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

2. Nothing to Disclose

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

4. 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

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

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

7. 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

9. 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

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

12. 73 Laparoscopic vs 73 Open repairs

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

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

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

17. 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

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

19. Port Placement

20. Mesh

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

22. Fasteners
Depth of fixation limited!

23. Abdominal Wall Fixation

24. Abdominal Wall Sutures

25. Tricks of the Trade

26. Marking of the Prosthesis

29. Primarily close the defect

30. Securing the mesh

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

32. Laparoscopic Component Separation - Technique

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

34. Rosen et al.
External oblique release

35. 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

36. 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

37. 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

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

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

41. 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

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

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

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

45. Moazzez et al (2010)

46. Moazzez et al (2010)

47. Moazzez et al (2010)
Fasica is closed

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

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