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Metachronous Contralateral Inguinal Hernia in the Paediatric Population
61
these will all develop into a true inguinal hernia. The fact that there was a small number of
MCIH that developed after a closed contralateral inguinal ring has been visualised does
support this uncertainty. A recent study reported this incidence to be 2.5% following
transinguinal visualisation of a closed contralateral ring [Juang et al., 2012]. The incidence of
bilateral inguinal hernia and CPPV has been shown to be age dependent; 61% occur in
younger children vs. 35% in older ones [Choi and Hall, 2012]. Because the laparoscopic
technique allows closure of both sides without additional incisions, if offers advantages. An
open repair has various potential complications including; damage to the vas deferens and
testicular vessels potentially leading to slightly decreased fertility or testicular atrophy;
iatrogenic cryptorchidism; and nerve damage with chronic neurogenic wound pain. Although
some of these are potentially minimised with the laparoscopic technique, they should still be
considered before routine contralateral repair. There is some evidence that the laparoscopic
technique may increase the risk of iatrogenic cryptorchidism in patients less than one year old
and also decrease testicular volume [Cho et al., 2013]. To further investigate this issue there
have been studies demonstrating that that there is no compromise on testicular perfusion or
growth with the laparoscopic technique, although this is still a potential concern [Schier,
2006; Parelkar et al., 2010].
The recurrence rate of inguinal hernia noted in this systematic review is comparable to
that found when the open technique is used, 1.2%. There are studies indicating an increased
recurrence rate in older children, although this subset analysis was not possible in this
chapter [Choi and Hall, 2012]. Various laparoscopic techniques that may be used to
minimise the recurrence rate, although these have not been proven against the standard
technique. These methods include incising the peritoneum lateral to the internal inguinal
ring, and including the connective tissue from medial to the epigastric vessels into the suture
to minimise the distance between the suture knot and these vessels [Schier et al., 2002]. The
increased recurrence rates that were noted historically may have reflected the learning curve
for this technique. One of the advantages of the laparoscopic technique is the ease of repair
of a recurrent inguinal hernia following an open repair, as it avoids all of the previously
created scar tissue.
Grading systems for the CPPV have examined criteria such as whether the whole of the
tip of the laparoscopic instrument enters the ring, but these have not been used consistently in
the various studies reviewed. In fact, some surgeons will always close an opening if it has
been visualised laparoscopically, and this has been demonstrated to negate the risk of a future
MCIH [Schier, 2006].
CONCLUSION
In summary, this chapter adds to the evidence base that helps to guide treatment of
paediatric inguinal hernias, especially with an emphasis toward the prevention of MCIHs. The
evidence in the published literature does not support exploration of both sides for the
prevention of a MCIH when the open approach is used; however, if the laparoscopic
technique is used a contralateral open ring should be closed as a way to decrease the
likelihood of MCIH.
Ramesh M. Nataraja and Shehryer Naqvi
62
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In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 5
VENTRAL HERNIA REPAIR: TECHNICAL PRINCIPLES
OF THE STANDARDIZED LAPAROSCOPIC APPROACH
Didier Mutter
*
, Stefano Mandala and Jacques Marescaux
Digestive and Endocrine Surgery Department; IRCAD; IHU Strasbourg, France
ABSTRACT
Ventral abdominal hernia (primary or incisional) is a common problem in general
surgery practice. The literature reports many surgical procedures to treat such defects, but
there is a marked trend towards favoring less invasive approaches. This includes the
concept of "tension-free repair" as well as prosthetic material application in order to
reduce recurrence rates. Currently, an “ideal” prosthesis made of an absorbable non-
adhesive biomaterial and a resistant non-absorbable large pore mesh combined with a
minimally invasive technique such as the laparoscopic approach can lead to favorable
surgical results with low complication and recurrence rates. The analysis of a series of
273 patients operated on for ventral hernia defects demonstrates the feasibility, safety,
and effectiveness of this approach. The surgical procedure is easily reproducible and
allows for a very short hospital stay.
Keywords: Hernia, mesh, ventral hernia, laparoscopy, composite mesh, umbilical hernia
INTRODUCTION
Ventral abdominal hernia (primary or incisional) is a common problem in general surgery
practice, with a reported incidence of up to 20% [Yuri et al., 2006; Turner and Park, 2008].
The incidence of umbilical hernia has been reported to be as high as 2% in the adult
population [Colon et al., 2013]. Many surgical procedures are described in the literature to
manage such defects, including open and minimally invasive approaches. However, there is
no global consensus regarding the ideal solution. When failure is as high as 52% for the
*
Corresponding author: IRCAD/EITS, 1 Place de l’Hôpital, 67091 Strasbourg Cedex, France. E-mail:
didier.mutter@ircad.u-strasbg.fr.
Didier Mutter, Stefano Mandala and Jacques Marescaux
68
primary sutured repair, a high failure rate of 25% is still observed when using a prosthetic
biomaterial in open surgery [LeBlanc, 2005]. Most authors agree with the concept of
"tension-free repair" and the repair should be carried out with applications of prosthetic
material in order to limit the recurrence rate. These principles are met by means of
laparoscopic repair. Since the first publication of laparoscopic ventral hernia repair [LeBlanc
and Booth, 1993], this approach has gained wide acceptance [Forbes et al., 2009]. Most series
report a similar technique, respecting the principle of retromuscular prosthetic reinforcement
tailored to the laparoscopic approach. Various prostheses are available to be placed in contact
with the bowel without any significant postoperative adhesions.
In our opinion, the combination of an “ideal” prosthetic material including absorbable
and non-absorbable biomaterials with the development of a minimally invasive technique
such as the laparoscopic approach can lead to good surgical results with low complication and
recurrence rates.
The size of the abdominal wall defect and patient characteristics (e. g., previous surgery,
obesity) represent two key points in the selection of the laparoscopic approach and may be a
limitation to the indications of such procedures. The objective of our study is to evaluate the
effectiveness and the safety of the laparoscopic approach in ventral hernia repair.
MATERIALS AND METHODS
A retrospective study was conducted on patients who underwent ventral hernia repair
between 2005 and February 2013. Of note, our data concerning follow-up were collected in a
prospective database. A series of 889 patients were operated on for ventral hernia, 273
(30.7%) of whom underwent a laparoscopic repair. We evaluated the results of all hernia
repairs, and analysed them for each type of defect.
Early postoperative pain was measured on the first postoperative day (POD), with most
patients being discharged at that time. Late postoperative pain was investigated at 6 months.
Data of intraoperative and postoperative complications, such as pain, seroma occurrence, and
recurrences were collected. Late follow-up was obtained from patient records and telephone
interviews.
Surgical Technique
After general anaesthesia, the patient is positioned supine with arms adducted to the
sides. Two monitors are placed at the patient's right side with surgeons standing on the
opposite side.
Before the incision, an antibiotic, usually a single shot of a first generation cephalosporin,
is administered as antibiotic prophylaxy during anaesthesia induction. A plastic drape covers
the patient's skin to prevent mesh contamination. A 30-degree angled laparoscope is
mandatory for optimal view and comfort purposes during operative steps. It provides an
adequate view to the roof of the abdominal cavity.
The defect of the parietal wall and its limits are drawn onto the skin to determine port
placement. Trocars are positioned on the patient's left side with respect to the triangulation
Ventral Hernia Repair
69
principle and to place instruments at a distance from the defect in order to dominate the defect
and to easily place and anchor the prosthesis. Ports are placed on the right side only in cases
of incisional hernia located in the left abdominal quadrant, or in case of previous surgery in
the left part of the abdomen.
The first trocar (10-12 mm) is introduced according to the open technique between the
costal margin and the iliac crest. It is placed 7 cm away from the edge of the defect. It allows
the surgeon to see the edges of the mesh overlapping the defect over a 5 cm distance in the
abdomen. The pneumoperitoneum pressure is set to 12 mm Hg. After exploration of the
abdominal cavity and identification of the defect, the two other 5 mm trocars are placed under
direct visualisation. This time is crucial for the intervention's success and for the surgeon's
comfort.
When necessary, an adhesiolysis is performed sharply, using limited force, and the hernia
content is reduced into the abdominal cavity. The peritoneal sac is usually left in place.
A needle is often inserted through the abdominal wall at the level of the defect's edges to
exactly determine the hernia edges, and consequently the mesh's size. This is drawn onto the
patient, and a 5 cm overlap is measured and also drawn. This makes it possible to select the
most suitable size of prosthesis. The position of the transfascial sutures is also drawn to
guarantee the correct position of the mesh into the abdomen.
The mesh is folded into a "cigar" shape and introduced into the abdomen through the
optical trocar. Its initial positioning and anchoring is ensured by four cardinal transparietal
permanent monofilament sutures (Prolene® 2/0, Ethicon Inc., Somerville, NJ, USA) to
stabilize the prosthesis. An Endoclose
®
(Covidien Inc., Mansfield, MA, USA) device is used
to pass stitches. After positioning of the mesh, a double crown of absorbable tacker
(AbsorbaTack,™ Covidien Inc., Mansfield, MA, USA; 5 mm device) is used on the perimeter
of the prosthesis every 1 to 2 cm in order to strongly apply the mesh onto the peritoneum and
to prevent bowel herniation between the mesh and the peritoneum. If any tension occurs on
the mesh, the pneumoperitoneum is reduced to 8 mm Hg during application of the tackers.
After mesh placement, a desufflation is performed under vision to confirm the correct
placement of the mesh. Fascial closure using suture Vicryl 1 (Ethicon Inc., Somerville, NJ,
USA) is performed at the 12mm trocar site. Subcutaneous sutures are used to re-approximate
the skin.
We use a Parietex™ composite mesh (Covidien Inc., Mansfield, MA, USA) made of
polyester and collagen, of different sizes depending on hernia defect size. Four transparietal
sutures are placed to anchor small implants, and in large meshes, we add 2 or 4 additional
stitches.
Prostheses are initially anchored using titanium tacker. These are now replaced by
absorbable material (AbsobaTack,™ Covidien Inc., Mansfield, MA, USA).
RESULTS
A total of 273 patients underwent laparoscopic ventral hernia repair, 139 of whom are
males (mean age: 53.6 years) and 134 of whom were females (mean age: 54.7 years). Mean
BMI was 31.2. The rate of patients treated laparoscopically has progressively increased over
the past 3 years. The laparoscopic approach was recently preferred to the open approach
Didier Mutter, Stefano Mandala and Jacques Marescaux
70
(Figure 1). In 2011, the percentage of laparoscopic procedures was 50.3%. In 2012, it was
54.5%, and in January and February 2013, it was 75%.
One-hundred-forty-two patients presented with incisional hernia (IH), 106 had umbilical
hernia (UH) and 25 had ventral hernia (VH) in the midline. Thirteen patients presented more
than one defect: two had incisional hernia and ventral hernia, six had incisional hernia and
umbilical hernia, and five had umbilical hernia and ventral hernia. A total of 286 defects were
treated.
Mean postoperative pain on POD 1, using a Visual Analogue Scale (VAS) method, was
3.1, in all patients, 3.25 in the IH group, 3 in the UH group, and 2.92 in the VH group. Mean
length of hospital stay was 3.06 days, for all patients, 3.59 in the IH group, 2.37 in the UH
group, and 2.59 in the VH group. Every patient received analgesia (paracetamol and
tramadol).
A total of 41 complications occurred, 24 in IH repair, 12 in UH repair, and 5 in VH
repair. The overall complication rate was 15%. There were three intraoperative complications
(1.1%): one bladder perforation, one bleeding at the port site (epigastric vessel injury) both of
which were treated intraoperatively, and finally one small bowel perforation. This lesion was
not identified. It was treated by open re-operation on POD 4, the mesh was removed and an
ileostomy was set up. It was closed after 2 months. There was no conversion in the series.
We observed 38 postoperative complications (13.9%): 18 cases of moderate but chronic
pain at 6 months after surgery, 6 haematomas, 4 superficial wound infections, 2 small bowel
obstructions, 1 case of respiratory distress requiring transfer to the intensive care unit, 1
hyperthermia, 1 ascites, 1 paresthesia of the arm, 1 eczema, 1 local oedema, 1 acute
pancreatitis on POD 10, and 1 case of large seroma requiring hospitalisation. None of the
cases required a re-operation.
Figure 1. Evolution of the surgical approach to ventral hernia between 2005 and 2013: open surgery vs.
laparoscopic surgery.