Laparoscopic Ventral Hernia Repair with a Non-Woven Hernia Mesh
Bruce Ramshaw, MD, Surgeon, Brandie (Remi) Forman, BA, Hernia Clinician, University Surgeons Associates, Knoxville, Tennessee, Eric Heidel, PhD, Associate Professor, Division of Biostatistics, Department of Surgery, University of Tennessee Graduate, School of Medicine, Knoxville, Tennessee, Elizabeth Barker, PhD, Assistant Professor, Department of Mechanical, Aerospace and Biomedical Engineering, Tickle College of Engineering, University of Tennessee, Knoxville, Tennessee
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Introduction: Laparoscopic ventral hernia repair is a commonly performed procedure with a variety of mesh options. A relatively new mesh option is a non-woven polypropylene mesh with a silicone barrier designed for intraabdominal placement. This non-woven randomly oriented polypropylene microfiber hernia mesh may have benefits with potentially better biocompatibility compared with other ventral hernia repair mesh options.
Materials and methods: A clinical quality improvement (CQI) program was initiated for ventral hernia patients to better measure and improve outcomes. From March 2013 to September 2015, 62 laparoscopic ventral hernia repairs were performed with this non-woven polypropylene mesh on 61 patients (one patient had two separate hernia repairs). Attempts were made to obtain long-term (> 2 years) follow up.
Results: There were 36 females and 25 males. The average age was 58.7 years (range 21–85). The average body mass index (BMI) was 36.2 (range 21.4–62.4). There were 51 (82%) incisional hernias and 11 (18%) primary hernias. There were 29 (47%) recurrent hernias. Mean hernia size was 83.4cm2 (range 1–400) and mean mesh size was 508.5cm2 (range 144–936). The mean operating room (OR) time was 108.2 minutes (range 38–418). The mean length of hospital stay was 2.7 days (range 0–13). There was one intraoperative complication—an injury to an inferior epigastric vessel that had a minor postoperative bleed that was self-limiting and required no treatment. There was one postoperative death due to aspiration on postoperative day #4. There has been one recurrence (1.6%) with long-term follow up. There were two patients (3.2%) with suture site pain postoperatively that resolved with suture site injections of local anesthetic in the clinic. There were no patients that required rehospitalization within 30 days after surgery. There were no mesh-related complications and no incidence of mesh removal was required.
Conclusion: The results for laparoscopic ventral hernia repair, using a relatively new non-woven randomly oriented polypropylene microfiber mesh, are good with long-term follow up completed in the majority of patients. More experience with this type of mesh could generate evidence for the benefits of this mesh material in laparoscopic ventral hernia repair.
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Laparoscopic Inguinal Hernia Repair Using ProGrip™ Self-Fixating Mesh: Technical Learning Curve and Mid-Term Outcomes
Logan T. Mellert, DO, Surgical Fellow, Advanced Laparoscopic and Bariatric Surgery, Summa Health, Akron, OH, Maureen E. Cheung, DO, MS, Chief Surgical Resident, Western Reserve Hospital, Cuyahoga Falls, OH, John G Zografakis, MD, FACS, FASMBS, Director, Weight Management Institute, Director, Adrian G Dan, MD, FACS, FASMBS, Director, Weight Management Institute, Program Director, Advanced Laparoscopic and Bariatric Surgery Fellowship, Associate Professor of Surgery, Northeast Ohio Medical University, Summa Health, Akron, OH
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Purpose: Self-fixating mesh has been introduced to further improve the quality results already seen with laparoscopic inguinal hernia repair. An observational study was undertaken to evaluate the technical learning curve and mid-term outcomes associated with the use of ProGrip™ (Medtronic, Minneapolis, MN, USA) laparoscopic self-fixating mesh in transabdominal preperitoneal (TAPP) inguinal herniorrhaphy.
Methods: Patients who underwent elective laparoscopic TAPP inguinal herniorrhaphy by a single surgeon using ProGrip™ laparoscopic self-fixating mesh within a one-year period were studied. The primary outcome measures included the time from mesh introduction to the final position (MI-FP), surgical complications, and pain scores. Demographic and other perioperative outcome data were collected and analyzed.
Results: Forty hernias were repaired in 29 patients with a laparoscopic TAPP approach. The average MI-FP was 249.4 seconds for the first 20 repairs, and 118.6 seconds (p < 0.001) for the final 20. Minor post-operative surgical complications were reported by 13.8% of patients; there were no major surgical complications. The average pain score on a scale of 0 to 5 was 0.9 (SD = 0.67, range 0–3).
Conclusions: Surgeons with reasonable laparoscopic experience can expect to become fully proficient in the manipulation of self-fixating mesh after 15 to 20 repairs. Use of this product yielded low intraoperative and mid-term postoperative complication rates as well as low postoperative pain.
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Robotic Inguinal Hernia Repair (TAPP)—First Experience with the New Senhance™ Robotic System
Robin Schmitz, MD, Resident Surgeon, Justin Barr, MD, PhD, Resident Surgeon, Sabino Zani, MD, Assistant Professor of Surgery, Duke University Medical Center, Durham, North Carolina, Frank Willeke, MD, PhD, Professor of Surgery, Chief Surgeon, Michael Scheidt, Resident Surgeon, Heike Saelzer, MD, Consultant Surgeon, Ibrahim Darwich, MD, Consultant Surgeon, Head of Minimal Invasive Surgery and Robotics Department of General Visceral, and Vascular Surgery, St. Marien – Krankenhaus, Siegen, Germany, Dietmar Stephan, MD, Visiting Professor of Gastroenterological Surgery, Saitama Medical University, International Medical Center, Yamane, Japan
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Introduction: This retrospective study was performed to evaluate the safety and feasibility of the new Senhance™ Robotic System (TransEnterix Inc., Morrisville, North Carolina) for inguinal hernia repairs using the transabdominal preperitoneal approach.
Materials and Methods: From March to September 2017, 76 inguinal hernia repairs in 64 patients were performed using the Senhance™ Robotic System. Patients were between 18 and 90 years of age, eligible for a laparoscopic procedure with general anesthesia, had no life-threatening disease with a life expectancy of less than 12 months, and a body mass index (BMI) < 35. A retrospective chart review was performed for a variety of pre-, peri-, and postoperative data including, but not limited to, patient demographics, hernia characteristics, and intraoperative and postoperative complications.
Results: Fifty-four male and 10 female patients were included in the study. Median age was 56.5 years (range 22–86 years), and median BMI was 25.9 kg/m2 (range 19.5–31.8 kg/m2). Median docking time was seven minutes (range 2–21 minutes), and median operative time was 48 minutes (range 18–142 minutes). Two cases were converted to standard laparoscopic surgery due to robot malfunction and abdominal wall bleeding, respectively. Median length of stay was one day.
Conclusion: We report the first series of laparoscopic inguinal hernia repairs using the new Senhance™ Robotic System. Compared to conventional laparoscopic transabdominal preperitoneal (TAPP) hernia repairs, there was no significant difference in operative time or perioperative complications. Additionally, there was no significant learning curve detected due to its intuitive applicability. Therefore, the Senhance™ Robotic System promises broad applicability across a range of laparoscopic general surgical operations.
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A Preliminary Assessment of Abdominal Wall Tension in Patients Undergoing Retromuscular Hernia Repair
Paul L. Tenzel, MD, Surgical Resident, Robert G. Johnson, MD, Surgical Resident, Jordan A. Bilezikian, MD, Surgical Resident, William F. Powers, MD, Assistant Professor of Surgery, William W. Hope, MD, Associate Professor of Surgery, Program Director, Department of Surgery, New Hanover Regional Medical Center, Wilmington, North Carolina
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A common technique for ventral and incisional hernia repair is the retrorectus repair (Rives-Stoppa). The posterior rectus sheath is incised bilaterally, and mesh is placed retromuscularly. There is little information on how this component separation technique affects abdominal wall tension. We evaluated abdominal wall tension in patients undergoing retrorectus repair of abdominal wall hernias.
Patients undergoing retrorectus repair of their ventral hernias were enrolled in a prospective, Institutional Review Board-approved protocol to measure abdominal wall tension from 8/1/2013 to 8/2/2017. Demographic information and operative details were documented. Abdominal wall tensions were measured using scales attached to Kocher clamps that were clamped to the fascia and brought together in the midline. Measurements were made before and after incising the posterior rectus sheaths. Data were analyzed with a repeated measures analysis of variance (ANOVA), and differences between individual groups were analyzed by least square differences.
Forty-five patients had tension measurements. Average age was 58 years (range 29–81)—78% Caucasian, 51% female, an average body mass index (BMI) of 35 kg/m2 (range 20–62), and 38% recurrent hernias. The average hernia defect was 121.9 cm2, and the average mesh size was 607.8 cm2. There was a significant reduction in tension after bilateral posterior rectus sheath incision (3.1 lbs vs. 5.6 lbs, p<0.0001). In this evaluation, abdominal wall tension measurements are shown to be a feasible adjunct during open hernia repair with retrorectus repair. Transection of the posterior rectus sheath decreases tension during hernia repair and may help guide surgeons regarding when to use this procedure.
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Initial Experience with Robotic Hernia Repairs: A Review of 150 Cases
Ty Kirkpatrick, DO, Minimally Invasive Surgery Fellow, Our Lady of the Lake Physician Group, Baton Rouge, Louisiana, Bethany Zimmerman, MD, Resident, Louisiana State University Health Science Center, New Orleans, Louisiana, Karl LeBlanc MD, MBA, FACS, FASMBS, Associate Medical Director, Our Lady of the Lake Physician Group, Baton Rouge, Louisiana
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Background: Robotic-assisted surgery has proved to be a valuable modality in specialties such as urology and gynecology and has gained wide acceptance in those fields. Its value in general surgery, however, has had a slower acceptance rate among surgeons. This study reviews my first 150 cases using the robot for one of the most common general surgery operations—the repair of hernias.
Materials and Methods: All robotic hernia cases performed by a single surgeon were documented in an Excel® (Microsoft Corporation, Redmond, Washington) spreadsheet beginning in April, 2014. Data recorded included patient diagnosis, hernia defect size, mesh type and size, console time and total operative time, as well as first assistant (fellow, resident, or none). The postoperative course was carefully reviewed through the electronic medical record to identify complications and readmissions.
Results: The average total case time was 138 minutes, while the average console time was 100 minutes. Incisional hernias made up 50.4% of the procedures, inguinal hernias—17.2%, ventral/umbilical—9.8%, parastomal—9.2%, lumbar—5.5%, hiatal—4.9%, and spigelian—2.5%. The average defect size was 48.47cm2. Complication rates were low at 5.3%, most of which were minor. There were no mortalities. There has been one known hernia recurrence.
Conclusions: This review shows that the use of the robot has proven to be safe and effective, and it has many benefits in hernia repair. One of those benefits is the ability to close the fascial defect with a running suture, thus avoiding the postoperative pain associated with transfascial sutures. The ability to intracorporeally fix a large piece of mesh to the abdominal wall that adequately and evenly covers the defect is another benefit. The high-quality three-dimensional view and the ability to articulate the instruments are well-established benefits of the robot as well. Robotic assistance also allows us to perform a minimally invasive hernia repair on large complex defects that would have otherwise been performed via an open approach.
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Can the General Surgeon Use Quilting Sutures to Prevent Seromas Following Abdominal Wall Surgery?
Sala Abdalla, BSc, MBBS, MRCS, Specialist Registrar in General Surgery, Tayo Oke, MBBS, M.Med.Sci, FRCS (Gen), FRCS (Ed), Consultant Colorectal Surgeon, Queen Elizabeth Hospital, Lewisham & Greenwich NHS Trust, London, UK
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A common post-operative complication of many operations is seroma formation, which, while generally considered to be relatively minor, can be problematic for patients and a drain on healthcare resources due to the need for frequent outpatient reviews and repeated aspirations. Several mechanisms have been implicated in the development of seromas, and drains have traditionally been used as a preventative strategy. However, drains are falling out of favour, not least because the evidence to support their use is limited and conflicting. In recent years, the use of quilting sutures, also known as progressive tension sutures, is starting to emerge as a favourable alternative for preventing post-operative seroma formation. Several studies and trials support their use in abdominal wall operations such as abdominoplasties and at abdominal wall donor sites in reconstructive breast operations. General surgeons perform many operations on the abdominal wall, such as ventral hernia repair, that predispose the patient to seroma formation. Can quilting sutures be used in operations on the abdominal wall to prevent seroma formation? This aim of this review was to evaluate the use of quilting sutures as described in several studies to reduce the incidence of post-operative seroma.
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