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16 Biomaterials forAbdominal Wall Hernia Repair
183
tion and shrinkage for different mesh types
specically designed for intra-peritoneal placement [37].
International Endo-hernia Society guidelines recommend the use of only the materials
approved for use in the abdominal cavity such
as PTFE, PVDF and composite meshes for laparoscopic incisional and ventral hernia repair
[36]. The guidelines also recommend 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 because of the risk of high
recurrence rates. Biological meshes are not
impervious to infection and 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 [36].
Key Points
• There is a wide range of biomaterials available
for abdominal wall hernia repair. They may
differ in their chemical characteristics, physi-
cal properties like ber size, pore size, weight
and pliability. They may also behave differ-
ently when in contact with host tissue due to
the various modications made to them.
Different companies make various types of
meshes using the same compound; however,
the current available literature for inguinal
hernia repair supports lightweight meshes as it
gives fewer symptoms in the short term but for
long-term outcomes the benets seem to be
less apparent as heavyweight meshes have
shown satisfactory results when used by expe-
rienced hands. This observation proves that
the surgical technique and experience can be
more important than the type, size, weight,
pore size and the make of the mesh in treating
inguinal hernia [1].
• The literature shows that the minimally inva-
sive approach with laparoscopic or robotic
techniques have signicantly improved the
surgical morbidity associated with ventral her-
nia repair. There have been reports of major
complications such as stulas and mesh infec-
tions, but the incidence of these complications
seems relatively low compared to open repair,
regardless of the type of mesh used. Usage of
polypropylene meshes inside the abdominal
cavity needs to be evaluated again with the
addition of new lightweight, large pore composite meshes. These meshes have shown to
cause less inammation and less postoperative pain due to less implanted mesh
material which subsequently results in fewer
adhesions. Currently the literature is unable to
give general recommendations for choice of
mesh based on randomized controlled trials
and no difference seems to exist in relevant
outcome parameters from clinical series
between different mesh materials [35]. The
nal choice of the ideal biomaterial for
abdominal wall hernia repair will therefore
typically be based on surgeons’ preference
and cost, till the results of further randomized
controlled clinical trials and their metaanalysis appear in the literature.
References
1. Jacob BP, Ramshaw B.The SAGES manual of hernia
repair. NewYork: Springer; 2013.
2. Shillcutt SD, Clarke MG, Kingsnorth AN. Costeffectiveness of groin hernia surgery in the Western
Region of Ghana. Arch Surg. 2010;145:954–61.
3. Scott NW, McCormack K, Graham P, et al. Open
mesh versus non-mesh for repair of femoral and
inguinal hernia. Cochrane Database Syst Rev.
2002;(4):CD002197.
4. Nieuwenhuizen J, van Ramshort GH, Ten Brinke JG,
etal. The use of mesh in acute hernia: frequency and
outcome in 99 cases. Hernia. 2011;15(3):297–300.
5. Atila K, Guler S, Inal A, etal. Prosthetic repair of
acutely incarcerated groin hernias: a prospective clinical observational cohort study. Langenbeck’s Arch
Surg. 2010;395:563–8.
6. Babcock WW.The range of usefulness of commercial
stainless steel cloths in general and special forms of
surgical practice. Ann West Med Surg. 1952;6:15–23.
7. Moloney GE, Grill WG, Barclay RC.Operations for
hernia: technique of nylon darn. Lancet. 1948;2:45–8.
8. Handley WS.A method for the radical cure of inguinal hernia (darn and stay-lace method). Practitioner.
1918;100:466–71.
9. Lichtenstein IL, Shulman AG.Ambulatory outpatient
hernia surgery. Including a new concept, introducing
tension-free repair. Int Surg. 1986;71:1–4.
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10. Muldoon RL, Marchant K, Johnson DD, et al.
Lichtenstein vs. anterior preperitoneal prosthetic
mesh placement in open inguinal hernia repair: a prospective randomized trial. Hernia. 2004;8(2):98–103.
11. Kurzer M, Belsham PA, Kark AE.The Lichtenstein
repair. Surg Clin North Am. 1998;78:1025–46.
12. Wolstenholme JT. Use of commercial Dacron fabric
in the repair of inguinal hernias and abdominal wall
defects. Arch Surg. 1956;73:1004–8.
13. DeBord JR. The historical development of prosthetics in hernia surgery. Surg Clin North Am.
1998;78:973–1006.
14. Langenbach MR, Schmidt J, Zirngibl H.Comparison
of biomaterials: three meshesand TAPP for inguinal
hernia. Surg Endosc. 2006;20:1511–7.
15. Cobb WS, Peindl RM, Zerey M, etal. Mesh terminology 101. Hernia. 2009;13:1–6.
16. Weyhe D, Belyaev O, Muller C, etal. Improving outcomes in hernia repair by the use of light meshes—a
comparison of different implant constructions based
on a critical appraisal of the literature. World J Surg.
2007;31:234–44.
17. Bringman S, Wollert S, Osterberg J, etal. Three-year
results of a randomized clinical trial of lightweight or
standard polypropylene mesh in Lichtenstein repair of
primary inguinal hernia. Br J Surg. 2006;93:1056–9.
18. Nikkolo C, Lepner U, Murruste M, etal. Randomized
clinical trial comparing lightweight mesh with
heavyweight mesh for inguinal hernioplasty. Hernia.
2010;14:253–8.
19. O’Dwyer PJ, Kingsnorth AN, Molloy RG, et al.
Randomized clinical trial assessing impact of a lightweight or heavyweight mesh on chronic pain after
inguinal hernia repair. Br J Surg. 2005;92:166–70.
20. Post S, Weiss B, Willer M, etal. Randomized clinical
trial of lightweight composite mesh for Lichtenstein
inguinal hernia repair. Br J Surg. 2004;91:44–8.
21. Coda A, Lamberti R, Martorana S.Classication of
prosthetics used in hernia repair based on weight and
biomaterial. Hernia. 2012;16(1):9–20.
22. Kingsley D, Vogt DM, Nelson T, etal. Laparoscopic
intraperitoneal onlay inguinal herniorrhaphy. Am J
Surg. 1998;176:548–53.
23. Amid PK. Classication of biomaterials and their
related complications in abdominal wall hernia surgery. Hernia. 1997;1:15–21.
24. Champault G, Barrat C.Inguinal hernia repair with
beta glucan coated mesh: results at two-year follow
up. Hernia. 2005;9:125–30.
25. Champault G, Bernard C, Rizk N, etal. Inguinal hernia repair: the choice of prosthesis outweighs that of
technique. Hernia. 2007;11:125–8.
26. Bringman S, Wollert S, Osterberg J, etal. One year
results of randomized controlled multi-centre study
comparing Prolene and Vypro II-mesh in Lichtenstein
hernioplasty. Hernia. 2005;9:223–7.
27. Khan N, Bangash A, Sadiq M, et al. Polyglactine/
polypropylene mesh vs. propylene mesh: is there a
need for newer prosthesis in inguinal hernia? Saudi J
Gastroenterol. 2010;16:8–13.
28. Bell RCW, Price JG. Laparoscopic inguinal hernia repair using an anatomically contoured threedimensional mesh. Surg Endosc. 2003;17:1784–8.
29. Pajotin P. Laparoscopic groin hernia repair using a
curved prosthesis without xation. Le Journal de
Celio-Chirurgie. 1998;28:64–8.
30. Simons MP, Aufenacker T, Bay-Nielsen M, et al.
European Hernia Society guidelines on the treatment of inguinal hernia in adult patients. Hernia.
2009;13(4):343–403.
31. Bittner R, Montgomery MA, Arregui E, Bansal V,
Bingener J, Bisgaard T, etal. Update of guidelines on
laparoscopic (TAPP) and endoscopic (TEP) treatment
of inguinal hernia (International Endohernia Society).
Surg Endosc. 2015;29(2):289–321.
32. Schmidbauer S, Ladurner R, Hallfeldt KK, et al.
Heavy-weight versus low weight polypropylene
meshes for open sublay mesh repair of incisional hernia. Eur J Med Res. 2005;10(6):247–53.
33. Weyhe D, Schmitz I, Belyaev O, et al.
Experimental comparison of mono file light and
heavy polypropylene meshes: less weight does
not mean less biological response. World J Surg.
2006;30(8):1586–91.
34. Gemma Pascual G, Rodrıguez M, Gomez-Giln V,
et al. Early tissue incorporation and collagen deposition in lightweight polypropylene meshes: bioassay
in an experimental model of ventral hernia. Surgery.
2008;144(3):427–35.
35. Eriksen JR, Gögenur I, Rosenberg J. Choice of
mesh for laparoscopic ventral hernia repair. Hernia.
2007;11(6):481–92.
36. Bittner R, Bingener-Casey J, Dietz U, Fabian
M, Ferzli G, Fortelny R, et al. Guidelines for
laparoscopic treatment of ventral and incisional
abdominal wall hernias (International Endohernia
Society [IEHS])—Part III. Surg Endosc. 2014;
28(2):380–404.
37. Silecchia G, Campanile FC, Sanchez L, Ceccarelli
G, Antinori A, Ansaloni L, et al. Laparoscopic
ventral/incisional hernia repair: updated guidelines from the EAES and EHS endorsed
Consensus Development Conference. Surg Endosc.
2015;29(9):2463–84.
Laparoscopic Incisional
andVentral Hernia Mesh Repair
DavideLomanto andHrishikeshP.Salgaonkar
17
17.1 Introduction
Surgical practice has been revolutionized by the
advent of minimal invasive surgery by imparting
the ability to avoid major abdominal-wall incisions [1, 2]. Thus, laparoscopic surgery by utilizing smaller incisions is expected to reduce the
burden of incisional hernias, but such morbidity
of the era of conventional, open surgery is likely
to remain a common problem for the foreseeable
future. It is well-established that repair of sizeable
incisional hernias with a mesh is associated with
signicantly reduced incidence of recurrence of
hernia as compared to suture-repair without mesh
[3]. Also, the mechanical superiority of meshplacement in the pre-peritoneal or retro-muscular
space (sublay or underlay) over onlay is conceptually apparent [4, 5]. Following Pascal’s law, the
description of laparoscopic ventral hernia repair
(LVHR) was published over 20years ago and this
technique involves either an intra-peritoneal onlay
D. Lomanto (*)
Minimally Invasive Surgical Centre, KTP Advanced
Surgical Training Centre, Yong Loo Lin School of
Medicine, National University Health System,
National University of Singapore, Singapore
e-mail: davide_lomanto@nuhs.edu.sg
H. P. Salgaonkar
Department of Surgery, Minimally Invasive Surgical
Centre, National University Health System and Yong
Loo Lin School of Medicine, National University
of Singapore, Singapore
mesh (IPOM) or pre- peritoneal mesh-placement
(PPOM) as in the open sublay repair.
LVHR has gained sufcient popularity to be
considered as one of the procedure of choice in
selected cases and several systematic or randomized comparative clinical trials have showed its
benets. The reliability of repair, measured by the
clinical outcome e.g. recurrence and complications
as compared to the vast popular open mesh repair
has shown similar or at times better clinical outcomes [6, 7]. Denitive comparison is difcult
because of heterogeneity in case-mix, technique as
well as length and accuracy of follow- up. But overall, LVHR appears to be at least as secure as open
mesh repair; this impression is consistent with the
similar prevalence of operations for recurrent incisional hernia before and after the introduction of
LVHR, in a large population [8]. The well-established benets of a minimally invasive approach,
such as early recovery after surgery, reduced pulmonary complications, decreased risk of wound
infection particularly in patients with higher body
mass index (BMI) and better cosmesis favours the
continuing increase in practice of LVHR.
17.2 Indications andContra-
indications forLVHR
Ventral and incisional hernias are operated
mainly due to symptoms i.e. pain, discomfort,
cosmesis or to prevent complications i.e. strangulation, respiratory dysfunction, skin problems. It
© Springer Nature India Private Limited 2020
P. Chowbey, D. Lomanto (eds.), Techniques of Abdominal Wall Hernia Repair,
https://doi.org/10.1007/978-81-322-3944-4_17
185
186
D. Lomanto and H. P. Salgaonkar
is still unclear, whether asymptomatic ventral and
incisional hernias should be treated surgically
and whether the indication for surgery should be
inuenced by the size of the hernia or the age of
the patient. According to the International
Endolaparoscopic Hernia Society (IEHS)
Guidelines here the Indications and
Contraindications (IEHS Guidelines) note [9].
Indications:
– Primary ventral hernia with defect size vary-
ing from 3 to 15cm
– Incisional hernia below 15cm
– Patients with multiple defects (“Swiss cheese”
type)
Contra-indications:
– Loss of domain
– Previous peritonitis
– Defect size greater than 15cm
– Contra-indications for general anaesthesia e.g.
severe cardiomyopathy, pulmonary disease
Relative contra-indications:
– Multiple previous surgery
– Multiple previous mesh repair with extensive
adhesions
– Acute and sub-acute intestinal obstruction
– Ascitis and portal hypertension
Advanced age is no longer considered a con-
traindication for LVHR. In fact the Cochrane
review [10] showed a clear and consistent result
of reduced risk for surgical site infections with
laparoscopic surgery in elderly patients.
It is debatable if defects <3 cm should be
repaired with laparoscopy or by using mesh as
many surgeons still repair these small defects
without mesh. This, even after signicant message
from Burger etal. [11] after their long-term randomized clinical trial (RCT), showed that ventral
hernia repair with only suture at 10-year follow-up
had a recurrence rate of 63%. Similarly, in 2010 a
meta-analysis of RCTs and an extensive review by
Aslani et al. [12] favour mesh repair regarding
recurrence. A guideline published by Italian
Consensus Conference recommended that hernias
with a defect size <3cm should not be approached
laparoscopically [13]. This recommendation was
based on expert opinion and a survey showing that
less than 10% of surgeons used prosthetics in
defects less than 3cm; it was, therefore, deemed
“an indirect indication of a minimum size limit for
laparoscopy” [13]. But the recent published literature did not reveal any evidence in support of this
recommendation. Therefore, additional evidence
is needed before a minimum size for laparoscopic
repair can be dened.
17.3 Pre-operative Evaluation
A detailed history and complete physical examination during the initial surgical consultation needs to
be emphasized. This helps to identify patient risk
factors such as diabetes, obesity and smoking, which
cause peri-operative morbidity and mortality.
Routine use of radiological imaging
(Computed tomography {CT} or Magnetic resonance imaging {MRI}) for diagnosis and planning is not required. CT scan can be used in
selected cases, particularly in those with a recurrent hernia, complex hernias, multiple hernias,
hernias in uncommon or challenging locations
and when physical examination is unrevealing or
limited due to Obesity.
Strict control of blood sugar levels in diabetics
may help in reducing wound infections. Similarly,
cessation of smoking needs to be emphasized.
Some centres perform urine cotinine test evaluating compliance with smoking cessation.
In complex hernia with large contents, it is
useful to assess respiratory functions in case of
planning bridging or defect closure.
17.4 Surgical Technique
17.4.1 OT Layout andPatient
Positioning: (Fig.17.1)
The procedure is performed under general anesthesia. All pressure points are well padded and the
patient is secured to the operating table with
Second Assistant
Camera P
Anesthetist
17 Laparoscopic Incisional andVentral Hernia Mesh Repair
Fig. 17.1 Operation
theatre layout
Monitor
Operating
Surgeon
erson
187
Monitor
Scub Nurse
safety belts. The patient is placed in supine position with a slight elevation of the ipsilateral side in
non-midline hernias. The operating surgeon and
the rst assistant (camera person) are positioned
either on the left or right side facing the patient.
The scrub nurse stands at the foot end of the operating table. The primary monitor is placed on the
opposite side in line with the operative site. It is
preferable to have at least one additional monitor
on ipsilateral side especially in complex cases.
Urinary bladder may be catheterized in lower
abdominal hernia or if length of surgery is anticipated to be prolonged beyond 90min.
17.4.2 Abdominal Access andPort
Positioning: (Fig.17.2)
Either Veress needle, open technique (Hasson) or
optical viewing trocar can be utilized for abdominal cavity access. In case of previous abdominal
Instrument
Tr olley
surgery access can be done in Palmar’s point (left
subcostal midclavicular line at the lateral edge of
the rectus abdominus muscle) using Veress or
optical viewing trocar. In patients with multiple
previous surgeries open technique is advisable
because of intra-abdominal adhesions. Lately 3D
cameras enhance the vision especially in complex cases where severe adhesions or multiple
defects need to be repaired.
For subxiphoid defects the patient is given a
modied lithotomic position with the surgeon
standing in between the patient’s legs. The camera port is placed at the umbilicus, and a 5-mm
trocar on either side provides good triangulation
around the hernia. For suprapubic defects with
patient in Trendlenbergs position trocars can be
placed on the opposite side if defect is lateral.
In most cases 3-trocars with a primary
10–12mm-trocar and one or two 5mm trocars
are inserted depending on the intra-abdominal
anatomical situation [14]. Most surgeons
188
D. Lomanto and H. P. Salgaonkar
5 mm
Additional 5mm
in selected cases
Fig. 17.2 Port placement
10/11 mm
5 mm
frequently choose the port positions depending
upon the intra-abdominal anatomy, many insert
instruments from the side of the patient in direct
opposition to the viewing laparoscope for allowing a better viewing of all the adhesions [15].
Additional trocar on the opposite side may facilitate the mesh xation even though they produce
paradoxical movement.
17.4.3 Reduction ofHernia
andAdhesiolysis
It is safe to use blunt and sharp dissection for
adhesiolysis. Use of monopolar diathermy may
lead to an injury due to lateral thermal spread
and which is usually not visualized at the time of
surgery and patient may present with a delayed
leak. Alternative energy source like ultrasonic
shears, bipolar or combined (Thunderbeat,
Olympus, Japan) should be considered in dif-
Fig. 17.3 Adhesiolysis
cult and complex repair to improve hemostasis
and optimize operative time (Fig.17.3).
Adhesiolysis is at high risk of bowel injury,
from simple serosal tear to complete injury.
Sharp dissection is recommended or bipolar or
ultrasonic device in case of dense omental adhesions. It is important to achieve complete adhesiolysis of the abdominal contents to allow
adequate overlap of mesh. A complete adhesiolysis may help in identication of other multiple
defects (Swiss cheese). Hernias other than the
palpable ones are not infrequently identied. In
hernias over lower abdominal wall or suprapubic
region this may require to enter the pre-peritoneal
layer and to expose the Cooper’s ligament for a
better mesh xation. Similarly, superiorly this
may require division of the falciform ligament to
facilitate mesh xation. In extreme and difcult
adhesiolysis a partial or complete preperitoneal
dissection may facilitate the lysis and avoid
bowel injury.
For subxiphoid hernias it is important to dissect
the retroxiphoidal space. Space should be dissected from the dorsal aspect of the xiphoid process by blunt dissection and if necessary followed
by detachment of the diaphragm’s sternal portion
and nally separation of the pericardium from the
sternum. This step is mandatory for safe and effective mesh positioning with sufcient overlap.
In case of dense bowel adhesions if no progress
is made, a combined open approach can be used
with a skin incision made over the hernial defect to
help in reducing the contents. If not it is wiser to
17 Laparoscopic Incisional andVentral Hernia Mesh Repair
189
convert to an open approach or a dissection above
the peritoneum in the retromuscular plane.
17.4.4 Mesh Repair andSize
Mesh size matters as an inadequate overlap of the
defect, is the key factor for recurrences. The general consensus is to achieve an overlap of at least
3–5cm all around the defect with more overlap
(6–7 cm) if patients are obese. The reason being
mesh shrinkage, increased mesh-abdominal wall
interface. By Pascal’s principle larger the mesh,
better the chances of mesh attaching to the
abdominal wall due to intra-abdominal pressure.
Irrespective of material used, all meshes are
reduced in size with time, thereby exposing the
defect. On the other hand in incisional hernia
importance should be given to cover the entire
previous scar in order to avoid a weak area,
potential site for development of recurrence or a
new hernia [16]. In our experience 5cm or more
overlap is the preferred size.
The hernia defect should be measured after
lowering the pneumoperitoneum pressure (10–
11 mmHg). In obese patients it is preferable to
measure the defect intra-corporeally as the discrepancy between the intra-abdominal and external measurements may be signicant. Once
measured an adequate overlap of at least 5–7cm
all over the edge of the defect (3–5cm in routine
patient) with established margin in case of obese
patients is necessary.
17.4.5 Choice ofMesh
Three main types of mesh are feasible to be used
in IPOM technique: polypropylene, polyester or
polytetrauoroethylene (PTFE) based. The rst
two types of mesh are known to cause bowel adhesions and so are coated with various agents to provide an anti-adhesive barrier. PTFE is available in
expanded (e PTFE) and condensed (OMYRA, B
Braun, Germany) with the latter having large pore
to improve tissue in growth and reduce seroma but
further clinical data is needed to compare.
The role of biological meshes is their suitability for use in a contaminated and infected surgi-
cal eld as these meshes produce less-pronounced
foreign body reaction and get incorporated into
the host tissue. But there is paucity of data in literature on the use of biological meshes for incisional hernia repair with some showing high
recurrence rates. It would be premature to comment on its efcacy. The only acceptable indication so far is its use in a contaminated or infected
environment.
17.4.6 Mesh Insertion andFixation
The mesh should be rolled tightly and inserted
through the 10/12 mm port. For larger-sized
meshes a larger port may be used. Mesh should
be opened just before its use and avoid contact
with the skin to reduce contamination with
Staphylococcus aureus.
Mesh xation technique has been a debatable
topic in LVHR, today either tackers or transfacial
suture (TS) or combinations of both are used. In
the last year we noticed a shift from permanent
xation or tackers to absorbable materials
because of postoperative chronic pain and
recurrence.
In the International Endohernia Society
(IEHS) Guidelines, which evaluated the outcomes of 23 studies with more than 5000 patients,
a cumulative recurrence rate of 3.95% for all 3
(sutures + tacks, sutures only, and tacks only)
groups was reported during a median follow-up
period of 35.5months. The 3 groups did not differ signicantly in terms of recurrence rates or
follow-up periods [9]. Similarly, Guidelines of
EAES (European Association for Endoscopic
Surgery and other interventional techniques) and
the EHS (European Hernia Society) reported
that, at present, there are no adequate clinical
studies about the use of absorbable devices, and
they could not make any recommendation [17].
17.4.7 Bridging or Augmentation
Another topic of debate in LVHR is whether closure of defect should be attempted in all hernias
or is mesh bridging acceptable. The major proponents of defect closure are of the view that it
190
D. Lomanto and H. P. Salgaonkar
increases the mesh to abdominal wall interface
and also restores the physiology of the abdominal
muscles. The proposed advantages are reduced
recurrence and reduced seroma formation. Such
repair combines the closure of the musculoaponeurotic defect with the intra-peritoneal onlay
mesh placement in the form of an “augmentation
repair” (or IPOM-Plus). Multiple techniques
have been proposed for defect closure [18–23].
Orenstein et al. [24] in 2011 presented the
shoe-lacing technique for physiological abdominal wall reconstruction. To enable the defect closure in large hernias some authors have suggested
additional operative steps commonly known as
Hybrid procedures [25–27]. In our experience
multiple interrupted, non-absorbable transfascial
sutures in combination with or without intracorporeal suturing are utilized to approximate the
defect in IPOM plus technique [28].
By not closing the defect and bridging the
mesh in IPOM we create an area which is functionally adynamic. This increases the risk for
bulging, seroma formation and possible wound
infection. Moreover, the defect closure increases
the total surface area of mesh abdominal wall
interface for future tissue in-growth and improves
the solidity of xation.
17.4.8 Port Closure
All 10–12mm should be closed to reduce the risk
of developing a port site hernia [29]. This may be
accomplished in a variety of ways. Ideally, the
fascia is directly visualized with the aid of retractors, the edges grasped and sutured with interrupted or continuous suture. A number of
specialized instruments have been devised for
fascial closure at the port site. The benet of
these devices is yet to be proven.
17.4.9 Novel Approach
The International Endohernia Society (IEHS)
Guidelines [30] suggests that laparoscopic preperitoneal abdominal wall hernia repair via the
transabdominal preperitoneal [TAPP] and totally
extraperitoneal [TEP] repair techniques in smalland medium-sized primary and incisional
abdominal wall hernias is feasible and has minimal morbidity.
The advantages are:
1. Cost-effective due to use of standard polypropylene or polyester mesh;
2. Hernia sac excised and removed;
3. Mesh is extra-peritoneal;
4. The defect is closed and the abdominal wall
reconstructed anatomically.
However, the technique is more demanding,
takes longer to perform than standard procedures
and few clinical studies are available on its clinical outcomes.
17.4.10 Endoscopic Component
Separation (ECS)
In large and complex ventral hernia component
separation (CS) may be added to achieve closure
of defect. Advancement of layers of abdominal
wall by separating the lateral muscular layers is
performed. In case of abdominal wall reconstruction augmentation with prosthesis is necessary (IPOM plus). By performing an ECS
10–15 cm advancement of defect margin is
possible.
Technique of ECS involves a small incision
below the coastal margin. The external oblique
is split in the line of its bers and a standard
inguinal hernia balloon dissector is placed in
between the external and internal oblique muscles, pointing towards the pubis. Standard trocars are then placed in the space created and
dissection done extending from pubis to few
centimeters above the coastal margin. After
identifying the linea semilunaris the external
oblique is incised from beneath staring 2–3cm
lateral to the linea semilunaris and muscle
released from pubis to few centimeters above
the coastal margin. The procedure is repeated on
the other side. Although this relatively new
technique is feasible, the long term data of its
equivalence to OCS are lacking.
17 Laparoscopic Incisional andVentral Hernia Mesh Repair
191
17.5 Post-operative Care
Routine antibiotic prophylaxis in ventral hernia
repair is recommended [9]. Except in selected
complex cases, use of antibiotics post-operatively
is not recommended. Similarly, thromboembolic
prophylaxis should be given in accordance with
the presence of risk factors for the individual
patient [9].
Most patients will go home the same day of surgery, while some stay few days more postoperatively mainly due to pain. Frequently, patients
will require analgesics for few days. The surgeon
may at times extend the hospital stay depending on
the extent of the operative procedure.
At home, patients are encouraged to engage in
all routine activities. Most patients are able to get
back to their normal activities in a short period of
time. These activities include showering, driving,
walking up stairs, work and sexual intercourse.
Patient and relatives should be counseled to call
the surgeon immediately if they have fever, chills,
vomiting, are unable to urinate, or experience
drainage from the incisions. Also, in case of prolonged soreness and no relief with the prescribed
analgesics, they should notify their surgeon.
Patients need to be counseled about possibility
of seroma formation and that this will disappear
on its own with time. If not, then it may need
aspiration. Use of abdominal binder needs to be
stressed particularly in large hernias.
17.6 Complications andClinical
Outcomes
17.6.1 Mesh Infections
Perhaps the greatest advantage of LVHR is lower
wound infection rate than open hernia repair. It is
one of the most serious complication and equally
difcult to treat. An infected mesh may lead to
disastrous consequences e.g. entero-cutaneous
stula, abdominal wall and intra-abdominal wall
abscess, sepsis. If ePTFE mesh gets infected it
requires removal. With other meshes conservative trails can be attempted such as parenteral and
local antibiotic treatment, with drainage of
infected area, wound debridement, partial mesh
removal and vacuum dressing application. At any
point if infection is not getting controlled, it warrants complete mesh removal. The resultant morbidity of remnant defect, which most surgeons
will close under tension, will inevitably lead to
recurrence.
17.6.2 Seroma
In LVHR, the hernial sac is not resected and
hence a seroma is a common occurrence. In most
cases these seromas will resolve over a time as
the mesh gets incorporated on the hernia sac. It is
important to counsel patients pre-operatively that
it is imperative to expect a temporary seroma
after LVHR.We reserve aspiration only in symptomatic patients or if seroma is persistent after
6–8weeks. But by repeated aspirations we may
expose the patient to infection.
17.6.3 Enterotomy Intra-operative or Occult
Injury to bowel during adhesiolysis can be catastrophic. Controversy exists in managing an
intra-operatively identied bowel injury.
Management depends on the segment of intestine
injured i.e. small or large bowel, amount of spillage and surgeon’s skills. Options may range from
aborting the surgery, closure of enterotomy
followed by an open mesh repair (sublay or
onlay), using an intra-peritoneal biologic mesh or
delayed mesh repair after 3–4days. As a principle if there is gross contamination, the use of synthetic mesh is not advisable.
An occult bowel injury is invariably identied
late and ultimately may lead to wound infection
with subsequent need for mesh removal. Although
it appears that there is a greater risk of bowel
injury during laparoscopic hernia repair, but
clearly, more data is needed. The increased risk
compared with the open approach seems relatively low and acceptable.
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D. Lomanto and H. P. Salgaonkar
17.6.4 Pain
Theoretically laparoscopic surgery should be
associated with minimal post-operative pain. In
contrast, early post-operative abdominal pain is a
regular nding in LVHR.The use of transfascial
sutures and tacks can cause substantial early
postoperative pain as well as chronic pain months
to years after surgery. A Cochrane review [10],
comprising 880 patients, measured pain after surgery. They reported that the intensity of pain
between the open and laparoscopic repair groups
was similar. As a rule, excessive pain after laparoscopic surgery is a reliable indicator of a serious intra-abdominal complication. But the
specicity of pain as a marker of occult bowel
injury cannot be applied to LVHR. Correctly
interpreting excessive post-operative pain is
important. There is no evidence in literature to
guide us on this issue.
17.6.5 Recurrence
There is paucity of data in literature regarding the
rates of recurrence following LVHR in comparison to open mesh repair. Most trails and studies
have a short follow-up period with small number
of patients. Laparoscopy allows us to inspect the
entire incision and area around the defect. This
allows us to cover it with adequate mesh overlap,
thus reducing the probability of recurrence. But
most surgeons do not close the defect and hence
rely completely on the tensile strength of the
mesh and its xation. Further randomized control
trails with larger patient size are required to validate these assumptions. LVHR has gained sufcient popularity to be considered as a standard
procedure.
17.6.6 Hospital Stay
sional and ventral hernia repair, as compared to
open repair.
The Cochrane review [10] reported a signicant advantage for LVHR in term of reduced hospital stay. Similar ndings were reported by two
meta-analysis by Forbes et al. [31] and Sajid
etal. [32].
17.6.7 Return toWork
Return to activity and to work is an indirect measurement of the economic and social impact of
any procedure or technique. In the Cochrane
review [10], two RCTs reported on return to
activity. Itani etal. [33] showed that time to work
was shorter in laparoscopic group as compared to
open repair group. But, Pring etal. [34] did not
nd any signicant difference between the two
groups. Olmi etal. [35] in his RCT reported that
patients in laparoscopic group had a signicantly
shorter time of return to work. Hence, it would be
safe to assume that return to work is shorter or
equivalent in LIVHR as compared to open repair.
17.6.8 Quality ofLife (QOL)
Patient satisfaction after any procedure is important and gives us an indication of post-operative
quality of life and overall cosmetic outcome of
any procedure. In the Cochrane review [10], no
signicant difference was reported in open and
LVHR. Mussak et al. [36] in his study on QOL
did not nd any signicant difference in between
the two groups. Whereas Hope etal. [37] reported
LVHR to be better in most parameters in his
study on QOL as compared to open repair. It is
reasonable to assume that minimal invasive techniques give better or equivalent patient satisfaction and QOL in comparison to open repair.
Hospital stay serves as an indirect indicator of
multiple post-operative variables such as acute
complications, post-operative pain, return of
bowel movements and early mobilization.
Hospital stay is shorter after laparoscopic inci-
17.7 Summary
The laparoscopic approach is a safe and viable
technique for the treatment of ventral and incisional hernias. It has an equivalent or lower