Comparative Study of Laparoscopic versus Open Ventral Hernia Repair.

Abstract

Ventral hernias (VH) occur as a result of weakness in the musculofascial layer of the anterior abdominal wall. The most popular classification is: congenital, acquired, incisional and traumatic. A successful series of laparoscopic repair for VH was done by LeBlanc in 1993. Operative costs may be optimized with selection of mesh and optimal use of trans-abdominal suture and fixation devices. This original article reveals recent advances and progression in laparoscopic ventral hernia repair technique, even in patients with incisional and umbilical hernia. INTRODUCTION Ventral hernias (VH) occur as a result of weakness in the musculofascial layer of the anterior abdominal wall. The most popular classification is: congenital, acquired, incisional and traumatic. A successful series of laparoscopic repair for VH was done by LeBlanc in 1993. Operative costs may be optimized with selection of mesh and optimal use of trans-abdominal suture and fixation devices. This original article reveals recent advances and progression in laparoscopic ventral hernia repair technique, even in patients with incisional and umbilical hernia. AIMS The aim of this article is to compare the effectiveness and safety of laparoscopic and open repair of ventral hernia and to discuss important controversial issues for both procedures like, Patient selection 1. Technique and operative care for laparoscopic 2. repair of ventral hernia Operative time of laparoscopic repair of ventral 3. hernia Intraoperative and postoperative complications 4. Postoperative pain and amount of different drugs 5. used Time until resumption of diet and movement 6. Postoperative morbidity 7. Length of hospital stay 8. Cost effectiveness and mesh selection 9. Recurrence and re-recurrence after both 10. procedures. PATIENTS AND METHODS This study which is non-randomized and prospective, involved 50 patients with ventral hernia that presented during the period of July 2006 to January 2007 in our institute (G.G. Hospital Jamnagar) and were subjected either to repair by laparoscopy or to open repair. INDICATION FOR LAPAROSCOPIC REPAIR OF VENTRAL HERNIA: Ventral hernia more than 3cm in size. 1. Obesity and recurrent incisional hernia even with 2. small size. Swiss cheese type hernia (because clearer 3. laparoscopically). CONTRAINDICATIONS Multiple scars on the abdominal wall, which make 1. intra-peritoneal access difficult3. Large defect where 3 to 5 cm meshes overlap is not 2. Comparative Study of Laparoscopic versus Open Ventral Hernia Repair. 2 of 7 possible intra-abdominally2. Patient with large amount of redundant skin and fat 3. on the abdominal wall are better suited for abdominoplasty procedures3. Infection and peritonitis. 4. Acute and subacute intestinal obstruction. 5. Severe cardiopulmonary disease. 6. Portal hypertension. 7. RISK FACTORS Morbid obesity, prostatism, chronic cough, wound infection, large incision, and malnutrition are considered as risk factors for ventral hernia and incisional hernia. EVOLUTION OF LAPAROSCOPIC REPAIR OF VENTRAL HERNIA Laparoscopic repair of ventral hernias was done at a time when laparoscopic appendectomy and cholecystectomy had shown definite benefit over open procedures. Although technically demanding and time-consuming, it is safe and feasible. With introduction of different prosthetic meshes and great improvement in the laparoscopic techniques, it is hoped that an improvement in the complication rate would be realized. Increasing application of laparoscopic surgery all over the world indicates that these goals might indeed be achieved. There are many controversies but laparoscopic surgery continues to evolve with regard to laparoscopic repair of ventral hernias and there is more data in the literatures available as compared to the past due to the increased popularity of this procedures. OPERATIVE PROCEDURES In our study, 25 patients underwent open repair and 25 patients underwent laparoscopic repair of ventral hernia. OPEN MESH TECHNIQUES Open surgical technique was popularized by Rives, Stoppa and Wantz. After taking patients to operation theater and under general anesthesia, endotracheal intubation and close monitoring, the operation started. Foleys catheter was put for patients with lower abdominal ventral hernia repair and nasogastric tube for upper abdominal hernia repair with perioperative single-dose antibiotic in form of cefotaxime. Then, after proper cleaning, painting and draping of the abdomen, the skin incision was made according to site and size of defect, a subcutaneous flap was raised up to 3 to 5cm around the defect and after the hernia sac was found, the contents were reduced. Then posterior rectus sheath and muscle were dissected, and rectus muscle and peritoneum in the lower abdomen. The posterior rectus sheath and peritoneum were closed primarily with 2:0 absorbable suture, then polypropylene meshes of suitable size with a minimum of 3cm overlap beyond the margin of the defect were placed over posterior rectus sheath/peritoneum and rectus muscle and fixed in four corners with 2:0 polypropylene sutures taken out through abdominal muscle on the anterior rectus sheath. The anterior rectus sheath was closed over the mesh with a loop of polypropylene or nylon without tension. Then the skin was closed over the drain depending upon size and extension of the wound. LAPAROSCOPIC REPAIR OF VENTRAL HERNIA Almost all types of ventral hernia can be repaired by minimal access surgical techniques and it should be clear to the patient that laparoscopic repair will not help cosmetically if the skin is lax, hanging loosely in large hernias. In laparoscopic repair of ventral hernia, evacuation of the urinary bladder in lower abdominal surgery and nasogastric tube in upper abdominal surgery is a must, because in most cases the access is through Palmer’s point, 2 to 3cm below the left costal margin in the mid-clavicle line. Bowel should be prepared to make more room in the abdominal cavity. Laparoscopic repair of ventral hernia can be done with intraperitonial meshplasty. ANESTHESIA General anesthesia with endotracheal intubation, close monitoring, I.V. cannula and proper fluid and electrolyte balance PATIENT POSITION Supine position without any tilt, so that the bowel is distributed evenly POSITION OF SURGICAL TEAM The surgeon stands left to the patient with the camera man on his left or right depending upon the location of the ventral hernia. If the hernia is below the umbilicus the camera operator stands right to the surgeon and if the defect is above the umbilicus, the camera operator should stand left to the surgeon. The monitor should be placed opposite to the surgeon and the instrument trolley should be towards the leg of the patient. Comparative Study of Laparoscopic versus Open Ventral Hernia Repair. 3 of 7 Figure 1 Port position PORT PLACEMENT TECHNIQUE AND OPERATIVE PROCEDURE The patient should be cleaned, painted and draped with checking light cable, insufflation tube, electro-surgical cautery wires and suction/irrigation tube. A 10mm-trochar is inserted in the epigastrium with open method and the pneumoperitoneum is created. Once the pneumoperitoneum is created, a 5-mm port and another 10mm-port are put under vision according to the Baseball diamond concept, after diagnostic laparoscopy. If there is any adhesion, careful adhesiolysis is performed and the content of the hernia sac which is either omentum or bowel is returned as shown below. Figure 2 Fig. 1: