Karl A. LeBlanc

Laparoscopic incisional and ventral hernia repair: complications-how to avoid and handle.

Complications will occur with any operative procedure. The possibility of this must be considered for laparoscopic incisional and ventral hernia repair (LIVH) as well. The most commonly reported of these include: intraoperative intestinal injury (1–3.5%), infection involving the prosthetic biomaterial (0.7–1.4%), seromas (2.6–100%), postoperative ileus (1–8%), and persistent postoperative pain (1–2%). The incidence of enterotomy can be reduced by careful dissection and judicious use of any energy source. Infection can be minimized by the use of perioperative antibiotics, an antimicrobially impregnated biomaterial, and careful manipulation of the prosthesis during the procedure. Seromas are so common that they should be expected but can be decreased by the use of a postoperative abdominal binder. Aspiration will be necessary in a few instances. Similarly, ileus is expected when there is significant bowel dissection and bleeding. Early ambulation and standard use of postoperative bowel care will aid in the treatment of this problem. Persistent pain will generally occur at the site of a transfascial suture. It cannot be predicted or prevented with certainty. When it occurs, local injection with bupivacaine, steroids, or non-steroidal agents will help, but occasionally, removal of the offending suture(s) will be required. The average recurrence rate for LIVH is approximately 5.6% in the literature. Rates as high as 15.7%, however, have been reported. Recurrence will be increased by inadequate prosthetic overlap of the fascial defect, infection that involves the biomaterial, which then requires its removal, and lack of the use of transfascial sutures. To prevent these risks, the surgeon must assure that there is at least a 3-cm overlap of all portions of the hernia defect and insist that sutures are used at 5-cm intervals to fix the biomaterial. Infection that requires explantation of the patch will generally result in recurrence, as this must be repaired primarily. Alternatively, the use of a collagen prosthesis may allow immediate repair, but this is associated with a high failure rate. A staged repair will be necessary in the future in most patients.

Association between gastroesophageal reflux disease and laparoscopic sleeve gastrectomy

BACKGROUND Gastroesophageal reflux disease (GERD) is a common co-morbidity identified in obese patients. It is well established that patients with GERD and morbid obesity experience a marked improvement in their GERD symptoms after Roux-en-Y gastric bypass. Conflicting data exist for adjustable laparoscopic gastric banding and GERD. Laparoscopic sleeve gastrectomy (LSG) has become a popular adjunct to bariatric surgery in recent years. However, very little data exist concerning LSG and its effect on GERD. METHODS A retrospective chart review was performed of 176 LSG patients from January 2006 to August of 2009. The preoperative and postoperative GERD symptoms were evaluated using follow-up surveys and chart review. RESULTS Of the 176 patients, 85.7% of patients were women, with an average age of 45 years (range 22-65). The average preoperative body mass index was 46.6 kg/m(2) (range 33.2-79.6). The average excess body weight lost at approximately 6, 12, 24 months was calculated as 54.2%, 60.7%, and 60.3%, respectively. Of the LSG patients, 34.6% had preoperative GERD complaints. Postoperatively, 49% complained of immediate (within 30 d) GERD symptoms, 47.2% had persistent GERD symptoms that lasted >1 month after LSG, and 33.8% of patients were taking medication specifically for GERD after LSG. The most common symptoms were heartburn (46%), followed by heartburn associated with regurgitation (29.2%). CONCLUSION In the present study, LSG correlated with the persistence of GERD symptoms in patients with GERD preoperatively. Also, patients who did not have GERD preoperatively had an increased risk of postoperative GERD symptoms.

Laparoscopic incisional and ventral herniorraphy : our initial 100 patients

A review of our initial 100 patients upon whom we attempted a laparoscopic repair of either a ventral and incisional hernia is presented. The average follow-up period of these individuals was 51 months. The operation was completed with the laparoscopic technique in 96 cases. The average defect size was 155 cm2 and the average prosthetic biomaterial size to repair these defects was 214.8 cm2. The major complication rate was 4.1%.The incidence of recurrence in these patients was 9.3%. In all of these cases of recurrence, the method of attachment was that of staples or spiral tacks alone. In 5 patients, it appeared that the prosthesis was too small to cover the defect adequately. We believe that this is an effective operation but one that has two technical mandates. The prosthetic biomaterial (DualMesh®) must cover the fascial edges by a minimum of a three-centimeter overlap. Additionally, the attachment of the patch by staples or tacks alone is inadequate; consequently, the herniorraphy must include the use of through and through sutures to assure adequate fixation of the prosthesis.

Laparoscopic incisional and ventral herniorrhaphy in 100 patients

BACKGROUND Laparoscopic incisional and ventral herniorrhaphy, a procedure first described 7 years ago, continues to gain acceptance. A series of about 100 patients who underwent the operation is described. Follow-up in this series was longer (mean 51 months) than that in previously reported series. METHODS A retrospective review was conducted of operative and follow-up records of a series of patients scheduled to undergo laparoscopic incisional or ventral herniorrhaphy between 1992 and 1997. RESULTS Laparoscopic repair was completed in 96 of 100 patients. The complication rate was 14%, with seromas accounting for half of the postoperative problems. Mean hospital stay was 1 day. The late recurrence rate was 9%, with 4 of the 9 recurrences developing >2 years postoperatively. CONCLUSIONS Laparoscopic incisional and ventral herniorrhaphy is safe and effective. Most patients require hospitalization for </=24 hours. Use of an adequately sized prosthesis secured with more than one method is essential. Patients should be observed >/=3 years.

Laparoscopic incisional hernia repair: are transfascial sutures necessary? A review of the literature

BackgroundLaparoscopic repair of incisional and ventral hernias is rapidly becoming more commonplace in the armamentarium of general surgeons. Its utility and low recurrence rates make it a very attractive option. As with all newer procedures, controversies exist with this approach. One significant aspect is the method of fixation for the biomaterial. Most authors add the use of transfascial sutures. Others, in the minority, do not.MethodsA literature search using Medline and PubMed was used to evaluate the best practice for fixation in laparoscopic incisional and ventral hernia repair.ResultsThis review of the current literature (including comparative series) seems to show that the recurrence rate is approximately 4% with the use of sutures and 1.8% without their use. However, these data do not show that there is tremendous variation in the method and manner of placing transfascial sutures or that long-term follow-up evaluation is inadequate in most series. No firm conclusions can be drawn about whether it is detrimental to omit the use of transfascial sutures.ConclusionsOn the basis of this review, a larger overlap of the prosthesis (5 vs 3 cm) is necessary if sutures are not used. If sutures are used, they should be placed no more than 5 cm apart. Prospective randomized trials with and without of transfascial sutures using a consistent biomaterial are necessary to settle this issue.

Incisional Hernia Repair: Laparoscopic Techniques

Repair of incisional hernias using the laparoscopic technique has continued to evolve since its inception in 1991. An analysis of the current literature has revealed that hernias as large as 1600 cm2 have been successfully repaired with this method. The average size appears to be about 105 cm2. Several choices of a biomaterial are available today, differing in the type of synthetic product or products that are used to manufacture them. Others incorporate an absorbable component. The goal of all of them is to prevent adhesion formation. The fixation devices that can be used are also varied. The results of laparoscopic incisional hernia repair are described. The conversion rate of these procedures is an impressive 2.4% with an enterotomy rate of 1.8%. These results affirm the low risk of this operation. The recurrence rate of 4.2% confirms the permanence of the repair. This procedure may become the standard of care in the near future.

Laparoscopic parastomal hernia repair using a nonslit mesh technique

BackgroundThe management of parastomal hernia is associated with high morbidity and recurrence rates (20–70%). This study investigated a novel laparoscopic approach and evaluated its outcomes.MethodsA consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence.ResultsA total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2–38 months), 4% (1/25) of the patients experienced recurrence.ConclusionOn the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

Tissue attachment strength of prosthetic meshes used in ventral and incisional hernia repair

AbstractsBackground: Many prosthetic materials are used in incisional hernia repair, including polypropylene (PP) and expanded polytetrafluoroethylene (ePTFE). However, PP forms severe adhesions and ePTFE has raised concerns about the adequacy of tissue attachment. Methods: The early tissue attachment strength of PP and two new forms of ePTFE (DLM and DLMC) was compared in a rabbit model (n = 12) in which disks of the three meshes (n = 8 of each material) were implanted against the abdominal wall for 3 days. Results: Tensiometer testing found that DLMC mesh had significantly greater attachment strength than PP (p = 0.02). Histologic studies indicated that this was due to cellular ingrowth. Tissue adhesions were observed with all eight PP disks, one DLMC disk, and none of the DLM disks. Conclusion: Modified forms of ePTFE mesh may provide abdominal wall repairs that are as strong or stronger than those obtained with PP, with early tissue attachment and without adhesions.

In vivo study of meshes implanted over the inguinal ring and external iliac vessels in uncastrated pigs

AbstractBackground: The effects of placing a prosthesis directly on the internal inguinal ring and external iliac vessels in inguinal hernia repair are unknown. We compared tissue responses to five prostheses implanted in this position in uncastrated male pigs. Methods: Three types of polypropylene and two types of expanded polytetrafluoroethylene (ePTFE) mesh were implanted in 20 pigs (n= 8 for each prosthesis type). Specimens of the implants and surrounding tissue were obtained 30 and 90 days after implantation and assessed histologically. Results: The polypropylene implants had more adhesions, more surface area covered by adhesions, and more tenacious adhesions than did the ePTFE implants. Perivascular cuffing was observed in eight polypropylene and one ePTFE specimen; ossification, necrosis, and testicular venous congestion were seen in polypropylene specimens. Conclusions: Abnormal healing processes after implantation of polypropylene mesh may increase complications of the transabdominal preperitoneal and total extraperitoneal approaches in laparoscopic inguinal hernia repair, whereas the minimal response to ePTFE meshes may make them safer for use in the preperitoneal space.

Laparoscopic repair of paraostomy hernias: early results.

The paracolostomy hernia represents one of the difficult challenges for the hernia surgeon. The creation of the fascial defect to create the ostomy predisposes the patient to this problem. Other mitigating factors include many comorbid conditions such as obesity, diabetes mellitus, steroid usage, age, and so forth. There have been many attempts to provide a permanent solution to this hernia, many of which do not result in a long-lasting and satisfactory result. These have included the sutured repair of the defect itself, the prosthetic repair of the defect, and the relocation of the ostomy. The repair, whether open or laparoscopic, is necessitated by poor function of the ostomy, a poorly fitting appliance, obstruction, or the cosmetic deformity that accompanies the larger defects with a large hernia content. These problems are not limited to the colostomy hernia but will also be seen in the patient with a paraileostomy hernia. The primary or prosthetic repair of the hernia defect usually has a greater appeal to the patient, because the patient has become familiar with the ostomy at that location, and the use of the appliance is preferred in that location. On the other hand, many surgeons believe that the location of the ostomy must be changed to effect a long-lasting result. In either case, the operation is traditionally performed with a laparotomy. There have been a few reports of successful laparoscopic repair of paracolostomy hernias. Based on the success we have had with the laparoscopic repair of incisional and ventral hernias, we also believe that this methodology can be used effectively for the repair of paraostomy hernias. Three of these cases are presented in this report. TECHNIQUES Patient 1 This patient has been a long-standing patient of one of the authors. In August 1994, at the age of 71 years, she underwent a laparoscopically assisted abdominoperineal resection for rectal adenocarcinoma. She presented with a symptomatic paracolostomy hernia in April 1995. She underwent an open repair of this defect with nonabsorbable sutures in May 1995. In that repair, the fascial defect was repaired to approximate the size of the colon, and the colon was sutured to the fascial ring. This surgery eliminated the patient’s symptoms until 1998, when she presented with a partial colonic obstruction secondary to a recurrent hernia at the colostomy site. This was treated conservatively, with resolution without surgical intervention. She declined surgical intervention at that time. The patient then presented to the office with an enlarging hernia at the site of the colostomy in October 2000. Because this hernia prevented an adequate seal of the ostomy appliance, she desired surgery. At the time of this examination, she was noted to have a broad laxity of the abdominal wall adjacent to the colostomy in addition to the herniation of intraabdominal viscera. That is, her abdominal wall musculature was quite lax at this site in addition to the hernia deformity. Because she desired to maintain the location of the ostomy and because an earlier nonprosthetic repair had failed, we elected to repair this with the laparoscopic method. A standard bowel prep was administered before surgery. Her abdominal wall was draped with an iodineimpregnated plastic drape. Perioperative antibiotics were also administered. The abdomen was entered with the Optiview trocar (Ethicon Endosurgery, Inc., Cincinnati, OH). The location of the trocars that is typical for these procedures is shown in Figure 1. Several adhesions of omentum and small bowel were lysed to expose the hernia defect (Fig. 2). The colon was located superiolaterally in the fascial Dr LeBlanc is a member of the Speaker’s Bureau for WL Gore and Associates.