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Ventral andIncisional Hernias Mesh Technology
. Fig.32.5 Final view of the laparoscopic IPOM with
defect closure and biological mesh
32.2 Mesh Infection: What Should
BeDone?
An important advantage of the laparoscopic intraperitoneal onlay mesh (IPOM) technique over
open repair of incisional and ventral hernias is
the lower rate of wound and mesh infection [10].
Meta-analyses demonstrated that laparoscopic
repair of incisional and ventral hernias signicantly is attended by fewer wound infections and
less need for mesh removal (level 1A) [11–16].
In the meta-analysis of Sauerland et al.
[14], the local infection rate in the laparoscopic
groups was 3.1% versus 13.4% in the open group
(p < 0.00001). A local infection requiring mesh
removal was found in 0.7% of the laparoscopic
group and 3.5% of the open group (p =0.009).
Only one third of wound infections did result in
mesh removal [10]. So the statements on level 1A
in the guidelines of the International Endohernia
Society were that the rate of mesh infection aer
laparoscopic ventral and incisional hernia repair
is with 1% low. e mesh does not need to be
removed in all cases of wound infection aer laparoscopic ventral and incisional hernia repair [10].
In the literature, case reports on the treatment
of mesh infections aer laparoscopic repair of
incisional and ventral hernias discuss both mesh
removal and mesh salvage [17–19].
For interventional and conservative treatment
of a mesh infection aer laparoscopic repair of
incisional and ventral hernias, the authors advocate
percutaneous drainage of accumulated pus around
the mesh and insertion of a drain through which
irrigation with gentamycin 80 mg in 20ml saline
solution is carried out three times daily together
with intravenous antibiotic treatment [18, 19].
Treatment of mesh infections also depends
on the material used [10]. In a comparative study
353
(level 2B), Hawn etal. [20] demonstrated less need
to remove a polypropylene mesh than a PTFE
mesh because of a mesh infection (p< 0.0001).
Petersen et al. [21] also showed that for mesh
repair of incisional hernias, with which mesh
infection occurring in 8.1% of cases aer the use
of ePTFE and in 3.9% aer the use of polypropylene, in no case was it possible to salvage the
infected ePTFE mesh, whereas all the infected
polypropylene meshes were preserved [10].
e guidelines of the International Endohernia
Society recommended on Grade B level that an
infected ePTFE mesh aer laparoscopic ventral
and incisional hernia repair should be removed.
A further Grade D recommendation is that preservation of an infected composite mesh aer laparoscopic ventral and incisional hernia repair can
be attempted using percutaneous drainage, drain
irrigation with gentamycin, and intravenous antibiotics [10].
If an interventional conservative attempt
proves unsuccessful, various options can be used
[22–25].
5 Mesh removal and primary skin closure, with
the repair repeated aer 6–9months
5 Mesh removal using the component separa-
tion technique, with the skin le open and
vacuum-assisted wound closure or open–
wound dressing applied
5 Mesh removal, repair of the defect with a
biologic mesh leaving the skin open, and
applying vacuum-assisted wound closure or
open– wound dressing
5 Mesh removal, repair of the defect with an
intraperitoneally placed biologic mesh, close
the defect over the biologic mesh, and close
the skin (
32.10)
5 Mesh salvage, with the skin le open, and
vacuum– assisted closure or open– wound
dressing applied
Because the treatment options available in the literature relate only to individual cases or to small
case series, currently, no concrete evidence- based
recommendation can be made for the optimal
management [10]. e use of a biological mesh
for replacement resulted in a high recurrence rate,
if bridging was required. Biological mesh seems to
work as a replacement, when fascial closure can
be achieved [26]. But the high costs of the biological meshes limit their routine use.
. Figs.32.6, 32.7, 32.8, 32.9, and
32
354
F. Köckerling and B. Ramshaw
32
. Fig.32.6 Mesh infection with stula formation to the
mesh after laparoscopic IPOM.Excision of the stula and
the chronically infected soft tissue
. Fig.32.7 Incisional hernia defect with infected
composite mesh still in place
. Fig.32.8 Incisional hernia defect after removal of the
chronically infected soft tissue and the mesh
32.3 Long-Term Results
ofLaparoscopic Ventral
Hernia Mesh Repair
e use of prosthetic materials in repair of abdominal wall hernias can lower the risk of hernia
recurrence. erefore, large numbers of meshes
are used worldwide every year. All types of meshes
. Fig.32.9 Repair of the incisional hernia defect with a
porcine dermis biological mesh (Fortiva) in open IPOM
position
. Fig.32.10 Closure of the incisional hernia defect with
nonabsorbable running suture and primary skin closure
on the market have the potential to cause certain
complications, such as stula formation, migra-
tion, infection, and rejection [27].
In a series of 225 laparoscopic ventral hernia repairs, Sasse et al. [28] reported over a
period of 42months following surgery of 9.7%
of patients dissatised because of mesh sensation and pain. Fourteen patients (6.22%) experienced postoperative ileus requiring hospital stay
>48h.
In a randomized controlled trail including 194
patients with laparoscopic or open incisional hernia repair with a mean follow-up of 35months, a
recurrence rate of 18% for the laparoscopic and
14% for the open group was found [29].
In a prospective comparative study, the recurrence rate for the laparoscopic group aer a mean
follow-up of 30months was 12% and for the open
group aer a mean follow-up of 36 months 9%
[30]. As in incisional hernia repair 65% of the
recurrences appear within in rst 3years, a nal
recurrence rate of 30% following laparoscopic
incisional hernia repair must be expected [31].
Ventral andIncisional Hernias Mesh Technology
355
32
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3. Eriksen JR, Gögenur I, Rosenberg J.Choice of mesh for
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4. Shankaran V, Weber DJ, Reed RL 2nd, Luchette FA. A
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5. Halm JA, de Wall LL, Steyerberg EW, Jeekel J, Lange
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6. Deeken CR, Faucher KM, Matthews BD. A review of
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7. Huber A, McCabe GP, Boruch AV, Medberry C, Honerlaw M, Badylak SF.Polypropylene-containing synthetic
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8. Franklin ME Jr, Trevino JM, Portillo G, Vela I, Glass JL,
Gonzalez JJ.The use of porcine small intestinal submucosa as a prosthetic material for laparoscopic hernia
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9. Rosen MJ, Bauer JJ, Harmaty M, Carbonell A, Cobb
WS, Matthews B, Goldblatt MI, Selzer DJ, Poulose BK,
Hannsson BME, Rosman C, Chao JJ, Jacobsen GR.Multicenter, prospective, longitudinal study of the recurrence, surgical site infection, and quality of life after
contaminated ventral hernia repair using biosynthetic
absorbable mesh: the COBRA study. Ann Surg. 2015.
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10. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli GS,
Fortelny RH, Köckerling F, Kukelta J, LeBlanc K, Lomanto
D, Misra MC, Morales-Conde S, Ramshaw B, Reinpold
W, Rim S, Rohr M, Schrittwieser R, Simon T, Smietanski
M, Stechemesser B, Timoney M, Chowbey P.Guidelines
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abdominal wall hernias (International Endohernia
Society [IEHS])– part 2. Surg Endosc. 2014;28:353–79.
https://doi.org/10.1007/s00464-013-3171-5.
11. Goodney PP, Birkmeyer CM, Birkmeyer JD.Short- term
outcomes of laparoscopic and open ventral hernia
repair: a meta-analysis. Arch Surg. 2002;137(10):1161–5.
12. Forbes SS, Eskicioglu C, RS ML, Okrainec A. Metaanalysis of randomized controlled trials comparing
open and laparoscopic ventral and incisional hernia
repair with mesh. Br J Surg. 2009;96(8):851–8. https://
doi.org/10.1002/bjs.6668.
13. Sajid MS, B okhari SA, Mallick AS, Cheek E, Baig MK.Laparoscopic versus open repair of incisional/ventral hernia: a meta-analysis. Am J Surg. 2009;197(1):64–72.
https://doi.org/10.1016/j.amjsurg.2007.12051.
14. 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;16(3):CD007781. https://doi.
org/10.1002/14651858.CD007781.pub2.
15. 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;19:449–63.
https://doi.org/10.1007/s10029-015-1351-6.
16. Al Chalabi H, Larkin J, Mehigan B, McCormick P.A systematic review of laparoscopic versus open abdominal
incisonal 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.
17. Fortelny RH, Petter-Puchner AH, Glaser KS, Oner F, Benesch T, Rohr M. Adverse eects of polyvinylidene uoride-coated polypropylene mesh used for laparsocopic
intraperitoneal onlay repair of incisional hernia. Br J Surg.
2010;97(7):11.40–5. https://doi.org/10.1002/bjs.7082.
18. Aguilar B, Chapital AB, Madura JA 2nd, Harold KL.Conservative management of mesh-site infection in hernia
repair. J Laparoendosc Adv Surg Tech A. 2010;20(3):249–
52. https://doi.org/10.1089/lap.2009.0274.
19. Trunzo JA, Ponsky JL, Jin J, Wiliams CP, Rosen ML. A
novel approach for salvaging infected prosthetic mesh
after ventral hernia repair. Hernia. 2009;13(5):545–9.
https://doi.org/10.1007/s10029-009-0470-9.
20. Hawn MT, Gray SH, Snyder CW, Graham LA, Finan KR,
Vick CC. Predictors of mesh explantation after incisional hernia repair. Am J Surg. 2011;202(1):28–33.
https://doi.org/10.1016/j.amjsurg.2010.10.011.
21. Petersen S, Henke G, Freitag M, Faulhaber A, Ludwig
K.Deep prosthesis infection in incisional hernia repair:
predictive factors and clinical outcome. Eur J Surg.
2001;167(6):453–7.
22. Saettele TM, Bachman SL, Costello CR, Grant SA,
Cleveland DS, Loy TS, Kolder DG, Ramshaw BJ. Use of
porcine dermal collagen as a prosthetic mesh in a contaminated eld for ventral hernia repair: a case report.
Hernia. 2007;11(3):279–85.
23. Sanchez VM, Abi-Haidar YE, Itani KM.Mesh infection in
ventral incisional hernia repair: incidence, contributing
factors, and treatment. Surg Infect. 2011;12(3):205–10.
https://doi.org/10.1089/sur.2011.033.
24. Baharestani MM, Gabriel A. Use of negative pressure wound therapy in the management of infected
abdominal wounds containing mesh: an analysis of
outcomes. Int Wound J. 2011;8(2):118–25. https://doi.
org/10.1111/j.1742-481X.2010.00756.x.
25. Tamhankar AP, Ravi K, Everitt NJ.Vacuum assisted closure therapy in the treatment of mesh infection after
hernia repair. Surgeon. 2009;7(5):316–8.
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26. Montgomery A, Kallinowski F, Köckerling F.Evidence
for replacement of an infected synthetic by a biological mesh in abdominal wall hernia repair. Front Surg.
2015;2:67. https://doi.org/10.3389/fsurg.2015.00067.
27. Seker D, Kulacglu H.Long-term complications of mesh
repairs for abdominal wall hernias. J Long- Term E
Med Implants. 2011;21(3):205–18.
28. Sasse KC, Lim DCL, Brandt J.Long-term durability and
comfort of laparoscopic ventral hernia repair. JSLS.
2012;16:380–6. https://doi.org/10.4293/1086808
12X13462882736097.
29. Eker HH, Hansson BME, Buunen M, Janssen IMC, Pierik
REGJM, Hop WC, Bonjer J, Jeekel J, Lange JF.Laparo-
scopic vs open incisional hernia repair. JAMA Surg.
2013;148(3):259–63. https://doi.org/10.1001/jama-
surg.2013.1466.
30. Bingener J, Buck L, Richards M, Michalek J,
Schwesinger W, Sirinek K. Long-term outcomes in
laparoscopic vs open ventral hernia repair. Arch Surg.
2007;142(6):562–7.
31. Köckerling F, Koch A, Lorenz R, Schug-Pass C,
Stechemesser B, Reinpold W.How long do we need to
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357
Incisional andAbdominal
Wall Hernia Repair
withMinimally Invasive
Extraperitoneal Synthetic
Mesh Implantation Using
MILOS Technique
(Mini andLess Open
Sublay Surgery)
WolfgangReinpold
33
33.1 Summary – 363
References – 363
© 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_33
358
W. Reinpold
33
Incisional hernia is the most common complication aer abdominal surgeries at 10–30% worldwide [1, 2]. Abdominal wall hernias never heal
spontaneously. e risk of incarceration and
strangulation is 1–2% per year. e main cause
seems to be genetically determined insucient
cross-links between the collagen molecules.
Since the advent of synthetic mesh [3], recurrence rates could be reduced from 25–60% to
below 15%.
e open sublay mesh implantation based on
techniques of Jean Rives and René Stoppa and the
laparoscopic intraperitoneal onlay mesh plasty
(lapIPOM) are the internationally leading procedures for the treatment of incisional hernias [4–7,
11–16] (. Fig.33.1a, b).
In open sublay surgeries, the stabilising synthetic mesh is introduced through a large skin
incision outside the abdominal cavity between the
peritoneum and the abdominal wall. e disadvantages of the procedure are the more invasive
access trauma and, according to the literature, the
higher infection rate.
Despite the advantages of the small skin incisions in lapIPOM surgery, the pain level is not low.
A further concern is the implantation of a foreign
body in the abdominal cavity, which is a risk factor
for adhesion formation to the gut and injuries to
the viscera [16]. In addition the mesh has to be xated with many staples, clips, tacks or extensive
sutures to the pain-sensitive peritoneum [8–11]
(. Fig.33.1a). Expensive implants with adhesion
barriers on the area facing the gut have to be used.
Reoperations have shown that all IPOM prostheses can lead to massive adhesions and do not provide secure protection against adhesion. Another
disadvantage of lapIPOM repair is the fact that the
hernia defect is oen not fully closed but only
bridged by the synthetic prosthesis. is oen
leads to a persisting protrusion that frequently
regresses slowly or not at all. Current data from the
German hernia register “Herniamed” show significantly more 1 year recurrences aer lapIPOM
hernia repair than aer open sublay operations.
Because of the disadvantages of the established
surgical procedures and in order to minimise
complications and pain in abdominal wall hernia
repair, we developed a new minimally invasive
concept – the mini/less open sublay (MILOS)
repair. e MILOS repair permits placement of a
large mesh in the retromuscular/ preperitoneal
space and anatomical reconstruction of the
a
b
. Fig33.1 a Extensive tack xation of the lap IPOM mesh. b Large incision in open sublay surgery
MILOS Repair of Abdominal Wall Hernias
Mesh
Hernia defect
Skin incision
359
33
. Fig.33.2 Incision of 2–6 cm directly above the hernia
defect. Showing synthetic mesh (black interrupted line),
hernia defect (green), incision (red)
abdominal wall via a small transhernial incision.
Using the MILOS technique, major trauma to the
abdominal wall and entering the abdominal cavity
is avoided. e MILOS operation can be performed mini open with light- armed laparoscopic
instruments either under direct vision or endoscopically assisted. Today, in our institution, all
primary and incisional abdominal wall hernias are
operated on with the MILOS concept. Exceptions
are small hernias with an hernia defect diameter
smaller than 2cm and extremely large hernias.
Every MILOS operation starts with an incision of 2–6 cm directly above the centre of the
hernia defect (. Fig.33.2). e abdominal wall is
lied with retractors. e preparation is carried
out in “mini-open” technique under direct vision
or endoscopically assisted (
. Figs.33.3 and 33.4).
Aer transhernial mini- open preparation of an
extraperitoneal space of at least 8 cm diameter
and closing of the abdominal cavity, the procedure can be continued as total extraperitoneal gas
endoscopy [TEP of the abdominal wall (endoscopic minimally open sublay repair (EMILOS))]
using either standard trocars (. Fig. 33.5) or a
transhernial single port (. Fig.33.6) [17, 18].
e MILOS/EMILOS technique enables the
extraperitoneal preparation of the whole rectus
compartment and both lateral compartments.
Very large synthetic meshes can be implanted
(. Fig.33.12) minimally invasively if the size of
the hernia requires it.
e steps in the surgery:
1. Small incision directly above the centre of
the hernia defect (. Fig.33.2).
. Fig.33.3 Laparoscopic forceps armed with light
tube– Endotorch TM
. Fig.33.4 Transhernial dissection with endotorch
under direct vision
2. Hernia sac preparation.
3. Small incision of the peritoneum for
diagnostic laparoscopy.
4. Resection of the hernia sac.
5. Complete and precise exposure of the fascial
edge of the hernia orice.
6. While the abdominal wall is lied with
rectangular retractors, transhernial extraperitoneal dissection around the hernia gap
is performed using laparoscopic instruments
armed with a light tube specically designed
by the company WOLF and us (Endotorch
TM,
. Figs.33.3 and 33.4). Via a 4cm
incision, the Endotorch TM allows circumferential dissection of the extraperitoneal
plane with a radius of up to 20cm from the
fascial border of the hernia gap.
33
360
W. Reinpold
5-mm
Two transhernial ports
. Fig.33.5 MILOS operation: gas endoscopy with
standard trocars
. Fig.33.6 MILOS operation: gas endoscopy with
transhernial single port
10-mm
Transhernial longitudinal incision of the
posterior rectus sheath is performed in all
quadrants to correspond with mesh size
(. Figs.33.7 and 33.8). . Figure33.9 depicts
the endoscopic incision of the cranial section
of the le posterior rectus sheath.
7. Closure of the abdominal cavity with
peritoneal suture.
8. Transhernial and extraperitoneal implantation of synthetic mesh. In the midline, the
mesh is placed in the preperitoneal space
and on both sides laterally in the retromuscular position (
. Fig.33.10).
9. Mesh xation is only necessary in cases
where the hernia defect cannot be closed
with low tension (bridging of large hernia
defects). e intra-abdominal pressure
xates the mesh between the peritoneum
and supporting abdominal wall. We use
large pore standard polypropylene or
polyvinylidenuoride meshes, which cover
the hernia defect with a radius of 5–20cm
(. Figs.33.11 and 33.12) according to the
hernia defect size.
10. e hernia defect is closed anatomically with
nonabsorbable or long-term absorbable
suture.
e MILOS technique is also appropriate for
lateral abdominal wall hernias. In the case of
large incisional hernias, the surgery is carried out in “less open” technique (skin incision
>6cm–12cm).
From January 2010 to December 2015, we carried out 715 MILOS surgeries for surgical hernias
and an approximately equal number of primary
abdominal wall hernias. Data on all patients were
documented in the “Herniamed” register.
e hernia orices and the size of the mesh are
given in . Tables 33.1 and 33.2. Postoperative
consumption of analgesics is comparably low. e
standard postoperative pain medication is metamizol 4×1 g p.o. Additional opioids are necessary in only 10% of the cases. Even in the case of
large incisional hernias, a peridural analgesic
catheter is dispensable.
In 36 cases of hernia surgery, the MILOS technique was combined with posterior or anterior
endoscopic component separation (hybrid procedure) in order to achieve a low-tension anatomical
closure of the large hernia defect aer the insertion of a large extraperitoneal synthetic mesh.
e average operating time of MILOS repair is
103min, 8 and 21min longer than open sublay
(95min) and lapIPOM repair (82min), respectively. e complication rate aer MILOS incisional hernia repair is very low (. Tables 33.3 and
33.4). ere was only one enterotomy. Two super-
cial wound infections healed preserving the synthetic mesh. In four patients, revision was carried
out with haematoma evacuation. To obtain
MILOS Repair of Abdominal Wall Hernias
. Fig.33.7 Transhernial
longitudinal incision of the
posterior rectus sheath
with light armed laparoscopic scissors
Peritoneum
Posterior rectus
sheath
Long rectangular
retractors
Hernia defect
Linea Alba
361
Endotorch TM
Transhernial
longitudinal incision
of the posterior
rectus sheath
33
. Fig.33.8 Incision of the posterior rectus sheath 1cm
lateral to the medial border of muscle
Left rectus muscle
Xiphoid
. Fig.33.9 Single port TEP: incision of the upper left
posterior rectus sheath
. Fig.33.10 Retromuscular/preperitoneal mesh
position; hernia defect is anatomically closed
. Fig.33.11 Young woman with 3cm incisional hernia
after suture closure of an umbilical hernia. MILOS repair with
3mm instruments, 5mm endoscope and 2cm incision.
Implantation of a 15×15cm standard synthetic mesh
362
P
W. Reinpold
. Fig.33.12 Abdominal
wall after MILOS operation
of the fourth recurrence of
an incisional hernia after
open prostatectomy: multiple defect 15×9cm hernia
gap marked in red broken
line and 30×20 polypropylene mesh (marked in white
broken line)
30 × 20 cm
olypropylene
mesh
6 cm MILOS
scar
Hernia defect
. Table33.1 Size of hernia gap in incisional hernias (MILOS-OP; n=715)
33
Area (in cm2) 0–5 5–10 10–20 20–50 50–100 100–200 > 200
Number 79 55 91 137 112 150 91
2
Area (in cm
statistically valid results of patients with comparable hernias and comorbidity, a propensity score
matching of 601 MILOS, lapIPOM and open
sublay operations of the German Herniamed registry, was carried out. Aer MILOS operation,
there were signicantly fewer postoperative complications, cases of bleeding requiring revision,
general complications and chronic pain compared
to lapIPOM and open sublay repair.
)
. Table33.2 Size of mesh in incisional hernia operations (MILOS-OP; n=715)
Area (in cm2) 0 bis 50 50 bis100 100 bis 200 > 200
Number 0 8 77 630
2
Area (in cm
)
One year aer MILOS operation, the rate of
chronic pain induced by physical activities was
highly signicantly lower than aer open sublay
and lapIPOM repairs. Moreover, the infection
rate was highly signicantly lower aer MILOS
repair compared to open sublay operations. e
rate of infection aer MILOS repair was even
lower than aer lapIPOM operations but not at a
statistically signicant rate.