Laparoscopic Ventral Hernia – Suturing With Onlay Mesh Repair

BACKGROUND Laparoscopic repair of incisional abdominal hernias was first reported in 19931 – “tension-free” technique We started laparoscopic ventral hernia repair in 1995 First 254 cases by the “tension-free” technique. 10 (3.9%) recurrences and 33 (13%) seroma formation LeBlanc KA, Booth WV. Surg Laparosc Endosc 1993.

ETHNIC POPULATION Physiognomy of Indian population, especially women: Pendulous lower abdomen. Poor abdominal muscle tone. Thus, two problems manifested themselves post-op.: Poor contour of the lower abdomen. Poor abdominal muscle functioning – c/o difficulty in getting up from supine position ; abdominal muscular pain on exertion.

SUTURED CLOSURE From 2000 onwards, we started suturing the defect with non-absorbable material before fixing a mesh with intra-corporeal suturing techniques.

Total number of incisional hernias 721 Recurrent incisional hernias 185 (25.7%) Previous meshplasty 93 (12.9%) More than one prior hernia repairs (range: 2-7) 23 (3.2%) Supra-umbilical: Infra-umbilical 138:583 Multiple fascial defects 159 (22.1%) Single fascial defect 562 (77.9%) Hernia contents Nil Omentum Bowel 265 (36.8%) 384 53.3%) 72 (9.9%) Incarcerated hernias 22 (3.1%)

RATIONALE 4-5 cm. overlap can be achieved on either side of the defect by using 9-10 cm. wide mesh. Potential dead space decreased & segregated from peritoneal cavity, decreasing chances of seroma formation. In case abdominoplasty/ mini-lap for adhesiolysis required, mesh is separated from abdominal incision by closure of defect, thus decreasing risk of mesh infection.

PRINCIPAL RATIONALE 4. Defects in midline or paramedian - detachment of origin or insertion of muscles of abdominal wall. Sutured closure of the defect muscles are re-attached to their point of insertion or origin this aids in proper functioning.

TENSION-FREE REPAIR Tension-free repair is meant for ing. hernia: In inguinal hernia, conventional repair entails forcibly suturing musculo-tendinous structure in an unnatural positon. In sutured closure of ventral hernia, the muscles are re-attached to their natural points of origin or insertion. Not suturing the defect is unphysiological

ANALOGY FOR A RUPTURED TENDON OF BICEPS MUSCLE YOU WOULD RE-ATTACH THE TENDON TO ITS INSERTION WHY NOT APPLY THE SAME PRINCIPLE FOR A RUPTURED INSERTION (OR ORIGIN) OF ABD. WALL MUSCLE?

Surgeon stands at the head end of the pt. for infra-umb defects OTHER TECHNICALITIES Surgeon stands at the head end of the pt. for infra-umb defects Advantages: Triangulation. Most of the defects are vertically oriented – both sides of the adhesions visible with angled scope – inadvertent bowel injury avoided. Standardized port positions

Defect closure with polyamide 1 ( Ethilon ® ) Mesh used is Parietex® (Sofradim, France) – 90% or Goretex ® (WL Gore and Associates, USA) – 10%

MESH CONFIGURATION MESH SIZE – 10 X 15 Cms. Intracorporeal sutures – polyester (Ethibond®)/ polydiaxanone (PDS®)/ polygalactin (Vicryl®) Tacking sutures – polyamide (Ethilon®)

OTHER TECHNICALITIES We do not use tackers for mesh fixation: Not cost-effective Experimental evidence: Tensile strength with sutures is 2.5 times that with tackers.1 1.van’t Riet M, et al. Surg Endosc 2002

OTHER TECHNICALITIES Difficult bowel adhesions: Small mini-lap incision extra-corporeal adhesiolysis bowel replaced fascia closed pneumoper. induced & lap. repair. Advantages: No skin flaps. 3-4 cms. skin incision – minimum pain. Hospital stay not prolonged N = 20 (2.8%).

OTHER TECHNICALITIES Pendulous abdomen After laparoscopic suturing of defect and mesh placement, abdominoplasty done. Advantages: No skin flaps no drain/flap necrosis. By suturing the defect, the mesh is segregated from the area of abdominoplasty reduced risk of mesh infection. Absence of drain + reduced incidence of wound infection short hospital stay. N = 28 (3.9%)

OTHER TECHNICALITIES Suprapubic midline hernias: Peritoneal flap raised (as in TAPP) to create preperitoneal space upto the pubic symphysis. Defect closed with continous sutures. Double mesh placed outer polypropelene mesh covered by inner Parietex/Goretex mesh

RESULTS Average operating time in min. (range) 95 (60-115) Return of bowel function (days) 1.5 Average hospital stay in days (range) 2 (1-6) Resumption of normal routine work (days) 6

RESULTS Seroma 55 (7.6%) Lower respiratory tract infection 7 (1%) Trocar site hematoma 6 (0.8%) Bowel injury – full thickness 2 (0.3%) Bowel injury - seromuscular Recurrences 4 (0.6%) Total 78 (10.8%)

RESULTS - Seroma Seroma formation: Most common complication – 7.6% Aspirated if it seroma persisted beyond 8 weeks, which happened in 22 patients (3%) In 9 (1.2%) patients, more than 1 (2-5) aspiration was required Of these, 4 patients required placement of a drainage tube under local anasthesia, which could be removed after the effluent decreased (range: 6-18 days). One pt. required excision of an seroma with sac after 12 weeks

RESULTS - Seroma Author Year Total no. of pts. Seroma (%) LeBlanc1 2003 200 15 (7.5) Carbajo2 270 32 (11.8) Sanchez3 2004 85 8 (9.4) Palanivelu 2006 721 55 (7.6) LeBlanc KA, et al. Hernia 2003 2. Carbajo MA, et al. Surg Endosc 2003 3. Sanchez LJ, et al. Hernia 2004

RESULTS - Recurrence 4 recurrences In 3 cases, recurrences were by side of mesh - through new defects - false recurrences In the last case, the pt had 2 previous abdominal surgeries: through low pfannensteil incision & vertical midline subumbilical incision. Lap sutured IPOM repair of incisional hernia in the vertical midline scar. Subsequently, the patient developed hernia in lateral part of the pfannensteil incision Case for using a large mesh covering all potential sites of defects in selected patients: Weak surrounding fascia Scarred abdomen

RESULTS - Recurrence Author Year Total no. of pts. Seroma (%) LeBlanc1 2003 200 13 (6.5) Carbajo2 270 12 (4.4) Sanchez3 2004 85 3 (3.5) Palanivelu 2006 721 4 (0.6) LeBlanc KA, et al. Hernia 2003 2. Carbajo MA, et al. Surg Endosc 2003 3. Sanchez LJ, et al. Hernia 2004

CHANGE IN TECHNIQUE – CENTRAL TACKING SUTURES ONLY RESULTS - Pain All patients receive oral diclofenac (50 mg. bid) for 5 days. Analgesic requirement beyond 5 days in 68 patients (9.4%). Sharply localized lateral pain. ? Due to neural entrapment by the tacking sutures or fixation transfascial sutures We have found pain to be less in intensity and duration in the central tacking sutures group of pts. CHANGE IN TECHNIQUE – CENTRAL TACKING SUTURES ONLY

RESULTS - Costs To improve cost-effectiveness: Largest Parietex ® mesh – 30 X 20 cms. – cut into 2-4 pieces – each piece sterilized with Sterrad ® (peroxide-based) sterilization system Intracorporeal sutures instead of tackers Use of reusable autoclavable instruments

EXCEPTIONS Only closure of defect, no mesh: Small (< 3 cm. defect) with strong surrounding fascia. However, if surrounding fascia is weak, place a mesh. Women who have not completed child-bearing. Only mesh, no closure of defect: Multiple ‘swiss cheese’ defects. Thinned out surrounding fascia, not strong enough to bear sutures. Scarred fascia with fibrosis due to multiple prior laparotomies.

REPRODUCIBILITY 4 Consultants & 12 Registrars trained over the last 5 years. After a median of 5 supervised surgeries, all could perform independently. The operative time was related to the amount of laparoscopic experience. Senior’s help was sought for difficult cases as defined by: Very large hernia. Dense bowel adhesions. Initially, intracorporeal knotting is difficult. So, intracorporeal suturing with extracorporeal knotting can be done.

CONCLUSION With the tech. of laparoscopic sutured closure of defect with intraperitoneal onlay mesh repair, it is possible: To reduce the recurrence rate to very low level To minimise morbidity Seroma formation Persistent post-operative pain To regain abdominal wall domain, to improve the function. To improve the cosmesis Avoid skin incision Revision scar Abdominoplasty To resume routine work early

CONCLUSION Laparoscopic sutured closure of ventral hernia defects followed by IPOM placement is a physiologically, logically and functionally sound repair It gives good results as far as seroma formation, mesh infection and recurrences are concerned Requires ability to carry out intracorporeal suturing in upside-down position – “practice makes perfect”

THANK YOU