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Complex Ventral andIncisional Hernias
343
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Indications for surgery are ill-tting appliances causing leakage, pain, discomfort, and cosmetic complaints. Treatment is mandatory when
incarceration or strangulation of hernia content
occurs [20].
In a systematic review and meta-analysis
comparing extraperitoneal versus transperitoneal colostomy placement, it was observed that
extraperitoneal colostomy leads to a lower rate of
parastomal hernias and stoma prolapse [21].
In a meta-analysis of randomized trials, the
role of prophylactic mesh in end-colostomy construction was evaluated [22]. Prophylactic placement of a mesh at the time of a stoma formation
seems to be associated with a signicant reduction
in the incidence of parastomal hernia and reoperation related to parastomal hernia aer surgery
for rectal cancer, but not the rate of stoma- related
morbidity. However, the results should be interpreted with caution because of the heterogeneity
among the studies [22].
In a systematic review, Fortelny et al. [23]
found for prevention of a parastomal hernia by
biological mesh reinforcement that the majority
of studies revealed signicant better results in
terms of parastomal herniation and without any
mesh-related complications in comparison.
In a systematic review by Hansson et al.
[20], 30 studies were included with the majority
retrospective. Suture repair resulted in a signicant increased recurrence rate when compared
with mesh repair (OR 8.9; 95% CI, 5.2–15.1;
p < 0.0001). Recurrence rates for mesh repair
ranged from 6.9% to 17% and did not dier signicantly.
In the laparoscopic repair group, the
Sugarbaker technique had less recurrences than
the keyhole technique (OR 2.3; 95% CI, 1.2–4.6;
p = 0.016). Morbidity did not dier between
techniques. e overall rate of mesh infections
was low (3%) and comparable for each type of
mesh repair. e authors concluded that in laparoscopic repair the Sugarbaker technique is superior over the keyhole technique showing fewer
recurrences [20].
Another meta-analysis of laparoscopic
parastomal hernia repair by DeAsis et al. [24]
found for the modied laparoscopic Sugarbaker
approach a recurrence rate of 10.2%, whereas
the recurrence rate was 27.9% for the keyhole
approach. e authors concluded that laparo-
scopic intraperitoneal mesh repair is safe and
eective for treating parastomal hernia. A modied Sugarbaker approach appears to provide the
best outcomes [24].
In a systematic review about parastomal hernia
repair with biologic gras, the ndings was that
the use of reinforcing or bridging biologic gras
during parastomal hernia repair results in acceptable rates of recurrence and complications [25].
e guidelines of the International Endohernia
Society recommend that a laparoscopic approach
for parastomal hernia repair should be considered
a dicult technique with larger operating time,
more intraoperative complications, and more
dicult adhesiolysis than standard laparoscopic
ventral hernia repair [26]. Results of laparoscopic
repair of parastomal hernias could not be compared to the general results of laparoscopic ventral hernia repair because the rates of recurrences
and morbidity are higher. Laparoscopic repair of
a parastomal hernia is a more complex technique
because a concomitant midline hernia present
in a high percentage of patients must also be
repaired [26]. e same laparoscopic technique
can be performed for a hernia occurring with a
colostomy, ileostomy, or urostomy or due to an
ileal conduit [26].
As a classication of parastomal hernias
is needed to compare dierent populations
described in various trials and cohort studies, the
European Hernia Society proposed a classication based on the defect size (small is ≤5cm; large
is >5cm) [27].
Muysoms [28] and Hansson etal. [29] descr ibed
the modied Sugarbaker technique.
e patient is operated on while in the supine
position with both arms placed along the body.
e surgeon and the assistant stand at the contralateral site of the stoma. Aer application of
pneumoperitoneum following open placement
of the camera trocar, one 5mm and one 10mm
working trocars are introduced (
careful adhesiolysis is performed. Aer freeing
the adhesions, the stoma loop is completely dissected free from the fascia and the peritoneum
(. Fig.31.2). Defect size reduction by the use of a
running loop suture (. Fig.31.3) and transfascial
pullout of the two sutures (. Fig.31.4) and knotting on the fascia supports the optimal defect closure (. Fig.31.5). e trephine opening is covered
with an intraperitoneally placed mesh.
. Fig. 31.1). A
344
F. Köckerling et al.
31
. Fig.31.1 Application of three trocars on the opposite
site of the parastomal hernia
. Fig.31.2 The stoma loop is completely dissected free
from the fascia and the peritoneum
. Fig.31.4 Transfascial pullout of the two sutures
. Fig.31.5 Optimal defect closure
. Fig.31.3 Defect size reduction by the use of the
running loop suture
(TiMesh strong, pfm medical, Cologne,
Germany). e bowel is lateralized, passing from
the hernia sac between the abdominal wall and the
prosthesis into the peritoneal cavity. In this way a
tunnel is created between the abdominal wall and
the prosthesis (. Fig.31.6). It is of utmost importance to prevent narrowing of the bowel in the
tunnel and angulation of the bowel when entering the abdominal cavity and the hernia sac. e
prosthesis is xed to the abdominal wall using the
double-crown technique [29]. is technique can
also be used to prevent parastomal hernias during
laparoscopic abdominoperineal resection [30].
. Fig.31.6 Coverage of the stoma opening with the
intraperitoneally placed mesh (TiMesh strong, pfm
medical, Cologne, Germany)
31.5 Obese Patients
In the SAGES guidelines for laparoscopic ventral and incisional hernia repair, obesity belongs
to the factors reported in the literature that
increase the complexity of laparoscopic ventral
and incisional hernia repair [31]. But all metaanalyses comparing open versus laparoscopic
ventral and incisional hernia repair clearly
demonstrate superiority of the laparoscopic
approach in terms of wound infection and
wound complications [32–35]. erefore, the
International Endohernia Society recommends
Complex Ventral andIncisional Hernias
345
31
in the guidelines for laparoscopic treatment of
ventral and incisional abdominal wall hernias
[36] for obese patients presenting with a ventral
or incisional hernia the laparoscopic approach,
because it reduces the wound infection rate and
complications. In obese patients, the defect sizes
are signicantly larger, something that must be
considered when the laparoscopic approach is
advised [36]. For obese patients (BMI ≥30kg/
m2) with a defect size greater than 8–10 cm,
there may be a need for additional technical steps (greater mesh xation, more overlap,
suture closure of the defect) when the laparoscopic approach is indicated.
e Consensus Development Conference-
based guidelines [37] also recommend laparoscopy for the treatment of ventral and incisional
hernia repair in obese patients.
A study of Pernar et al. [38] aimed to deter-
mine at what body mass index (BMI) threshold
postoperative complications increase. Patients
were divided into ve groups based on BMI: group
1 (< 25kg/m2), group 2 (25–29.99kg/m2), group 3
(30–34.99kg/m2), group 4 (35–39.99kg/m2), and
group 5 (≥40kg/m2). e adjusted odds of complications in group 5 was 2.89 times greater compared to group 1 (OR 2.89; 95% CI=1.22–6.84),
while there were no signicant dierences in odds
of postoperative complications for group 2, 3, or
4 compared to group 1. BMI category was also
signicantly associated with undergoing recurrent ventral hernia repair, with 28,7% of patients
in group 5 having a recurrent repair compared to
14% in patients in group 1 (p=0.03).
e authors concluded that aer ventral her-
nia repair, complications are most likely to occur
in patients with BMI≥ 40 kg/m2. is subset of
patients also had a signicantly higher risk of
undergoing surgery for a recurrent hernia [38].
In an analysis of the American College of
Surgeons National Surgery Quality Improvement
Program (ACS NSQIP), a total of 12.004 patients
who underwent ventral hernia repair were
included. Of the patients with body mass index
2
(BMI) > 30 kg/m
, 3–4% developed supercial
surgical site infections in the open ventral hernia
repair group compared with 0.72% of the patients
in the laparoscopic ventral hernia repair group
(p<0.01) [39].
In another study of the American College of
Surgeons National Surgery Quality Improvement
Program (ACS NSQIP) database, patients with
elective ventral hernia repair were stratied by
BMI (20–25, 25–30, 30–35, 35–40, and ≥40kg/
m2) and 30-day surgical site occurrence evaluated across BMI groups for laparoscopic vs open
ventral hernia repair [40]. A total of 106.968
patients met inclusion criteria, with 60% patients
obese. Laparoscopic ventral hernia repair
decreased surgical site occurrence for all patients
(Odds ratio 0.4, CI 0.19–0.60). Obesity classes I/
II/III have increased odds of supercial surgical
site infections, deep surgical site infections, and
dehiscence for open compared with laparoscopic
ventral hernia repair. e authors concluded that
obese patients are overrepresented in ventral hernia repairs. irty-day postoperative wound complications increase with higher BMI.Laparoscopic
ventral hernia repair minimizes both surgical site
infection and surgical site occurrence, especially
in higher obesity classes (. Figs.31.7, 31.8, 31.9,
31.10, 31.11, and 31.12).
. Fig.31.7 Laparoscopic incisional hernia repair in an
obese patient with BMI 45kg/m2 following open repair of
a gastroduodenal perforation
. Fig.31.8 4×4cm defect in the lateral part of the
horizontal incision
346
F. Köckerling et al.
31
. Fig.31.9 Defect closure with the use of a nonabsorb-
able loop suture
. Fig.31.10 Transfascial extraction of the two ends of
the loop suture
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Obese Patients
31. Earle D, Roth JS, Saber A, Haggerty S, Bradley JF, Fanelli
R, Price R, Richardson WS, Stefanidis D, SAGES Guidelines Committee. SAGES guidelines for laparoscopic
ventral hernia repair. Surg Endosc. Published online:
12 July 2016. https://doi.org/10.1007/s00464-016-
5072-x.
32. Sauerland S, Walgenbach M, Habermalz B, Seiler CM,
Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane
Database Syst Rev. 2011;(3):CD007781. https://doi.
org/10.1002/14651858.CD007781.pub2.
33. Zhang Y, Zhou H, Chai Y, Cao C, Jin K, Hu Z. Laparoscopic
versus open incisional and ventral hernia repair: a
systematic review and meta-analysis. World J Surg.
2014;38(9):2233–40. https://doi.org/10.1007/s00268-
014-2578-z.
34. Al Chalabi H, Larkin J, Mehigan B, McCormick P.A systematic review of laparoscopic versus open abdominal
incisional hernia repair, with meta- analysis of randomized controlled trials. Int J Surg. 2015;20:65–74. https://
doi.org/10.1016/j.ijsu.2015.05.050.
35. Awaiz A, Rahman F, Hossain MB, Yunus RM, Khan S,
Memon B, Memon MA.Meta-analysis and systematic
review of laparoscopic versus open mesh repair for
elective incisional hernia. Hernia. 2015;19(3):449–63.
https://doi.org/10.1007/s10029-015-1351-z.
36. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli
GS, Fortelny R, Köckerling F, Kukleta J, LeBlanc K,
Lomanto D, Misra MC, Bansal VK, Morales-Conde S,
Ramshaw B, Reinpold W, Rim S, Rohr M, Schrittwieser
R, Simon T, Smietanski M, Stechemesser B, Timoney
M, Chowbey P.Guidelines for laparoscopic treatment
of ventral and incisional abdominal wall hernias
(International Endohernia Society [IEHS]) – part 1.
Surg Endosc. 2014;28:2–29. https://doi.org/10.1007/
s00464-013-3170-6.
37. Silecchia G, Campanile FC, Sanchez L, Ceccarelli G,
Antinori A, Ansaloni L, Olmi S, Ferrari GC, Cuccurullo
D, Baccari P, Agresta F, Vettoretto N, Picolli M.Laparoscopic ventral/incisional hernia repair: updated guidelines from the EAES and EHS endorsed consensus
development conference. Surg Endosc. 2015;29:2463–
84. https://doi.org/10.1007/s00464-015-4293-8.
38. Pernar LI, Pernar CH, Dieenbach BV, Brooks DC, Smink
DS, Tavakkoli A. What is the BMI threshold for open
ventral hernia repair?. Surg Endosc. 2016. Epub ahead
for print.
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org/10.1097/SLE.0000000000000100.
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349
Ventral andIncisional
Hernias Mesh Technology
FerdinandKöckerling andBruceRamshaw
32.1 Pure Polypropylene (PP), Polyester, PVDF,
PTFE, Titanized PP, Synthetic Absorbable,
Biologicals – 350
32.2 Mesh Infection: What Should BeDone? – 353
32.3 Long-Term Results ofLaparoscopic
Ventral Hernia Mesh Repair – 354
References – 355
32
© 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_32
32
350
F. Köckerling and B. Ramshaw
32.1 Pure Polypropylene (PP),
Polyester, PVDF, PTFE,
Titanized PP, Synthetic
Absorbable, Biologicals
In the guidelines [1] for laparoscopic ventral hernia
repair of the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES), no recommendation can be made about a specic prosthetic, since there are few data available directly
comparing the long-term outcomes of dierent
prosthetics in humans [1]. Selection of the prosthetics is typically based on surgeon’s experience,
intraoperative handling characteristics, and the
purported features associated with the prosthetic
[1]. Post-market, continuous evaluation in terms
of patient-centered outcomes of all prosthetics is
needed [1].
When meshes are inserted intraperitoneally
during laparoscopic intraperitoneal onlay meshes
(IPOM), they must meet stringent requirements
because they directly contact intestines [2].
Eriksen et al. [3] formulated the following
characteristics for an optimal mesh to be used
for laparoscopic repair of ventral and incisional
hernias:
5 Minimal adhesion formation
5 Excellent tissue ingrowth
5 Minimal shrinkage
5 No infection or stula formation
5 Minimal pain
5 Minimal seroma formation
5 No change in abdominal wall compliance
5 Low price
5 Easy to manipulate
Typically, meshes are made of the basic materials PP, polyester, polyvinylidene uoride, or
PTFE.e use of pure PP meshes and polyester
meshes is not recommended for laparoscopic
IPOM [2–5]. It is accepted that PP and polyester
meshes are coated either with a protective membrane or a protective lm (absorbable or nonabsorbable) or with a titanium layer (
and
32.2) to protect the viscera [2]. ese com-
posite meshes, as they are known, and ePTFE
meshes are generally recommended for intraperitoneal use [2–4, 6, 7]. It is assumed that the use
of these meshes reduced adhesion formation and
. Figs. 32.1
. Fig.32.1 Titanium-coated composite mesh (TiMesh
strong) in laparoscopic IPOM
. Fig.32.2 Fixation of the titanium-coated composite
mesh (TiMesh strong) with absorbable tackers following
defect closure in laparoscopic IPOM
hence lowered the risk of intestinal damage and
stula formation (
. Table 32.1). erefore, the
International Endohernia Society recommended
in their guidelines on the evidence level Grade
C that for laparoscopic incisional and ventral
hernia repair, only materials approved for use in
the abdominal cavity (PTFE, PVDF, and composite meshes) should be used [2]. In a systematic
review by Shankaran et al. [4] of the implants
available for treatment of incisional and ventral
hernias, biological meshes are listed as a possible
alternative. In this respect, biological meshes can
be used in an extraperitoneal as well as an intraperitoneal position [2]. e main advantage cited
for biological meshes in their suitability for use in
contaminated and infected surgical elds [2, 8]
(. Table32.2).
According to a statement on evidence level 1b
in the guidelines of the International Endohernia
Society, the use of non-cross-linked biological
351
Ventral andIncisional Hernias Mesh Technology
. Table32.1 Meshes approved for use in the abdominal cavity
Group Name of mesh Material Company name
PTFE Mycromesh ePTFE W.L. Gore
DualMesh ePTFE W.L. Gore
Dulex ePTFE C.R. Bard
MotifMESH ePTFE Proxy Biomedical
Omyramesh cPTFE Aesculap AG
PVDF Dynamesh PP/polyvinylidene uoride FEG Textiltechnik/Dahlhausen
Composite
mesh with
absorbable
barrier coated
Composite
mesh with
permanent
barrier coated
Glucamesh PP with beta glucan coating Genzyme
Proceed PP with ORC layer Ethicon
Sepramesh PP with resorbable layer Genzyme
Parietene composite PP with collagen coating Medtronic
Parietex composite Polyester with collagen coating Medtronic
Symbotex Polyester with collagen coating Medtronic
Ventralight ST PP with absorbable hydrogel
barrier
TiMesh PP with titanium coating pfm medical AG
Composix PP/ePTFE C.R. Bard
Ventrio hernia patch PP/ePTFE C.R. Bard
Intramesh T1 PP/ePTFE Cousin Biotech
Intramesh W3 Polyester mesh with silicone layer Cousin Biotech
C.R. Bard
32
Modied after Eriksen etal. [11]
PTFE polytetrauoroethylene, ePTFE expanded PTFE, cPTFE condensed PTFE, PVDF polyvinyl diuoride, PP
polypropylene, ORC oxidized regenerated cellulose
meshes for elective laparoscopic bridging repair
of incisional ventral hernias shows a high recurrence rate [2]. So the Grade A recommendation is
that elective laparoscopic repair of incisional and
ventral hernias should not be performed with the
use of non-cross-linked biological mesh with a
bridging technique [2].
e International Endohernia Society gives a
statement on evidence level 4 that laparoscopic
repair of incisional and ventral hernias in an
infected or potentially contaminated surgical eld
can be performed with non-cross-linked biological meshes but the defect should be closed with
sutures [2]. e guidelines recommended a Grade
D level that laparoscopic repair of incisional and
ventral hernias with non-cross-linked biological
meshes in an infected or potentially contaminated
surgical eld may be a viable option if the hernia
defect is closed primarily (Abb. 3–5). But the very
high costs of the biological meshes limit their use
in routine practice (. Figs.32.3, 32.4, and 32.5).
Biosynthetic absorbable meshes could be in
the future an upcoming alternative to biological
meshes in contaminated or potentially contaminated ventral and incisional hernias. Studies in
laparoscopic ventral and incisional hernia repair
are missing. In a rst multicenter, prospective, longitudinal study with 104 patients with
32
F. Köckerling and B. Ramshaw
352
. Table32.2 Biological meshes on the market
Name Manufacturer Tissue source Material X-linking
AlloDerm LifeCell Human Acellular dermis No
AlloMax Bard Human Acellular dermis No
FlexHD Ethicon/MTF Human Acellular dermis –
DermaMatrix MTF Human Acellular dermis No
Permacol Covidien Porcine Acellular dermis Ye s
CollaMend Davol/Bard Porcine Acellular dermis Yes
Fortiva Tutogen Porcine Acellular dermis No
Strattice KCI/LifeCell Porcine Acellular dermis No
XenMatrix Brennan Medical Porcine Acellular dermis No
Surgisis Cook Porcine Small intestine submucosa No
Surgisis Gold Cook Porcine Small intestine submucosa No
Lyosis Cook Porcine Lyophilized small intestine submucosa No
FortaGen Organogenesis Porcine Small intestine submucosa Yes
SurgiMend TEI bioscience Bovine Fetal dermis No
Periguard Synovis Bovine Pericardium Yes
Veritas Synovis Bovine Pericardium No
Tutomesh Tutogen Bovine Pericardium No
Tutopatch Tutogen Bovine Pericardium No
. Fig.32.3 Laparoscopic IPOM with defect closure and
use of a biological mesh for treatment of an incarcerated
epigastric hernia. Placement of transfascial sutures
a contaminated or clean-contaminated operative eld and a hernia defect at least 9cm2 had a
biosynthetic mesh (open, sublay, retrorectus, or
intraperitoneal) repair with fascial closure [9].
Biosynthetic absorbable mesh showed ecacy
. Fig.32.4 Fixation of the biological mesh with
absorbable tackers
in terms of long-term recurrence and quality
of life and oers an alternative to biologic and
permanent synthetic meshes in these complex
situations [9].