Intraperitoneal Onlay Mesh Research Articles

Closure versus non-closure of fascial defects in laparoscopic ventral and incisional hernia repairs: a review of the literature.

The laparoscopic technique for repairing ventral and incisional hernias (VIH)is now well established. However, several issues related to laparoscopic VIH repair, such as the high recurrence rate for hernias with large fascial defects and in extremely obese patients, are yet to be resolved. Additional problems include seroma formation, mesh bulging/eventration, and non-restoration of the abdominal wall rigidity/function with only bridging of the hernial orifice using standard laparoscopic intraperitoneal onlay mesh repair (sIPOM). To solve these problems, laparoscopic fascial defect closure with IPOM reinforcement (IPOM-Plus) has been introduced in the past decade, and a few studies have reported satisfactory outcomes. Although detailed techniques for fascial defect closure and handling of the mesh have been published, standardized techniques are yet to be established. We reviewed the literature on IPOM-Plus in the PubMed database and identified 16 reports in which the recurrence rate, incidence of seroma formation, and incidence of mesh bulging were 0-7.7, 0-11.4, and 0%, respectively. Several comparison studies between sIPOM and IPOM-Plus seem to suggest that IPOM-Plus is associated with more favorable surgical outcomes; however, larger-scale studies are essential.

Comparison of two different concepts of mesh and fixation technique in laparoscopic ventral hernia repair: a randomized controlled trial.

Patients' need to improve outcomes and to reduce the number of complications triggers the development of new materials and surgery concepts. Currently, there are many implants and fixation systems dedicated for intraperitoneal onlay mesh procedure. The aim of this study was to compare two different mesh/fixation system concepts (PH: Physiomesh/Securestrap and VS: Ventralight ST/SorbaFix) for laparoscopic ventral hernia repair with respect to pain. A single-center, prospective, randomized study was designed to include 50 patients per group with a planned interim analysis for safety after 25 patients. The endpoints were pain occurrences and intensity, which was measured with the visual analogue scale 7 days, 30 days, 3 months and 6 months after surgery. The safety parameters included the number of recurrences and postoperative complications. During the interim analysis, the study was stopped due to safety reasons. We observed five (20 %) recurrences in the PH group in first 6 months and none in the VS group. We observed a significantly higher pain rate in the PH group after 3 months (p < 0.0001) and no difference after 7 days (p = 0. 7019). The pain intensity decreased significantly over time (p < 0.0001) and was significantly higher in the PH group (p < 0.0001). Although this clinical trial was terminated prior to the preplanned recruitment goal, the obtained results from the enrolled patients indicate that the PH system associated with significantly greater hernia recurrences and postoperative pain compared with the VS system. This confirms the superiority of the elastic mesh concept, which may be a safer and more efficacious option for laparoscopic ventral hernia repairs.

Long-term outcomes of 1326 laparoscopic incisional and ventral hernia repair with the routine suturing concept: a single institution experience.

This retrospective chart analysis reports and assesses the long-term (beyond 10 years) safety and efficiency of a single institution's experience in 1326 laparoscopic incisional and ventral hernia repairs (LIVHR), defending the principle of the suturing defect (augmentation repair concept) prior to laparoscopic reinforcement with a composite mesh (IPOM Plus). This study aims to prove the feasibility and validity of IPOM Plus repair, among other concepts, as a well-justified treatment of incisional or ventral hernias, rendering a good long-term outcome result. A single institution's systematic retrospective review of 1326 LIVHR was conducted between the years 2000 and 2014. A standardized technique of routine closure of the defect prior to the intraperitoneal onlay mesh (IPOM) reinforcement was performed in all patients. The standardized technique of "defect closure" by laparoscopy approximating the linea alba under physiological tension was assigned by either the transparietal U reverse interrupted stitches or the extracorporeal closure in larger defects. All patients benefited from the implant Parietex composite mesh through an Intraperitoneal Onlay Mesh placement with transfacial suturing. LIVHR was performed on 1326 patients, 52.57% female and 47.43% male. The majority of our patients were young (mean age 52.19 years) and obese (average BMI 32.57 kg/m2). The mean operating time was 70 min and hospital stay 2 days, with a mean follow-up of 78 months. On the overall early complications of 5.78%, we achieved over time the elimination of the dead space by routine closure of the defect, thus reducing seroma formation to 2.56%, with a low risk of infection <1%. Post-op sepsis occurred in only nine cases. Three secondary serosal breakdowns and two late perforations were re-operated, and three diabetic patients had infected hematomas, necessitating mesh removal. Through technical improvement in the suturing concept and our growing experience, we managed to reduce the incidence of transient pain to a low acceptable rate of 3.24% (VAS 5-7) that decreased to 2.56% on a chronic pain stage, which is comparable to the literature. On the overall rate of late complications of 10.74%, we noticed also that by reducing the dead space, the chronic pain, skin bulging, and rate of recurrence were reduced to, respectively, 2.56, 1.50, and 4.72%. One case of mortality was due to a tracheal stenosis, responsible for an acute respiratory syndrome. On a second-look follow-up of 126 patients (9.5%), 45.23% were adhesion free, 42.06% had minor adhesions classified as Müller I, and 12.69% had serosal adhesions classified as Müller II. Our long series confirms the unexpected high rate of feasibility in the suturing concept or augmentation technique, and confers additional benefits to the conventional advantages of LIVHR in terms of reducing the overall morbidity, with a low rate of recurrences. Based on our experience and study, the current best indications for a successful LIVHR procedure should be tailored upon the limitations of the defect's width and proper patient selection, to restore adequately the optimal functionality of the abdominal muscles and provide better functional and cosmetic outcomes.

Is laparoscopic treatment of incisional and recurrent hernias associated with an increased risk for complications?

IntroductionHernias of the ventral abdominal wall can be treated with an intraperitoneal onlay mesh (IPOM). The aim of this cohort study was to analyze the complications and recurrence rates after laparoscopic ventral hernia repair focusing especially on incisional and recurrent hernias. MethodsThe study population comprised 149 patients with a hernia of the abdominal wall, which was treated with an IPOM between January 2006 and January 2011. ResultsFifty-one patients had a primary hernia (group I) and 98 patients had preceding abdominal surgery (group II). In group II 64 patients had an incisional hernia and 34 patients had a recurrent hernia. The median body mass index was 30.3 kg/m2 (14.8-69.1) without any significance in sub-group comparison. The mean duration of surgery and the length of stay were significantly longer in group II (p < 0.05). The overall rate of minor complications was 18.1%. There were significantly more minor complications in group II (7.8% vs. 23.5%, p = 0.02). Notably, there were also significantly more major complications in group II (14.3% vs. 2.0%; p = 0.02). The recurrence rate was significantly higher in group II (group I: 3.9% vs. group II: 16.3%, p < 0.05). There were no early recurrences in group I, but 5 early recurrences in group II. ConclusionLaparoscopic treatment of complex hernias as incisional hernias, recurrent hernias and hernias with interenteric and enteroperitoneal adhesions is associated with high rates of minor and major complications. A high level of expertise of the surgeon and the camera-guiding assistant is therefore needed.

PMD21 - An assessment of the Economic impact of the adoption of a new Mechanical fixation device along with a new skirted intra-peritoneal onlay mesh (IPOM) on Hospital costs of open Ventral Hernia repair Surgeries

PMD21 An AssessMent of the econoMic iMPAct of the ADoPtion of A new MechAnicAl fixAtion Device Along with A new skirteD intrAPeritoneAl onlAy Mesh (iPoM) on hosPitAl costs of oPen ventrAl herniA rePAir surgeries Panish J.M.1, Chekan E.2, Roy S.1 1Ethicon, Somerville, NJ, USA, 2Johnson & Johsnon (Ethicon), Cincinnati, OH, USA Objectives: Demonstrating economic value of new products is important for hospitals adoption. The combination of two devices: ETHICON SECURESTRAP® Open Absorbable Strap Fixation Device and ETHICON PHYSIOMESHTM Open Flexible Composite Mesh Device, offers a standardized approach to open IPOM repair of ventral hernia. This analysis assesses the potential economic value of using these devices when compared with other meshes and a hand-sutured fixation approach. MethOds: An economic model was developed to evaluate the budget impact to hospitals adopting ETHICON SECURESTRAPTM Open Fixation Device with ETHICON PHYSIOMESHTM Open in ventral hernia repair. A 1to 3-year time horizon was included in the Excel-based model. An increasing utilization rate for ETHICON SECURESTRAPTM Open (20% 60%), and ETHICON PHYSIOMESHTM Open (10% 30%) was assumed over 3-year horizon. Costs of the mechanical fixation device, suture supplies, mesh, OR time, anesthesia time, and potentially avoided surgical site infections were considered. The differences in total costs were calculated. Results: Based on the model inputs, a 3-year total potential saving of $240,650 was estimated for 100 annual open ventral hernia surgeries using ETHICON SECURESTRAPTM Open Fixation Device versus suture of various meshes. Over three years, although the use of ETHICON SECURESTRAPTM Open Fixation Device added $54,600 in supplies costs, this was completely offset by potential savings in OR time costs ($167,520), potential reduction in avoided surgical site infection or seroma costs due to shorter operating room time ($126,903), and potential reduction in anesthesia costs ($17,189). Similarly, a savings of $40,108 was expected in the very first year. cOnclusiOns: This analysis represents the first economic evaluation of ETHICON SECURESTRAPTM Open Fixation Device with ETHICON PHYSIOMESHTM Open in open ventral hernia surgery. Adoption of the two devices would likely result in savings for hospitals, driven by shorter procedure time and related expected clinical benefits.

If the clinical experience is very important for everyday practice….

Editorial comments on the leading article: New minimally invasive technique of parastomal hernia repair – methods and review M. Szczepkowski, P. Skoneczny, A. Przywozka, P. Czyzewski, K. Bury Prof. Marek Szczepkowski is the head of the Department of General and Colorectal Surgery of Bielanski Hospital in Warsaw, one of the most experienced surgical departments in parastomal hernia repair in Poland. Several surgical techniques of parastomal hernia repair have been described. Currently, the Sugarbaker technique, described in 1980, and the sandwich technique, which was first described by Berger, are the most common for surgical repair [1, 2]. The laparoscopic approach to parastomal hernia repair seems to be superior to the open approach due to its lower rate of recurrence and lower rate of postoperative complications, and this method was suggested by Hansson et al. [3]. Laparoscopy in other hernia repair regions has been advocated for many times by numerous surgeons, including in the pages of Videosurgery, and it was extremely encouraging that the Hybrid Operation was used by a team of Prof. Szczepkowski in parastomal hernia repair [4, 5]. Polish surgeons’ contribution to the development of this very difficult field of hernia repair surgery is very visible. The classification currently in force and suggested by the European Hernia Society (EHS) takes into account the experience of the center which is headed by Prof. Szczepkowski [6, 7]. From this center there have been published several papers concerning the experience of Bielanski Hospital. During the consensus meeting on Parastomal Hernia Repair in Gdansk in 2011, the Working Group of Polish specialists in this domain was established. The goal of this group was to give a recommendation and the proper approach to this surgical problem, which is very difficult to resolve. This consensus was published in the Polish Journal of Surgery as a contribution to further discussion and studies and is still the indicator for many surgeons [8]. This original paper presents a prospective single center and single surgeon study which shows early results of the novel concept of the minimally invasive surgical technique of parastomal hernia repair – the HyPER technique (Hybrid Parastomal Endoscopic Re-do). It also contains a short review of the most popular methods of resolving this difficult surgical problem. This technique consists of three main parts: the initial, laparoscopic part (adhesiolysis of the region of the ostomy and hernia sac; the next part – open technique (excision of stoma and hernia sac, intraperitoneal placement of special, dedicated for parastomal hernia intraperitoneal on-lay mesh (IPOM) with a funnel and creation of a new stoma with narrowing of the hernia orifice); and the third part – a return to laparoscopy with fixation of this special mesh to the abdominal wall by tacks. According to the initial results this new technique is very promising because it combines the advantages of the open and laparoscopic approach. The authors believe that factors such as narrowing the fascia aperture and removal of the hernia sac have greatly attributed to reduction of the recurrence rate of parastomal hernia. Another important factor is adequate mesh selection. Nevertheless, further studies need to be conducted to confirm this thesis in the context of a large group of patients and long-term follow-up.

Hybrid NOTES transvaginal intraperitoneal onlay mesh in abdominal wall hernias: an alternative to traditional laparoscopic procedures.

Abdominal wall hernias are increasingly treated by laparoscopic placement of an intraperitoneal onlay mesh (IPOM). We present an alternative technique for women: the laparoscopic-assisted transvaginal IPOM. Before surgery, all patients underwent a gynecological examination. The patients agreed to IPOM repair via a transvaginal approach, and written informed consent for surgery was obtained. Pneumoperitoneum was established with a Veress needle at the umbilicus. This access was subsequently dilated to 5 mm (VersaStep), and a 5-mm laparoscope was inserted. Under laparoscopic view, the transvaginal trocars (12-mm VersaStep and 5-mm flexible accesses) were safely inserted after lifting the uterus with a uterus manipulator. After preparation of the falciform ligament, the ligamentum teres and the preperitoneal fat, a lightweight composite mesh was introduced through the transvaginal access and fixed with absorbable tacks using the double-crown technique. From September 2011 to December 2012, we performed six laparoscopic-assisted transvaginal IPOM procedures (one epigastric, three umbilical, two combined epigastric and umbilical hernias; all were primary hernias). In the initial phase, only patients with small or medium primary abdominal wall hernia were selected (max. 3 cm diameter). Median hospital stay was 3 days (range 2-6 days). One minor complication occurred perioperatively (second-degree skin burn to the labia majora). At 1-year follow-up, we identified one recurrence in a high-risk patient with a body mass index higher than 35 kg/m(2). No infection and no mortality were observed. Although no final conclusion can be made regarding the presumed non-inferiority of this technique in terms of recurrence and mesh infection compared with traditional laparoscopic IPOM, laparoscopic-assisted transvaginal IPOM is a feasible alternative to treat abdominal wall hernias.

Early- Versus Late-Onset Prosthetic Mesh Infection: More than Time Alone.

Prosthetic mesh used for ventral incisional hernia makes hernia repair surgery simple, effective, and safe. The mesh infection is a formidable complication and bimodal distribution. The differences between early- and late-onset are unknown. This is a cohort study of patients undergoing ventral incisional hernia (VIH) repair from January 2003 to September 2013. Data of specific risk variables were collected from electronic medical record systems in Jinling Hospital. And, the quality of lives was evaluated by WHO Quality of Life-BREF. A total of 102 VIH repair patients were analyzed and followed including the noninfection group and early- and late-onset group. There were significant differences between the early- and late-onset group in clinical manifestation, descriptive analysis of the study population, and postoperative quality of lives. These differences might imply the different pathophysiologic process of early- and late-onset mesh infection. Permanent prosthetic mesh should be used with caution, and the study of intraperitoneal onlay mesh is still needed in long-term follow-up.

Time Savings and Surgery Task Load Reduction in Open Intraperitoneal Onlay Mesh Fixation Procedure.

Background. This study assessed the reduction in surgeon stress associated with savings in procedure time for mechanical fixation of an intraperitoneal onlay mesh (IPOM) compared to a traditional suture fixation in open ventral hernia repair. Study Design. Nine general surgeons performed 36 open IPOM fixation procedures in porcine model. Each surgeon conducted two mechanical (using ETHICON SECURESTRAPTM Open) and two suture fixation procedures. Fixation time was measured using a stopwatch, and related surgeon stress was assessed using the validated SURG-TLX questionnaire. T-tests were used to compare between-group differences, and a two-sided 95% confidence interval for the difference in stress levels was established using nonparametric methodology. Results. The mechanical fixation group demonstrated an 89.1% mean reduction in fixation time, as compared to the suture group (p < 0.00001). Surgeon stress scores measured using SURG-TLX were 55.5% lower in the mechanical compared to the suture fixation group (p < 0.001). Scores in five of the six sources of stress were significantly lower for mechanical fixation. Conclusions. Mechanical fixation with ETHICON SECURESTRAPTM Open demonstrated a significant reduction in fixation time and surgeon stress, which may translate into improved operating efficiency, improved performance, improved surgeon quality of life, and reduced overall costs of the procedure.

Single-port onlay mesh repair of recurrent inguinal hernias after failed anterior and laparoscopic repairs.

Background and Objectives:Despite the exponential increase in the use of laparoscopic inguinal herniorrhaphy, overall recurrence rates have remained unchanged. Therefore, a growing number of patients are presenting with recurrent hernias after conventional anterior and laparoscopic repairs have failed. This study reports our experience with single-incision laparoscopic (SIL) intraperitoneal onlay mesh (IPOM) repair of these hernias.Methods:Patients referred with two or more recurrences of inguinal hernia underwent SIL-IPOM from November 1, 2009, to June 24, 2014. A 2.5-cm infraumbilical incision was made, and an SIL port was placed intraperitoneally. Modified dissection techniques were used: chopstick and inline dissection, 5.5-mm/52-cm/30° angled laparoscope, and conventional straight dissecting instruments. The peritoneum was incised above the pubic symphysis, and dissection was continued laterally and proximally, raising the inferior flap below the previous extraperitoneal mesh while reducing any direct, indirect, femoral, or cord lipoma before placement of antiadhesive mesh, which was fixed to the pubic ramus, as well as superiorly, with nonabsorbable tacks before the inferior border was fixed with fibrin sealant. The inferior peritoneal flap was then tacked back onto the mesh.Results:Nine male patients underwent SIL-IPOM. Their mean age was 53 years and mean body mass index was 26.8 kg/m2. Mean mesh size was 275 cm2. Mean operation time was 125 minutes, with a hospital stay of 1 day. The umbilical scar length was 23 mm at the 6-week follow-up. There were no intra-/postoperative complications, port-site hernias, chronic groin pain, or recurrence of the hernia during a mean follow-up of 24 months.Conclusion:Inguinal hernias recurring after two or more failed conventional anterior and laparoscopic repairs can be safely and efficiently treated with SIL-IPOM.

A comparative study between laparoscopic intraperitoneal onlay mesh hernioplasty and open underlay mesh hernioplasty for ventral hernias

Background: Even after nearly two decades of experience with laparoscopic ventral hernia repair, there is a surprising paucity of good data clearly proving the benefits of this technique over standard open procedure. The aim of this prospective study was to analyse the surgical technique and perioperative outcomes of laparoscopic intraperitoneal onlay mesh hernioplasty in comparison with the open underlay mesh hernioplasty for ventral hernias. Methods: Sixty patients with ventral hernia included in this study were divided into two groups after randomisation. Study group patients underwent laparoscopic intraperitoneal mesh hernioplasty and control group patients underwent open underlay mesh hernioplasty. Follow-up was done for a period of 6 months and the intraoperative and postoperative outcomes were compared. Results: Patients operated by laparoscopic ventral hernia repair and open underlay mesh hernioplasty were comparable with respect to age, sex, comorbidities, previous history of abdominal surgery, body mass index and size of defect. The laparoscopic approach was associated with shorter operative time, lower blood loss and lesser postoperative pain requiring opioid analgesics for a shorter duration compared to the open approach. Also the length of hospital stay and duration of antibiotic requirement was less with laparoscopic approach. Incidence of seroma and recurrence was lower in the laparoscopic group. Conclusions: Laparoscopic ventral hernia repair although technically demanding, is safe and feasible. It has fewer complications and a better postoperative course, with shorter operative time, less blood loss, lesser postoperative pain, quicker ambulation and shorter duration of hospital stay.

Concomitant Laparoscopic Intraperitoneal Onlay Mesh Repair with Other Clean Contaminated Procedures—Study of Feasibility and Safety

Laparoscopic ventral hernia mesh repair has gained wide popularity with the benefits of shorter hospital stay, improved patient outcome, and fewer complications compared with traditional open procedures. It also offers the advantage of combining procedures at different quadrants of the abdomen. In this article we have retrospectively studied the safety of combining laparoscopic intraperitoneal onlay mesh (IPOM) repair with clean contaminated surgeries like cholecystectomy and hysterectomy. The data of all patients who received concomitant laparoscopic ventral hernia repairs along with cholecystectomy and hysterectomy were collected retrospectively. The details of these surgeries and the immediate postoperative outcome parameters were analyzed. Between January 2006 and January 2011, 246 cases of laparoscopic IPOM in combination with clean contaminated surgeries were performed. Of these, 126 were hysterectomies, and 120 were cholecystectomies. Mean operating time for laparoscopic IPOM with cholecystectomy was 136 minutes (range, 112-172 minutes), and that for laparoscopic IPOM with hysterectomy was 224 minutes (range, 196-285 minutes). The average hospital stays were 4.3 days (range, 3-7 days) for laparoscopic IPOM with hysterectomy and 2.73 days (range, 1-5 days) for laparoscopic IPOM with cholecystectomy. Thirty-six patients (14.6%) developed seroma, for which 16 patients (6.5%) warranted aspiration. We had 0.8% mesh infection in total. The recurrence rates were 0.83% (n=1) in the cholecystectomy group and 0.8% (n=1) in the hysterectomy group. Laparoscopic IPOM can be performed simultaneously with selected clean contaminated surgeries with acceptable morbidity. Combining clean contaminated surgeries does not significantly alter the outcome of the procedure.

The study of total peritoneum intraperitoneal onlay mesh repairing inguinal hernia on rabbits

Objective To invcstigate the security of 1 aparoscopic inguinal hernia repair with median umbilicus fold overlap mesh on rabbits,and provide basic theory for clinical application of total peritoneum intraperitoneal onlay mesh (TPIPOM).Methods 64 healthy New-Zealand male rabbits were divided into two teams randomly.There were 32 rabbits in each team.TPIPOM was operated in one team,and IPOM was operated in the other team.8 rabbits in each teams were observated under laparoscope in the 7th,15th,30th,60th days after operation.The anti-tension strengthes when hernial inner ring cracking were measured in both teams.Repair region of TPIPOM were resected.The syzygial status of median umbilical fold,mesh and peritoneum tissue were observed by histological section.Results None rabbits died during the research.6 cases of ankylenteron in the IPOM team have been discovered,but none in TPIPOM team.The defferences have statistical significance (P ＜ 0.05).None of intestinal perforation,intestinal necrosis,hernia relapses and ect.complications have been discovered in the both teams.The anti-tension strengthes of rabbits in both teams in the postoperative 7th,15th,30th,60th days respectively.The defferences have statistical significance (P ＜ 0.05).The syzygial status of median umbilicus fold,mesh and peritoneum tissue are fine and have no atrophy.Histological section observation:the agglutination of repair region in TPIPOM consistents with reparative process of chronic nonbacterial inflammation.Conclusion The operation of 1 aparoscopic inguinal hernia repair with median umbilicus fold overlap mesh on New-Zealand rabbits is reliable. Key words: Laparoscope ; Median umbilical fold ; Animal experiment; Inguinal hernia; Hernia model; Total peritoneum intraperitoneal onlay mesh; Intraperitoneal onlay mesh

Triple-step laparoscopic incisional hernia repair: midline suture closure supported by dorsal component separation and intraperitoneal onlay mesh reinforcement.

Incisional hernias remain a surgical challenge when balancing surgical morbidity, functional restoration, and risk of recurrence. Laparoscopic intraperitoneal onlay mesh (IPOM) placement reduces postoperative wound infections and allows fast patient recovery. Yet, current IPOM techniques do not achieve closure of the midline hernia gap, thereby increasing the risk of persistent mesh bulging with poor abdominal wall function. We propose a novel triple-step hernia repair technique that includes tension-free midline reconstruction. It is achieved through laparoscopic dorsal component separation and laparoscopic suture closure of the midline with a 1.0 polydioxanone suture sling. Combining dorsal abdominal wall component separation, a midline closure with adequate suture strength, and IPOM reinforcement merges the benefits of open and laparoscopic hernia repair. This triple-step technique allows static and functional laparoscopic abdominal wall reconstruction.Electronic supplementary materialThe online version of this article (doi:10.1007/s00268-014-2747-0) contains supplementary material, which is available to authorized users.

Indications for laparoscopic treatment of large incisional hernias

Hernia surgeons and patients have learned to appreciate the advantages of minimally invasive laparoscopic procedures. After overcoming the early learning curve phase, smaller wound surface areas, shorter operation times and briefer hospital stays have become routine. Severe surgery-related complications are rare. Patients with poor risk profiles (e.g. age >70 years, BMI >30 and nicotine consumption) profit especially from these advantages. This positive picture is clouded, however, by the need for an intraperitoneal mesh and specifically by the unchanged recurrence rate. The latter is not significantly lowered even by laparoscopic intraperitoneal on-lay mesh (laparoscopic IPOM) procedures. The current literature shows that irrespective of surgical technique, e.g. retromuscular mesh or laparoscopic IPOM, the risk profile and size of the hernia defect are independent factors that determine the prognosis for recurrence. While a cure of incisional hernia is no longer the only goal, the new indication scenario has two main goals: (a) for young patients at low risk or in patients for whom functional and morphological reconstruction of the abdominal wall are of primary importance, an open retromuscular mesh procedure is indicated (despite the higher morbidity) and (b) for older patients and chiefly for patients with a complex risk profile for whom treatment of the ventral hernia symptoms is paramount, laparoscopic procedures are indicated (due to the lower morbidity). This algorithm assumes that the treating surgeons have the requisite expertise and is discussed using the examples of four complex case reports.

Laparoscopic Inguinal Hernia Repair by Intraperitoneal Onlay Mesh (IPOM) Technique in Specific Cases as an Alternative Method

Purpose: Despite advancements in surgery, laparoscopic totally extraperitoneal (TEP) repair for inguinal hernia in patients with previous lower abdominal surgeries has been a burden to surgeons. This study was conducted in order to assess the feasibility of laparoscopic intraperitoneal onlay m esh (IPOM) hernia repair as an alternative method for these cases. Methods: From May 2006 to November 2010, 48 IPOM repairs were performed in 43 patients. All medical records were reviewed retrospectively. Results: Mean age of patients was 61 years old and male to female ratio was 37:6. Five were direct and 43 were indirect hernias. There were 15 recurrent inguinal hernias after either open or laparoscopic hernia repair, and five of 15 were recurrent cases more than two times. Mean operative time was 44.5 minutes, and mean postoperative hospital stay was 1.41 days. There were two cases of postoperative swelling at the groin area and two patients complained of pain that required oral pain-killers during out-patient follow-ups. Recurrence developed in one case. Conclusion: Even though laparoscopic IPOM repair is not a preferred m ethod for inguinal hernia, it can be applied as an alternative method in specific cases involving difficulties in approaching the usual plane of repair.

Spigelian hernia: a diagnostic dilemma and laparoscopic management.

Spigelian hernias, also called as lateral ventral hernias, are rare hernias to present themselves in clinical practice. The significance of these hernias lies in the fact that they are commonly intraparietal hernias and are, hence, difficult to diagnose clinically. Moreover, the neck of these hernias is usually small, posing a fair risk of strangulation. With the advancement in laparoscopic hernia repair, there is evidence that Spigelian hernias too can be repaired laparoscopically, thereby causing less morbidity and shorter hospital stay. Here, we present a rare case of large Spigelian hernia that posed to us as a diagnostic dilemma. The symptoms, clinical findings, and ultrasound of the patient were not specific, and a CT scan had to be used as the measure to confirm the diagnosis. The patient was then managed successfully with laparoscopic intraperitoneal onlay mesh repair. The details of the case and a brief discussion are included.

PGI6 - An assessment of the economic impact of mechanical versus hand-sutured fixation of intra-peritoneal onlay mesh (IPOM) in open ventral hernia repair

PGI6 - An assessment of the economic impact of mechanical versus hand-sutured fixation of intra-peritoneal onlay mesh (IPOM) in open ventral hernia repair

Modified laparoscopic intraperitoneal onlay mesh in complicated inguinal hernia surgery.

To analyse the recurrence rate and postoperative complications in inguinal hernia patients where the laparoscopic intraperitoneal onlay mesh technique (IPOM) was used due to preperitoneal fibrosis. Patients who had undergone inguinal herniotomy with the IPOM technique at Horsens Regional Hospital during the calender years of 2004 through 2010 filled out a questionnaire specific for recurrence and postoperative complications and had a clinical examination. Furthermore the medical records and national databases were analysed for reoperations for recurrent hernias. 37 patients (38 hernias) were operated. Two patients had a recurrent hernia (5 %), four patients (11 %) reported chronic pain and six patients (16 %) reported various bowel symptoms after the operation. The optimal treatment of these relatively rare and complicated patients is still an issue of debate, but in the light of the present study it seems that the IPOM technique is equal to or has a better profile compared to Lichtenstein in terms of re-recurrence and chronic pain. We believe that the IPOM technique has a place in the treatment of these patients.

English

Background: Traditionally, ventral hernia repair has been done using preperitoneal mesh placement through an open technique. The laparoscopic technique is believed to have fewer complications and a better postoperative course, with quicker ambulation, shorter hospital stay, less postoperative pain and low recurrence rates. In this study, we have evaluated the laparoscopic technique and its outcome. METHODS: All patients presenting in our unit between March 2011 and March 2013 with a ventral hernia greater than 4 cm were planned for laparoscopic repair under general anesthesia. A polypropylene mesh was used as an intraperitoneal onlay mesh. A minimum overlap of the prosthesis of 3 cm in all directions was obtained. RESULTS: In 49 patients, out of 52 patients planned, laparoscopic repair was performed. Early postoperative complications were seen in nine patients (18.4%) and late postoperative complications in three patients (6.1%). CONCLUSION: Laparoscopic repair of incisional and ventral hernia is a safe alternative for open mesh repair. Further definition of indications is needed regarding size and localization of hernia.