Home Current issue Ahead of print Search About us Editorial board Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 38  |  Issue : 4  |  Page : 674-678

Laparoscopic preperitoneal ventral hernia repair with prolene mesh with fixation through transabdominal prolene stitches


Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt

Date of Submission02-Apr-2019
Date of Acceptance17-Apr-2019
Date of Web Publication16-Oct-2019

Correspondence Address:
Samy Gamil
Department of General Surgery, Faculty of Medicine, Ain Shams University, Postal/zip code 659866
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejs.ejs_70_19

Rights and Permissions
  Abstract 


Objective To evaluate the efficacy and safety of our technique in laparoscopic repair of ventral hernias.
Summary background data Laparoscopic ventral hernia repair (LVHR) was first reported in 1993. The successful application of laparoscopic techniques for the repair of ventral hernias has been well accepted. The recurrence rate after standard repair of ventral hernias may be as high as 10%, and the wide surgical dissection required often results in wound complications. Use of a laparoscopic approach may decrease rates of complications and recurrence after ventral hernia repair.
Patients and methods Data on all patients who underwent LVHR performed using our procedure between February 2013 and February 2015 were collected retrospectively.
Results LVHR was completed in 27 of the 30 patients (nine men and 21 women) in whom it was attempted. The patients’ mean BMI was 36.5; the mean defect size was 3.2 cm. Mesh averaging 6.3 cm was used in all cases. Mean operating time was 105 min, and hospital stay averaged 1.9 days. Our complication rates were 16.6%. The most common complications were ileus (6.6%) and prolonged seroma (6.6%). During a mean follow-up time of 12 months, the hernia recurrence rate was 3.3%. Overall, 10% of patients had pain for 1 month. Recurrence was associated with vigorous exercise within the first 3 months postoperatively.
Conclusion In this series, the preperitoneal laparoscopic technique for ventral hernia repair had a low rate of conversion to open surgery, a short hospital stay, a moderate complication rate, and a low risk of recurrence avoiding the potential complications related to intraabdominal mesh position.

Keywords: laparoscopic ventral hernia, prolene mesh, transabdominal stitches


How to cite this article:
Ghali MS, Mahmoud MA, Gamil S. Laparoscopic preperitoneal ventral hernia repair with prolene mesh with fixation through transabdominal prolene stitches. Egypt J Surg 2019;38:674-8

How to cite this URL:
Ghali MS, Mahmoud MA, Gamil S. Laparoscopic preperitoneal ventral hernia repair with prolene mesh with fixation through transabdominal prolene stitches. Egypt J Surg [serial online] 2019 [cited 2020 Jul 6];38:674-8. Available from: http://www.ejs.eg.net/text.asp?2019/38/4/674/269373




  Introduction Top


Laparoscopic ventral hernia repair (LVHR) was first reported in 1993. The successful application of laparoscopic techniques for the repair of ventral hernias has been well accepted [1],[2]. In fact, many authors have suggested LVHR with mesh as the new procedure of choice for the treatment of abdominal wall fascial defects [3],[4]. Fascial defects involving the umbilicus are common. Typically, these defects are small, symptomatic, and mandate repair once detected [5],[6]. They are easily repaired using an open technique and usually require only local anesthetic with light intravenous sedation [7],[8]. For typical defects (2 cm), a primary repair is often performed with the use of mesh reserved for either large or recurrent hernias [9]. Problems with conventional ventral hernia repair include a relatively high rate of recurrence (>10% in some series) [9],[10] and a potentially increased risk of infection relative to other skin incisions, particularly with the use of mesh, owing to the location in and around the umbilical crease. Several small series and case reports have demonstrated the feasibility of LVHR as a potential means of avoiding these problems [11],[12].


  Patients and methods Top


A 24-month retrospective hernia study was started in February 2013 and continues up until February 2015 at the General Surgery Unit at Ain Shams University Hospital or Ain Shams specialized hospital. The study was approved by the ethical and scientific committee of the General Surgery Department, Ain-Shams University will be added in pat and methods. It was initially started and primarily performed for internal observance with follow-up evaluation; a case series of 30 patients having laparoscopic repair of ventral wall abdominal hernia was performed. For the evaluation, a minimum of a 1-year follow-up had to be passed.

Patients presenting at the General Surgery Unit at Ain Shams University Hospital who were 18 years of age or older, with a diagnosis of ventral wall hernia, were eligible for random assignment to laparoscopic preperitoneal ventral hernia repair with prolene mesh with fixation through transabdominal prolene stitches. Patients gave written informed consent before inclusion into the study. In general, four exclusion criteria for the participation were defined: (a) infants or children with anatomic limitation for laparoscopic approach, (b) elderly patients with comorbidity where it was preferable to perform surgery with intravenous sedation and local anesthesia, (c) patients who had extensive abdominal surgery in the past which would have made the laparoscopic dissection difficult or even impossible, and (d) patients’ choice for a no laparoscopic operative approach. There were no exclusion criteria for the evaluation, and all files and patient medical histories were complete for evaluation. Data collection included postoperative pain, use of pain medication, return to work, potential complications, and recurrence rate. All patients were asked before surgery to rate their pain or discomfort on a visual analog scale from 0 (=none) to 10 (=worst) pain preoperatively, and again for 7 days after surgery, and at 1 month and at 1 year postoperatively. The number of days until return to work was recorded. An evaluation for potential complications and recurrence was performed during follow-up as well.

Surgical technique

The laparoscopic repair technique consisted of trocar placement followed by CO2 peritoneal insufflation to obtain pneumoperitoneum. The initial entry site was usually just inferior to the tip of the 11th rib using Veress needle followed by the placement of two to three additional working trocars. The contents of the hernia sac were then reduced back into the peritoneal cavity and the fascial edges delineated ([Figure 1]).
Figure 1 Hernia defect from inside.

Click here to view


An incision of the wall of the peritoneum was made starting at the level of the superior margin of the ventral wall defect then we dissected the sac from the subcutaneous space ([Figure 2]). Now we started to dissect peritoneal flap about 4 cm all around the edge of the defect through the preperitoneal dissection.
Figure 2 An incision of the wall of the peritoneum at the level of±the superior margin.

Click here to view


The mesh was cut to a dimension of ∼3 cm+the defect size, and four separate 2-0 prolene stitches with straight needle were used to transfix the abdominal wall from outside to inside and then dragged to the outside of the abdomen through a 10-mm trocar, then we tied the prolene stitches to the four angles of the mesh separately ([Figure 3]), then we rolled the mesh, and then dragged it to the inside of the abdomen with the help of prolene stitch ([Figure 4]) and Mesh was placed in the preperitoneal space ([Figure 5]).
Figure 3 Prolene stitches tied to the four angles of the mesh.

Click here to view
Figure 4 Rolled mesh ready to be entered the abdomen.

Click here to view
Figure 5 Mesh placed in the preperitoneal space.

Click here to view


At the end, we tied the prolene stitch over the skin of abdomen region ([Figure 6]). The peritoneal flaps were then closed using small, continuous, absorbable 2/0 sutures or by using surgical clips. At the end, we put a gauze between the skin and the prolene tie to avoid stitch mark. The prolene stitches were removed after 10 days postoperative during follow-up after natural mesh fixation started.
Figure 6 Prolene stitch tied over the skin of abdomen region.

Click here to view



  Results Top


Patient characteristics

The demographic and perioperative data are shown in [Table 1]. Most patients were obese, and many had coexistent medical problems. In general, the hernia defects were an average size of 3.2 cm, and they were repaired with a large piece of mesh (equal to 3 cm plus defect size). Although the mean hospital stay was ∼1.9 days, some patients were discharged the day of surgery.
Table 1 Patient characteristics

Click here to view


Conversion to open surgery was necessary in three (10%) of the 30 patients owing to failure to make preperitoneal space and failure to make adequate peritoneal coverage.

Complications

Considering both wound and mesh infections, only one case had port site infection (1/30) with the overall infection rate was 3.3%. There were no infections in the converted cases. There was no intestinal injury. In two (6.6%) patients, a seromasover the mesh at the site of the retained hernia sac were developed, although many seromas were not noticedby the patient and most were resolved withoutintervention within 1 month.

Three (10%) of the 30 patients who underwent LVHR had pain for 1 month. In most patients, discomfort occurred only with movement. Patients with prolonged pain were treated with nonsteroidal anti-inflammatory agents. Prolonged ileus developed postoperatively in two (6.6%) patients, all of whom required hospitalization until oral intake could be tolerated, which mostly resolved within 2 days. There was no postoperative bleeding or hematoma.

Hernia recurrences

There is only one (3.3%) case of recurrence, as the patient did vigorous exercise within the first 3 months postoperatively against our recommendation.


  Discussion Top


LVHR with our technique is a successful procedure that is very likely to become the standard of care in the future. Most repairs are performed with the use of preperitoneal prolene patch with transabdominal sutures fixation, and additional metal or absorbable fixation devices are not needed. These methods decrease the rate of recurrence and cost of the maneuver.

In our series (30 patients), LVHR using prosthetic mesh was associated with a low rate of conversion to open surgery in three (10%) patients. There were reported cases of conversion to a laparotomy mainly owing to severe adhesions with a range of 3–9.9% [13]. Here we have a short hospital stay (1.9 days), whereas in the literature, the duration of hospital stay range from less than 1 to 6.5, with a mean of 2.5 days [14].

We report a moderate complication rate, and only one case of port site infection (3.3%). One of the greatest benefits of LVHR is the reduction in wound and mesh infections. In a detailed analysis of wound complications from a pooled data of 45 published series involving 5340 patients, Piece et al. [15] reported wound infection rates of 4.6–8 times fold higher in open versus LVHR. Here two patients developed a seroma over the mesh at the site of the retained hernia sac. Seroma formation is one of the most commonly reported complications in LVHR though it is not unique to laparoscopy [14]. It occurs immediately after operation in virtually all patients. Most seromas develop above the mesh and within the retained hernia sac [16]. Carbanjo reported a higher incidence of seroma formation with expanded polytetrafluoroethylene than prolene-based meshes. The low incidence in the latter meshes has been attributed to the large pores of the prolene-based meshes that allow more efficient resorption of wound secretions into the abdominal cavity than expanded polytetrafluoroethylene meshes [17]. Three (10%) of the 30 patients developed pain at the site of surgery, which resolved in 1-month follow-up. After LVHR, ∼5% of patients complained of persistent pain and point tenderness at the transabdominal suture site which usually resolves spontaneously within 6–8 weeks [17].

Whether LVHR is safer and more effective than open repair is not yet known. Several series of LVHRs have been reported by North American and European researchers ([Table 2]). The results show a marked consistency with respect to low perioperative morbidity and low rates of hernia recurrence during follow-up [1]. Other advantages of LVHR over open repair were cited but remain speculative. Nevertheless, these investigations have also consistently indicated that LVHR has advantages over the open procedure concerning perioperative complications, hospital stay, and hernia recurrences.
Table 2 Studies comparing laparoscopic ventral hernia repair and open ventral hernia repair

Click here to view


The specific LVHR technique used in our series is probably the laparoscopic approach to repair of ventral hernias reasonable operative time, although some surgeons have attempted to reduce operating time and possibly postoperative discomfort by discontinuing the use of transabdominal sutures entirely, or substantially reducing their numbers and relying primarily on a laparoscopic tacker. However, as most of the meshes used for LVHR are ∼1-mm thick and the spiral tacks employed are 4-mm long and take up a 1-mm profile on the surface of the patch, a perfectly placed tack can be expected to penetrate only 2 mm beyond the mesh; thus, tacks will probably not provide the same holding strength provided by full-thickness abdominal wall sutures. In fact, Lyons et al. [23] demonstrated in a porcine model that the tensile strength of sutures in intraabdominal mesh is up to 2.5 times greater than that of tacks. In addition, higher hernia recurrence rates have been observed clinically in some cases in which only tacks were used, though not in others. So we believe that suture fixation of the mesh in LVHR is mandatory [24].

The extraperitoneal (preperitoneal) placement of the prostheses (as in our study) would in principle diminish the intraabdominal complications associated with formation of adhesions. It would also allow the safe use of the conventional meshes like prolene, which has high intrinsic tensile strength, has good memory, and is cheaper. In addition, the peritoneal coverage over the entire mesh provides additional security of fixation and a better mechanical advantage [25]. In this study, there is a low hernia recurrence rate of 3.3% during a mean follow-up time of 12 months. The recurrence rate in our series is low. Interestingly, but not surprisingly, we found that morbid obesity, large defect size, and postoperative vigorous exercise are associated with an increased risk of recurrences. Recurrence rates after LVHR range from 1.1 to 13%, whereas those after the open repairs ranged from 25 to 49% [26].

One of the original concerns of LVHR was the requirement that the mesh be placed intraabdominally, directly adjacent to the intestine. An ongoing debate continues to center on appropriate mesh choices. However, in our study, we used simple prolene mesh and placed it in preperitoneal pouch under cover of peritoneum.


  Conclusion Top


Our experience with 30 LVHRs accumulated over 2 years. The use of a new technique has demonstrated it to be an effective and safe approach to the abdominal wall hernia. In this series, the preperitoneal laparoscopic technique for ventral hernia repair had a low rate of conversion to open surgery, a short hospital stay, a moderate complication rate, and a low risk of recurrence avoiding the potential complications related to intraabdominal mesh position.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kingsorth A, Sanders DL. General introduction and history of hernia surgery. Management of abdominal hernias.Cham: Springer; 2018. 3–30.  Back to cited text no. 1
    
2.
Earle D, Roth JS, Saber A, Haggerty S, Bradley JF, Fanelli R et al. SAGES Guidelines Committee.SAGES guidelines for laparoscopic ventral hernia repair. Surg Endosc 2016; 30:3163–3183.  Back to cited text no. 2
    
3.
Morales-Conde S. Laparoscopic ventral hernia repair. E-book Springer Science & Business Media. 2013.  Back to cited text no. 3
    
4.
LeBlanc KA, Sharma A, Kukleta JF. Standard technique laparoscopic repair of ventral and incisional hernia. Laparo-endoscopic Hernia Surgery. Berlin, Heidelberg: Springer; 2018. 287–303.  Back to cited text no. 4
    
5.
Menzo EL, Hinojosa M, Carbonell A, Krpata D, Carter J, Rogers AM. American Society for Metabolic and Bariatric Surgery and American Hernia Society consensus guideline on bariatric surgery and hernia surgery. Surg Obes Relat Dis 2018; 14:1221–1232.  Back to cited text no. 5
    
6.
Zens T, Nichol PF, Cartmill R, Kohler JE. Management of asymptomatic pediatric umbilical hernias: a systematic review. J Pediatr Surg 2017; 52:1723–1731.  Back to cited text no. 6
    
7.
Lisiecki J, Kozlow JH, Agarwal S, Ranganathan K, Terjimanian MN, Rinkinen J et al. Abdominal wall dynamics after component separation hernia repair. J Surg Res 2015; 193:497–503.  Back to cited text no. 7
    
8.
LeBlanc KA, Kingsnorth A, Sanders DL. Management of abdominal hernias. E-Book Springer; 2018.  Back to cited text no. 8
    
9.
Köckerling F, Sharma A. Ventral and incisional hernias: differences and indications for laparoscopic surgery. Laparo-endoscopic hernia surgery. Berlin, Heidelberg: Springer; 2018. 261–266.  Back to cited text no. 9
    
10.
Kaufmann R, Halm JA, Eker HH, Klitsie PJ, Nieuwenhuizen J, van Geldere D et al. Mesh versus suture repair of umbilical hernia in adults: a randomised, double-blind, controlled, multicentre trial. Lancet 2018; 391:860–869.  Back to cited text no. 10
    
11.
Kulaçoğlu H. Current options in umbilical hernia repair in adult patients. Turk J Surg 2015; 31:157.  Back to cited text no. 11
    
12.
Froylich D, Segal M, Weinstein A, Hatib K, Shiloni E, Hazzan D. Laparoscopic versus open ventral hernia repair in obese patients: a long-term follow-up. Surg Endosc 2016; 30:670–675.  Back to cited text no. 12
    
13.
Rubby SA, Rangaswamy P, Sundar P. A prospective study comparing laparoscopic and open ventral hernia repair. Int Surg J 2016; 4:170–176.  Back to cited text no. 13
    
14.
Naveen PG, Khan A. Laparoscopic repairs for anterior abdominal wall hernias. Int Surg J 2019; 6:349–354.  Back to cited text no. 14
    
15.
Piece RA, Spitter JA, Frisella MM et al. Pooled data analysis of laparoscopic versus open ventral hernia repair; 14 yrs of patients data accrual. Surgendosc 2007; 21:378–386.  Back to cited text no. 15
    
16.
Warren JA, Cobb WS, Ewing JA, Carbonell AM. Standard laparoscopic versus robotic retromuscular ventral hernia repair. Surg Endosc 2017; 31:324–332.  Back to cited text no. 16
    
17.
Nardi M, Millo P, Contul RB, Lorusso R, Usai A, Grivon M et al. Laparoscopic ventral hernia repair with composite mesh: analysis of risk factors for recurrence in 185 patients with 5 years follow-up. Int J Surg 2017; 40:38–44.  Back to cited text no. 17
    
18.
Holzman MD, Purut CM, Reintgen K et al. Laparoscopic ventral and incisional hernioplasty. Surg Endosc 1997; 11:32–35.  Back to cited text no. 18
    
19.
Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998; 124:816–821; discussion  Back to cited text no. 19
    
20.
Ramshaw BJ, Schwab J, Mason EM et al. Comparison of laparoscopic and open ventral herniorrhaphy. Presented at: Southeastern Surgical Congress, February 1999.  Back to cited text no. 20
    
21.
DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic interperitoneal PTFe prosthetic patch repair of ventral hernia. Surg Endoscopy 2000; 14:326–329.  Back to cited text no. 21
    
22.
Carbajo MA, Martin Del Olmo JC, Blanco JI et al. Laparoscopic approach to incisional hernia. Surg Endosc 2003; 17:118–122.  Back to cited text no. 22
    
23.
Lyons M, Mohan H, Winter DC, Simms CK. Biomechanical abdominal wall model applied to hernia repair. Br J Surg 2015; 102:e133–e139.  Back to cited text no. 23
    
24.
Sánchez LJ, Piccoli M, Ferrari CG, Cocozza E, Cesari M, Maida P et al. Laparoscopic ventral hernia repair: results of a two thousand patients prospective multicentric database. Int J Surg 2018; 51:31–38.  Back to cited text no. 24
    
25.
Wennergren JE, Askenasy EP, Greenberg JA, Holihan J, Keith J, Liang MK et al. Laparoscopic ventral hernia repair with primary fascial closure versus bridged repair: a risk-adjusted comparative study. Surg Endosc 2016; 30:3231–3238.  Back to cited text no. 25
    
26.
Hauters P, Desmet J, Gherardi D, Dewaele S, Poilvache H, Malvaux P. Assessment of predictive factors for recurrence in laparoscopic ventral hernia repair using a bridging technique. Surg Endosc 2017; 31:3656–3663.  Back to cited text no. 26
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed371    
    Printed33    
    Emailed0    
    PDF Downloaded46    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]