Outcomes and complications of open, laparoscopic, and hybrid giant ventral hernia repair

BACKGROUND An incisional hernia is a common complication of abdominal surgery.AIM To evaluate the outcomes and complications of hybrid application of open and laparoscopic approaches in giant ventral hernia repair.METHODS Medical records of patients who underwent open,laparoscopic,or hybrid surgery for a giant ventral hernia from 2006 to 2013 were retrospectively reviewed.The hernia recurrence rate and intra-and postoperative complications were calculated and recorded.RESULTS Open,laparoscopic,and hybrid approaches were performed in 82,94,and 132 patients,respectively.The mean hernia diameter was 13.11±3.4 cm.The incidence of hernia recurrence in the hybrid procedure group was 1.3%,with a mean follow-up of 41 mo.This finding was significantly lower than that in the laparoscopic(12.3%)or open procedure groups(8.5%;P<0.05).The incidence of intraoperative intestinal injury was 6.1%,4.1%,and 1.5%in the open,laparoscopic,and hybrid procedures,respectively(hybrid vs open and laparoscopic procedures;P<0.05).The proportion of postoperative intestinal fistula formation in the open,laparoscopic,and hybrid approach groups was 2.4%,6.8%,and 3.3%,respectively(P>0.05).CONCLUSION A hybrid application of open and laparoscopic approaches was more effective and safer for repairing a giant ventral hernia than a single open or laparoscopic procedure.

Evolution and advances in laparoscopic ventral and incisional hernia repair

Primary ventral hernias and ventral incisional hernias have been a challenge for surgeons throughout the ages. In the current era, incisional hernias have increased in prevalence due to the very high number of laparotomies performed in the 20 th century. Even though minimally invasive surgery and hernia repair have evolved rapidly, general surgeons have yet to develop the ideal, standardized method that adequately decreases common postoperative complications, such as wound failure, hernia recurrence and pain. The evolution of laparoscopy and ventral hernia repair will be reviewed, from the rectoscopy of the 4th century to the advent of laparoscopy, from suture repair to the evolution of mesh reinforcement. The nuances of minimally invasive ventral and incisional hernia repair will be summarized, from preoperative considerations to variations in intraoperative practice. New techniques have become increasingly popular, such as primary defect closure, retrorectus mesh placement, and concomitant component separation. The advent of robotics has made some of these repairs more feasible, but only time and well-designed clinical studies will tell if this will be a durable modality for ventral and incisional hernia repair.

Long term recurrence,pain and patient satisfaction after ventral hernia mesh repair

AIM: To compare long term outcomes of laparoscopic and open ventral hernia mesh repair with respect to recurrence, pain and satisfaction.METHODS: We conducted a single-centre follow-up study of 194 consecutive patients after laparoscopic and open ventral hernia mesh repair between March 2000 and June 2010. Of these, 27 patients(13.9%) died and 12(6.2%) failed to attend their follow-up appointment. One hundred and fifty-three(78.9%) patients attended for follow-up and two patients(1.0%) were interviewed by telephone. Of those who attended the follow-up appointment, 82(52.9%) patients had received laparoscopic ventral hernia mesh repair(LVHR) while 73(47.1%) patients had undergone open ventral hernia mesh repair(OVHR), including 11 conversions. The follow-up study included analyses of medical records, clinical interviews, examination of hernia recurrence and assessment of pain using a 100 mm visual analogue scale(VAS) ruler anchored by word descriptors. Overall patient satisfaction was also determined. Patients with signs of recurrence were examined by magnetic resonance imaging or computed tomography scan.RESULTS: Median time from hernia mesh repair to follow-up was 48 and 52 mo after LVHR and OVHR respectively. Overall recurrence rates were 17.1% after LVHR and 23.3% after OVHR. Recurrence after LVHR was associated with higher body mass index. Smoking was associated with recurrence after OVHR. Chronic pain(VAS > 30 mm) was reported by 23.5% in the laparoscopic cohort and by 27.8% in the open surgery cohort. Recurrence and late complications were predictors of chronic pain after LVHR. Smoking was associated with chronic pain after OVHR. Sixty point five percent were satisfied with the outcome after LVHR and 49.3% after OVHR. Predictors for satisfaction were absence of chronic pain and recurrence. Old age and short time to follow-up also predicted satisfaction after LVHR.CONCLUSION: LVHR and OVHR give similar long term results for recurrence, pain and overall satisfaction. Chronic pain is frequent and is therefore important for explaining dissatisfaction.

Giant ventral hernia simultaneously containing the spleen, a portion of the pancreas and the left hepatic lobe: A case report

BACKGROUND Ventral hernia,also known as incisional hernia,is a common complication of previous surgery.The contents of ventral hernia may include omentum,preperitoneal fat,small intestine or colon.However,ventral hernia with protrusion of more than two parenchymal organs simultaneously is extremely rare,and its repair is very complex and difficult.Surgeons should make a comprehensive assessment based on their own experience and the individual characteristics of the hernia.In addition,psychological therapy should be emphasized in the whole treatment process.CASE SUMMARY We report a rare case of asymptomatic giant ventral hernia for 15 years in a 21-year-old female.The patient underwent umbilical hernia repair at the age of 1 year.Approximately 5 years later,ventral hernia recurred and repair with Mesh was performed,but the operation failed due to postoperative infection,and a huge mass appeared in the left abdominal wall.The mass increased gradually with the development and maturity of the body.Computerized tomography scan demonstrated that the patient's total spleen,part of the pancreas and left lobe of the liver were simultaneously herniated through the abdominal incisional hernia.As the patient was unable to endure the inconvenience of life and the potential risk of spleen or liver rupture,she underwent a ventral hernia repair with Mesh at our hospital.The operation was successful and the patient had a good recovery.During a 3-mo follow-up,the patient remained asymptomatic and the appearance of the surgical incision was greatly improved.CONCLUSION Ventral hernia is a common complication of abdominal surgery.Ventral hernia with protrusion of more than two parenchymal organs simultaneously is extremely rare.Surgeons should pay attention to the psychological treatment while restoring the abdominal physiological function in ventral hernia patients.

Ventral hernia after high-intensity focused ultrasound ablation for uterine fibroids treatment:A case report

BACKGROUND High-intensity focused ultrasound(HIFU) ablation is a minimally invasive approach in gynecology that is used to manage uterine fibroids.Although this procedure is safe and effective,adverse outcomes are becoming a major problem.CASE SUMMARY We present a case of ventral hernia that occurred as a rare and delayed complication of HIFU ablation for uterine fibroids treatment.The patient came to the hospital with abdominal bloating that occurred 6 mo after ultrasound-guided HIFU ablation for managing uterine fibroids.The ventral hernia,which occurred due to atrophied muscle layers following the procedure,was confirmed by imaging studies and intraoperative findings.She required a hernia repair with mesh and hysterectomy for definitive treatment of uterine fibroid.CONCLUSION High-intensity ultrasound ablation should be performed only on appropriate candidates.Patients should be educated about potential complications of the procedure and the possibility of subsequent treatment.Post-procedural long-term follow-up for detecting delayed adverse effects is important.

Laparoscopic management of ventral hernia repair using intraperitoneal synthetic mesh: A 10-year retrospective observational study

Objective:Ventral hernia is an anterior abdominal wall hernia,with an incidence of 2%-13%.Laparoscopic ventral hernia repair is the preferred method worldwide with all the advantages of the laparoscopic technique proven to be an effective treatment option.This study aims to assess the long-term outcomes of laparoscopic management of ventral hernia repair using intraperitoneal onlay mesh(IPOM)or intraperitoneal onlay mesh with defect closure(IPOM PLUS)technique with the usage of variety of synthetic meshes intraperitoneally.Methods:A retrospective study of 821 patients of a single institution for a decade was conducted.Longterm outcomes such as pain,mesh infections,enterocutaneous fistula,bowel adhesions and recurrence were assessed.Results:There were 801 primary,12 incisional,and 8 recurrent hernia cases,including 532 females and 289 males with a mean age of 45.62±9.37 years.IPOM PLUS were underwent in 674(82.10%)cases.Polypropylene,dual,titanium,composite meshes were applied in 473(57.61%),208(25.33%),82(9.99%),and 58(7.06%)cases respectively.Intraoperative bleeding occurred in 3(0.37%)cases,seroma in 8(0.97%),wound infection in 4(0.49%),stitch abscess in 2(0.24%).Recurrence was found in 8(0.97%)cases,with 5 used polypropylene mesh and 3 used dual mesh.Mesh infections were discovered in 6(2.88%)cases used dual,and foreign body sensation in 4(0.85%)cases used polypropylene.Three(0.37%)patients had suture site hernia,and 3(0.37%)had chronic sinus.Conclusion:IPOM or IPOM PLUS holds good in small or medium sized ventral hernias.The safety and efficacy of intraperitoneal polypropylene mesh is comparable to that of other synthetic meshes.A mesh overlap of minimum 5 cm beyond defect edge is must to minimise hernia recurrence.Absorbable suture can be considered as alternative to tackers.

Alternative to mesh repair for ventral hernias: Modified rectus muscle repair

BACKGROUND Mesh utilization for ventral hernia repair is associated with potential complications such as mesh infections,adhesions,seromas,fistula formation and significant postoperative pain.The modified rectus muscle repair(RMR)is as an option to repair midline ventral hernias without mesh.AIM To evaluate the short term outcomes when the modified RMR was used to repair ventral hernias.METHODS This was a 5-year prospective study that examined the outcome of all consecutive patients with ventral abdominal wall hernias>5 cm in maximal diameter who underwent repair using the modified RMR technique in a single surgeon unit.Patients were reviewed in an outpatient clinic at 3,6 and 12 mo and evaluated for hernia recurrence on clinical examination.Each patient’s abdominal wall was also assessed with using ultrasonography at 24 mo to detect recurrences.All data were examined with SPSS ver 18.0.RESULTS Over the 5-year study period,there were 52 patients treated for ventral hernias at this institution.Four patients were excluded and there were 48 in the final study sample,at a mean age of 56 years(range 28-80).The mean maximal diameter of the hernia defect was 7 cm(range 5-12 cm).There were 5(10.4%)seromas and 1 recurrence(2.1%)at a mean of 36 mo follow-up.CONCLUSION The authors recommend the modified RMR as an acceptable alternative to mesh repair of ventral hernias.The seroma rate can be further reduced with routine use of drains.The modified RMR also has the benefit of eliminating all mesh-specific complications.

Laparoscopic Transabdominal Preperitoneal Repair of Spigelian Hernia: Case Report

Spigelian Hernia (SH) is an uncommon anterior abdominal wall defect, it represents 0.1% - 2% of all abdominal wall hernias. SHs have been traditionally repaired by open technique, but laparoscopic approaches are becoming more common and widely described in the literature. Here we present a case report of a 69-year-old woman who presented with abdominal pain, nausea, abdominal distention and absence of bowel movements for 2 days. A computed tomography performed in an external facility revealed a right-sided and incarcerated SH containing bowel and mesentery. The patient was treated surgically and the abdominal wall defect was repaired by a laparoscopic transabdominal preperitoneal (TAPP) approach. The patient was discharged 24 hours after surgery in excellent conditions. We hold that the TAPP approach is anatomically the soundest repair, with all the added benefits of minimally invasive surgery.

Robotic versus open transversus abdominis release and incisional hernia repair: A case-control study

Objective:Transversus abdominus release(TAR)is often required to achieve apposition of the rectus muscles and achieve wide mesh reinforcement of the abdominal wall.Traditionally,TAR has been done with an open technique(oTAR),and the benefits of the newer robotic approach(rTAR)has not been well established in the Australian setting.The aim of this study was to compare the results of oTAR with rTAR to demonstrate its safety and efficacy.Methods:A retrospective review of patients who underwent rTAR and oTAR at two tertiary hospitals was conducted between January 2018 and January 2020 in New South Wales,Australia.Patient demographics,perioperative and postoperative outcomes were compared in both groups.Results:There were 26 patients identified to have undergone TAR(13 rTAR,13 oTAR).Both groups were comparable in regards to age,sex and defect size.oTAR was associated with a higher American Society of Anaesthesiologist score.rTAR was associated with significantly longer average operative time(260.0±78.9 min vs.185.7±64.5 min,p=0.017)but found to have a significantly shorter length of stay(3.6±2.1 d vs.6.9±3.6 d,p=0.007)with a comparable complication rate.Conclusions:rTAR is associated with shorter length of hospital stay with comparable postoperative outcomes when compared to oTAR.We are seeing increasing evidence supporting the safety and benefits of robotics,however larger scale studies are required to fully understand this approach.

Abdominal wall hernia in a rural population in India—Is spectrum changing?

Hernia is a common word that most surgeons are familiar with. A retrospective study was planned to analyse the spectrum of abdominal wall hernias in a rural population inIndia. Majority of the patients were of 40 - 70 yrs. Male to female ratio was 7:1. Incidence of groin hernias showed an increasing trend with advancing age. Out of total 320 cases, inguinal hernias were predominating in 77.81% cases. Ventral hernias were present in about 18% cases. However, femoral hernias were rare. We concluded that spectrum of abdominal wall hernias is almost the same all over the globe despite having differences in their socioeconomic and educational status.

Role of botulinum toxin a in the management of complex incisional hernias

Despite the technological breakthroughs and discover of abdominal meshes, ventral hernia has always been challenging in therapeutic strategies by the surgeons, with high recurrence rates. The use of botulinum toxin A (BTA) for the management of ventral and incisional hernia (IH) poses an increasingly interesting practice, especially for the intimidating complex one. The preoperative administration of the toxin to the lateral abdominal muscles by use of Ultra-Sound guidance causes muscle paralysis and a reduction of intraabdominal pressure. Thus, the hernia defect can be primarily closed without tension, if the length of the defect is up to 10 cm. In larger hernia, this method can be combined with component separation techniques or the use of a mesh. The mesh placement seems to be better by laparoscopy. The site of injection and the dosage of BTA are still under discussion amongst authors. The optimal administration is proposed by some authors to be at least 2 weeks before repair. There is also an analgesic effect of BTA to the patients that underwent hernia reconstruction. Ultimately, the role of BTA in the reconstruction of ventral hernia seems to be promising, but there is a necessity for several randomized clinical trials.

腹腔镜腹壁切口疝修复术中腹壁功能重建

腹壁切口疝的治疗已从单纯的修补(repair)、加强(reinforcement)向重建(reconstruction)、重塑(restora⁃tion)和再生(regeneration)进展。腹壁切口疝有肌前、肌后、腹膜前、腹腔内等修补层次,均可通过开放或腹腔镜手术来完成。腹腔镜手术主要包括腹腔内补片修补术(IPOM)和微创非腹腔内补片修补术(MINIM)。无论哪种技术,既要遵循腹壁功能重建的原则,又要结合自身的微创特性,才能充分体现其临床价值。腹腔镜腹壁切口疝术中腹壁功能重建的核心可归纳为恢复腹壁解剖结构(Anatomy),保护腹壁生物力学(Biomechanics),维持腹壁顺应性(Compliance),提供机体整体动态活力(Dynamics)。

MSCT诊断易嵌顿并发肠梗阻腹外疝的临床应用价值

目的探讨易嵌顿并发肠梗阻腹外疝的多层螺旋CT表现及临床应用价值。方法回顾分析24例经手术证实腹外疝并发肠梗阻的螺旋CT表现。结果 24例中,根据疝所在的位置,螺旋CT诊断腹股沟斜疝16例(右侧10例、左侧6例),腹股沟直疝1例,股疝3例(右侧2例、左侧1例),闭孔疝2例(右侧),腹壁切口疝2例。疝囊内容物均为小肠,伴大网膜7例(腹股沟斜疝6例、腹股沟直疝1例)。小肠不全梗阻11例,完全性梗阻13例,腹腔积液3例。结论多层螺旋CT不仅能明确腹外疝并发肠梗阻的部位及程度,而且能为临床提供疝内容物的种类、大小、与周围解剖关系等精细信息,对临床选择合理的治疗方案及患者预后具有重要价值。

婴幼儿先天性胸腹裂孔疝的手术治疗

目的探讨婴幼儿先天性胸腹裂孔疝的治疗方法,提高生存率。方法回顾我院1986～2003年收治16h～2岁先天性胸腹裂孔疝53例的手术治疗,其中5例经胸手术,48例经腹手术。结果治愈47例熏死亡6例。随访30例2月～10年,X线透视肺膨胀良好,术后早期体重增加,呼吸道感染明显减少。结论提高诊断、急救技术,完善新生儿围手术期措施,可提高婴幼儿先天性胸腹裂孔疝的生存率。

腹腔镜或杂交技术修补大型、巨大型腹壁切口疝的技巧

目的探讨腹腔镜或杂交技术修补大型(缺损8~12 cm)、巨大型(缺损>12 cm)腹壁切口疝的操作技巧。方法 2009年7月~2015年6月,对45例腹壁切口疝进行修补,包括大型20例,巨大型25例。腹腔镜修补20例,杂交修补25例,均使用防粘连补片。结果腹腔镜修补和杂交修补手术的手术时间分别为(113.0±35.4)min、(127.0±31.6)min,术中出血(36.0±19.8)ml、(92.0±36.2)ml,术后住院时间(10.3±2.6)d、(11.0±2.2)d。无手术死亡、腹腔感染、切口感染发生,1例左下肢深静脉血栓形成经抗凝与活血化瘀治愈,2例切口血清肿穿刺加压包扎治愈,3例持续腹壁痛3个月后缓解。随访1~5年,(3.1±1.8)年,无疝复发。结论腹腔镜或杂交技术防粘连补片修补切口疝,具有创伤小、恢复快、复发率低等优点。操作时避免肠管损伤、修复腹壁缺损或封闭疝环、选择合适补片、可靠固定是关键。

异体腹直肌前鞘细胞外基质框架用于疝修补

目的 探讨异体腹直肌前鞘细胞外基质框架 (ASECM )作为疝修补材料的效果。方法 12只犬随机分为 2组 :(1)ASECM修补组 (实验组 ) ,6只 ;(2 )人工材料修复组 (对照组 ) ,6只。手术于腹直肌左右侧腹壁制成一 3cm× 5cm的缺损区 ,右侧缺损区实验组用ASECM行修补 ,对照组用人工材料补片修补。左侧缺损区不作修补用作自体对照。两组分别于术后2 ,8,16周取材行光镜、免疫组化、扫描及透射电镜检查。结果 两组动物左侧腹壁缺损处 2d后出现腹壁疝 ,而修补区均未出现腹壁疝。实验组光镜检查显示 ,术后 2～ 8周ASECM中长入的宿主成纤维细胞逐渐增多 ,术后 16周时成纤维细胞数量减少。各时期均无明显的炎性细胞浸润。实验组电镜检查术后 16周修补局部基本为排列整齐的细胶原。对照组光镜检查显示 ,术后 2～ 16周时可见由少量～大量的成纤维细胞附于材料层面上 ,但人工材料网丝间隙之间未见明显的成纤维细胞生长。且在各个时期均有炎性细胞浸润。术后 16周对照组电镜检查时 ,成纤维细胞生长出的突起包饶材料表面 ,类似宿主对异物组织的包裹反应 ,且人工材料补片未与宿主组织融合。免疫组化检查显示为I ,III型胶原。结论 ASECM为机体提供了一良好的供宿主成纤维细胞“爬行替代”的框架 。

腔镜手术治疗新生儿及婴幼儿膈肌发育缺陷

目的探讨腔镜手术治疗新生儿及婴幼JLN肌发育缺陷的可行性和优越性。方法38例膈肌发育缺陷患儿，其中膈疝4例，膈膨升5例，食管裂孔疝29例。术前均经上消化道造影及胸腹CT检查确诊；腹腔镜下探查膈肌病变类型及有无合并病变；膈疝患儿行膈肌修补缝合术，食管裂孔疝行食管裂孔修补Nissen胃底折叠术，膈膨升患儿行膈肌折叠术。结果38例中3例中转开放手术，其余35例采用腹腔镜技术完成手术。平均手术时间147min（75—210min）；手术中出血量平均5mL（1—10mL）。患儿术后平均24h饮水，5d恢复饮食；术后平均住院时间6．7d。随访1个月至5年，原有症状消失，体重增加，生长发育正常，无明显并发症发生。2例食管裂孔疝术后3个月及1年复发，经再次腔镜手术后治愈。2例食管裂孔旁疝分别复发2次，1例现第3次腔镜手术后1年余无复发；另1例术后4个月食管裂孔疝复发、胃小弯侧靠近幽门处穿孔，行膈肌修补、胃穿孔修补；第二次手术后3个月再次复发，行生物补片修补，随访至今4个月无异常。结论腔镜手术治疗新生儿及婴幼儿膈肌发育缺陷疗效确切，安全可行。

无张力疝修补术治疗腹壁切口疝的临床应用

目的 探讨腹壁切口疝的手术方式。方法 应用人工合成材料行腹壁切口疝的无张力修补术。结果 本组32例患者因各种原发疾病经外科手术后发生腹壁切口疝,其中13例经传统的手术缝合1次以上而复发,均采用本方法手术。治愈31例,治愈率96 .87% ,复发1例,复发率3.13%。结论 腹壁切口疝是腹部手术后的常见并发症,多见于老年患者;使用人工合成材料作腹壁切口疝的无张力疝修补术效果确切。

新生儿先天性膈疝诊治及预后相关因素分析——单中心近10年经验总结

目的总结本院近10年来收治的新生儿先天性膈疝(congenital diaphragmatic hernia,CDH)病例临床特点、治疗变化及预后情况,探讨新生儿膈疝的诊治与预后相关因素。方法本院于1985年1月至2004年12月(第一阶段)收治31例,2005年01月至2015年12月收治117例。第一阶段均采取开放手术,第二阶段采取腔镜手术32例,开放手术66例。对性别、年龄、出生体重、Apgar评分、产前诊断、胎龄、合并畸形、血气分析、延期手术、围术期NO吸入、手术方法、术后并发症及预后情况进行回顾性分析。统计学处理采用方差分析、卡方检验和Logistic回归分析等方法。结果第一阶段:重症20例,轻症11例;男19例,女12例;左侧28例,右侧3例;产前诊断3例,伴发畸形6例;存活25例,死亡6例。第二阶段:重症64例,轻症53例;男75例,女42例;左侧102例,右侧15例;产前诊断21例,伴发畸形24例;存活91例,死亡26例。第一阶段重症组平均住院时间(17.2±11.5)d,呼吸机使用时间(3.28±2.30)d,ICU平均住院时间(11.7±14.5)d。第二阶段重症组平均住院时间(19.7±12.7)d,平均呼吸机使用时间(6.56±4.63)d,ICU平均住院时间(12.9±12.3)d,术后出现败血症3例,心包积液2例,胃食管返流1例。膈疝复发7例,其中腔镜手术复发4例。结论近10年来本院收治重症膈疝患儿病情更为复杂、危重;入院时较低血PH值、1分钟Apgar评分、5分钟Apgar评分与预后相关。

腹腔镜腹壁切口疝补片修补术的应用体会

目的：探讨腹腔镜腹壁切口疝补片修补术的临床应用价值及安全性。方法：2005年8月至2006年10月我院为8例腹壁切口疝患者使用自膨胀式聚丙烯-膨化聚四氟乙烯双面复合型补片行腹腔镜腹壁切口疝修补术，其中2例联合行胆囊切除术。结果：8例手术均获成功，手术时间55～150min，平均85min，无手术死亡病例及并发症发生，患者术后8～24h后下床活动，1—2d排气，术后疼痛轻，2—3d后完全缓解，3—7d（平均4d）患者顺利康复出院。随访12～24个月无复发。结论：腹腔镜腹壁切口疝修补术安全可靠，具有创伤小、术后康复快、并发症少、不增加手术穿刺孔、可完成联合手术等优点，临床应用前景广阔。