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Hernia Repair

Long-Term Outcome After Laparoscopic Repair of Primary, Unilateral Inguinal Hernia Using a Self-Adhering Mesh
Tim Tollens, MD, Consultant, Halit Topal, MD, Surgical Trainee, Alexander Lucardie, BSc, Registrar, Koen Vermeiren, MD, Consultant, Chris Aelvoet, MD, Consultant, Kurt Devroe, MD, Consultant, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium

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Abstract


Following our previous study about a lightweight self-adhering mesh (Adhesix®, Cousin Biotech, Wervicq-Sud, France; distributed by Davol Inc., subsidiary of C.R. Bard, Inc.), we report the long-term results with the use of this mesh in patients treated for a primary, unilateral inguinal hernia without any other hernias. Prospectively collected data of 100 patients between February 2011 and February 2014 were analyzed. The mean follow-up time was 2.7 years (range 1–4), and mean length of hospital stay was 0.6 days (range 0.5–1). At the time of the last follow-up visit, two patients (2%) had a recurrent inguinal hernia. Compared to preoperative values, patients reported a significant reduction in their pain sensation (visual analogue scale, VAS) after one month (4.61 vs. 1.32; P<0.001). A difference in VAS scores remained significant at the last follow-up visit (1.31 vs. 0.28; P<0.001). Patients reported high quality of life scores. Only one patient (1%) developed a clinically significant seroma that required an evacuating puncture. Two patients (2%) had superficial wound infections. Neither mesh infections nor mortalities occurred. This study, with a long follow-up, confirms our previous results: use of the Adhesix® mesh is safe, feasible, and efficient in laparoscopic hernia repair.

 

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Laparoscopic Treatment of Giant Ventral Hernia: Experience of 35 Patients

Michele Grande, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Giorgio Lisi, MD, Resident, Department of Surgery, University Hospital of Borgo Roma, Verona, Italy, Michela Campanelli, MD, Resident, Department of Surgery, University Hospital of Modena, Modena, Italy, Simona Grande, Intern, Department of Surgery, University Hospital of Messina, Messina, Italy, Dario Venditti, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Casimiro Nigro, MD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy, Francesca Cabry, MD, Researcher, Department of Surgery, University Hospital of Modena, Modena, Italy, Massimo Villa, MD, PhD, Assistant Professor, Department of Surgery, University Hospital of Tor Vergata, Rome, Italy

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Abstract


Background: Minimal access surgery for incisional hernia repair is still debated, especially for giant wall defects. Laparoscopic repair may reduce pain and hospital stay. This study was designed to evaluate the feasibility of the laparoscopic technique in giant hernia.
Materials and Methods: From 2007 to 2013, 35 consecutive patients with giant ventral hernia, according to the Chevrel classification, underwent laparoscopic repair. Fourteen patients were obese, with a body mass index (BMI) > 30 and in 21 patients the mean BMI was 24 (range 22–28). In all patients, the wall defect was larger than 20 cm.
Results:
Mean operative time was 159±30 minutes, and, for defects larger than 25 cm, it was 210±20 minutes. Patient conversion did not occur. In 29 patients, the mean wall defect was 20x25 cm, and in six patients the mean wall defect was 26x31 cm, and, as measured from within the peritoneal cavity, the mean overlap was 5 cm (range 3–6). Short-term antibiotic prophylaxis consisted of Cefazolin 2 g IV (intravenous) the day of surgery. All patients were discharged within 72–96 hrs. The mean follow-up was 24 months. No infection occurred and no chronic pain was recorded. However, three seroma were observed (outpatient treatment) and two xiphoid recurrences were observed.
Conclusions: Laparoscopic hernia repair is technically feasible and is safe in patients with giant fascial defects as well as obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence. This approach should be reserved for patients with no history of previous hernia repair. Further studies are expected to confirm these promising results.

 

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Real-World Clinical Quality Improvement for Complex Abdominal Wall Reconstruction
Bruce Ramshaw, MD, Professor and Chair, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, Brandie (Remi) Forman, BA, Hernia Clinician and Patient Care Manager, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, Karla Moore, PhD, Dean, Academic Assessment and Planning, Daytona State College, Daytona Beach, Florida, Eric Heidel, PHD, Assistant Professor, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, Michael Fabian, MD, Surgeon, Department of Surgery, Halifax Health, Daytona Beach, Florida, Greg Mancini, MD, FACS, Associate Professor, Program Director, Department of Surgery, University Surgeons Associates, Knoxville, Tennessee, Girish P. Joshi, MBBS, MD, FFARCSI, Professor, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Director of Perioperative Medicine and Ambulatory Anesthesia, Parkland Health and Hospital System, Dallas, Texas

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Abstract


Introduction: Traditional methods of clinical research may not be adequate to improve the value of care for patients undergoing abdominal wall reconstruction (AWR). These patients are prone to high complication rates and high costs. Here, we describe a clinical quality improvement (CQI) effort to enhance outcomes for patients undergoing AWR.
Materials and Methods: CQI was applied for the entire care cycle for consecutive patients who underwent AWR from August 2011–September 2015. Initiatives for improving value during this period included use of long-term resorbable synthetic mesh as well as administration of preoperative bilateral transversus abdominus plane (TAP), and intraoperative abdominal wall blocks using long-acting bupivacaine as a part of a multimodal regimen. Outcomes data that measure value in the context of AWR were collected to compare outcomes for the patients who received TAP blocks only, TAP and intraoperative blocks, and those who received no block.
Results: One hundred and two patients who had AWR for abdominal wall pathology were included. Outcomes including total opioid use, duration of stay and opioid use in the postanesthesia care unit (PACU), length of hospital stay (LOS), major wound complications, and costs, all improved over time. Specifically, PACU opioid use, total opioid use, and LOS were decreased in the two groups that received blocks versus a group that did not have any type of block.
Conclusions: CQI program implementation in patients undergoing AWR resulted in measurable improvement of value-based outcomes over time. A CQI effort applied to the entire patient cycle of care should be routinely utilized.

 

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