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445
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_40,
© Springer Science+Business Media New York 2013
40. Bridging versus Closing the Defect
During Laparoscopic Ventral Hernia
Repair: It Is OK to Bridge
Stephen M. Kavic and Adrian Park
Our surgical approach to the repair of incisional and ventral hernias has
evolved dramatically only over the last two decades. Reports that surgeons
yearly repair nearly 200,000 incisional hernias in the United States [ 1 ]
contribute to making the lowly hernia a most important topic of discussion .
This chapter reviews the rationale for laparoscopic ventral hernia repair
and discusses the advantages offered by using a permanent prosthetic for
bridging the hernia defect. In considering the optimal management and
repair of hernias, we take into account conceptual arguments, technical
considerations, practical advantages, and experience.
Bridging Versus Closing: Hernia
Consequences and Repair
The pathophysiology of hernia formation is well described in detail
in this volume’s earlier chapters and elsewhere [ 2 ] . Failure of a defect
once established to heal is due to the pressure that remains and exceeds
the native resistance of the abdominal wall [ 3 ] . As such, any repair of an
incisional or ventral hernia must address the pressures that exist on the
anterior abdominal wall in order to optimize the repair and to minimize
the likelihood of recurrence.
It is commonly stated that the forces that create a hernia will actually
reinforce the strength of a laparoscopic repair [ 4 ] . Pascal’s principle—
modi fi ed to the irregular contour of the abdominal wall—suggests that
the intra-abdominal pressure will maintain the prosthetic against the
inner aspects of the abdominal wall [ 2 ] .
446
S.M. Kavic and A. Park
In the abdominal midline, hernias most commonly develop in the
postoperative setting. This represents the simplest scenario of acquired
hernia development, where the surgically altered tissues no longer have
structural integrity.
Pain is widely recognized as the predominant symptom of ventral or
incisional hernias. Activity limitation and aesthetic distress may also
present as reasons to repair. In addressing the symptoms, the surgeon,
mindful of incarceration risk, avoids the life-threatening complication of
strangulation, estimated to occur in approximately 5 % of patients with a
ventral hernia [
5, 6 ] .
Traditionally, hernia repairs have been accomplished with an open
incision, reduction of hernia contents, excision of the sac, and primary
repair of the native fascia. The hernia recurrence rate, however, was
found to be unacceptably high. As recognized with inguinal hernias
many decades ago, the enemy of a primary repair is tension. As ventral
hernias enlarge, it becomes increasingly dif fi cult to reapproximate the
tissues without undue tension.
Primary repair was compared with mesh use in a multicenter trial
conducted by Luijendijk et al. Its convincingly decisive conclusion
demonstrated reduction in the recurrence rate of midline abdominal
herniation with the use of mesh [ 7 ] . Systematic reviews, since undertaken,
have strongly promoted the employment of mesh, relating its use to an at
least 50 % decrease in the rate of hernia recurrence [ 8, 9 ] . Little debate
remains regarding the use of mesh, now considered the gold standard of
abdominal wall hernia repair.
Components separation also has been advocated as a means of
minimizing the tension on a midline closure [ 10, 11 ] . Several disadvantages
are, however, associated with this technique. It is a substantial operative
procedure. Although occasionally performed with laparoscopic
assistance, the greatest tension decrease is achieved when done in an
open fashion, and this is accompanied with increased wound complication
risks ranging from overt infection to skin necrosis. When the ultimate
measure of an operation—its success rate at treating the underlying
condition—is applied to separation of components for hernia repair, the
recurrence rates that have been produced are variable at best and often
disappointing [ 12, 13 ] . Better operative results are achieved with this
technique when it is augmented with use of resorbable mesh, an addition
that may considerably increase the expense of the procedure [ 14 ] .
Bridging a hernia defect satis fi es the conceptual requirements of a
successful hernia repair. Speci fi cally, it addresses the pressures that
447
40. Bridging versus Closing the Defect During Laparoscopic
perpetuate a hernia, avoids the consequence of strangulation of entrapped
viscera, and provides for a tension-free environment to maintain durability
of repair.
Technical Considerations
Laparoscopic ventral hernia repair is a well-established technique.
The procedure may be complicated but has the advantage of conceptual
simplicity. After adhesiolysis through a lateral approach, a bridging mesh
may be introduced and secured intracorporeally, deep to the fascia and
the peritoneum. Care is taken to ensure adequate overlap—generally
considered to be 5 cm or greater—of the hernia defect.
Importantly, use of a bridging mesh largely preserves the abdominal
domain. Although the physical space for the viscera is necessarily smaller
than that of the extended hernia sac, the volume of the abdominal
compartment is retained. In reapproximating the midline, too signi fi cant
a decrease in the abdominal cylinder could occur, resulting at the extreme
in compressed viscera and development of the abdominal compartment
syndrome. More commonly, the patient suffers some degree of
diaphragmatic restriction and pulmonary compromise.
Practical Advantages
Use of mesh in laparoscopic ventral hernia repair to bridge a hernia
defect is safe, rapid, and ef fi cacious as research has demonstrated. Even
in the face of such data, some may claim that it remains a fundamentally
better operation to align and approximate the edges of the hernia defect.
The arguments for this go beyond the desire to add a novel approach to
hernia repair. Speci fi cally, the detractors of the established technique
may challenge the modi fi cations of the fundamental technique, the
functional result of the repair, and the cosmetic outcome.
No substitute exists, however, for actual data. In the case of bridging the
laparoscopic hernia defect, many large-scale series—summarized in
Table 40.1 —demonstrate excellent long-term outcomes. In fact, laparoscopic
ventral hernia repair may be considered the standard of care [ 34 ] .
448
S.M. Kavic and A. Park
Table 40.1. Large series (>100 cases) of laparoscopic incisional hernia repair using mesh.
Author Year n BMI
Defect
(cm
2
)
Patch
(cm
2
)
Prior
repair
(%)
Conversion
(%)
Patch
material
Trans-
fascial
sutures Complications Recurrence
Total
(%)
Seroma
(%)
LOS
(d) (%)
F/U
(m)
Alkhoury [ 15 ] 2011 141 31 144 257 NS 0 PP N 8 1 1.1 6 40
Bageacu [
16 ] 2002 159 NS NS NS 23 14 PTFE Y 44 16 3.5 16 49
Ben-Haim [
17 ] 2002 100 NS NS NS 25 4 PTFE N 24 11 5 2 14
Berger [
18 ] 2002 150 29 94 350 13 2 PTFE Y 97 93 9.1 3 15
Bower [
19 ] 2004 100 34 124 280 32 1 PTFE Y 15 1 NS 2 6.5
Carbajo [
20 ] 2003 270 NS 145 300 27 1 PTFE N 15 12 1.5 4 44
Chowbey [
21 ] 2000 202 NS NS NS NS 1 PP N 30 25 1.8 1 35
Franklin [
22 ] 2004 384 NS NS NS NS 4 PP, PTFE N 10 3 2.9 3 47
Frantzides [
23 ] 2004 208 NS 173 NS NS 0 PTFE N 3 NS 1.4 1 24
Gillian [
24 ] 2002 100 NS NS NS NS 0 Composix N 7 3 NS 1 NS
Heniford [
25 ] 2003 850 32 118 344 34 4 PTFE Y 13 3 2.3 5 20
Kirshtein [
26 ] 2002 103 34 175 324 41 3 PTFE N 6 0 3.1 4 26
LeBlanc [
27 ] 2003 200 NS 111 258 21 4 PTFE Y 18 NS 1.3 7 36
Olmi [
28 ] 2006 178 30 144 NS NS 0 Polyester Y 7 4.4 2.1 2.5 12
Perrone [
29 ] 2005 121 35 109 256 29 10 PTFE, PP Y 27 9 1.7 9 22
Rosen [
30 ] 2003 100 31 96 354 38 12 PTFE, PP Y/N 14 4 1.8 17 30
Sharma [
31 ] 2011 1,242 32 26 NS NS 1.5 PTFE, PP Y/N 67 31 NS 4.4 65
Toy [
32 ] 1998 144 NS 98 216 26 0 PTFE Y 26 16 2.3 4 8
Ujiki [
33 ] 2004 100 33 97 259 24 3 PTFE Y 23 13 2 6 3
NS not speci fi ed
449
40. Bridging versus Closing the Defect During Laparoscopic
Modi fi cations
Type of mesh used and the means of mesh fi xation constitute the
most common modi fi cations in the laparoscopic ventral hernia repair.
Although initially the types of mesh were fairly limited, a large variety
of available implants now exists [
35 ] . With these mesh materials, it is
entirely probable that some will prove to be superior in the long term,
and some may even prove unacceptable. Regarding biologic mesh, the
argument has been advanced that its use in bridging a defect does not
result in a durable hernia repair [ 13 ] . Derisively, its use has been labeled
as resulting in the “world’s most expensive hernia sac” [ 14 ] . The
contention is easily avoided through use of a permanent prosthetic.
Mesh Fixation
The standard of mesh fi xation remains permanent trans-fascial sutures
accompanied by edge fi xation [ 36 ] . The degree of overlap of the hernia
defect has been recommended to be 5 cm by most authorities, and many
place tacking points approximately 1 cm apart along the circumference.
However, there is substantial variation in this model, and it is this
variation that may account for differences in result.
Functional Repair Results
A criticism of the bridging technique centers on the fact that it does
not recreate physiology, only static anatomy. The abdominal wall
continues to move and fl ex, which may lead to distortion of properly
placed mesh [ 37 ] . Additionally, even if the mesh itself is fl exible, the
scar tissue surrounding the operative site may not be, leading to poor
functional outcomes. Although mesh repairs resolve the majority of
hernia complications, they are imperfect substitutes for the patient’s
actual abdominal wall.
The abdominal wall is indeed a complex arrangement of overlapping
layers of muscle and connective tissue. Yet, it is precisely this complexity
that should dissuade us from oversimpli fi ed attempts to re-create the dynamic
interplay of its individual layers. It is possible to bridge the defect and achieve
450
S.M. Kavic and A. Park
a functional result. It may not be possible to reapproximate the midline in
mass fashion and achieve a complete restoration of normal function.
It has been recently suggested that primary closure of the defect may
be accomplished laparoscopically with improved physiologic results
[ 38 ] . Little data exists, however, to support this claim. There have been
no studies documenting signi fi cant impairment of abdominal wall
function using bridging techniques nor demonstrations of superior
function with midline closure. At present, what constitutes the most
optimal functional outcome of abdominal wall remains speculative only.
Cosmetic Repair Results
Few would argue against the cosmetic bene fi ts of laparoscopic
surgery in comparison with open surgery. Some advantages, however,
exist in regard to open excisional techniques that may be potentially
contributory to a cosmetically superior result.
The skin and hernia sac is left in situ above a bridging hernia repair.
In most instances, this does not result in any signi fi cant complication or
cosmetic deformity. It is true that a widened scar from initial incision is
better addressed by excision. Circumstances where the skin does not
have an acceptable appearance following laparoscopic repair may be
addressed at any point in a secondary operation. In addition, some centers
have suggested that the positive impact of laparoscopic surgery is more
pronounced in patients with larger hernias, and laparoscopy is more
strongly indicated in patients with large defects [ 39 ] .
Although the development of a seroma may be a consequence of a
laparoscopic ventral hernia repair, it is seldom of true clinical signi fi cance.
The use of a postoperative abdominal binder has been advocated to
minimize seroma formation, with at least some anecdotal success [ 40 ] .
Reports regarding the high rate of seroma resolution without intervention
as well as the excellent cosmetic results of the laparoscopic technique are
common [ 41 ] .
Conclusion
The laparoscopic ventral hernia repair is the standard of care for the
repair of incisional and ventral hernias. As described, it involves bridging
the fascial defect, which produces good results that have been reproduced
451
40. Bridging versus Closing the Defect During Laparoscopic
in multiple centers. Although select patients may be considered for open
repairs or alternative approaches, bridging the defect remains the quality
option and should remain the standard approach for laparoscopic repair.
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455
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_41,
© Springer Science+Business Media New York 2013
41. The Bariatric Patient with
a Complex Ventral Hernia
Jenny J. Choi and Alfons Pomp
The overall incidence and complexity of ventral and incisional hernias
have increased. Patients live longer, accumulating comorbidities, and
undergo more surgeries. Moreover, obesity is now a worldwide epidemic.
Wound infections and incisional hernia formation more frequently complicate
laparotomies on obese patients with a large abdominal girth. The management
of hernias continues to evolve as we learn more about genetic predisposition
and the pathophysiology of the disease. There are now multiple options for
hernia repair. What historically began as the primary repair of simple ventral
hernias has evolved to mesh repair of larger hernias and now encompasses
complex procedures such as multiple layers of component separation
complemented with synthetic and biologic mesh. With increasing numbers
of bariatric procedures performed, hernias in these patients have now
emerged as an important topic that needs to be addressed both preoperatively
and postoperatively.
Morbidly obese patients are at an increased risk for primary as well
as incisional hernias. Studies have shown that obese patients have
increased intra-abdominal pressures (IAP) when compared to normal
weight control patients [ 1, 2 ] . When comparing obese patients (mean
BMI 55 ± 2 kg/m
2
) to controls, the mean IAP for the morbidly obese
group was 12 ± 0.8 cm H
2
O, signi fi cantly increased when compared to
controls with IAP = 0 ± 2 cm H
2
O. Obese patients consistently had
elevated intra-abdominal pressures when compared to normal-weighed
controls during the activities of daily living such as walking, climbing
stairs, coughing, and lifting. Increased IAP puts added stress on the
abdominal wall and tensile strength of the mesh. Obese patients are
also more likely to be af fl icted with weight-related comorbidities,
which also predispose the development of hernias. A study looking at
62 patients with a mean BMI of 49 revealed that systemic hypertension,