Case Report Laparoscopic Excision of Large Intra-Abdominal ...
Laparoscopic abdominal wall surgery - 56k · Laparoscopic abdominal wall surgery Marc Miserez UZ...
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Laparoscopic abdominal wall surgery
Marc MiserezUZ Leuven
Filip MuysomsAZ Maria Middelares Gent
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
![Page 2: Laparoscopic abdominal wall surgery - 56k · Laparoscopic abdominal wall surgery Marc Miserez UZ Leuven Filip Muysoms AZ Maria Middelares Gent 8th edition “Warm‐up Package”](https://reader034.fdocuments.in/reader034/viewer/2022052408/5f0c42377e708231d4348343/html5/thumbnails/2.jpg)
• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
Inguinal hernia treatment:Inguinal hernia treatment:factors to considerfactors to consider
Recurrence
Quality of lifepostoperative recovery, chronic pain
Safetyrisk for perioperative complications
Learning curvegrade of difficulty/reproducibility
Costhospital and society costs
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Let us then speak the Let us then speak the same languagesame language
•• Hernia classificationHernia classification
•• Outcome parametersOutcome parameters
The EHS Groin Hernia ClassificationThe EHS Groin Hernia Classification
≤ 1 finger 1-2 fingers
> 2 fingers
indirect
femoral
direct
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The EHS guidelines on the treatmentof inguinal hernia in adult patients
Simons et al, Hernia 2009; 13: 343-403
TopicsTopics•• Risk factors/preventionRisk factors/prevention•• DiagnosticsDiagnostics•• Indications for treatmentIndications for treatment•• ClassificationClassification•• TreatmentTreatment
– General– Bilateral– Recurrent– Laparoscopy: TAPP vs TEP– Women– Young men (18-30)
•• BiomaterialsBiomaterials
Simons et al, Hernia 2009; 13: 343-403
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TopicsTopics•• Training/specialist centersTraining/specialist centers
•• Complications (excl recurrence)Complications (excl recurrence)
•• Chronic painChronic pain
•• Antibiotic prophylaxisAntibiotic prophylaxis•• AnesthesiaAnesthesia•• Day SurgeryDay Surgery•• Postoperative pain controlPostoperative pain control•• Postoperative recoveryPostoperative recovery•• AftercareAftercare
•• CostsCosts
Simons et al, Hernia 2009; 13: 343-403
Levels of evidenceOxford Centre for EvidenceOxford Centre for Evidence--based Medicine Levels of Evidence (2001)based Medicine Levels of Evidence (2001)
1a systematic reviews of RCTs1b individual high quality RCT
2a systematic reviews of cohort studies2b individual cohort study or low quality RCT2c “outcomes” research
3a systematic reviews of case-control studies3b individual case-control study
4 case-series and poor quality cohort and case-control studies
5 expert opinion
RecommendationA
B
C
D
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Treatment:
All male adult (>30 years) patients with a All male adult (>30 years) patients with a symptomatic inguinal hernia should be operated symptomatic inguinal hernia should be operated on using a mesh technique.on using a mesh technique.
The open Lichtenstein and endoscopic inguinal The open Lichtenstein and endoscopic inguinal hernia techniques are recommended as the best hernia techniques are recommended as the best evidenceevidence--based options for repair of a primary based options for repair of a primary unilateral hernia unilateral hernia providing the surgeon is sufficiently providing the surgeon is sufficiently experienced in the specific procedure. experienced in the specific procedure.
Grade AGrade A Mc Cormack et al, 2005Mc Cormack et al, 2005Schmedt et al, 2005Schmedt et al, 2005
Lichtenstein hernioplastyLichtenstein hernioplasty
Lichtenstein and Shulman, Int Surg 1986
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large prosthesis withreinforcement of the whole myopectineal orifice
~ minimally invasive STOPPA repair~ minimally invasive STOPPA repair (GPRVS)Chirurgie, 1973; 99: 119-123
Endoscopic groin hernia repairEndoscopic groin hernia repair
Flow diagram treatmentFlow diagram treatment
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Endoscopic vs Lichtenstein Endoscopic vs Lichtenstein FU > 48 monthsFU > 48 months
RecurrenceRecurrence
± 5%
Postoperative recovery
It is recommended that an endoscopic It is recommended that an endoscopic technique is considered if a quick technique is considered if a quick
postpost--operative recovery is particularly important.operative recovery is particularly important.
Grade AGrade A
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Endoscopic mesh techniques result in a Endoscopic mesh techniques result in a lower chance of chronic pain/numbness lower chance of chronic pain/numbness than Lichtenstein.than Lichtenstein.
In the longIn the long--term (> 3term (> 3--4 years FU), these differences4 years FU), these differencesseem to decrease for the aspect pain, seem to decrease for the aspect pain, but not for numbness.but not for numbness.
Level 1B
Treatment : chronic pain
It is recommended that risks of development of It is recommended that risks of development of chronic postoperative pain are taken into accountchronic postoperative pain are taken into accountwhen the method of hernia repair is decided uponwhen the method of hernia repair is decided upon
Grade BGrade B
lower age lower age (level 2A)(level 2A)
preoperative groin pain preoperative groin pain (level 2B)(level 2B)
preoperative chronic pain conditions (level 2B)
female gender (level 2B)
Treatment – chronic pain
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Minimally invasive surgery is there to stay Minimally invasive surgery is there to stay
ButBut……
Endoscopic hernia techniques vs. Endoscopic hernia techniques vs. Lichtenstein repair result in aLichtenstein repair result in a
Longer operation time (8Longer operation time (8--13min),13min),Higher incidence of seromaHigher incidence of seroma
Level 1A
Mc Cormack et al, 2005Mc Cormack et al, 2005Schmedt et al, 2005Schmedt et al, 2005
Treatment
Need for general anesthesia
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It is recommended that, It is recommended that, from a from a hospital hospital perspective, perspective, an open mesh procedure is used an open mesh procedure is used for the treatment of primary unilat. inguinal hernia.for the treatment of primary unilat. inguinal hernia.
From a From a sociosocio--economiceconomic perspective, perspective, an endoscopic procedure is proposed an endoscopic procedure is proposed for the active working population, for the active working population, especially for bilateral herniasespecially for bilateral hernias
Grade AGrade A
Costs
How to reduce hospital costsHow to reduce hospital costsReusable instrumentsReusable instruments
TrocarsTrocars
Fixation devices (selective)Fixation devices (selective)
Ambulatory surgeryAmbulatory surgery
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Endoscopic surgery:Endoscopic surgery:long and steep learning curvelong and steep learning curve
Treatment: Complications laparoscopy
There appears to be a higher rate of rare but There appears to be a higher rate of rare but serious complications with endoscopic repair,serious complications with endoscopic repair,
especially during the especially during the learning curve learning curve periodperiod
Level 2BLevel 2B
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Training: the learning curve
The learning curve for performing endoscopic inguinal hernia repair (especially TEP) is longer than for open Lichtenstein repair,
and ranges between 50 and 100 procedures, with the first 30-50 being most critical
Level 2C
Learning curve errors in laparoscopic surgery
Not (longer) tolerated
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The learning curve depends also on the The learning curve depends also on the structure of the training program! structure of the training program!
A learning curve is far from a straight progression
The most important variables The most important variables in the learning curvein the learning curve
Structured training programStructured training program
Laparoscopic experience of the traineeLaparoscopic experience of the trainee
Patient selection– No recurrent or scrotal hernia– No previous appendectomy for right sided hernia– Female patient
Type of supervisionType of supervision– Mentoring vs proctoring– Expertise and motivation of the trainer
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Groin hernia: endoscopic repairGroin hernia: endoscopic repair
• TAPP (Transabdominal Preperitoneal)more easy to learn - endoscopic suturingtransperitoneal approach
higher risk for postoperative intestinal obstructionDuron et al, Arch Surg 2000 Bringman and Blomqvist, Hernia 2005
laparoscopic exploration
•TEP (Totally ExtraPeritoneal) more difficult to learn
anatomy more difficult to understandlimited working space
preservation of peritoneal integrity – safer?laparoscopic exploration also easily possible
Groin hernia: anatomic aspectsGroin hernia: anatomic aspects
Be familiar with the anatomy!Be familiar with the anatomy!
inguinal ligament (Poupart)
genital branch of genitofemoral nerve
falx inguinalis – conjoint tendon
lacunar ligament (Gimbernat)
obturator artery
= pectineal ligament
ramus superior ossis pubis
pubic symphysis
TRIANGLE OF PAINTRIANGLE OF DOOM
indirect inguinal herniadirect
inguinal hernia
femoral hernia
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• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
![Page 17: Laparoscopic abdominal wall surgery - 56k · Laparoscopic abdominal wall surgery Marc Miserez UZ Leuven Filip Muysoms AZ Maria Middelares Gent 8th edition “Warm‐up Package”](https://reader034.fdocuments.in/reader034/viewer/2022052408/5f0c42377e708231d4348343/html5/thumbnails/17.jpg)
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
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Systematic TEP inguinal hernia Systematic TEP inguinal hernia repair in 10 consecutive stepsrepair in 10 consecutive steps
Miserez et al, Surg Lap Endosc Percut Tech 2009Miserez et al, Surg Lap Endosc Percut Tech 2009
1.1. Introduction of first trocarIntroduction of first trocar2.2. Introduction of second trocarIntroduction of second trocar3.3. Dissection to BogrosDissection to Bogros’’ space and space and
introduction of third trocarintroduction of third trocar4.4. Reduction of direct inguinal herniaReduction of direct inguinal hernia5.5. Reduction of femoral/obturator herniaReduction of femoral/obturator hernia6.6. Reduction of indirect inguinal herniaReduction of indirect inguinal hernia7.7. Lateral dissection and reduction of Lateral dissection and reduction of
preperitoneal lipoma preperitoneal lipoma 7’ Contralateral dissection8.8. Preparation and introduction of the meshPreparation and introduction of the mesh9.9. Placement of the mesh and fixation Placement of the mesh and fixation
in selected casesin selected cases10.10. DesufflationDesufflation basic advanced
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8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
• Video TEP Marc
Treatment: laparoscopyTAPP vs. TEP
For endoscopic inguinal hernia techniques,For endoscopic inguinal hernia techniques,TAPP seems to be associated with higher ratesTAPP seems to be associated with higher ratesof portof port--site hernias and visceral injuriessite hernias and visceral injuries
while there appear to be more conversions with TEPwhile there appear to be more conversions with TEP
Level 2ALevel 2A TAPPTAPP TEPTEP openopen
VascularVascularinjuriesinjuries
0.13%0.13% 0%0% 0%0%
VisceralVisceralinjuriesinjuries
0.65%0.65% 0.16%0.16% 0.14%0.14%
Memon et al, Br J Surg 2003Memon et al, Br J Surg 2003McCormack et al, Health Technology Assessment 2005McCormack et al, Health Technology Assessment 2005
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Treatment: laparoscopy
TAPP vs. TEP
It is recommended that anIt is recommended that anextraperitoneal approach (TEP)extraperitoneal approach (TEP)is used for endoscopic inguinal hernia operationsis used for endoscopic inguinal hernia operations
Grade BGrade B
Our personal vision
“you do the best what you do the most”
posterior approach: laparoscopic (tep)
anterior approach: lichtenstein
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• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
Acces to the peritoneum
• Verres needle
• Hasson trocar:– Previous laparotomies
– Obstruction with great distention of the small bowel
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8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
Case 1
• Incarcerated omentum + cyst in the hernial sac
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8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
Case 2
• Reversible ischemia of small bowel
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8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
Case 3
• Small bowel necrosis and perforation
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8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
Conclusions
• Laparoscopy provides a good evaluation of the intraabdominal situation and extent of small bowel ischemia
• TAPP provides an adequate mesh repair for the hernia if no bowel resection is nessecary
• In cases of small bowel resection we plan a secondary hernia repair 4 weeks later
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• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
Start slide
VENTRAL HERNIASClassifications and Definitions
Filip MuysomsAZ Maria Middelares
Gent
IRCAD Strasbourg, Thursday April 7th 2011
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• classifications and definitions of hernias• classification of mesh positions• classification of complications after surgery• ventral hernias and the RIZIV-INAMI
VENTRAL HERNIASClassifications and Definitions
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The abdominal wall
“ The abdominal wall is the musculo-fibreus covering of the contents of the abdominal
cavity.”
Including: the anterior and lateral abdominal wall muscles, the diaphragm, the psoas muscles and the perineal muscles.
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Abdominal wall hernia
“ An abdominal wall hernia is an abnormal protrusion of the contents of the abdominal
cavity or of pre-peritoneal fat through a defect or a weakness in the abdominal wall.”
Ventral hernia
“ A ventral hernia is a hernia of the abdominal wall excluding the inguinal area, the
diaphragm and the pelvic area.”
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Primary ventral hernia
“ A primary ventral hernia is a ventral hernia that was present at birth or that developed
spontaneously without trauma to the abdominal wall as a cause of the hernia.”
Primary ventral hernia
• Umbilical hernia• Epigastric hernia • Spighelian hernia• Lumbar hernia
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Secondary ventral hernia
“ A ventral hernia that developed after a traumatic breach of the integrity of the
abdominal wall.”
Secondary ventral hernia
• Incisional hernia• Traumatic hernia
– blunt or penetrating trauma • Ventral hernias after tissue loss
– oncological surgery– open abdomen treatment
• Parastomal hernias
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www.springerlink.com
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VARIABELS FOR CLASSIFICATION OF VENTRAL AND INCISIONAL HERNIAS
Chevrel and Rath
Korenkov Shumpelich ammarturo Swedish Dietz BSAWS-DHS
Size of the hernia defect: surface area, lenght, width
Width Width or lenght
Maximal size
Width Width andlenght
Width and lenght
Width
Size of the hernia sac
Number of hernia defects X X
BMI of the patient X X
Ratio anterior abdominal wall surface/ wall defect surface
X
Ratio between the abdominal volume / the volume of the hernia sac
Primary versus incisional hernias X
Recurrent hernias (number of previous repairs)
X X X X X X
Previous mesh implantation X
Indication for primary operation of the incisional hernia
X
Type and localisation of the incision X
Symptoms of the hernia X
Reducibility of the hernia X X X
Localisation of the hernia X X X X X X X
The anatomy of the pantient in the subcostal area: sternocostal angle
X
Risk factors for hernia recurrence X
E H S
Primary Abdominal Wall Hernia
Classification
Diameter
cm
Small
<2cm
Medium
≥2-4cm
Large
≥4cm
Epigastric Midline
Umbilical
Spigelian Lateral
Lumbar
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E H S
Incisional Hernia Classification
subxiphoidal M1
epigastric M2
umbilical M3
infraumbilical M4
Midline
suprapubic M5
subcostal L1
flank L2
iliac L3 Lateral
lumbar L4
Recurrent incisional hernia? Yes O No O
length: cm width: cm
Width
cm
W1
<4cm
O
W2
≥4-10cm
O
W3
≥10cm
O
E H S
Incisional Hernia Classification
subxiphoidal M1
epigastric M2
umbilical M3
infraumbilical M4
Midline
suprapubic M5
subcostal L1
flank L2
iliac L3 Lateral
lumbar L4
Recurrent incisional hernia? Yes O No O
length: cm width: cm
Width
cm
W1
<4cm
O
W2
≥4-10cm
O
W3
≥10cm
O
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E H S
Incisional Hernia Classification
subxiphoidal M1
epigastric M2
umbilical M3
infraumbilical M4
Midline
suprapubic M5
subcostal L1
flank L2
iliac L3 Lateral
lumbar L4
Recurrent incisional hernia? Yes O No O
length: cm width: cm
Width
cm
W1
<4cm
O
W2
≥4-10cm
O
W3
≥10cm
O
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• classifications and definitions of hernias• classification of mesh positions• classification of complications after surgery• ventral hernias and the RIZIV-INAMI
VENTRAL HERNIASClassifications and Definitions
drawing courtesy of Prof Ulrich Dietz, Würzburg
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SkinRectus fasciaPeritoneumRectus muscle
Hernia sac
Hernia orifice
SkinRectus fasciaPeritoneumRectus muscle
Onlay mesh position
mesh
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SkinRectus fasciaPeritoneumRectus muscle
Inlay mesh position
mesh
SkinRectus fasciaPeritoneumRectus muscle
Retromuscular mesh positionConventional transfixing sutures
mesh
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SkinRectus fasciaPeritoneumRectus muscle
mesh
Retromuscular mesh positionNon tension sutures
SkinRectus fasciaPeritoneumRectus muscle Glue or self‐fixation
Retromuscular mesh positionFixation with glue or self‐fixating mesh
mesh
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SkinRectus fasciaPeritoneumRectus muscle
Preperitoneal mesh position
mesh
SkinRectus fasciaPeritoneumRectus muscle
Intraperitoneal mesh positionOpen surgery
mesh
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SkinRectus fasciaPeritoneumRectus muscle
Intraperitoneal mesh positionLaparoscopic surgery
mesh
Mesh bridging (sutures & tackers)
SkinRectus fasciaPeritoneumRectus muscle
Intraperitoneal mesh position
mesh
Laparoscopic surgery Mesh bridging (Double Crown)
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SkinRectus fasciaPeritoneumRectus muscle
Intraperitoneal mesh position
mesh
Laparoscopic surgery Mesh augmentation (closure of hernia defect)
• classifications and definitions of hernias• classification of mesh positions• classification of complications after surgery• ventral hernias and the RIZIV-INAMI
VENTRAL HERNIASClassifications and Definitions
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Grade 0 No complications
Grade I Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions (are allowed: antiemetica, antipyretica, analgetics, diuretics, electrolytes and physiotherapy. This grade includes wound infections opened at the bedside)
Grade II Requiring pharmacological treatment with drugs other than such allowed for grade I complications. Blood transfusion and TPN are included.
Grade III Requiring surgical, endoscopic and radiological interventionsIIIa intervention not under general anesthesiaIIIb intervention under general anaesthesia
Grade IV Life threatening complication requiring IC/ICU managementIVa single organ dysfunctionIVb multiorgan dysfunction
Grade V Death of the patient
Clavien-Dindo classification
• classifications and definitions of hernias• classification of mesh positions• classification of complications after surgery• ventral hernias and the RIZIV-INAMI
VENTRAL HERNIASClassifications and Definitions
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• nomenclature of hernia operations• nomenclature of meshes• material forfaits art 35bis for laparoscopy
Ventral hernias and the RIZIV-INAMI
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open 241150‐241161 N200
laparoscopic 241312‐241323 N200
278,36 euro
(A1) Operatieve behandeling van een éénzijdige liesbreuk (inclusief inguinale, femorale, obturator hernia).
N200
(A2) Operatieve behandeling van een bilaterale liesbreuk (inclusief inguinale, femorale, obturator hernia).
N325
(A3) Operatieve behandeling van een primaire buikwandhernia (inclusief navelbreuk, epigastrische hernia, Spigheliaanse hernia, lumbale hernia).
N200
(A4) Operatieve behandeling van een incisionele buikwandhernia (inclusief recidief na behandeling van een primaire buikwandhernia en parastomale hernias).
N400
Ventral hernias and the RIZIV-INAMI
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• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
PolypropylenePolypropylene•• most commonly used most commonly used –– many different many different
productsproducts
•• ProPro• macroporous (type I)• mostly monofilament• high tensile strength• mechanically stable• optimal tissue ingrowth• good tolerance to infection
•• ConCon• very rigid• not to be used in contact with viscera
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Polyester (polyethylene)Polyester (polyethylene)•• Mersilene (Ethicon) and Parietex (Covidien)Mersilene (Ethicon) and Parietex (Covidien)
•• ProPro• macroporous• optimal tissue ingrowth• softer than polypropylene
•• ConCon• multifilament (type III) ~ increased harvesting of bacteria• not to be used in contact with viscera• hydrolytic disintegration over years
(esp. in case of persisting infection)
Expanded polytetrafluoroethylene Expanded polytetrafluoroethylene (ePTFE)(ePTFE)
•• ProPro• flexible, soft, nonfraying• high tensile strength• mechanically stable• can be used in contact with viscera• easily visible on ct-scan (foto dubois)
•• ConCon• microporous multifilament (type II)• less intense tissue ingrowth (encapsulation) – more
shrinkage• secure permanent fixation necessary• need for removal when infected (hydrophobic)
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Classification of biomaterialsClassification of biomaterialsType IType I totally macroporoustotally macroporous > 75> 75µµType IIType II totally microporoustotally microporous < 10< 10µµ
(in at least one of the 3 dimensions)(in at least one of the 3 dimensions)
Type IIIType III macroporous with multifilamentous or macroporous with multifilamentous or microporous componentsmicroporous components
Type IVType IV submicronic pore size submicronic pore size (only used in composite materials for adhesion prevention)(only used in composite materials for adhesion prevention)
pores > 75pores > 75µµ needed for admission of polymorphonuclear needed for admission of polymorphonuclear leucocytes (> 10leucocytes (> 10µµ), macrophages (), macrophages (≥≥ 5050µµ), fibroblasts, ), fibroblasts,
blood vessels and collagen fibers into the poresblood vessels and collagen fibers into the porestotal removal of the type II prosthesis and at least partial total removal of the type II prosthesis and at least partial
removal of the type III prosthesis is required removal of the type III prosthesis is required in order to manage infection (bacteria = 1in order to manage infection (bacteria = 1µµ))
Amid, Hernia 1997; 1: 15Amid, Hernia 1997; 1: 15
Lightweight or not?Lightweight or not?
• Current polypropylene meshes are likely to be too strong and too rigid
• Foreign body reaction too pronounced
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• Pore size• Macroporous (> 75-100µm) vs. megaporous (> 700-1000µm)• Textile porosity vs. effective porosity
(% pores > 1000µm diameter)
• Weight or density
• > 80 g/m2
• < 40 g/m2
• Surface area
Lightweight or not:Lightweight or not:weight versus pore sizeweight versus pore size
Lightweight or not?Lightweight or not?• Resulting mesh characteristics
• Tensile strength
• Uniaxial load testing• Load per unit width (N/cm)• Load per unit surface (N/cm2)
• Biaxial ball-burst testing
• Mesh elasticity
• Testing in different directions for anisotropic meshes
Cobb et al, Hernia 2009
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Maximal abdominal pressure: 20 kPa (=150 mmHg)
• Mesh augmentation Thin walled ball
• Mesh bridging Thin walled cylinder
Maximal abdominal wall tensile strength: 82N/cm (horizontal)32N/cm (vertical)
FD
rD
l
D
L
Klinge et al, Chirurg 1996Klinge et al, World J Surg 2005
16N/cm
32N/cm
Tensile strength requirementsTensile strength requirements
•• Closure percutaneously or via minilaparotomyClosure percutaneously or via minilaparotomy
•• Nonresorbable monofilament sutureNonresorbable monofilament suture
•• Less seromaLess seroma•• Less bulgeLess bulge•• Not more chronic painNot more chronic pain
Chelala et al, Surg Endosc 2007Chelala et al, Surg Endosc 2007
•• Small defect (<5x5cm)Small defect (<5x5cm)not needednot needed
•• Large defect (>7x7cm)Large defect (>7x7cm)difficult/impossibledifficult/impossible
•• Intermediate defect orIntermediate defect orellipsoid defectellipsoid defect
Closure of the defect?Closure of the defect?
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Mesh elasticity most important Mesh elasticity most important in vertical directionin vertical direction
Junge et al, Hernia 2001
Early dislocation of a too light Early dislocation of a too light mesh?mesh?
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The ideal mesh for intraabdominal useThe ideal mesh for intraabdominal use
Optimal tissue incorporation/remodelling at the parietal side (macroporous)
No or minimal adhesion formationat the visceral side (microporous)
Easy handling capacities
Transparent and a bit sticky
Low cost
Tissue separating meshes (1):Tissue separating meshes (1):bioabsorbable barriersbioabsorbable barriers
•• Hydrophilic collagenHydrophilic collagen--polyethylene glycolpolyethylene glycol--glycerol glycerol coatingcoating
– polyester Parietex® Composite– polypropylene Parietene®Composite
•• Sodium hyaluronate + carboxymethylcellulose Sodium hyaluronate + carboxymethylcellulose (Seprafilm(Seprafilm®®))
– polypropylene Sepramesh®
•• Oxidized regenerated cellulose (ORC)Oxidized regenerated cellulose (ORC)– polypropylene Proceed® (light weight)
•• Omega 3 fatty acidOmega 3 fatty acid– polypropylene C-Qur (Lite)™ (light weight)
Absorbable barrier Absorbable barrier for for
77--10 days 10 days Sufficient?Sufficient?
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Tissue separating meshes (2):Tissue separating meshes (2):composite meshes/coated meshescomposite meshes/coated meshes
•• ePTFEePTFE– polypropylene Composix®
Composix® E/X
Composix® L/P(lightweight)
Tissue separating meshes (3): ePTFETissue separating meshes (3): ePTFE
– DualMesh®
– DualMesh® Plus• antimicrobial agents:
– silver– chlorhexidine
– DualMesh® Plus with Holes • macropores for faster tissue attachment
corduroy surface
20-22µ
< 3µ
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How to choose?How to choose?
••A lot of (often conflicting) animal dataA lot of (often conflicting) animal data
••No RCT comparing only two different No RCT comparing only two different mesh materialsmesh materials
• No human clinical studies needed for FDA approval/CE marking
• Mesh half life is often (very) short
••Retrospective data on mesh Retrospective data on mesh complicationscomplications
Few data on relook laparoscopiesFew data on relook laparoscopiesChelala et al, Hernia 2010Chelala et al, Hernia 2010
••N=85N=85
••Neoperitoneum perfectly covering the Neoperitoneum perfectly covering the meshmesh
••No shrinking or wrinkling of the meshNo shrinking or wrinkling of the mesh
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How to choose?How to choose?••CaveatCaveat
• ePTFE mesh component in case of (potential) contamination
• secure permanent fixation necessary when using full ePTFE
• Laparoscopic ventral/incisional hernia repair• Fragile antiadhesive barrier• Bulky mesh when rolling• Lightweight mesh for bridging large defect• Transparence, memory, abdominal wall adhesive capacity• Adequate dimension or easy to be cut without loosing
antiadhesive properties• Cost!
Mesh fixation: what to use?Mesh fixation: what to use?
1. sutures1. sutures
2. fixation devices2. fixation devices
3. combination of both3. combination of both
4. glue4. glue
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Mesh fixation: what to use?Mesh fixation: what to use?suturessutures
nonnon--resorbableresorbable(slowly) resorbable(slowly) resorbable
fixation devicesfixation devicessingle crownsingle crown
double crowndouble crownCarbajo et alCarbajo et al
MoralesMorales--Conde et alConde et al
CombinationCombination
GlueGlueto cover fixation devices and mesh edges?to cover fixation devices and mesh edges?to diminish the number of fixation devices?to diminish the number of fixation devices?
??
Fixation: sutures + fixation devicesFixation: sutures + fixation devicesfull thickness transparietal sutures
slowly resorbableaccurate orientation and placement of the mesh
additional fixation first 3-4 weeks minimising the risk for chronic pain
at least 4 - every 6cm
careful grasping of the suture
enough tissue incorporation (1enough tissue incorporation (1--1.5cm)1.5cm)
nonresorbable sutures in case of full ePTFE meshnonresorbable sutures in case of full ePTFE mesh
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LVHR: fixation devicesLVHR: fixation devices
Protack®
titanium (n=30)
absorbable5mm
Sorbafix
AbsorbaTackabsorbable
5mm
Tensile strength and adhesion Tensile strength and adhesion formation to fixation systemsformation to fixation systems
Absorba Tack and SorbaFix are resp. solid and hollow screw tacks, completely resorbed after one year
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Parietene Composite Parietene Composite --AbsorbatackAbsorbatack
Tensile strength and adhesion Tensile strength and adhesion formation to fixation systemsformation to fixation systems
Hollinsky et al, Surg Endosc 2010Hollinsky et al, Surg Endosc 2010
Rat modelParietex Composite mesh
Prolene suture
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What about pain?What about pain?Kumar Bansal et al, Surg Endosc 2011Kumar Bansal et al, Surg Endosc 2011
RCT, laparoscopic repair, majority polypropylene mesh
ProtackPolypropylene
ButButWassenaar et al, Surg Endosc 2010Wassenaar et al, Surg Endosc 2010
+ tacks+ tacks
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Fixation: sutures + fixation devicesFixation: sutures + fixation devicesfixation devices
every 2cm and at least 1cm from the edge of the meshavoid recurrence between mesh and abdominal wall !avoid recurrence between mesh and abdominal wall !
double crown techniqueto reduce dead space
to increase tissue ingrowth
deep enough(≠ peritoneum or preperitoneal fat)
external counterpressure!
extra 5mm trocar contralaterally if needed
• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
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8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
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• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair
– Technique of TEP for inguinal hernia repair
– Laparoscopic approach to incarcerated femoral hernias
• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques
– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair
– Clinical evidence on open vs laparoscopic ventral hernia repair
8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
Laparoscopic vs. open: Laparoscopic vs. open: arguments pro arguments pro
minimal abdominal wall tissue traumaminimal abdominal wall tissue traumaless hematoma, seroma, wound infectionless hematoma, seroma, wound infectionprosthetic infection?prosthetic infection?
cosmetic benefitcosmetic benefit
shorter hospital stay, better recoveryshorter hospital stay, better recovery
less postoperative painless postoperative pain
easier exploration of the whole scareasier exploration of the whole scarless recurrences less recurrences ±± 5%??5%??
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Laparoscopic vs. open: Laparoscopic vs. open: arguments con arguments con
extensive adhesiolysis necessaryextensive adhesiolysis necessary
prolonged ileusprolonged ileus
missed or delayed enterotomy, postoperative peritonitis, missed or delayed enterotomy, postoperative peritonitis, mesh infection & removal, mortalitymesh infection & removal, mortality
no reconstruction of the no reconstruction of the abdominal wallabdominal wall
recurrence vs. bulgingrecurrence vs. bulging
cave lightweight meshcave lightweight mesh
meshbridging
mesh augmentation
2%??
Laparoscopic vs. open: Laparoscopic vs. open: arguments con arguments con
longlong--term effects of intraabdominal mesh term effects of intraabdominal mesh and fixation devicesand fixation devicesintestinal obstructionintestinal obstructionintestinal erosion and fistulisationintestinal erosion and fistulisation
more expensive prosthetic materialsmore expensive prosthetic materialsantiadhesive capacitiesantiadhesive capacities(chronic) infection risk(chronic) infection risk
chronic painchronic paintransfascial sutures and/or fixation devices?transfascial sutures and/or fixation devices?
chronic seroma formationchronic seroma formation ~ retention of hernia ~ retention of hernia sacsac
trocar site hernias trocar site hernias
longlong--term followterm follow--up necessaryup necessary(min. 3 years)(min. 3 years)
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•• 10 RCT10 RCT
•• Almost 1000 patientsAlmost 1000 patients
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•• ClinicalClinical• Hernia size/location
• Surgical technique• Open:
• onlay, sublay• fascial closure
• Laparoscopic: • mesh overlap• mesh fixation
• Learning curve effect
= IPOM
Large heterogeneity in the different Large heterogeneity in the different trialstrials
Large heterogeneity in the different Large heterogeneity in the different trialstrials
•• MethodologicalMethodological
randomisation process
(primary outcome parameter)
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Operation timeOperation time
Results too heterogenous to be pooled
ComplicationsComplications
Any complicationAny complication
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Major vs. minor complicationsMajor vs. minor complications•• MinorMinor
• Wound infection• Seroma formation: problem of definition• Hematoma• Acute and chronic pain
•• MajorMajor• (Missed) enterotomy• Mesh removal• Reoperation• Mortality
EnterotomyEnterotomy
recognised and unrecognisedrecognised and unrecognised
No results extractable on ICU admission
No mortality(described)
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HematomaHematoma--seromaseroma
Seroma vs. open mesh placementSeroma vs. open mesh placement
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Wound infectionWound infection
Wound infection vs. Wound infection vs. open mesh placementopen mesh placement
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Hospital stayHospital stay
Significantly shorter in 6/9 trialsSignificantly shorter in 6/9 trialsBut large heterogeneityBut large heterogeneity
Hospital stayHospital stay
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ShortShort--term pain term pain
Hernia recurrenceHernia recurrence
Follow-up > 2 years in only 3 trials
3.3%
0%
0%
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EBM based conclusionsEBM based conclusions
•• Large heterogeneity in the different trialsLarge heterogeneity in the different trials
•• Laparoscopic incisional hernia repairLaparoscopic incisional hernia repair• Is safe • Benefit of decreased wound infections and shorter
hospital stay• No increased recurrence rates with medium-term
follow-up
• The key to succes is a careful adhesiolysis and avoiding/immediate treatment of enterotomy
• No decrease in acute pain
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My personal conclusions My personal conclusions ••Excellent indication inExcellent indication in
• Obese patients – diabetics• Lateral hernias• Parastomal hernias
••Beware for patients withBeware for patients with• Wide hernias or a diffuse bulge• Hernias close to bony edges: extraperitoneal mesh
••Careful patient selection in learning curveCareful patient selection in learning curve• Eg. umbilical hernia/trocar site hernia in obese patient• Exploration of the whole scar
rectus muscle
posterior rectus sheath/peritoneum
Miserez and Penninckx, Surg Endosc 2002; 16: 1207-1213
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8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011
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Ventral hernias and the RIZIV-INAMI
684434-684445
implanteerbaar netje voor herstel van breuk of eventratie.
Y2 per 10 cm2
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Ventral hernias and the RIZIV-INAMI
a-a’ netje voor herstel van abdominaal wanddefect of voor herstel van liesbreuk of voor bescherming van orgaan tot 300cm2
U5 per 10 cm2
b-b’ netje voor herstel van abdominaal wanddefect of voor herstel van liesbreuk of voor bescherming van orgaan vanaf 300cm2
U4 per 10 cm2
c-c’ netje voor herstel van abdominaal wanddefect (exclusief herstel van liesbreuk) en ontworpen voor intraperitoneale plaatsing met orgaancontact tot 300cm2
U30 per 10 cm2
d-d’ netje voor herstel van abdominaal wanddefect (exclusief herstel van liesbreuk) en ontworpen voor intraperitoneale plaatsing met orgaancontact vanaf 300cm2
U20 per 10 cm2
e-e’ voorgevormd netje voor herstel van liesbreuk U195 aandeel patient 25%
f-f’ voorgevormd netje voor herstel van abdominaal wanddefect (exclusief herstel van liesbreuk)
U195 aandeel patient 25%
Ventral hernias and the RIZIV-INAMI
• c-c’/d-d’/e-e’/f-f’ limitative list• criterium:
– at least one prospective study with at least 1 year follow-up published in a peer-reviewed journal, with an outcome showing equivalency on safety and efficacy compared to the gold standard
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Ventral hernias and the RIZIV-INAMI