications

• short hospital stay