1. Laparoscopic Ventral Hernia: avoiding and managing complications Brian Jacob MD FACS

2. Synthetic mesh will react like a foreign body Fibrous ingrowth into mesh –Strength may peak between 4 – 12 weeks* May incite chronic inflammatory response –↑ Rigidity –↓ Elasticity –↓ Compliance –Nerve entrapment or inflammation / irritation *Majercik S, Tsikitis V, Iannitti DA (2006) Strength of tissue attachment to mesh after ventral hernia repair with synthetic composite mesh in a porcine model. Surg Endosc. 20(11):1671-4

3. Mesh can lose compliance Courtesy Dr. Bruce Ramshaw

4. Mesh can incite adhesions

5. Mesh shrinks Video clip of shrunken mesh

6. Mesh can get infected Courtesy Dr. Ramshaw

7. “never judge the laparoscopic surgeon until you have seen him or her do a laparoscopic ventral hernia repair.” Increased Risk of Recurrence And Complications Technique

8. What we don’t want: Bowel can adhere to polyester surface Inadequate overlap Inadequate fixation

9. Many variations on a theme Prosthetic Choice Fixation Wide Overlap What to do with the defect Sterile Technique / Adhesiolysis

10. Adherence to Good Technique

11. Safe Adhesiolysis Sharp dissection if bowel involved Important to get all of the contents reduced Video clip of adhesiolysis

12. Reduce all hernia contents Sharp dissection if bowel involved Important to get all of the contents reduced Small defects can contain a lot of incarcerated omentum

13. Measuring the defect Draw on abdomen Needles Use a ruler

14. Pole the audience During a laparoscopic ventral hernia for a small to medium-sized defect, in addition to inserting mesh with good overlap, do you believe there is a benefit to also closing the defect?

15. Closing the defect: (small or large ones) May limit seroma formation Less mesh bulging in larger defects Limits mesh exposure to infection

16. LVHR: Closing the defect No randomized data exists in laparoscopic ventral hernia literature –More anatomic and physiologic (wound healing) –May limit morbidity (seroma) –Larger sized defects: may offer cosmetic and functional benefits Less bulging (known morbidity) –Benefit in initiating the wound healing process?

17. Closing the defect - large

18. Closing the defect : consider lap component separation as needed Video clip of lap component separation

19. Surgical Technique: Mesh Selection and Preparation Measure defect Select mesh with at least 4cm overlap if possible Map out your plan on abdomen Use letters to mark transfascial fixation points Prepare mesh with sutures for transfascial fixation

20. Surgical Technique: Securing of Mesh Make small skin incision with 11 blade scalpel Bring 2 ends through individually using needle-type suture passer

21. The Art of Tacking

22. Polyester-based mesh at 3 year follow-up

23. Wound and Mesh Complications N = 3276 (19 articles with >50 pts) Seroma (11.4%) Mesh Infection (0.6%) Wound Infection (1.1%) Fistula (0.1%) Cobb WS, Kercher KW, and Heniford BT 2005 Surg Clin N Am 91-103

24. Other associated risks of laparoscopic ventral hernia repair Ileus (2-3%) Enterotomy (1.8%) –Identified and repaired (80%) –Missed (20%) Increases mortality rate to 7.7% Acute Pain (99%) –“Forewarned is forearmed” Chronic pain (1.6%) –Suture and tack removal may only help some patients LeBlanc KA, Elieson MJ, Corder JM, Enterotomy and mortality rates of laparoscopic incisional and ventral hernia repair: a review of the literature JSLS 2007 Oct-Dec;11(4):408-14

25. Bleeding

26. Bleeding after tacking Video clip

27. Morbidities: Seroma / Hematoma Incidence –5 - 12 % Management –Conservative –Postpone aspiration as long as possible

28. Enterotomy

29. Mechanisms of enterotomy Immediate injury –Trocar –Adhesiolysis Delayed injury –Thermal burn Cautery Ultrasonic shears

30. Mechanisms of enterotomy Video clip

31. Chronic Pain

32. Avoiding Pain

33. Managing Pain

34. Recurrence

35. Morbidities: Recurrence Incidence –0 – 9% Management –Case specific

36. Recurrence Literature Video clip

37. Morbidities: Wound / Mesh Infection Incidence –2 – 5.6% Management –Perc drains ?antibiotic irrigations –Mesh removal

39. Macrophage: preoccupied with bacteria

41. Foreign Body: Biofilm Bacteria adhere to mesh fibers Lay down a biofilm –Protect bacteria from host immune system –Bacteria survive –Chronic infections Material used doesn’t matter!!

42. Biocompatibility of bacterial contaminated prosthetic meshes and porcine dermal collagen used to repair abdominal wall defects 96 rats N = 12 (sterile and contaminated) –PPM –PPM with titanium –Polygylcol (absorbable) –Porcine dermal collagen (biologic) Ott R et al. Germany. Langenbecks Arch Surg. 2007

43. Mesh and Infection Don’t Mix Well Independent of type, all mesh was infected at 28 days Infected mesh intra-abdominally can lead to more adhesions and even fistulas Insertion of biologic mesh into an infected field can become infected Ott R etal. Biocompatibility of bacterial contaminated prosthetic meshes and porcine dermal collagen used to repair abdominal wall defects Germany. Langenbecks Arch Surg. 2007

44. Despite material, know when your routine laparoscopic repair isn’t going to be enough Increased Risk of Recurrence And Complications Technique

45. LVHR: When should I say “no”? Limitations: –Very large defects that might require component separation –Significant intraabdominal adhesions –Eroding mesh to skin –Other complex hernias

46. Combined open component separation with laparoscopic mesh fixation

47. Patient Selection: Identifying a tough patient Risk for recurrence? Obesity Diabetes COPD and smoking history Malnutrition Steroids Radiation history Abnormal collagen metabolism Risk for mesh infection? Immunocompromised Fistula in the past Infectious diseases Clean contaminated cases YES No YES No Routine Hernia Repair with mesh Large Small Defect Size? TOUGH PATIENT

48. Tough Patient Bowel Resections Cholecystectomy Enterotomy Enteroentero Fistulas Inflammatory Bowel Cases Appendectomy Is this also a Complex Hernia? Active Infections (Contaminated Case) Potential Infections (Clean contaminated) Mesh Infections Colocutaneous fistulas Perforations Peritonitis Recurrence risk Infection risk Large Defect Atypical Hernia Location Loss of Domain Giant Defects ( >10cm) Routine Hernia Repair NO If Yes, then……

49. Abdominal Wall Reconstruction: grossly infected or contaminated hernia Stoppa or Component separation No mesh vs biologic vs absorbable Staged operations Progressive preoperative pneumoperitoneum ePTFE serial excision (silo) Free tissue flaps

50. Conclusions: keys to success Laparoscopic ventral hernia –Low morbidity Reproducible technique that should be adhered to –Defects and patients are NOT created equal Choose the right procedure and product for each patient

51. Thank you