Minimally Invasive Advances in AWR Tommy H Lee, MD Creighton University Omaha, NE

Nothing to Disclose

Overview Laparoscopic ventral hernia repair Laparoscopic component separation Hybrid procedures Which approach to use?

Incisional/Ventral Hernia: The Facts A Frequent Complication of Laparotomy 3% to 13% of All Laparotomies 4 to 5 Million Laparotomies Annually in the US = 400,000 To 500,000 Incisional Hernias = 200,000 Repairs The American Journal of Surgery, Vol 197, No 1, January 2009

“Traditional” Hernia Repair Open +/- Mesh Onlay Inlay Underlay Component Separation

Laparoscopic Repair Wide overlap (3? 4? 5cm?) +/- Transfascial sutures +/- Primary closure of defect

Why Laparoscopic? Open vs. Laparoscopic PRO ↓ Operative Time ↓ Risk of Serious Complications ↓ Cost Muscle Approximation → Better Functional Result CON↑ Infection Rate? ↑ Recurrence Rate? Greater Post Operative Pain? Longer Time for Return to Usual Activities

Bisgaard et al (2009) All patients aged 18 years or older who had elective surgery for incisional hernia in Denmark between 1 January 2005 and 31 December 2006 2896 Incisional hernia repairs 1872 Open/1024 Laparoscopic 2754 Primary /142 Recurrent

Bisgaard et al (2009) Unsatisfactory results Severe complication rate 3.5% Mortality rate 0.4% Reality of the disease?

73 Laparoscopic vs 73 Open repairs

Itani et al (2010) Laparoscopic - fewer complications, more serious

British Journal of Surgery 2009; 96: 851–858 8 RCTs, 536 patients Hernia 23.2 to 141.2 cm2 F/U 6 to 40.8 months

Forbes et al (2009) Laparoscopic No difference in recurrence Fewer wound complications Laparoscopic at least equivalent to open repair

Laparoscopic Ventral Hernia Technique General anesthesia / Antibiotic prophylaxis Table to table Prep Insufflation needle - away from midline Hasson Initial 5 mm “Optical Trocar” Three cannulae technique, all in the anterior axillary line

Technique Lysis of adhesions Size defect (avoid oversizing) Intra-abdominal Deflate abdomen Primary closure of defect? Place and secure mesh

Port Placement

Mesh

Fasteners Absorbable Slow-absorbing No long-term foreign body ?Adequate fixation Non-absorbable Protack

Fasteners Depth of fixation limited!

Abdominal Wall Fixation

Abdominal Wall Sutures

Tricks of the Trade

Marking of the Prosthesis

Primarily close the defect

Securing the mesh

Laparoscopic Component Separation Why laparoscopic? Fewer wound complications Seroma Infection Flap necrosis Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.

Laparoscopic Component Separation - Technique http://www.sages.org/video/details.php?id=100888

Is it effective? Laparoscopic component separation achieved 86% advancement compared to open

Rosen et al. External oblique release

Is it effective? Comparable amount of release Tranversus abdominus and posterior sheath release compared to traditional ext. oblique + post. sheath release p values not significant

Is it effective? Large series lacking 7 patients, average follow-up of 4.5 months External oblique released laparoscopically Posterior sheath released as necessary (open) Alloderm underlay 1 SSI, 1 hematoma, 1 resp failure

Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000. Is it effective? Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000. Posterior sheath release followed by ext. oblique release +/- mesh 7 laparoscopic, 30 open, 1 year follow-up Fewer complications in laparoscopic group No ischemia, wound infection, dehiscence

Is it effective? 5 patients, less than 1 year follow-up Am Surg. 75(7). 572-8. 5 patients, less than 1 year follow-up Laparoscopic ext oblique release 4 had mesh underlay (biologic) 2 mild wound complications 1 recurrence (!)

Hybrid Procedure? Combine elements: Laparoscopic/Open lysis of adhesions Laparoscopic intraperitonal mesh repair Laparoscopic/Open component separation Rives-Stoppa repair

Cox et al. Open lysis of adhesions Rives-Stoppa repair Laparoscopic component separation to mobilize ant. sheath Bridging mesh as needed 6 patients, F/U 4-14 months No recurrences 1 recurrent EC fistula

Combined laparoscopic component separation and intraperitoneal mesh placement 4 patients, 30-100 day follow-up Good outcomes

Surg Endosc. 2010 Nov 5 Primary “shoelace” closure of defect Better function? Component separation (laparoscopic) as needed No recurrences at 16.2 months

Moazzez et al. Surg Technol Int. 2010;20:185- 91.

Moazzez et al (2010)

Moazzez et al (2010)

Moazzez et al (2010) Fasica is closed

Guidelines... (Ventral Hernia Working Group - 2010) Breuing et al, Surgery (2010), 148(3), pp 544-558.

Conclusion Laparoscopic techniques are being developed Approach needs to be tailored to particular needs of patient No “universal” technique Advantages/disadvantages to each