Consultant Laparoscopic Surgeon

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Presentation transcript:

Consultant Laparoscopic Surgeon Laparoscopic Ventral Hernia Repair (LVHR) Endoscopic defect closure with IPOM, without any 10mm Port (P10) & Atraumatic suture fixation of mesh Dr. Brij B. Agarwal Consultant Laparoscopic Surgeon Sir Ganga Ram Hospital India

LVHR “Standard of Care” Prerequisites for success Generous overlap >3 cms Transfascial suture fixation Cobb Ws et al SCNA 2005 www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

What are the concerns? Pascal’s principle Does it really help, or ? Beutner S et al. Surg Endosc 2007 Agarwal BB (2008) JLAST www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

What are the concerns? Mass of the mesh Large port needed - port site hernia (2-22%) Infection Open hernial orifice is counter productive Le Blanc et al. Contemp Surg 2006 Bololo E et al. Surg Endosc 2007 Smietanski M et al (2007) Surg Endosc www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

What are the concerns? Transfixation using suture passer Suture hernia Trauma to parietal wall Suture site pain Tip Breakage Suture hernia Le Blanc KA Surg Endosc 2007 Chelela et al (2007) Surg Endosc www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Principles of Our Technique Close the defect: Mayo’s repair Decreases the mass of mesh Myofascial continuity Myofascial barrier between skin / mesh Decrease dead space Decrease seroma Pascal’s principle respected Agarwal BB et al, SAGES 2007 Agarwal BB et al, EAES 2007 Agarwal BB et al, ELSA 2007 Agarwal BB et al, JLAST 2008 www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Principles of our Technique Avoid 10 mm port Mesh introduced through the hernial defect Mesh introduced through the 10 mm trocar Agarwal BB et al, SAGES 2007 Agarwal BB et al, EAES 2007 Agarwal BB et al, ELSA 2007 Agarwal BB et al, JLAST 2008 www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Principles of Our Technique All sutures passed using #18 spinal needles Hence less trauma Agarwal BB et al, SAGES 2007 Agarwal BB et al, EAES 2007 Agarwal BB et al, ELSA 2007 Agarwal BB et al, JLAST 2008 www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Watch the video at: www.endosurgeon.org

Sutures www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Results Total patients 37 Defects 46 Comorbidity Male 18 Female 19 Incisional 13 Recurrent 2 Comorbidity COPD 15 DM 9 HTN 19 Hypothyroid 2 Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Results GA 36 Epidural 1 Mean HD length (after closure) 11.5 cms Mean OT 90 min Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Results No technical difficulty No conversion No bleeding / use of energy sources No compression bandage Only Paracetamol used as Analgesic Agarwal BB et al, SAGES 2007 Agarwal BB et al, EAES 2007 Agarwal BB et al, ELSA 2007 Agarwal BB et al, JLAST 2008 Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Results Mean follow up 12 months No significant SSP No seroma No visible bulge No palpable defect No re-hospitalization No early recurrence Agarwal BB et al, SAGES 2007 Agarwal BB et al, EAES 2007 Agarwal BB et al, ELSA 2007 Agarwal BB et al, JLAST 2008 Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Conclusion “VOP” closure of HD reinforced by mesh introduced through HD and fixed transfasciallly using spinal needle technique is scientifically appealing A larger series is required to further evaluate it Agarwal BB et al, SAGES 2007 Agarwal BB et al, EAES 2007 Agarwal BB et al, ELSA 2007 Agarwal BB et al, JLAST 2008 www.endosurgeon.org Agarwal BB et al. Surg Endosc. 2009 Apr;23(4):900-5. Agarwal BB et al. J Laparoendosc Adv Surg Tech A. 2008 Apr;18(2):222-9.

Questions or Comments? Thankyou for your kind attention. Watch the video at: www.endosurgeon.org Thank you Pooja, Krishna Adit & Nayan