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Surgical Technology International XXIV contains 48 articles with color illustrations.

 

 

San Francisco, March, 2014

ISBN: 1-890131-20-2

 

1 year Institutional Subscription 

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Sections

Hernia Repair

 

  • Bard Bard
Dynamesh
  • Dynamesh Dynamesh

Prospective Analysis of Laparoscopic Ventral Hernia Repair Using the Ventralight™ ST Hernia Patch With or Without the ECHO PS™ Positioning System
Tim Tollens, MD, Consultant, Halit Topal, MD, Surgical Trainee, Koen Vermeiren, MD, Consultant, Chris Aelvoet, MD, Consultant, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium

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PMID: 24574018

Abstract

The purpose of the current prospective study was to confirm the results of our previous study on the use of the Ventralight™ ST mesh. In this study we also evaluated a pre-attached positioning system. Between July 2011 and October 2013 prospectively collected data of 61 consecutive patients who underwent a laparoscopic ventral hernia repair were analyzed. Short- and long-term outcomes were described. A total of 61 patients were treated in this period (men/women ratio 44/17). Overall median follow-up was 7 months (range 2–29). There were 30 patients with a follow-up of at least 12 months. Mean hernia diameter was 6 x 5 cm (craniocaudal x laterolateral) (range 1.5 x 1.5 to 20 x 15 cm). Overall mean length of hospital stay was 4.4 days. Postoperative visual analog scale (VAS) at last follow-up was significantly lower than the preoperative VAS (3.01 vs 0.68; P = 0.011) There were no intraoperative complications. In the whole group, only 6 patients (10%) showed minor complications. Four patients had mild discomfort, another 2 patients developed a clinically significant seroma. The complication rate in the subgroup with a follow-up of at least 1 year was 13%. No recurrences were observed. This study confirms our preliminary findings on the use of this mesh. The optional positioning system offers a significantly more quick and proper mesh positioning.

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Dynamic Inguinal Hernia Repair with a 3D Fixation-free and Motion-compliant Implant: A Clinical Study

Giuseppe Amato, MD, Consultant Professor, Department of General Surgery and Emergency, University of Palermo, Palermo, Italy, Giorgio Romano, MD, Associate Professor, Department of General Surgery and Emergency, University of Palermo, Palermo, Italy, Antonino Agrusa, MD, Research Fellow, Department of General Surgery and Urgency, University of Palermo, Palermo, Italy, Gianfranco Cocorullo, MD, Associate Professor, Department of General Surgery and Urgency, University of Palermo, Palermo, Italy, Gaspare Gulotta, MD, Professor, Department of General Surgery and Urgency, University of Palermo, Palermo, Italy, Thorsten Goetze, MD, Postdoctoral Research Fellow, Department of General and Visceral Surgery, Ketteler Krankenhaus, Offenbach, Germany

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PMID: 24526424

Abstract

Static solutions for highly motile structures such as the groin seem to represent a procedural incongruence. Another important issue in prosthetic hernia repair is related to the poor quality of tissue ingrowth within conventional flat meshes and plugs. These are all static, passive devices, and thus do not move in synchrony with the natural movements of the groin. In the literature there is a clear understanding of how conventional prostheses used for inguinal hernia repair are incorporated by rigid fibrotic tissue. The term “scar plate” well emphasizes this occurrence. The ingrowth of this kind of stiff fibrotic scar leads to mesh shrinkage and to the reduction of the mesh surface area. This is considered a significant cause of recurrence and discomfort. With this in mind, the need for a more physiologic procedure to further decrease complications and recurrences in inguinal hernia repair due to implant design seems obvious. This report shows how, by eliminating invasive fixation and improving the quality of tissue ingrowth within the implant, it is possible to reduce complications. To achieve these results, a new type of 3D dynamic (inherent recoil), self-retaining implant has been developed. This newly designed implant was previously implanted in the porcine model, showing excellent outcomes. Of note were the quality of tissue ingrowth and the near absence of shrinkage, even a long time after implantation. The present study describes the outcome of this device used in open inguinal hernia repair in 91 patients having direct and indirect inguinal hernia. In this patient cohort, evaluations were made for: operation length, intraoperative complications, late complications such as seroma, infection, chronic pain, and pain assessment through VAS score. Patient follow-up was made at 1 and 2 weeks, and 1, 3, 6, 12, and 36 months. Ultrasound scans were performed for the detection of any possible implant dislodgment, shrinkage, and implant incorporation. The results of this study demonstrate that by using a purposefully designed 3D geometric implant expulsion forces can be switched into gripping forces, avoiding the need for traumatic fixation. This eliminates the typical complications related to mesh fixation such as bleeding, hematoma, chronic pain, and tissue tearing, often resulting in mesh dislodgement and recurrence. This new 3D implant results in open hernia repair procedures being safer, faster, and easier.

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WL Gore
  • WL Gore WL Gore
Acell
  • Acell Acell

Components Separation in Complex Ventral Hernia Repair: Surgical Technique and Post-operative Outcomes
Samuel W. Ross, MD, MPH, Clinical Research Fellow, General Surgery Resident, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, Bindhu Oommen, MD, MPH, Minimally Invasive Surgery Fellow, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, B. Todd Heniford, MD, FACS, Professor of Surgery, Director, Carolinas Hernia Center, Chief, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, Vedra A. Augenstein, MD, FACS, Assistant Professor of Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC

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PMID: 24700223

Abstract

There are over 350,000 ventral hernia repairs (VHR) performed in the United States annually and a variety of laparoscopic and open surgical techniques are described and utilized. Complex ventral hernias such as recurrent hernias, those with infected mesh, open wounds, coexisting enteric fistulas, parastomal hernias, and massive hernias—especially those with loss of abdominal domain—require sophisticated repair techniques. Many of these repairs are performed via an open approach. Ideally, the aim is to place mesh under the fascia with a large overlap of the defect and obtain primary fascial closure. However, it is often impossible to bring together fascial edges in very large hernias. Component separation is an excellent surgical technique in selected patients which involves release of the different layers of the abdominal wall and in turn helps accomplish primary fascial approximation. The posterior rectus sheath, external oblique or the transverse abdominis fascia can be cut and allows for closure of fascia in a tension free manner in a majority of patients. In this chapter we describe the various techniques for component separation, indications for use, how to select an appropriate type of release and post-operative outcomes.

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Prospective, Single Center Single Surgeon’s Experience with an Atraumatic Self-adhering Mesh in 100 Consecutive Patients
Tim Tollens, MD, Consultant, Halit Topal, MD, Surgical Trainee, Jelle Kennes, BSc, Bachelor in Medicine, Koen Vermeiren, MD, Consultant, Chris Aelvoet, MD, Consultant, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium

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PMID:

Abstract

The purpose of the current prospective study was to confirm the results of our previous study on the use of the Ventralight™ ST mesh. In this study we also evaluated a pre-attached positioning system. Between July 2011 and October 2013 prospectively collected data of 61 consecutive patients who underwent a laparoscopic ventral hernia repair were analyzed. Short- and long-term outcomes were described. A total of 61 patients were treated in this period (men/women ratio 44/17). Overall median follow-up was 7 months (range 2–29). There were 30 patients with a follow-up of at least 12 months. Mean hernia diameter was 6 x 5 cm (craniocaudal x laterolateral) (range 1.5 x 1.5 to 20 x 15 cm). Overall mean length of hospital stay was 4.4 days. Postoperative visual analog scale (VAS) at last follow-up was significantly lower than the preoperative VAS (3.01 vs 0.68; P = 0.011) There were no intraoperative complications. In the whole group, only 6 patients (10%) showed minor complications. Four patients had mild discomfort, another 2 patients developed a clinically significant seroma. The complication rate in the subgroup with a follow-up of at least 1 year was 13%. No recurrences were observed. This study confirms our preliminary findings on the use of this mesh. The optional positioning system offers a significantly more quick and proper mesh positioning.

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A Novel Technique of Midline Mesh Repair for Umbilical Hernia Associated with Diastasis Recti

Ovidio-Angel Matei, MD, Visiting Surgeon from Military Hospital Cluj-Napoca, Cluj, Romania, Norbert Runkel, MD, PhD, Director, Department of General Surgery, Black Forest Hospital, Villingen-Schwenningen, Germany

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PMID: 24526430

Abstract

Mesh repair has evolved as the gold standard for umbilical hernias. Surgical reconstruction of umbilical hernias in association with diastasis recti has not been discussed in the recent literature. We describe a novel surgical technique of midline mesh repair for this combined lesion. This is a retrospective review of 44 consecutive patients. Forty-four patients underwent surgery for umbilical hernia with diastasis recti between January 2010 and August 2012. All excess skin, subcutaneous tissue, and distracted midline (linea alba) were excised supraumbilically and paraumbilically according to preoperative marking. Surgical repair began with a midline running suture of the posterior rectal sheath. A light prolene mesh was placed retromuscularly into this sheath and anchored in all directions with a distance of about 5 cm from the midline using U-shaped stitches. The anterior rectal fascia was closed with a continuous suture. All information was obtained from the hospital records. The median operative time was 93.3 minutes (28 to 219 minutes). The median length of postoperative hospital stay was 5.9 days (3 to 12 days). There was no major complication. One minimal umbilical skin necrosis was observed. Analgesic medication was required in all patients. Opiods were added in 84.0% of patients on day 1, in 75.0% on day 3, and in 2.3% on day 7. Our novel technique of sublay mesh repair for combined umbilical hernia and diastasis recti is safe and effectively restores the abdominal midline.

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Pubic Inguinal Pain Syndrome: the So-called Sports Hernia

Marta Cavalli, MD, Resident in General Surgery, Univeristy of Insubria, Istituto Clinico Sant’Ambrogio, Milano, Italy, Grazia Bombini, MD, Medical Student, Univeristy of Insubria, Istituto Clinico Sant’Ambrogio, Milano, Italy, Giampiero Campanelli, MD, Professur of Surgery, Univeristy of Insubria, Istituto Clinico Sant’Ambrogio, Milano, Italy

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PMID: 24526429

Abstract

The “sportsman’s hernia” commonly presents as a painful groin in those sports that involve kicking and twisting movements while running, particularly in rugby, football, soccer, and ice hockey players. Moreover, sportsman’s hernia can be encountered even in normally physically active people. The pain experienced is recognized at the common point of origin of the rectus abdominis muscle and the adductor longus tendon on the pubic bone and the insertion of the inguinal ligament on the pubic bone. It is accepted that this chronic pain caused by abdominal wall weakness or injury occurs without a palpable hernia. We proposed the new name “pubic inguinal pain syndrome.” In the period between January 2006 and November 2013 all patients afferent in our ambulatory clinic for chronic groin pain without a clinically evident hernia were assessed with medical history, physical examination, dynamic ultrasound, and pelvic and lumbar MRI. All patients were proposed for a conservative treatment and then, if it was not effective, for a surgical treatment. Our etiopathogenetic theory is based on three factors: (1) the compression of the three nerves of the inguinal region, (2) the imbalance in strength of adductor and abdominal wall muscles caused by the hypertrophy and stiffness of the insertion of rectus muscle and adductor longus muscle, and (3) the partial weakness of the posterior wall. Our surgical procedure includes the release of all three nerves of the region, the correction of the imbalance in strength with the partial tenotomy of the rectus and adductor longus muscles, and the repair of the partial weakness of the posterior wall with a lightweight mesh. This treatment reported excellent results with complete relief of symptoms after resumption of physical activity in all cases.

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A Prospective Study of One-year Clinical Outcomes Utilizing a Composite Three-dimensional Device with a Tissue-separating Layer for Repair of Primary Ventral and Small Incisional Hernia

Tim Tollens, MD, Consultant, Department of General Surgery, Imelda Hospital, Bonheiden, Belgium, Jenny Mitchell, BA, Manager, Ethicon Clinical Development, Livingston, United Kingdom, Peter Jones, MS, Statistician, Clinical Development, Ethicon Surgical Care, Livingston, United Kingdom, Frederik Berrevoet, MD, PhD, Associate Professor of Surgery, Department of General and Hepatobiliary Surgery, Liver Transplantation Service, University Hospital Ghent, Ghent, Belgium

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PMID: 24574019

Abstract

Primary ventral and even small incisional hernias have historically been repaired by primary closure; however, data proves that use of mesh can significantly reduce hernia recurrence. Here we report clinical outcomes at one year using the International Hernia Mesh Registry following the use of a three-dimensional tissue-separating mesh device (Proceed Ventral Patch™, Ethicon, Somerville, NJ). This ongoing prospective multi-center registry collects preoperative, perioperative, and postoperative outcome data including adverse events at 1, 6, 12, and 24 months. Patient-reported outcomes are collected including a hernia-specific questionnaire. A total of 234 patients (72.1% male, 27.9% female) from 13 sites in the United States and Europe were enrolled. Mean age and BMI were 52.2 (SD 15.0) and 29.2 kg/m2 (SD 5.2), respectively. Hernia types: umbilical 67.1%, epigastric 11.5%, small incisional including trocar 21.3%. Preoperatively 46.9% and 38.3% of patients reported symptomatic pain and movement scores, respectively. At 1 year, these were significantly reduced to 8.9% and 5.0%, respectively (p < 0.001). At 12 months hernia recurrence was 3.0% (95% CI, 1.2% to 6.1%), seroma (2.1%), infection (2.1%) with other events being less than 1%. These results indicate repair using this device led to significant improvement in pain and movement limitations and were associated with low complication and recurrence rates.

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Fixation Devices in Laparoscopic Ventral Hernia Repair: A Review
Sanne Shiroma Harsløf, MD, PhD-student, Resident, Surgical Department, Regional Hospital Horsens, Denmark, Pål Wara, MD, DMSc, Chief Surgeon, Surgical Department, Aarhus University Hospital, THG, Denmark, Hans Friis-Andersen MD, Chief Surgeon, Surgical Department, Regional Hospital Horsens, Denmark

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PMID: 24700224

Abstract

Laparoscopic ventral hernia repair (LVHR) has undergone significant change during the past two decades. Most surgeons perform the operation in a similar manner, and some procedures are standard: Careful access to the abdomen, dissection of adhesions and choice of overlap. The choice of biomaterial and the method of fixation, however, are still areas of great controversy. Primarily the mesh and fixation device should be compatible. Prosthetic meshes are divided into macro- and micro porous according to pore size. Thus, when selecting a fixation device the mesh pore size has to be considered. If the pores are too large compared to the fixation device the interface between mesh and device will be too small and fixation can be compromised. Given that, fixation can be accomplished in many different ways. Currently, there are 16 different types of fixation devices that can be categorized into four groups: Non-absorbable tacks, absorbable tacks, sutures and tissue glue (Table 1). In addition, two self-adhering meshes are available. There are many factors to consider when selecting a fixation device: Post-operative pain, infection, formation of seromas, adhesions, fixation strength, strength of ingrowth, shrinkage, fistulas, tack migration and most importantly recurrence. This paper reviews the current fixation devices and their role in the above-mentioned problems.

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