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Surgical Technology International XXVI contains 50 peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
2015 - ISSN:1090-3941
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Hernia Repair
Detecting Incisional Hernia at Clinical and Radiological Examination
Dennis Björk, MD, Resident Surgeon, Department of Surgery, Sundsvall Hospital, Sundsvall, Sweden, Yücel Cengiz, MD, PhD, Senior Lecturer, Senior Consultant Surgeon, Department of Surgery and Perioperative Science, Umeå University, Umeå, Sweden, Lena Weisby, MD, Senior Consultant Radiologist, Department of Radiology, Sundsvall Hospital, Sundsvall, Sweden, Leif A. Israelsson, MD, PhD, Associate Professor, Senior Consultant Surgeon, Department of Surgery and Perioperative Science, Umeå University, Umeå, Sweden
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Purpose: In clinical studies, incisional hernia is usually diagnosed by clinical examination. No other modality has been proven an aid in the diagnosis. The aim was to investigate the correlation between findings at clinical examination and at computed tomography when detecting incisional hernia after midline incisions. Methods: Patients underwent clinical examination by three surgeons. Computed tomography was performed in both the supine position and in the prone position and was examined by three radiologists. The correlation between investigators and methods were estimated by calculating the Fleiss Kappa values. Results: Twenty-four patients were assessed. For the clinical examination, the Kappa was 0.81. For computed tomography with the patient in the supine position, the Kappa was 0.94 and in the prone position it was 0.89. The Kappa for clinical examination and computed tomography combined was 0.80. Conclusions: At clinical examination, incisional hernia can be defined as any detectable defect in the abdominal wall with intra-abdominal contents protruding beyond the aponeurosis. The same definition can be used at computed tomography with the addition that any visible hernia sac is also regarded an incisional hernia. With this definition, there is very good agreement between investigators at clinical investigation and at computed tomography in the prone or in the supine position. The highest agreement among investigators is achieved with computed tomography in the supine position. In clinical studies, clinical examination seems adequate for diagnosing herniation but in overweight patients a CT-scan may be a further aid.
Value-based Clinical Quality Improvement (CQI) for Patients Undergoing Abdominal Wall Reconstruction
Bradley Stephan, MD, Surgery Resident, PGY3, Halifax Medical Center, Daytona Beach, Florida, Bruce Ramshaw, MD, FACS, Co-Director, Advanced Hernia Solutions, Chairman and Chief Medical Officer, Surgical Momentum, Chairman, General Surgery Residency Program, Halifax Medical Center, Associate Clinical Professor, Florida State University, Daytona Beach, Florida, Brandie Forman, Director, Patient Care Management, Advanced Hernia Solutions, Daytona Beach, Florida
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Patients with complex ventral/incisional hernias often undergo an abdominal wall reconstruction (AWR). These operations have a high cost of care and often result in a long hospital stay and high complication rates. Using the principles of clinical quality improvement (CQI), several attempts at process improvement were implemented in one hernia program over a 3-year period. For consecutive cases of patients undergoing abdominal wall reconstruction, process improvement attempts included the use of a long-term resorbable synthetic mesh (TIGR® Resorbable Matrix, Novus Scientific, Uppsala, Sweden) in place of a biologic mesh, the use of the transversus abdominis release approach in place of an open or endoscopic component separation (external oblique release) technique, and the use of a preoperative transversus abdominis plane (TAP) block using a long-acting local anesthetic (Exparel®, Pacira Pharmaceutical, Parsippany, NJ) as a part of perioperative multi-modal pain management and an enhanced recovery program. After over 60 cases, improvement in materials costs and postoperative outcomes were documented. No mesh-related complications occurred and no mesh removal was required. In this real-world, value-based application of CQI, several attempts at process improvement led to decreased costs and improved outcomes for patients who underwent abdominal wall reconstruction for complex ventral/incisional hernias. Value-based CQI could be a tool for improved health care value globally.
Resection of Ileoinguinal and Ileohypogastric Nerves Combined with Gluing in Modified Lichtenstein Repair
Andreas Baer, MD, Specialist for Visceral Surgery, Assistant Physician, Nicholas Bohnert, MD, Specialist for Visceral Surgery, Assistant Medical Director, Peter E. Goretzki, MD, Specialist for Visceral, Endocrine, and Thorax Surgery, Professor and Head of Department, General, Visceral, Thorax, and Vascular Surgery, Coloproctology, and Hernia Surgery, Bernhard J. Lammers, MD, Specialist for Coloproctology and Hernia Surgery, Chief Operating Physician of Coloproctology and Hernia Surgery, Department of Colorectal and Hernia Surgery, Lukaskrankenhaus Neuss GmbH, Academic Teaching Hospital of Heinrich Heine University, Düsseldorf, Germany
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We conducted a cohort trial to investigate the relevance of resection of the ilioinguinal and iliohypogastric nerves in combination with mesh fixation with BioGlue™ (CryoLife® Inc., Kennsaw, Georgia) in modified Lichtenstein repair to the development of chronic pain and hernia recurrence.1 In all, 430 patients underwent Lichtenstein repair. In 247 patients the mesh was fixed by means of glue, and in 183 patients it was fixed with conventional sutures. In all cases the inguinal nerves N. ilioinguinalis and N. iliohypogastricus were located and resected after identification to prevent nerve reaction to the mesh. The pain intensity was measured with a numeric analogous scale (NAS) 24 hours after surgery. All complications were recorded with a follow-up of up to 5 years. There was a significantly lower pain intensity level in the gluing group compared with the suture group 24 hours after surgery (0.016 t test). The level was 3.8±2.4 in bilateral hernia and 3.3±2.1 in unilateral hernia in the gluing group. It was 4.7±3.3 in unilateral and 3.7±2.2 in bilateral hernia in the suture group. The cut-suture time was lower in the gluing group. There were no severe pain syndromes (NAS≥4) in the gluing group and only 1.1% in the suture group. There was a higher incidence of non-bacterial wound infections in the gluing group (3.6%) than in the suture group (1.1%). The rate of recurrence after 5 years amounted to 2.0% in the gluing group and 2.2% in the suture group. The technique of using BioGlue™ for mesh fixation combined with systematic nerve dissection reduces acute and chronic postoperative pain after modified Lichtenstein repair. Only 2 of 430 patients suffered from severe chronic pain. Combined gluing and systematic resection of the inguinal nerves is more comfortable than standard Lichtenstein repair.
Middle Term Follow up of TAPP Hernia Repair Without Staples and Glue: An Audit of the Data
Giuseppe Piccinni, MD, Associate Professor of Surgery, University of Bari, Bari, Italy, Giuseppe Massimiliano De Luca, MD, General Surgeon, AOU Policlinic of Bari, Bari, Italy, Alessandro De Luca, MD, Resident in General Surgery, University of Bari, Bari, Italy, Simone Giungato, MD, Resident in General Surgery, University of Bari, Bari, Italy, Mario Testini, MD, Full Professor of Surgery, University of Bari, Bari, Italy
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Groin hernia repair by using the laparoscopic TransAbdominalPrePeritoneal (TAPP) repair approach presents lower post-operative pain with a quicker return to normal patients’ activity compared to the open technique. Nevertheless, the long learning curve, general anesthesia and increased costs due to devices are the arguments against TAPP. Currently the only mesh fixation techniques are those using glue or tacks. We report the audit of two-years follow-up about our experience using a self-gripping lightweight mesh Parietex ProGrip™ (Covidien™). The records of 39 patients for the first 50 procedures were reported. We registered wound infection, hematoma, seroma, neuralgia, numbness, and recurrence. In our opinion TAPP procedure with ProGrip™ mesh is a feasible procedure without using fixation devices: costs, chronic pain and recovery are improved. Moreover in the medium-term follow-up we are able to reduce foreign body sensation and numbness.
Long-term Outcome on the use of the Ventralight™ ST Hernia Patch in Laparoscopic Ventral Hernia Repair
Tim Tollens, MD, Consultant, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium, Halit Topal, MD, Surgical Trainee, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium, Alexander Lucardie, BSc, Apprentice, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium, Koen Vermeiren, MD, Consultant, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium, Chris Aelvoet, MD, Consultant, Department of General and Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium
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Background. Laparoscopic ventral hernia repair (LVHR) is a common procedure in abdominal surgery. Use of mesh has become the gold standard in the last decade because of significantly fewer recurrences. Subsequently, the attention shifted to reduce mesh related complications in the short- and long-term as well as to facilitate its handling and positioning. In continuation of our previous study, we conducted a final analysis about the use of the Ventralight™ ST hernia patch (Davol Inc, Subsidary of C. R. Bard, Inc. Warwick, RI). Methods. Prospectively collected data of 61 consecutive patients (men/women: 44/17) from July 2011 to October 2013 were analysed in this final study. Patients were evaluated clinically at four time points in total. At the final clinical check- up, 97% of the total study population was reassessed. The primary outcome parameter was recurrence. Secondary outcome parameters were described in terms of mesh related complications, pain scores, and quality of life. Results. Mean follow-up time was 23 months (range 16–44). Mean length of hospital stay was four days (range 2–17). There were no operative complications. Two patients (both > 80 years old) died more than one year after the procedure because of a cardiovascular event. One morbidly obese patient (2%) treated for a recurrent incisional hernia showed a second recurrence at the last follow-up visit. A clinical significant seroma was observed in two patients (3%) one month postoperatively. At last follow-up, two patients (3%) reported persistent mild discomfort at one specific spot. There was a significant reduction in the visual analogue scale (VAS) scores at the last follow-up visit compared to preoperative scores (3.01 vs. 0.27; P < 0.01). Quality of life measurements using the SF-36 questionnaire showed good results. Conclusion. This final analysis of long-term follow-up results on the use of the Ventralight™ ST hernia patch in laparoscopic ventral hernia repair confirms our preliminary findings of the previous two reports. Use of the Ventralight™ ST hernia patch is associated with good short- and long-term outcomes and can be considered as safe and feasible in LVHR.
