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332
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29
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laparoscopic and open ventral hernia repairs: a prospective randomized study. Hernia. 2007;11:51–6.
81. Misra MC, Bansal VK, Kulkarni MP, Pawar DK.Comparison of laparoscopic and open repair of incisional and
primary ventral hernia: results of a prospective randomized study. Surg Endosc. 2006;20:1839–45.
82. Pring CM, Tran V, O'Rourke N, Martin IJ.Laparoscopic
versus open ventral hernia repair: a randomized controlled trial. ANZ J Surg. 2008;78:903–6.
83. Sajid MS, Bokhari SA, Mallick AS, Cheek E, Baig MK.Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg. 2009;197:64–72.
84. Cobb WS, Kercher KW, Heniford BT. Laparoscopic
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85. Müller-Riemenschneider F, Roll S, Fredrich M, Zieren J,
Reinhold T, von der Schulenburg JMG, Greiner W, Willich
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86. Cassar K, Munro A. Surgical treatment of incisional
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88. Berger D, Bientzle M, Müller A.Postoperative complications after laparoscopic incisional hernia repair. Incidence and treatment. Surg Endosc. 2002;16:1720–3.
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94. Edwards C, Geiger T, Bartow K, Ramaswamy A, Fearing
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333
Education andLearning
Curve inVentral Hernia
Repair
DavideLomanto andSujithWijerathne
30.1 Education andTraining Program – 334
30.2 Discussion – 336
References – 337
30
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_30
334
D. Lomanto and S. Wijerathne
30
Minimally invasive surgery has evolved with the
intent of minimizing surgical trauma and to
achieve better postoperative pain control and better cosmetic outcome. To achieve these goals with
minimal perioperative complications and acceptable clinical outcome, a surgeon needs to have an
adequate training and experience in any surgical
procedure, which demands specialized skills. In
some cases, the curve to reach the prociency
may be a stepwise process. Surgery for ventral
hernia has advanced over the years incorporating
the minimally invasive techniques and demands a
technically challenging learning curve in the current surgical practice.
Aer the rst successful laparoscopic ventral
hernia repair in 1993 by LeBlanc and Booth [1],
today several successful reports show the advantages of laparoscopic repair over open hernia
repair in terms of complications and recurrence
rates [2–5]. Laparoscopic ventral hernia repair is
based on the tenets of the open Rives-Stoppa
repair and also based on Pascal’s principle of
hydrostatics such that the forces that cause hernia
are currently used to hold the mesh in place, thus
decreasing the chance of recurrence and oering
the potential benets of minimally invasive surgery which are smaller scars, less postoperative
pain, shorter hospital stay, fewer infectious complications, and less overall cost [3–6]. e fundamental surgical steps in laparoscopic ventral
hernia repair involve access, adhesiolysis, closure
of the defect if possible, intraperitoneal placement
of the mesh (IPOM), and xation of the mesh. All
these steps can be challenging for an inexperienced surgeon. Obese patients, recurrent hernias,
multiple defects, defects larger than 10cm in size,
lower or upper abdomen location, lateral hernia,
etc. need to be addressed dierently to the standard approach. When we discuss about overall
prociency or learning curve, we should take into
account parameters like operating time, recurrence, and postoperative complications.
ere are few studies in the literature where
the “learning curve” in laparoscopic ventral hernia is evaluated.
In a study published in 2004, Bencini etal.
have analyzed their data on 64 consecutive
patients who underwent attempted laparoscopic
ventral hernia repair [7]. ey have divided the
patients into two groups: group 1 included the
rst 32 patients and group 2 included the second
32 patients. Demographic characteristics, types
of hernia, preoperative records, and hernia
defects were well matched between the groups.
Four patients (12%) in group 1 required conversion to laparotomy for bowel injuries, whereas no
conversion was required in group 2. e operative times and complication rates were similar in
both groups, but bowel injuries were signicantly
more common in group 1 (19% versus 0%,
p = 0.02). Group 1 also had three recurrences,
while no recurrences were reported in group 2.
ey concluded that a learning curve is needed
to decrease conversions and bowel injuries during laparoscopic ventral hernia repair and
improved experience could permit the treatment
of larger defects laparoscopically [7]. But this
study did not specify a minimum number of
cases required to achieve stability in the surgical
performance with a minimal and an acceptable
complication rate.
In 2014, we published our own experience and
data on the learning curve of laparoscopic ventral
hernia repair [5]. In our study we had a total of
181 (141 females and 40 males) patients who
underwent laparoscopic ventral hernia repair by
three surgeons. Aer analyzing the operative time
for each of the surgeons, we noticed that a plateau
is reached in the operative time by all three of
them within the rst 20 cases. When we compared the rst 20 patients of each surgeon with
the total number of cases they have performed
during the study period, we noticed that there was
a signicantly higher complication rate (5%) during the rst 20 cases (p < 0.03). To assess the
learning curve, the operative time was evaluated
for each surgeon and plotted on a graphical scale.
According to the plot, 12 cases seem to be necessary to achieve a plateau in the laparoscopic ventral hernia repair performance with a comparable
clinical outcome [5].
30.1 Education andTraining
Program
e surgical education is undergoing a paradigm
shi in the twenty-rst century from the traditional experience-based model to a structural
program that requires documentation of prociency. e old Chinese proverb “I hear, I forget…
I see, I remember… I do, I understand” had
emphasized the importance of learning by doing,
ages ago.
Education andLearning Curve inVentral Hernia Repair
In view of the abundance of resources available to patients to acquire knowledge and the
increase of the number of medico-legal trials and
also due to the complexity of the ventral hernia in
the current practice, it is necessary to provide the
trainees and the surgical residents an up-to-date
knowledge and surgical training with a wellstructured education. Several aspects should be
considered in establishing a training program:
1. Teaching faculty
2. Interactive classroom teaching
3. Practice at surgical technique
4. Proctorship/supervised surgery
5. Monthly case report/research projects
6. Residents’ operative logbook
7. Length of surgical training
8. National and international surgical confer-
ences/workshops
1. Teaching Faculty
e teaching faculty, program director, or primary
teacher of a hospital-based hernia training program
should be a fully trained, thoroughly experienced
general surgeon with credentials from a recognized
international surgical society. He/she should be
qualied and experienced in dierent types of hernia surgery both open and laparoscopic. He/she
should be passionately committed to training
young doctors to become qualied general surgeons. e program director should arrange for
qualied visiting faculty so that trainees get exposure of dierent surgeons from dierent hospitals.
2. Interactive Classroom Teaching
e classroom teaching should focus on clinical
and technical aspects like:
5 Detailed anatomy in both open and laparo-
scopic
5 Clinical presentations of ventral hernias
5 Preoperative assessment
5 Informed consent
5 Instrument requirements
5 Technology of meshes and their characteris-
tics
5 Knowledge of aseptic technique
5 Complications and their management
3. Practice at Surgical Technique (. Fig.30.1).
Patients expect to be treated by an experienced
surgeon, who is well trained in the eld of their
practice. Before practice, trainees should go
through dierent surgical techniques by dierent
surgeons with themes including how to do, what
to do, and what not to do in hernia surgery.
335
. Fig. 30.1 Practice at surgical technique on an animal
model
Practical sessions should be encouraged on live
tissues and/or virtual reality simulators. Both
types of training sessions provide learning in a
structurally controlled environment using inanimate strategies and modalities similar to learning
in a patient without compromising patient safety
(
. Fig. 30.2a, b). With the use of autonomous
“teaching and assessing” work stations, the eciency of educational side of medicine will
increase, and more trainees can be trained in a
shorter time period.
It was demonstrated at the author’s own training center that participants needed about 30% less
time to complete preselected tasks aer hands-on
training [8] (. Figs.30.3 and 30.4).
4. Proctorship/Supervised Surgery
Only aer the residents have demonstrated adequate prociency that they should be allowed to
operate on actual patients under direct expert
supervision of a consultant/surgical specialist.
When trainees operate with adequate supervision, results comparable to consultants have been
reported in literature for colorectal surgery [9],
upper gastrointestinal surgery [10], and pancreatic repair under expert supervision [11–13].
When unsupervised, junior trainees had signicantly higher recurrence rates for open mesh and
open sutured repairs than consultants [14].
5. Monthly Case Reports or Research Projects
Trainees at all levels learn more quickly and completely if they discover things by themselves.
Monthly written case reports or research projects
help residents to nd answers themselves to problems they encounter during their training. ey
30
336
D. Lomanto and S. Wijerathne
30
a
b
. Fig. 30.2 a Virtual reality simulators. b Practice on
virtual reality simulators
250
200
150
100
50
0
. Fig. 30.4 Trainee results on an intracorporeal suturing
task
201.5
(Pre test) (Post test)
Mean time (sec.)
148.67
tor’s responsibility to develop a surgical library
equipped with requisite textbooks and journals
and to make it available so that residents may read
and research whenever needed.
6. Resident’s Operative Logbook
Residents should also be required to keep a log of
all the hernia operations (both open and laparo-
scopic) they assist, perform, or teach to younger
residents. is will enable the program director to
keep track of areas that need more attention.
7. Attending National and International
Surgical Conferences/Workshops
Attending regional and international conferences
enables trainees to network with other surgeons,
gain experience in critiquing papers that are presented, present their own papers, and learn from
others. It also legitimizes well-conceived and
organized hernia programs and also allows other
surgeons to share experience and learn from surgeons in training.
80
75
70
65
60
. Fig. 30.3 Trainee results on an endoloop task
77.11
(Pre test) (Post test)
Mean time (sec.)
65.89
can be given projects like comparison of dierent
types of prosthetic materials used, xation or no
xation, or recovery aer laparoscopic versus
open ventral hernia repair. It is the program direc-
30.2 Discussion
In the last decade, ventral hernia surgery made a
great leap forward, from the simple suture repair
to the prosthetic repair either open or laparoscopic to the latest use of robotic devices.
erefore, in this era of rapid development, the
role of training and retraining (both open and
laparoscopic) becomes more and more important. erefore, it is important to stress the
important role of a well-structured hernia training program to provide adequate knowledge on
the insight and challenges in ventral hernia
repairs. Surgical workshops (both open and laparoscopic) are useful, eective, and indispensable
tools for continued surgical education but must
Education andLearning Curve inVentral Hernia Repair
337
30
be adequately structured. e use of virtual reality simulator is an objective way of evaluating
surgical trainees and eliminates potential for
actual patient morbidities. New technology (OT
suite, telementoring/proctoring) is helpful in
improving the outcomes together with deliberate
and continuous practice which is crucial to overcome the initial diculties and steepness of the
learning curve. e role of the proctorship and
supervision is essential to guide the learners and
trainees through the complexity and surgical
steps in order to achieve prociency in a shorter
time.
Laparoscopic ventral hernia repair has its own
challenges: challenges of any other minimally invasive procedure, familiarity of new instruments
(meshes, tackers, suture passers, energy devices,
etc.), and familiarity of laparoscopic anatomy
(though minimal for an experienced laparoscopic
surgeon). e exact denition of learning curve in
laparoscopic procedures is unclear and will need
more structured education programs to assess and
dene it. e possible factors which may inuence
learning curve can be surgeons’ experience with
other laparoscopic procedures and instrumentation, knowledge of laparoscopic anatomy, standardization of surgical technique, and stabilization
of operative time and complication rate.
References
1. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafuoroethylene: preliminary ndings. Surg Laparosc
Endosc. 1993;3:39–41.
2. Lomanto S, Iyer G, Shabbir A, etal. Laparoscopic versus
open ventral hernia mesh repair: a prospective study.
Surg Endosc. 2006;20:1030–5.
3. Chowbey PK, Sharma A, Khullar R, etal. Laparoscopic
ventral hernia repair. J Laparoendosc Adv Surg Tech A.
2000;10:79–84.
4. Misra MC, Bansal VK, Kulkarni MP, etal. Comparison of
laparoscopic and open repair of incisional and primary
ventral hernia: results of a prospective randomized
study. Surg Endosc. 2006;20:1839–45.
5. Al-Harazi A, Goel R, Tan CTK, etal. Laparoscopic ventral
hernia repair: dening the learning curve. Surg Laparosc Endosc Percutan Tech. 2014;24:475–7.
6. Sajid MS, Bokhari SA, Mallick AS, et al. Laparoscopic
versus open repair of incisional/ventral hernia: a metaanalysis. Am J Surg. 2009;197:64–72.
7. Bencini L, Sánchez LJ.Learning curve for laparoscopic
ventral hernia repair: 1. Am J Surg. 2004;187:378.
8. Lomanto D, Chua H, Chou P, Aung MM, Salonga MC, So
JBY, Cheah WK.Use of virtual reality simulators in preand post-training assessment of laparoscopic surgical
workshops. Oral presentation during the 8th Asia
Pacic meeting of the Endoscopic and Laparoscopic
Surgeons of Asia (ELSA), Hyderabad, 17–19 Aug 2007.
9. Hawkins WJ, Moorthy KM, Tighe D, Yoong K, Patel RT.
With adequate supervision, the grade of the operating
surgeon is not a determinant of outcome for patients
undergoing urgent colorectal surgery. Ann R Coll Surg
Engl. 2007;89:760–5.
10. Paisley AM, Madhavan KK, Paterson-Brown S, Praseedom RK, Garden OJ. Role of the surgical trainee in
upper gastrointestinal resectional surgery. Ann R Coll
Surg Engl. 1999;81:40–5.
11. Praseedom RK, Paisley A, Madhavan KK, Garden OJ,
Carter DC, Paterson-Brown S. Supervised surgical
trainees can perform pancreatic resections safely. J R
Coll Surg Edinb. 1999;44:16–8.
12. Sanjay P, Woodward A. Local anaesthetic inguinal
hernia repair performed under supervision: early and
long-term outcomes. Ann R Coll Surg Engl. 2009;
91(8):677–80.
13. Haidenberg J, Kendrick ML, Meile T, Farley DR.Totally
extraperitoneal (TEP) approach for inguinal hernia:
the favorable learning curve for trainees. Curr Surg.
2003;60(1):65–8.
14. Robson AJ, Wallace CG, Sharma AK, Nixon SJ, PatersonBrown S.Eects of training and supervision or recurrence
rate after inguinal hernia repair. Br J Surg. 2004;91:774–7.
339
Complex Ventral
andIncisional Hernias
FerdinandKöckerling, DavideLomanto, andPradeepChowbey
31.1 Recurrence After Previous Open Repair – 340
31.2 Recurrence After Previous Laparoscopic
Repair – 341
31.3 Giant Hernias: Loss ofDomain – 342
31.4 Parastomal Hernias – 342
31.5 Obese Patients – 344
References – 346
31
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_31
31
340
F. Köckerling et al.
A clear denition of “complex abdominal wall
hernia” is missing, though the term is oen used
[1]. e aim of a consensus meeting was to reach
consensus on criteria used to dene a patient with
“complex” hernia [1]. Consensus was reached on
22 patient and hernia variables for “complex” hernia criteria inclusion which were grouped under
four categories:
1. Size and location
2. Contamination/so tissue condition
3. Patient history/risk factors
4. Clinical scenario
e criteria for denition of a complex abdominal
wall hernia are listed in Table1.
Recurrent hernia aer an earlier mesh repair,
a large-sized abdominal wall hernia with a defect
of ≥10cm in width or loss of domain of ≥20%,
a parastomal hernia, and obese patients are all
criteria fullling the denition of a “complex”
abdominal wall hernia.
In particular, the management of complex
patients was addressed only by limited discussion
in a consensus conference [2]. ere were several
areas where high-quality data were lacking, and
the consensus could be reached by the panel [2].
Further high-quality studies are needed to better
assess the management of ventral and incisional
hernias in these complex patients [2].
Criteria forDenition ofaComplex
Abdominal Hernia (Patient) (Slater etal.) [1]
1. Size and location
5 Large-sized abdominal wall hernia,
≥10cm in width
5 Parastomal, lumbar, lateral, and
subcostal locations of hernias
5 Loss of domain ≥20%
2. Contamination and soft tissue condition
5 Wound environment with surgical
wound class III (“contaminated”) or IV
(“dirty”)
5 Full-thickness abdominal wall defects
5 Loss of substance(e.g., after tumor resec-
tion, trauma, infection)
5 Distorted anatomy (e.g., after multiple
previous procedures)
5 Denervated muscles
5 Skin grafts
5 Wound ulcers/nonhealing wound
5 Open abdomen
5 Disease related (omphalocele, necrotiz-
ing fasciitis)
5 Presence of enterocutaneous fistula
3. Patient history and risk factors
5 Recurrent hernia after an earlier mesh
repair or component separation
5 Comorbidities/risk factors that impair
wound healing: obesity, diabetes, old
age, steroid use, or poor nutritional state
(albumin <30g/dl)
5 Increased intra-abdominal pressure:
obesity, COPD
5 Previous wound dehiscence
5 Previous mesh infection
4. Clinical scenario
5 Emergency operation with bowel
resection
5 Intraperitoneal mesh removal
5 Multiple hernia defects (e.g., “battle-
scarred abdomen”)
31.1 Recurrence After Previous
Open Repair
Worldwide rates of operations for recurrent incisional hernias are 10–15% despite all therapeutic
improvements [3]. Conventional open repair of
primary incisional hernias entails an overall failure rate of 30–56%, whereas recent reviews point
out that laparoscopic repair seems to decrease the
recurrence rate to 3–4% [3].
Reoperations for recurrence of ventral and
incisional hernias are challenging [4]. Aer
open mesh repair, reoperation by the laparoscopic approach has certain advantages [4].
First, the repeat operation is performed at a
dierent site/level of the abdominal wall [4].
Second, in all instances, the entire incisional
scar can be covered by a mesh. Usually, it is not
necessary to remove the previously inserted
mesh, hence avoiding an extensive dissection of the abdominal wall [4]. e Consensus
Development Conference-based guidelines [5]
also recommend laparoscopy for the treatment
of recurrent ventral hernias.
Ferrari et al. [3] reported about 69 Patients
with a recurrent incisional hernia who underwent
laparoscopic repair. e operative technique has
been standardized and provides onlay placement
of an ePTFE mesh xed with titanium tacks.
e mean operative time was 147.6± 71.2 min
and mean hospital stay was 5.8± 1.8 days. No
conversion occurred, while ve intraoperative complications (7.2%) were recorded: three
bowel injuries treated by laparoscopic sutures,
Complex Ventral andIncisional Hernias
341
31
one omentum bleeding, and one epigastric vessel lesion. Postoperative mortality was null, while
overall morbidity was 13% (nine patients) with
a prevalence of seroma lasting over 8 weeks in
six patients (8.7%). Along a mean follow-up of
41 months (range 6–119), recurrence rate was
5.7% (four patients). Univariate analysis for width
of defects and BMI showed no signicant inuence on patient outcome [3].
Uranues etal. [6] reported about 85 consecutive patients aged 55 years (range 29–93 years)
with laparoscopic recurrent incisional hernia
mesh repair with previous failed repairs. Fascia
defect was 255cm2 (range 48–416cm2); mesh size,
600cm2 (range 285–884cm2); and operating time,
145min (80–210min). ere was one conversion.
Length of stay was 2 days (1–9 days). A 15.2%
adverse event rate included 1% port-site cellulitis, 7% seroma, and 7% persistent pain. Hernia
recurrence rate was 3.5% at 41-month (range
24–61months) follow-up. e authors concluded
that laparoscopic recurrent hernia mesh repair
resulted in a low rate of adverse events and a risk
of recurrence similar to the rates associated with
rst-time hernia repair [6].
In a study by McKinlay et al. [7], patients
with laparoscopic recurrent incisional hernia
repair (n= 69) were compared to patients with
laparoscopic primary incisional hernia repair
(n=101). e patients with laparoscopic recurrent incisional repair had a mean of 1.9 ± 1.3
previous repairs, higher body mass index (BMI)
(34±6kg/m2 vs 33±8kg/m2, p=0.46), larger
defect size (123 ± 115 cm
p=0.06), and longer operative time (119±61min
vs 109±44min, p=0.11). e complication rate
was higher in the recurrent group (28% vs 11%,
p=0.01), but the recurrence rate was not dierent
(7% vs 5%, p=0.53). e mean time to recurrence
was signicantly shorter in the recurrent group
(3±2months vs 14±7months, p<0.0001). e
mean follow-up interval was 19±18months in
the recurrence group and 27±20months in the
primary group. Although laparoscopic repair of
recurrent incisional hernia resulted in a higher
recurrence and complication rate than laparoscopic repair of primary incisional hernia, the
rates were lower than those reported for conventional repair of recurrent incisional hernia. e
authors concluded that laparoscopic repair of
recurrent incisional hernia is an eective alternative to conventional repair [7].
2
vs 101 ± 108 cm2,
Verbo et al. [8] prospectively analyzed
data from 41 consecutive patients with recurrent incisional hernia, who were submitted to a
laparoscopic repair procedure with an expanded
polytetrauoroethylene Dual Mesh. All of the
patients underwent clinical follow-up at 1, 6, and
12 months and then yearly. An ultrasound scan
of the abdominal wall was performed at 6 and
12months aer the procedure. e defects were
usually localized along midline laparotomies. e
mean mesh size was 400cm2, the mean operating
time was 68min, and the mean length of hospital
stay was 2.7 days. Complications were encountered in 17% of patients. e mean follow-up
was 38 months (range, 18–54). Recurrence was
reported in one case only (2.4%), which occurred
within the rst 6months aer the operation.
e authors concluded that the laparoscopic
repair of recurrent incisional hernia seems to
be an eective alternative to the conventional
approach, as it can give lower recurrence and
complication rates [8].
On the basis of the above mentioned literature, the International Endohernia Society gives
the statement in their guidelines for laparoscopic
treatment of ventral and incisional abdominal wall
hernias [4] that some evidence indicates reoperation for recurrence aer open repair is better performed laparoscopically (Level 4 Oxford criteria
of evidence-based medicine).
As recommendation Grade C, some cases of
recurrence aer open repair can be better managed
laparoscopically provided the surgeon has sucient
experience in laparoscopic ventral hernia repair.
31.2 Recurrence After Previous
Laparoscopic Repair
All meta-analyses did not nd a dierence in the
recurrence rates between open and laparoscopic
ventral and incisional hernia repair [9–12]. In
the guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias of the
International Endohernia Society, the risk factors for recurrence are analyzed [13]. e existing literature does not document the superiority
of any one mesh xation technique in relation to
recurrence. Size of the hernia ≥10cm, body mass
index (BMI) ≥30kg/m
repair or failed hernia repair, and perioperative
complications including surgical site infections
2
, history of previous open
342
F. Köckerling et al.
31
are risk factors for hernia recurrence irrespective
of the technique. e risk factors for recurrence
include patient status, underlying disease, and
perioperative factors, i.e., surgical techniques,
postoperative complications, deep abscesses, and
early reoperations. Smokers with previous failed
repair attempts have a higher risk of recurrence.
Postoperative mesh infection requiring removal
of mesh is a predictor of recurrence [13].
e mechanisms for recurrence of laparoscopic ventral and incisional hernia repair
described in the literature in decreasing order of
frequency are infection, lateral detachment of the
mesh, inadequate mesh xation, inadequate mesh
size, inadequate mesh overlap, missed hernias,
raised intra-abdominal pressure, and trauma [13].
e guidelines recommend a strictly standardized
technique to avoid failures such as mesh overlap
less than 3cm, improper xation, and mesh contraction and invagination into the hernia defect.
In the Danish Ventral Hernia Database, the
cumulative recurrence rate during a median
observation time of 40months was between 18%
and 28.5% for the patients with a laparoscopic
incisional hernia repair [14].
Studies or case series on re-laparoscopic repair
of a recurrence following laparoscopic ventral and
incisional hernia repair does not exist. Misiakos
etal. [15] report about their clinical experience with
re-laparoscopic recurrent ventral and incisional
hernia repair. Before surgery it is useful to have
CT imaging to help guide the approach. e old
mesh can be le in place if it is well incorporated.
If the mesh is bulky or has a curled edge, it may be
excised partially. If the mesh is palpable externally
and bothersome to the patient, the surgeon may
have to use an open approach to excise the mesh.
If a portion of the mesh is densely adherent to the
bowel, a small piece of it should be excised and le
attached to the bowel, to prevent deserosalization
or opening of the bowel wall, most oen with an
open approach [15]. e need to remove previously placed prosthetic mesh may represent a contraindication to laparoscopic repair [16].
31.3 Giant Hernias: Loss ofDomain
e guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias of the
International Endohernia Society recommend
that surgical treatment of a symptomatic ventral
and incisional hernia is indicated. e laparoscopic technique for ventral and incisional hernias should preferably be reserved for defect sizes
smaller than 10cm in diameter [17].
In the SAGES guidelines for laparoscopic ventral hernia repair, it is strongly recommended that
special situations such as loss of domain or large
abdominal wall defects may represent a contraindication for laparoscopic repair [18]. In a loss
of domain situation, the laparoscopic approach
to ventral hernia repair may be problematic
and associated with higher conversion rates and
potentially suboptimal outcomes [18]. In the literature large defects (>10cm in diameter) increase
the complexity of laparoscopic ventral and incisional hernia repair [18].
Ferrari etal. [19] reported about 36 patients
with laparoscopic management of incisional
hernias with abdominal wall defects ≥15 cm.
e wall defect was ≥20cm in eight cases. None
had loss of domain. Body mass index (BMI) for
18 patients was ≥30kg/m2. e mean duration
of operations was 195±28min (range 75–540).
One patient needed conversion for ileal injury
and massive adhesions. Postoperative complications occurred in nine patients; there were
six surgical complications. Morbidity in obese
and nonobese patients was not statistically different (p>0.005). ere was no postoperative
death. Mean hospital stay was 4.97± 3.4days
(range 2–18). Mean follow-up was 28 months
(range 2–68) and only one hernia recurrence
was observed.
e authors concluded that minimum-access
procedures can provide good results in the
repair of giant incisional hernia. Obesity is not a
contraindication to laparoscopic repair. Further
studies need to conrm these promising results
[19].
31.4 Parastomal Hernias
A parastomal hernia is an incisional hernia
related to the presence of an enterostomy [20].
For colostomies, the incidence ranges from 3%
to 39%, whereas for loop ileostomy, its incidence
is reported between 0% and 6% [20]. Most of the
parastomal hernias are asymptomatic and therefore can be treated conservatively.