1. Laparoscopic Ventral Hernia – Suturing With Onlay Mesh Repair

2. BACKGROUND
Laparoscopic repair of incisional abdominal hernias was first reported in – “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.

3. 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.

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

5. 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%) %)
72 (9.9%)
Incarcerated hernias
22 (3.1%)

6. 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.

7. 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.

8. 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

9. 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?

10. 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

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

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

19. 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

20. 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%).

21. 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%)

22. 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

23. 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

24. 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%)

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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.

32. 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.

33. 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

34. 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”

35. THANK YOU