Laparoscopic Ventral Hernia Repair Research Articles

Laparoscopic Ventral Hernia Repair Combined with Sleeve Gastrectomy in Morbidly Obese Patients: Early Outcomes.

Background Morbid obesity is a serious chronic condition with, among other symptoms, increased intra-abdominal pressure and subsequent abdominal wall hernias. The optimal management of these manifestations is still controversial. The objective of this study was to assess the early postoperative outcomes of a surgical approach combining laparoscopic ventral hernia repair (LVHR) with sleeve gastrectomy in morbidly obese patients. Methods In this retrospective study, we reviewed the files of patients who are obese with a primary ventral hernia of less than 10 cm in diameter who received simultaneous laparoscopic sleeve gastrectomy and LVHR at our institution between February 2016 and July 2018. LVHR was performed using an intraperitoneal only mesh. The individual mesh size was chosen based on the number and size of the defects. Clinical and radiological follow-ups were performed between 9 and 15 months. Results A total of 15 patients were included. Five of them were males. The mean body mass index was 45.2 kg/m 2 (range: 38.7–56.2 kg/m 2 ). The mean hernia defect size was 2.6 cm (range: 1.3–4.2 cm). Mesh size was 10 × 15 cm in five, 20 × 15 cm in seven, and 25 cm× 20 cm in three patients. All patients were discharged without complications on the second postoperative day. Mean follow-up was at 12 months. One patient presented with hernia recurrence 14 months after surgery and four patients presented with self-limited seroma. Conclusion Despite ambiguous guidelines and ongoing debate regarding simultaneous bariatric surgery and ventral hernia repair, the short-term outcomes of this approach appeared promising, provided that patients are carefully selected and receive an individually tailored approach.

Comparative Study between Fascial Defects Closure and Non-closure in Laparoscopic Incisional and Ventral Hernia Repair

Background: Incisional hernias are common after abdominal surgery. Laparoscopic repair has advantages over open repair. Traditionally, laparoscopic ventral repair of hernia has been done as a bridged repair to accomplish circumferential overlap of the fascial defect. More recently, there has been a growing trend to do primary fascial closure to reapproximate the fascia before mesh insertion.Aim of the work: to present our experience with laparoscopic ventral and incisional repair of hernia to determine outcomes and different results of fascial defects closure and non-closure.Patient and methods: From January 2016 to April 2018, 68 patients suffering from ventral and incisional hernias were treated in New Damietta University Hospital. Laparoscopic repair was decided for all patients. Results: Operative time for group A ranged from 50-120 minutes (average 96.8 min), 30-90 minutes (average 66 min) for group B. Chronic postoperative pain reported in 12.9% in group A and 6.6% in group B. 16.1% from group A had seroma lasting 4 weeks, while it was reported in 36.7% from group B, which remain for 6 weeks. There were 7 patients from group A complaint of post-operative respiratory embarrassment which resolved conservatively except for one patient, who necessitated ICU admission for two days. No one from group B complaint of post-operative respiratory complications. Conclusion: Although there were no major statistical differences between fascial closure and non-closure groups, the seroma and recurrence were less in fascial closure group.

Insufflation Effects on the Abdominal Wall Dimensions and Incisional–Ventral Hernia Orifice Size

The possibility that ventral hernia orifice size may increase with insufflation at the time of laparoscopic ventral hernia repair has a number of consequences, including mesh size used and trocar placement. We measured ventral hernia orifice defects intraoperatively at 8 mm Hg and 15 mm Hg for comparison. We also took measurements of the external abdominal wall at various points to determine the relationship between insufflation and the abdominal wall externally. Of 39 patients measured, we found a mean increase of 3.7 mm in the hernia defect transversely and 2.9 mm vertically. The external measurements showed correlation with insufflation pressure, as expected. The transverse measurements across the mid-abdomen showed a mean increase of 5 mm from 0 to 8 mm Hg insufflation and a full additional centimeter when insufflation was increased from 8 to 15 mm Hg. We were able to detect and quantify an increase in hernia defect size with insufflation, but the increase is so small it is unlikely to be clinically significant in the management of surgical patients.

Concurrent Laparoscopic Ventral Hernia Repair with Bariatric Surgery: a Propensity-Matched Analysis

BackgroundVentral hernias are a common finding during bariatric surgery; however, the risks and benefits of repair during surgery remain unclear. Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database, we examined the short-term outcomes of patients undergoing bariatric surgery with concurrent ventral hernia repair (VHR) versus bariatric surgery alone. MethodsPatients undergoing laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) were included. A propensity-matched analysis was performed between laparoscopic bariatric surgery with and without concurrent VHR. The primary outcome was the 30-day major complication rate which includes but is not limited to 30-day reoperation, deep surgical site infection, and sepsis. Secondary outcomes included operative time, length of hospital stay, 30-day readmission, and 30-day mortality. ResultsA total of 430,225 patients were included, of which 4690 (1.1%) received concomitant VHR. With one-to-one propensity score matching, 4648 pairs were selected. Concurrent VHR was associated with a higher major complication rate (5.8 vs 3.8%, p < 0.001) but no significant difference in mortality (0.3 vs 0.2%, p = 0.531). Both LSG with VHR (3.2 vs 2.4%, p = 0.007) and RYGB with VHR (9.3 vs 5.7%, p < 0.001) were associated with an increase in major complications. ConclusionsPatients undergoing VHR during bariatric surgery do not experience higher mortality. However, these patients have an elevated risk of major complications with this risk being higher among patients undergoing VHR and LRYGB. Bariatric surgeons should consider these risks when choosing to perform VHR at the time of bariatric surgery.

Screening surgical residents’ laparoscopic skills using virtual reality tasks: Who needs more time in the sim lab?

BackgroundThis study investigated the possibility of using virtual reality perceptual-motor tasks as a screening tool for laparoscopic ability. We hypothesized that perceptual-motor skills assessed using virtual reality will correlate with the quality of simulated laparoscopic ventral hernia repair. Materials and MethodsSurgical residents (N = 37), performed 2 virtual reality perceptual-motor tasks: (1) force matching and (2) target tracking. Participants also performed a laparoscopic ventral hernia repair on a simulator and final product quality score, and endoscopic visualization errors were calculated. Correlational analysis was performed to assess the relationship between performance on virtual reality tasks and laparoscopic ventral hernia repair. ResultsResidents with poor performance on force matching in virtual reality—“peak deflection” (r = –0.34, P < .05) and “summation distance” (r = –0.36, P < .05)—had lower final product quality scores. Likewise, poor performance in virtual reality–based target tracking—“path length” (r = –0.49, P < .05) and “maximum distance” (r = –0.37, P < .05)—correlated with a lower final product quality score. ConclusionOur findings support the notion that virtual reality could be used as a screening tool for perceptual-motor skill. Trainees identified as having poor perceptual-motor skill can benefit from focused curricula, allowing them to hone personal areas of weakness and maximize technical skill.

The quality of life after laparoscopic ventral and incisional hernia repair with closure and non-closure of fascial defect.

In this retrospective, non-randomized study, we compared the quality of life (QOL) of patients who underwent laparoscopic ventral and incisional hernia repair (LVIHR) with fascial defect closure or non-defect closure and examined the factors associated with the QOL after LVIHR. Between February 2013 and 2016, we conducted a single-center, follow-up study of 33 consecutive midline hernia patients who underwent LVIHR. Overall, 14 cases underwent intraperitoneal onlay mesh repair (IPOM), and 19 underwent IPOM with fascial defect closure (IPOM-plus). Patients were interviewed using the 36-item Short Form Health Survey (SF-36) to assess their pre- and postoperative QOL (at 1, 3, 6, and 12months after surgery). The QOL, as assessed by the SF-36, was compared before and at 1year after surgery, and the risk factors associated with the QOL were examined. Overall, scores for 5 of the 8 domains and 1 of the 3 components of SF-36 had improved by 1year after surgery compared with before surgery. The scores for the SF-36 domains and components at 1year post-surgery were comparable in patients undergoing IPOM or IPOM-plus. Obesity, operative time, hernia size, and mesh size were factors correlated with the QOL. LVIHR improved the QOL, regardless of defect closure.

Laparoscopic Incisional and Ventral Hernia Repair with Absorbable Tacks in a Long Term Follow-up: A Retrospective Control Study.

Laparoscopic Incisional and Ventral Hernia Repair (LIVHR) is a safe and worldwide accepted procedure performed using absorbable tacks. The aim of the study was to evaluate recurrence rate in a long term follow-up and whether the results of laparoscopic IVH repair in the elderly (≥65 years old) are different with respect to results obtained in younger patients. One hundred and twenty-nine consecutive patients (74 women and 55 men, median age 67 years, range = 30-87 years) with ventral (N = 42, 32.5%) or post incisional (N = 87, 67.5%) hernia were enrolled in the study. Patients were divided into two groups according to their age: group A (N = 55, 42.6%) aged <65 years and group B (N = 74, 57.4%) aged ≥65 years. The mean operative time was not significantly different between groups (66.7 ± 37 vs. 74 ± 48.4 min, p = 0.4). To the end of 2016, seven recurrences had occurred (group A = 3, group B = 4, p = 1). Complications occurred in 8 (16%) patients in group A and 21 (28.3%) patients in group B. In conclusion, our results confirm that the use of absorbable tacks does not increase recurrence frequency and laparoscopic incisional and ventral repair is a safety procedure also in elderly patients.

Effect of Surgery-Specific Opioid-Prescribing Education in a Safety-Net Hospital

BackgroundAs the nation works to improve the opioid epidemic, safer opioid prescribing is needed. Prescriber education is one method to assist with this aim. To gauge current surgical residents’ opioid prescribing practices at a safety-net hospital, an evaluation was completed before a general surgery–specific opioid prescribing education (OPE) session. The effectiveness of this OPE was measured through a postparticipation evaluation. MethodsA voluntary, anonymous evaluation immediately before and after a one-hour OPE session was performed at an urban safety-net hospital. Descriptive statistics and Student’s t-test comparisons of means were performed to analyze the results. ResultsTwenty-three residents completed the surveys. Eleven (47.8%) completed prior OPE with the most common modality being online (7, 63.6%). No participant performed an opioid risk assessment before prescribing opioids. More than half of the residents (14, 60.9%) never used the prescription drug monitoring program. Less than 1/3 (7, 30.4%) used preoperative gabinoids (gabapentin or pregabalin) for elective surgeries. Only two residents provided information on unused opioid disposal. After the OPE, the participants were more likely to prescribe preoperative gabinoids (7 versus 21, P < 0.001). The mean opioid pills prescribed for laparoscopic cholecystectomy, open inguinal hernia repair, laparoscopic ventral hernia repair, and laparoscopic appendectomy were reduced by 2.6 (14.2%, P = 0.23), 3.7 (18.9%, P = 0.07), 2.6 (13.1%, P = 0.23), and 1.1 (7.3%, P = 0.60) pills, respectively. ConclusionA short OPE delivered to surgical residents at a safety-net hospital significantly improved the use of preoperative gabinoids. Although the pill count reductions after the OPE were not statistically significant, there was a consistent reduction in amount of opiates prescribed after the OPE. However, clinical significance is important, as a reduction in any amount of opioid medication can help deter misuse and diversion. This suggests resident surgeons could participate in a specialty-specific OPE to improve opioid prescribing.

The influence of mesh removal during laparoscopic repair of recurrent ventral hernias on the long-term outcome.

IntroductionRecurrent hernias can be treated by laparoscopy without the need for mesh removal. However, shrinkage of the mesh following recurrence affects most of the patients, and leaving a partially floating and rigid foreign body could be discussed.AimTo compare the outcomes of patients regarding the removal of previous mesh during laparoscopic repair of recurrent abdominal wall hernias.Material and methodsPatients who underwent laparoscopic repair for recurrent ventral hernias between August 2012 and March 2015 were included in the study. The patients with complete removal of the mesh were included in the MR group and the patients with partial removal or without removal of the previous mesh were included in the non-MR group. Patient characteristics and demographics, previous hernia repair, defect size, mesh size, operative time, mean hospital stay, complications, recurrences, numeric pain rating scale (NRS), early termination of analgesics and prolonged use of analgesics were compared.ResultsA total of 112 patients with a mean age of 53.2 and mean body mass index of 31.1 kg/m2 underwent laparoscopic repair. There were 47 patients in the MR group and 54 patients in the non-MR group. Operative time was shorter in the non-MR group (p < 0.05), whereas symptomatic seroma and NRS scores on postoperative day 10 and at the 6th week were higher in comparison with the MR group (p < 0.05).ConclusionsMesh removal during laparoscopic repair of recurrent ventral hernias has an association with the reduction of pain and symptomatic seroma. However, further prospective comparative studies are required to verify this view.

1033 – Concurrent Laparoscopic Ventral Hernia Repair with Bariatric Surgery: A Propensity-Matched Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database

1033 – Concurrent Laparoscopic Ventral Hernia Repair with Bariatric Surgery: A Propensity-Matched Analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) Database

Laparoscopic ventral hernia repair with intraperitoneal onlay mesh-results from a general surgical unit.

Symptomatic ventral herniation is a common clinical presentation. The treatment, whether elective or as an emergency, can be difficult and a variety of surgical repairs are utilised. Intraperitoneal onlay mesh (IPOM) involves the placement of a reinforcing prosthesis, usually supported by primary closure of the defect. Intra-abdominal adhesions have been highlighted as a potential complication in utilising this form of mesh placement. Several methods of laparoscopic mesh placement outside of the peritoneal cavity are gaining prominence as potential alternatives to IPOM. This study reviews our experience with IPOM in the repair of ventral hernia by a single surgical team. A prospectively maintained electronic database of all laparoscopic ventral hernia repair (LVHR) performed within the study period was analysed and reported. Follow-up questionnaires were sent to patients to follow long-term outcomes. One hundred eight patients underwent LVHR over a 7-year period. Demographics demonstrated an obese patient group (BMI 30.89 ± 4.9kg/m2), with a variety of hernia sizes and morphologies. Hernia recurrence was found in two patients (1.8%). Twenty-nine (26.8%) patients suffered a complication, but only eight (7.4%) of those required intervention beyond pharmacotherapy. Two patients required mesh explantation. IPOM for the general surgeon is a relatively safe and effective method of repairing ventral hernias, with a low recurrence rate.

Selective muscle botulinum toxin A component paralysis in complex ventral hernia repair.

Repair of complex ventral hernia presents a significant challenge plagued by high morbidity and recurrence. Recent studies have demonstrated significant benefits achievable with preoperative Botulinum Toxin A (BTA) chemical component paralysis to the abdominal wall muscles, facilitating primary closure of complex ventral hernia defects. However, transversus abdominis is known to play an integral role in truncal stability, and its paralysis can result in unwanted physiological changes. This is the first study to report on selective administration of preoperative BTA to internal and external oblique muscles only, thus sparing transversus abdominis from paralysis. This is a prospective observational study of 46 patients who underwent either selective two-layer or standard three-layer abdominal wall muscle BTA injection prior to elective laparoscopic ventral hernia repair. Serial abdominal CT imaging was performed to compare defect size and length of the lateral abdominal musculature. 46 patients received preoperative BTA injections (23 in each group). A comparison of gains achieved from chemical component paralysis demonstrated no statistically significant difference between the two groups. Fascial closure was achieved in all cases, with no post-operative sequelae of abdominal hypertension. There are no hernia recurrences to date. Preoperative selective muscle chemical component paralysis is an effective technique to counteract the chronic muscle retraction observed in large ventral hernias. Transversus abdominis plays a significant role in truncal and spinal stability, and sparing it from paralysis preserves an important component of abdominal wall physiology and does not detract from the ability to primarily close complex defects.

Review of the Effectiveness of Composite Barrier Mesh Used for Laparoscopic Ventral Hernia Repair

Background: The objective of this research is to provide an overview of the physical and biomechanical properties of composite barrier meshes frequently used in Laparoscopic Ventral Hernia Repair as well as reviewing the existing relevant literature assessing the characteristics and effectiveness of both procedures. Methods: A secondary research is used using existing literature review of the preclinical and clinical literature designed to compare the Composite prostheses with permanent barriers (COMPOSIX, VENTRIO, DUALMESH, DYNAMESH and TiMESH ) to composite prostheses with absorbable barriers ( PROCEED, C-QUR, PHYSIOMESH, PARIETEX and SEPRAMESH ). Results: Significant differences were observed between Composite prostheses with regard to its physical and biomechanical properties. Amongst the permanent barrier meshes, Dualmesh showed the highest suture retention strength. On the other hand, between the absorbable barrier meshes, Sepramesh proved to have the most significant suture retention and tears strength. Overall, all meshes established tensile strengths greater than 16-32 N/cm. Moreover, that composite meshes with absorbable barriers had less complications of adhesions, recurrences and wound infection compared with meshes with permanent barriers. Conclusion: Composite meshes with absorbable barriers proved to be superior to permanent ones. Other findings demonstrated there was no significant difference of effectiveness among absorbable barriers.

Review of the Effectiveness of Composite Barrier Mesh Used for Laparoscopic Ventral Hernia Repair

Background: The objective of this research is to provide an overview of the physical and biomechanical properties of composite barrier meshes frequently used in Laparoscopic Ventral Hernia Repair as well as reviewing the existing relevant literature assessing the characteristics and effectiveness of both procedures. Methods: A secondary research is used using existing literature review of the preclinical and clinical literature designed to compare the Composite prostheses with permanent barriers (COMPOSIX, VENTRIO, DUALMESH, DYNAMESH and TiMESH ) to composite prostheses with absorbable barriers ( PROCEED, C-QUR, PHYSIOMESH, PARIETEX and SEPRAMESH ). Results: Significant differences were observed between Composite prostheses with regard to its physical and biomechanical properties. Amongst the permanent barrier meshes, Dualmesh showed the highest suture retention strength. On the other hand, between the absorbable barrier meshes, Sepramesh proved to have the most significant suture retention and tears strength. Overall, all meshes established tensile strengths greater than 16-32 N/cm. Moreover, that composite meshes with absorbable barriers had less complications of adhesions, recurrences and wound infection compared with meshes with permanent barriers. Conclusion: Composite meshes with absorbable barriers proved to be superior to permanent ones. Other findings demonstrated there was no significant difference of effectiveness among absorbable barriers.

Blood transfusions increase the risk of venous thromboembolism following ventral hernia repair.

Blood transfusions can affect the clotting cascade, leading to a hypercoagulable state. The association of a venous thromboembolic (VTE) event and perioperative blood transfusion has been identified previously in surgical patients, but not after ventral hernia repair (VHR). The aim of this study was to evaluate the risk of VTE in VHR patients who receive a perioperative blood transfusion. The American College of Surgeons National Surgery Quality Improvement Program was queried for open (n = 34,687) and laparoscopic (n = 11,544) VHRs that occurred from 2013 to 2015. Regression analyses were used to determine factors predictive of VTE within 30-day post-operatively, the impact of bleeding requiring blood transfusion, and the influence of surgical approach on VTE. Post-operative VTE occurred in 246 (0.5%) VHR patients. Among those patients, 53.0% occurred after discharge. Increased age, operative time, and comorbidities increased the risk of VTE (p < 0.05). Controlling for surgical approach, perioperative blood transfusion increased the risk of VTE 10.2-fold (p < 0.0001) in open and 12.2-fold in laparoscopic VHR (p < 0.0001). Perioperative blood transfusions are associated with an increased rate of VTE following VHR, more than 50% of which occur after discharge. This study highlights the importance of identifying quality initiatives for at risk patients, including adequate VTE screening and potential prophylaxis for those who receive perioperative blood transfusions.

Robotic-assisted ventral hernia repair with surgical mesh: how I do it and case series of early experience.

Laparoscopic ventral hernia repair provides several benefits over the open approach. Intraperitoneal surgical mesh placement without fascial defect closure is associated with increased seroma formation and other adverse hernia-site outcomes. Transfascial sutures and tacs for fascial closure and surgical mesh fixation are associated with greater post-operative pain. Robotic-assisted ventral hernia repair (rVHR) may afford benefits of the laparoscopic approach while facilitating a more robust and less painful repair. Consecutive patients managed by rVHR from May 2015 to August 2018 were identified from a prospectively maintained robotic database. Retrospective review of this data was performed. Fifty patients underwent rVHR during the study period. Median body mass index was 31 (interquartile range (IQR) 29-34). Forty-eight had previous abdominal surgery. Forty-seven hernias were midline and three were lateral. Regarding hernia width, 15 were <4 cm wide, 32 were 4-10 cm and three were >10 cm. Median total anaesthetic time, docking time and surgical console time were 214 min (IQR 182-252), 5 min (IQR 4-8) and 144 min (IQR 104-174), respectively. No major intra-operative complications occurred. No documented cases of adhesional complications or chronic post-operative pain have occurred. To date, two recurrences have occurred in our series. Median length of hospital stay was 3 days (IQR 2-4). We describe our rVHR technique and report on our series and early experience, showing that rVHR can be performed safely with good patient outcomes. We demonstrate a team approach to achieving a safe transition to new technology.

Laparoscopic repairs for anterior abdominal wall hernias

Background: Abdominal wall hernias are familiar surgical problem. Millions of patients are affected each year presenting with most commonly with ventral, incisional, and inguinal hernias. Hernia may be either symptomatic or asymptomatic and may cause pain or are aesthetically distressing. These problems coupled with the risk of obstruction and incarceration are the most common reasons, patients seeking surgical repair of hernias. Laparoscopic repair of hernia demands for significant expertise. Placement of mesh in a sublay position has found to be effective and to have a low recurrence in anterior abdominal wall hernia repairs.Methods: Prospective study involving 50 patients with anterior abdominal wall hernias undergoing laparoscopic mesh repair in a tertiary center. To determine the usefulness of laparoscopic repairs in the surgical treatment of Anterior Abdominal Wall Hernias (AAWH).Results: Laparoscopic Ventral Hernia Repair (LVHR) using Intraperitoneal Onlay Mesh Repair (IPOM) technique, and Transabdominal Preperitoneal Repair (TAPP) for inguinal hernias in author’s experience was safe, good cosmetic and resulted in short operative time, fewer complications, short hospital stays and no recurrence at 2years follow up. Thus, patients have less morbidity, good quality of life.Conclusions: Laparoscopic AAWH repair should be considered as the procedure of choice for anterior abdominal wall hernias. Effective, safe and feasible and reproducible technique with avoidance of large incisions and extensive dissections, lower incidence of wound infections, reduced analgesic requirements, early recovery, short length of hospital stay and early return to normal activities.

Managing complications in laparoscopic ventral hernia

Ventral or Incisional hernia repair is one of the commonest operations performed in surgical practice. High recurrence rates following standard open repair, combined with the advent of minimal invasive surgery has led surgeons towards accepting laparoscopy as an alternative to management of ventral or incisional hernias. Ever since the first laparoscopic ventral hernia repair in 1993, more surgeons have readily accepted it. In laparoscopic ventral or incisional hernia repair, the principles of conventional posterior approach (Rives-Stoppa-Wantz) are borrowed, wherein the mesh is placed either intra-peritoneally or in the sublay position. To facilitate laparoscopic repair, over the year’s newer instruments like tackers, specialized mesh, fixation devices have been developed. No procedure is immune to complications. In this review we explore the complications associated with laparoscopic ventral and incisional hernia repair and its management options.

Laparoscopic Repair of Small Ventral Hernias Using the "Ventralex™ Hernia Patch".

Laparoscopy of abdominal wall defects becomes more and more actual, considering the well-known advantages of minimally invasive surgery, and the reduced incidence of post-operative ventral infections and recurrence rates compared to the the open repair with or without mesh. We hereby present the technique of the laparoscopic repair of small ventral hernias (defect 2 centimetres), using the Ventralex mesh, which is bi-faceted, polypropylene and PTFE, circular preformed, it has 8 centimeters in diameter, fixated with 4 transparietal sutures. The mesh is created for open surgery but it is placed in the intraperitoneal cavity. This technique was used for 28 patients,16 women and 12 men, with an average age of 53,3 years (29-72 years), consisting of: 22 umbilical hernias (UH), 2 epigastric hernias (EH), one left-side Spiegelian hernia, one incisional hernia after an open surgery for an umbilical hernia with a Ventralex mesh, and 2 trocar eventrations (TE) after a laparoscopic cholecystectomy. Mean operating time was 52 minutes (42-70 minutes), post-operative hospital stay of 1,8 days (1-5 days). The main advantages are: circular preformed mesh, diameter of 8 centimeters, transfascial suture fixation, correct mesh placement and unfolding may be verified by laparoscopy, reduced costs. The technique is easy to reproduce.

Retrorectus sublay mesh repair using polypropylene mesh: Cost-effective approach for laparoscopic treatment of ventral abdominal wall hernias.

Introduction:Laparoscopic repair of ventral abdominal hernias has become a standard of care. The surgery involves placement of a composite mesh with 3–5 cm overlap at the edges of the defect. The disadvantage of this repair is one, the composite mesh used for intraperitoneal placement is quite costly and two, it leaves a foreign body inside the peritoneal cavity, with the potential to cause problems in the future. To circumvent both these issues, we have developed a new approach, called the retrorectus sublay Mesh (RRSM) repair, which allows placement of a plain polypropylene mesh in an extraperitoneal plane.Patients and Methods:Patients with paraumbilical hernia and lower midline incisional hernias were included in this pilot study performed at a single centre by the same surgeon. The steps of the technique are described in detail.Results:Since 2016, a total of 52 patients were operated by this technique, including both male and female patients. It included patients with para-umbilical hernias as well as incisional hernias. The RRSM repair could be successfully carried out in all the patients. In six of the patients, transversus abdominis release was added as the defect size was large to allow closure of the defect. The results were satisfactory with a low morbidity and no mortality.Conclusion:In our opinion, the RRSM technique is an important tool in the armamentarium of the laparoscopic surgeon dealing with ventral abdominal hernias, allowing placement of polypropylene mesh in an extraperitoneal space. It allows significant cost savings as compared to the prevalent intraperitoneal onlay mesh repair.