Laparoscopic abdominal wall surgery - 56k · Laparoscopic abdominal wall surgery Marc Miserez UZ Leuven Filip Muysoms AZ Maria Middelares Gent 8th edition “Warm‐up Package”

Laparoscopic abdominal wall surgery

Marc MiserezUZ Leuven

Filip MuysomsAZ Maria Middelares Gent

8th edition “Warm‐up Package”IRCAD Strasbourg, Thursday April 7th 2011

• Laparoscopic inguinal hernia repair– The EHS classification and EHS guidelines for inguinal hernias– Technique of TAPP for inguinal hernia repair

– Technique of TEP for inguinal hernia repair

– Laparoscopic approach to incarcerated femoral hernias

• Laparoscopic primary ventral and incisional hernia repair– Ventral hernias: classifications and repair techniques

– Meshes and fixation devices for lap ventral hernia repair– Techniques of laparoscopic ventral hernia repair

– Clinical evidence on open vs laparoscopic ventral hernia repair









Inguinal hernia treatment:Inguinal hernia treatment:factors to considerfactors to consider

Recurrence

Quality of lifepostoperative recovery, chronic pain

Safetyrisk for perioperative complications

Learning curvegrade of difficulty/reproducibility

Costhospital and society costs

Let us then speak the Let us then speak the same languagesame language

•• Hernia classificationHernia classification

•• Outcome parametersOutcome parameters

The EHS Groin Hernia ClassificationThe EHS Groin Hernia Classification

≤ 1 finger 1-2 fingers

> 2 fingers

indirect

femoral

direct

The EHS guidelines on the treatmentof inguinal hernia in adult patients

Simons et al, Hernia 2009; 13: 343-403

TopicsTopics•• Risk factors/preventionRisk factors/prevention•• DiagnosticsDiagnostics•• Indications for treatmentIndications for treatment•• ClassificationClassification•• TreatmentTreatment

– General– Bilateral– Recurrent– Laparoscopy: TAPP vs TEP– Women– Young men (18-30)

•• BiomaterialsBiomaterials


TopicsTopics•• Training/specialist centersTraining/specialist centers

•• Complications (excl recurrence)Complications (excl recurrence)

•• Chronic painChronic pain

•• Antibiotic prophylaxisAntibiotic prophylaxis•• AnesthesiaAnesthesia•• Day SurgeryDay Surgery•• Postoperative pain controlPostoperative pain control•• Postoperative recoveryPostoperative recovery•• AftercareAftercare

•• CostsCosts


Levels of evidenceOxford Centre for EvidenceOxford Centre for Evidence--based Medicine Levels of Evidence (2001)based Medicine Levels of Evidence (2001)

1a systematic reviews of RCTs1b individual high quality RCT

2a systematic reviews of cohort studies2b individual cohort study or low quality RCT2c “outcomes” research

3a systematic reviews of case-control studies3b individual case-control study

4 case-series and poor quality cohort and case-control studies

5 expert opinion

RecommendationA

B

C

D

Treatment:

All male adult (>30 years) patients with a All male adult (>30 years) patients with a symptomatic inguinal hernia should be operated symptomatic inguinal hernia should be operated on using a mesh technique.on using a mesh technique.

The open Lichtenstein and endoscopic inguinal The open Lichtenstein and endoscopic inguinal hernia techniques are recommended as the best hernia techniques are recommended as the best evidenceevidence--based options for repair of a primary based options for repair of a primary unilateral hernia unilateral hernia providing the surgeon is sufficiently providing the surgeon is sufficiently experienced in the specific procedure. experienced in the specific procedure.

Grade AGrade A Mc Cormack et al, 2005Mc Cormack et al, 2005Schmedt et al, 2005Schmedt et al, 2005

Lichtenstein hernioplastyLichtenstein hernioplasty

Lichtenstein and Shulman, Int Surg 1986

large prosthesis withreinforcement of the whole myopectineal orifice

~ minimally invasive STOPPA repair~ minimally invasive STOPPA repair (GPRVS)Chirurgie, 1973; 99: 119-123

Endoscopic groin hernia repairEndoscopic groin hernia repair

Flow diagram treatmentFlow diagram treatment

Endoscopic vs Lichtenstein Endoscopic vs Lichtenstein FU > 48 monthsFU > 48 months

RecurrenceRecurrence

± 5%

Postoperative recovery

It is recommended that an endoscopic It is recommended that an endoscopic technique is considered if a quick technique is considered if a quick

postpost--operative recovery is particularly important.operative recovery is particularly important.

Grade AGrade A

Endoscopic mesh techniques result in a Endoscopic mesh techniques result in a lower chance of chronic pain/numbness lower chance of chronic pain/numbness than Lichtenstein.than Lichtenstein.

In the longIn the long--term (> 3term (> 3--4 years FU), these differences4 years FU), these differencesseem to decrease for the aspect pain, seem to decrease for the aspect pain, but not for numbness.but not for numbness.

Level 1B

Treatment : chronic pain

It is recommended that risks of development of It is recommended that risks of development of chronic postoperative pain are taken into accountchronic postoperative pain are taken into accountwhen the method of hernia repair is decided uponwhen the method of hernia repair is decided upon

Grade BGrade B

lower age lower age (level 2A)(level 2A)

preoperative groin pain preoperative groin pain (level 2B)(level 2B)

preoperative chronic pain conditions (level 2B)

female gender (level 2B)

Treatment – chronic pain

Minimally invasive surgery is there to stay Minimally invasive surgery is there to stay

ButBut……

Endoscopic hernia techniques vs. Endoscopic hernia techniques vs. Lichtenstein repair result in aLichtenstein repair result in a

Longer operation time (8Longer operation time (8--13min),13min),Higher incidence of seromaHigher incidence of seroma

Level 1A

Mc Cormack et al, 2005Mc Cormack et al, 2005Schmedt et al, 2005Schmedt et al, 2005

Treatment

Need for general anesthesia

It is recommended that, It is recommended that, from a from a hospital hospital perspective, perspective, an open mesh procedure is used an open mesh procedure is used for the treatment of primary unilat. inguinal hernia.for the treatment of primary unilat. inguinal hernia.

From a From a sociosocio--economiceconomic perspective, perspective, an endoscopic procedure is proposed an endoscopic procedure is proposed for the active working population, for the active working population, especially for bilateral herniasespecially for bilateral hernias

Grade AGrade A

Costs

How to reduce hospital costsHow to reduce hospital costsReusable instrumentsReusable instruments

TrocarsTrocars

Fixation devices (selective)Fixation devices (selective)

Ambulatory surgeryAmbulatory surgery

Endoscopic surgery:Endoscopic surgery:long and steep learning curvelong and steep learning curve

Treatment: Complications laparoscopy

There appears to be a higher rate of rare but There appears to be a higher rate of rare but serious complications with endoscopic repair,serious complications with endoscopic repair,

especially during the especially during the learning curve learning curve periodperiod

Level 2BLevel 2B

Training: the learning curve

The learning curve for performing endoscopic inguinal hernia repair (especially TEP) is longer than for open Lichtenstein repair,

and ranges between 50 and 100 procedures, with the first 30-50 being most critical

Level 2C

Learning curve errors in laparoscopic surgery

Not (longer) tolerated

The learning curve depends also on the The learning curve depends also on the structure of the training program! structure of the training program!

A learning curve is far from a straight progression

The most important variables The most important variables in the learning curvein the learning curve

Structured training programStructured training program

Laparoscopic experience of the traineeLaparoscopic experience of the trainee

Patient selection– No recurrent or scrotal hernia– No previous appendectomy for right sided hernia– Female patient

Type of supervisionType of supervision– Mentoring vs proctoring– Expertise and motivation of the trainer

Groin hernia: endoscopic repairGroin hernia: endoscopic repair

• TAPP (Transabdominal Preperitoneal)more easy to learn - endoscopic suturingtransperitoneal approach

higher risk for postoperative intestinal obstructionDuron et al, Arch Surg 2000 Bringman and Blomqvist, Hernia 2005

laparoscopic exploration

•TEP (Totally ExtraPeritoneal) more difficult to learn

anatomy more difficult to understandlimited working space

preservation of peritoneal integrity – safer?laparoscopic exploration also easily possible

Groin hernia: anatomic aspectsGroin hernia: anatomic aspects

Be familiar with the anatomy!Be familiar with the anatomy!

inguinal ligament (Poupart)

genital branch of genitofemoral nerve

falx inguinalis – conjoint tendon

lacunar ligament (Gimbernat)

obturator artery

= pectineal ligament

ramus superior ossis pubis

pubic symphysis

TRIANGLE OF PAINTRIANGLE OF DOOM

indirect inguinal herniadirect

inguinal hernia

femoral hernia

















Systematic TEP inguinal hernia Systematic TEP inguinal hernia repair in 10 consecutive stepsrepair in 10 consecutive steps

Miserez et al, Surg Lap Endosc Percut Tech 2009Miserez et al, Surg Lap Endosc Percut Tech 2009

1.1. Introduction of first trocarIntroduction of first trocar2.2. Introduction of second trocarIntroduction of second trocar3.3. Dissection to BogrosDissection to Bogros’’ space and space and

introduction of third trocarintroduction of third trocar4.4. Reduction of direct inguinal herniaReduction of direct inguinal hernia5.5. Reduction of femoral/obturator herniaReduction of femoral/obturator hernia6.6. Reduction of indirect inguinal herniaReduction of indirect inguinal hernia7.7. Lateral dissection and reduction of Lateral dissection and reduction of

preperitoneal lipoma preperitoneal lipoma 7’ Contralateral dissection8.8. Preparation and introduction of the meshPreparation and introduction of the mesh9.9. Placement of the mesh and fixation Placement of the mesh and fixation

in selected casesin selected cases10.10. DesufflationDesufflation basic advanced


• Video TEP Marc

Treatment: laparoscopyTAPP vs. TEP

For endoscopic inguinal hernia techniques,For endoscopic inguinal hernia techniques,TAPP seems to be associated with higher ratesTAPP seems to be associated with higher ratesof portof port--site hernias and visceral injuriessite hernias and visceral injuries

while there appear to be more conversions with TEPwhile there appear to be more conversions with TEP

Level 2ALevel 2A TAPPTAPP TEPTEP openopen

VascularVascularinjuriesinjuries

0.13%0.13% 0%0% 0%0%

VisceralVisceralinjuriesinjuries

0.65%0.65% 0.16%0.16% 0.14%0.14%

Memon et al, Br J Surg 2003Memon et al, Br J Surg 2003McCormack et al, Health Technology Assessment 2005McCormack et al, Health Technology Assessment 2005

Treatment: laparoscopy

TAPP vs. TEP

It is recommended that anIt is recommended that anextraperitoneal approach (TEP)extraperitoneal approach (TEP)is used for endoscopic inguinal hernia operationsis used for endoscopic inguinal hernia operations

Grade BGrade B

Our personal vision

“you do the best what you do the most”

posterior approach: laparoscopic (tep)

anterior approach: lichtenstein








Acces to the peritoneum

• Verres needle

• Hasson trocar:– Previous laparotomies

– Obstruction with great distention of the small bowel


Case 1

• Incarcerated omentum + cyst in the hernial sac


Case 2

• Reversible ischemia of small bowel


Case 3

• Small bowel necrosis and perforation


Conclusions

• Laparoscopy provides a good evaluation of the intraabdominal situation and extent of small bowel ischemia

• TAPP provides an adequate mesh repair for the hernia if no bowel resection is nessecary

• In cases of small bowel resection we plan a secondary hernia repair 4 weeks later








Start slide

VENTRAL HERNIASClassifications and Definitions

Filip MuysomsAZ Maria Middelares

Gent

IRCAD Strasbourg, Thursday April 7th 2011

• classifications and definitions of hernias• classification of mesh positions• classification of complications after surgery• ventral hernias and the RIZIV-INAMI


The abdominal wall

“ The abdominal wall is the musculo-fibreus covering of the contents of the abdominal

cavity.”

Including: the anterior and lateral abdominal wall muscles, the diaphragm, the psoas muscles and the perineal muscles.

Abdominal wall hernia

“ An abdominal wall hernia is an abnormal protrusion of the contents of the abdominal

cavity or of pre-peritoneal fat through a defect or a weakness in the abdominal wall.”

Ventral hernia

“ A ventral hernia is a hernia of the abdominal wall excluding the inguinal area, the

diaphragm and the pelvic area.”

Primary ventral hernia

“ A primary ventral hernia is a ventral hernia that was present at birth or that developed

spontaneously without trauma to the abdominal wall as a cause of the hernia.”

Primary ventral hernia

• Umbilical hernia• Epigastric hernia • Spighelian hernia• Lumbar hernia

Secondary ventral hernia

“ A ventral hernia that developed after a traumatic breach of the integrity of the

abdominal wall.”

Secondary ventral hernia

• Incisional hernia• Traumatic hernia

– blunt or penetrating trauma • Ventral hernias after tissue loss

– oncological surgery– open abdomen treatment

• Parastomal hernias

www.springerlink.com

VARIABELS FOR CLASSIFICATION OF VENTRAL AND INCISIONAL HERNIAS

Chevrel and Rath

Korenkov Shumpelich ammarturo Swedish Dietz BSAWS-DHS

Size of the hernia defect: surface area, lenght, width

Width Width or lenght

Maximal size

Width Width andlenght

Width and lenght

Width

Size of the hernia sac

Number of hernia defects X X

BMI of the patient X X

Ratio anterior abdominal wall surface/ wall defect surface

X

Ratio between the abdominal volume / the volume of the hernia sac

Primary versus incisional hernias X

Recurrent hernias (number of previous repairs)

X X X X X X

Previous mesh implantation X

Indication for primary operation of the incisional hernia

X

Type and localisation of the incision X

Symptoms of the hernia X

Reducibility of the hernia X X X

Localisation of the hernia X X X X X X X

The anatomy of the pantient in the subcostal area: sternocostal angle

X

Risk factors for hernia recurrence X

E H S

Primary Abdominal Wall Hernia

Classification

Diameter

cm

Small

<2cm

Medium

≥2-4cm

Large

≥4cm

Epigastric Midline

Umbilical

Spigelian Lateral

Lumbar

E H S

Incisional Hernia Classification

subxiphoidal M1

epigastric M2

umbilical M3

infraumbilical M4

Midline

suprapubic M5

subcostal L1

flank L2

iliac L3 Lateral

lumbar L4

Recurrent incisional hernia? Yes O No O

length: cm width: cm

Width

cm

W1

<4cm

O

W2

≥4-10cm

O

W3

≥10cm

O

E H S


subxiphoidal M1

epigastric M2

umbilical M3

infraumbilical M4

Midline

suprapubic M5

subcostal L1

flank L2

iliac L3 Lateral

lumbar L4



Width

cm

W1

<4cm

O

W2

≥4-10cm

O

W3

≥10cm

O

E H S


subxiphoidal M1

epigastric M2

umbilical M3

infraumbilical M4

Midline

suprapubic M5

subcostal L1

flank L2

iliac L3 Lateral

lumbar L4



Width

cm

W1

<4cm

O

W2

≥4-10cm

O

W3

≥10cm

O



drawing courtesy of Prof Ulrich Dietz, Würzburg

SkinRectus fasciaPeritoneumRectus muscle

Hernia sac

Hernia orifice


Onlay mesh position

mesh


Inlay mesh position

mesh


Retromuscular mesh positionConventional transfixing sutures

mesh


mesh

Retromuscular mesh positionNon tension sutures

SkinRectus fasciaPeritoneumRectus muscle Glue or self‐fixation

Retromuscular mesh positionFixation with glue or self‐fixating mesh

mesh


Preperitoneal mesh position

mesh


Intraperitoneal mesh positionOpen surgery

mesh


Intraperitoneal mesh positionLaparoscopic surgery

mesh

Mesh bridging (sutures & tackers)


Intraperitoneal mesh position

mesh

Laparoscopic surgery Mesh bridging (Double Crown)


Intraperitoneal mesh position

mesh

Laparoscopic surgery Mesh augmentation (closure of hernia defect)



Grade 0 No complications

Grade I Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic and radiological interventions (are allowed: antiemetica, antipyretica, analgetics, diuretics, electrolytes and physiotherapy. This grade includes wound infections opened at the bedside)

Grade II Requiring pharmacological treatment with drugs other than such allowed for grade I complications. Blood transfusion and TPN are included.

Grade III Requiring surgical, endoscopic and radiological interventionsIIIa intervention not under general anesthesiaIIIb intervention under general anaesthesia

Grade IV Life threatening complication requiring IC/ICU managementIVa single organ dysfunctionIVb multiorgan dysfunction

Grade V Death of the patient

Clavien-Dindo classification



• nomenclature of hernia operations• nomenclature of meshes• material forfaits art 35bis for laparoscopy

Ventral hernias and the RIZIV-INAMI

open 241150‐241161 N200

laparoscopic 241312‐241323 N200

278,36 euro

(A1) Operatieve behandeling van een éénzijdige liesbreuk (inclusief inguinale, femorale, obturator hernia).

N200

(A2) Operatieve behandeling van een bilaterale liesbreuk (inclusief inguinale, femorale, obturator hernia).

N325

(A3) Operatieve behandeling van een primaire buikwandhernia (inclusief navelbreuk, epigastrische hernia, Spigheliaanse hernia, lumbale hernia).

N200

(A4) Operatieve behandeling van een incisionele buikwandhernia (inclusief recidief na behandeling van een primaire buikwandhernia en parastomale hernias).

N400









PolypropylenePolypropylene•• most commonly used most commonly used –– many different many different

productsproducts

•• ProPro• macroporous (type I)• mostly monofilament• high tensile strength• mechanically stable• optimal tissue ingrowth• good tolerance to infection

•• ConCon• very rigid• not to be used in contact with viscera

Polyester (polyethylene)Polyester (polyethylene)•• Mersilene (Ethicon) and Parietex (Covidien)Mersilene (Ethicon) and Parietex (Covidien)

•• ProPro• macroporous• optimal tissue ingrowth• softer than polypropylene

•• ConCon• multifilament (type III) ~ increased harvesting of bacteria• not to be used in contact with viscera• hydrolytic disintegration over years

(esp. in case of persisting infection)

Expanded polytetrafluoroethylene Expanded polytetrafluoroethylene (ePTFE)(ePTFE)

•• ProPro• flexible, soft, nonfraying• high tensile strength• mechanically stable• can be used in contact with viscera• easily visible on ct-scan (foto dubois)

•• ConCon• microporous multifilament (type II)• less intense tissue ingrowth (encapsulation) – more

shrinkage• secure permanent fixation necessary• need for removal when infected (hydrophobic)

Classification of biomaterialsClassification of biomaterialsType IType I totally macroporoustotally macroporous > 75> 75µµType IIType II totally microporoustotally microporous < 10< 10µµ

(in at least one of the 3 dimensions)(in at least one of the 3 dimensions)

Type IIIType III macroporous with multifilamentous or macroporous with multifilamentous or microporous componentsmicroporous components

Type IVType IV submicronic pore size submicronic pore size (only used in composite materials for adhesion prevention)(only used in composite materials for adhesion prevention)

pores > 75pores > 75µµ needed for admission of polymorphonuclear needed for admission of polymorphonuclear leucocytes (> 10leucocytes (> 10µµ), macrophages (), macrophages (≥≥ 5050µµ), fibroblasts, ), fibroblasts,

blood vessels and collagen fibers into the poresblood vessels and collagen fibers into the porestotal removal of the type II prosthesis and at least partial total removal of the type II prosthesis and at least partial

removal of the type III prosthesis is required removal of the type III prosthesis is required in order to manage infection (bacteria = 1in order to manage infection (bacteria = 1µµ))

Amid, Hernia 1997; 1: 15Amid, Hernia 1997; 1: 15

Lightweight or not?Lightweight or not?

• Current polypropylene meshes are likely to be too strong and too rigid

• Foreign body reaction too pronounced

• Pore size• Macroporous (> 75-100µm) vs. megaporous (> 700-1000µm)• Textile porosity vs. effective porosity

(% pores > 1000µm diameter)

• Weight or density

• > 80 g/m2

• < 40 g/m2

• Surface area

Lightweight or not:Lightweight or not:weight versus pore sizeweight versus pore size

Lightweight or not?Lightweight or not?• Resulting mesh characteristics

• Tensile strength

• Uniaxial load testing• Load per unit width (N/cm)• Load per unit surface (N/cm2)

• Biaxial ball-burst testing

• Mesh elasticity

• Testing in different directions for anisotropic meshes

Cobb et al, Hernia 2009

Maximal abdominal pressure: 20 kPa (=150 mmHg)

• Mesh augmentation Thin walled ball

• Mesh bridging Thin walled cylinder

Maximal abdominal wall tensile strength: 82N/cm (horizontal)32N/cm (vertical)

FD

rD

l

D

L

Klinge et al, Chirurg 1996Klinge et al, World J Surg 2005

16N/cm

32N/cm

Tensile strength requirementsTensile strength requirements

•• Closure percutaneously or via minilaparotomyClosure percutaneously or via minilaparotomy

•• Nonresorbable monofilament sutureNonresorbable monofilament suture

•• Less seromaLess seroma•• Less bulgeLess bulge•• Not more chronic painNot more chronic pain

Chelala et al, Surg Endosc 2007Chelala et al, Surg Endosc 2007

•• Small defect (<5x5cm)Small defect (<5x5cm)not needednot needed

•• Large defect (>7x7cm)Large defect (>7x7cm)difficult/impossibledifficult/impossible

•• Intermediate defect orIntermediate defect orellipsoid defectellipsoid defect

Closure of the defect?Closure of the defect?

Mesh elasticity most important Mesh elasticity most important in vertical directionin vertical direction

Junge et al, Hernia 2001

Early dislocation of a too light Early dislocation of a too light mesh?mesh?

The ideal mesh for intraabdominal useThe ideal mesh for intraabdominal use

Optimal tissue incorporation/remodelling at the parietal side (macroporous)

No or minimal adhesion formationat the visceral side (microporous)

Easy handling capacities

Transparent and a bit sticky

Low cost

Tissue separating meshes (1):Tissue separating meshes (1):bioabsorbable barriersbioabsorbable barriers

•• Hydrophilic collagenHydrophilic collagen--polyethylene glycolpolyethylene glycol--glycerol glycerol coatingcoating

– polyester Parietex® Composite– polypropylene Parietene®Composite

•• Sodium hyaluronate + carboxymethylcellulose Sodium hyaluronate + carboxymethylcellulose (Seprafilm(Seprafilm®®))

– polypropylene Sepramesh®

•• Oxidized regenerated cellulose (ORC)Oxidized regenerated cellulose (ORC)– polypropylene Proceed® (light weight)

•• Omega 3 fatty acidOmega 3 fatty acid– polypropylene C-Qur (Lite)™ (light weight)

Absorbable barrier Absorbable barrier for for

77--10 days 10 days Sufficient?Sufficient?

Tissue separating meshes (2):Tissue separating meshes (2):composite meshes/coated meshescomposite meshes/coated meshes

•• ePTFEePTFE– polypropylene Composix®

Composix® E/X

Composix® L/P(lightweight)

Tissue separating meshes (3): ePTFETissue separating meshes (3): ePTFE

– DualMesh®

– DualMesh® Plus• antimicrobial agents:

– silver– chlorhexidine

– DualMesh® Plus with Holes • macropores for faster tissue attachment

corduroy surface

20-22µ

< 3µ

How to choose?How to choose?

••A lot of (often conflicting) animal dataA lot of (often conflicting) animal data

••No RCT comparing only two different No RCT comparing only two different mesh materialsmesh materials

• No human clinical studies needed for FDA approval/CE marking

• Mesh half life is often (very) short

••Retrospective data on mesh Retrospective data on mesh complicationscomplications

Few data on relook laparoscopiesFew data on relook laparoscopiesChelala et al, Hernia 2010Chelala et al, Hernia 2010

••N=85N=85

••Neoperitoneum perfectly covering the Neoperitoneum perfectly covering the meshmesh

••No shrinking or wrinkling of the meshNo shrinking or wrinkling of the mesh

How to choose?How to choose?••CaveatCaveat

• ePTFE mesh component in case of (potential) contamination

• secure permanent fixation necessary when using full ePTFE

• Laparoscopic ventral/incisional hernia repair• Fragile antiadhesive barrier• Bulky mesh when rolling• Lightweight mesh for bridging large defect• Transparence, memory, abdominal wall adhesive capacity• Adequate dimension or easy to be cut without loosing

antiadhesive properties• Cost!

Mesh fixation: what to use?Mesh fixation: what to use?

1. sutures1. sutures

2. fixation devices2. fixation devices

3. combination of both3. combination of both

4. glue4. glue

Mesh fixation: what to use?Mesh fixation: what to use?suturessutures

nonnon--resorbableresorbable(slowly) resorbable(slowly) resorbable

fixation devicesfixation devicessingle crownsingle crown

double crowndouble crownCarbajo et alCarbajo et al

MoralesMorales--Conde et alConde et al

CombinationCombination

GlueGlueto cover fixation devices and mesh edges?to cover fixation devices and mesh edges?to diminish the number of fixation devices?to diminish the number of fixation devices?

??

Fixation: sutures + fixation devicesFixation: sutures + fixation devicesfull thickness transparietal sutures

slowly resorbableaccurate orientation and placement of the mesh

additional fixation first 3-4 weeks minimising the risk for chronic pain

at least 4 - every 6cm

careful grasping of the suture

enough tissue incorporation (1enough tissue incorporation (1--1.5cm)1.5cm)

nonresorbable sutures in case of full ePTFE meshnonresorbable sutures in case of full ePTFE mesh

LVHR: fixation devicesLVHR: fixation devices

Protack®

titanium (n=30)

absorbable5mm

Sorbafix

AbsorbaTackabsorbable

5mm

Tensile strength and adhesion Tensile strength and adhesion formation to fixation systemsformation to fixation systems

Absorba Tack and SorbaFix are resp. solid and hollow screw tacks, completely resorbed after one year

Parietene Composite Parietene Composite --AbsorbatackAbsorbatack

Tensile strength and adhesion Tensile strength and adhesion formation to fixation systemsformation to fixation systems

Hollinsky et al, Surg Endosc 2010Hollinsky et al, Surg Endosc 2010

Rat modelParietex Composite mesh

Prolene suture

What about pain?What about pain?Kumar Bansal et al, Surg Endosc 2011Kumar Bansal et al, Surg Endosc 2011

RCT, laparoscopic repair, majority polypropylene mesh

ProtackPolypropylene

ButButWassenaar et al, Surg Endosc 2010Wassenaar et al, Surg Endosc 2010

+ tacks+ tacks

Fixation: sutures + fixation devicesFixation: sutures + fixation devicesfixation devices

every 2cm and at least 1cm from the edge of the meshavoid recurrence between mesh and abdominal wall !avoid recurrence between mesh and abdominal wall !

double crown techniqueto reduce dead space

to increase tissue ingrowth

deep enough(≠ peritoneum or preperitoneal fat)

external counterpressure!

extra 5mm trocar contralaterally if needed

















Laparoscopic vs. open: Laparoscopic vs. open: arguments pro arguments pro

minimal abdominal wall tissue traumaminimal abdominal wall tissue traumaless hematoma, seroma, wound infectionless hematoma, seroma, wound infectionprosthetic infection?prosthetic infection?

cosmetic benefitcosmetic benefit

shorter hospital stay, better recoveryshorter hospital stay, better recovery

less postoperative painless postoperative pain

easier exploration of the whole scareasier exploration of the whole scarless recurrences less recurrences ±± 5%??5%??

Laparoscopic vs. open: Laparoscopic vs. open: arguments con arguments con

extensive adhesiolysis necessaryextensive adhesiolysis necessary

prolonged ileusprolonged ileus

missed or delayed enterotomy, postoperative peritonitis, missed or delayed enterotomy, postoperative peritonitis, mesh infection & removal, mortalitymesh infection & removal, mortality

no reconstruction of the no reconstruction of the abdominal wallabdominal wall

recurrence vs. bulgingrecurrence vs. bulging

cave lightweight meshcave lightweight mesh

meshbridging

mesh augmentation

2%??

Laparoscopic vs. open: Laparoscopic vs. open: arguments con arguments con

longlong--term effects of intraabdominal mesh term effects of intraabdominal mesh and fixation devicesand fixation devicesintestinal obstructionintestinal obstructionintestinal erosion and fistulisationintestinal erosion and fistulisation

more expensive prosthetic materialsmore expensive prosthetic materialsantiadhesive capacitiesantiadhesive capacities(chronic) infection risk(chronic) infection risk

chronic painchronic paintransfascial sutures and/or fixation devices?transfascial sutures and/or fixation devices?

chronic seroma formationchronic seroma formation ~ retention of hernia ~ retention of hernia sacsac

trocar site hernias trocar site hernias

longlong--term followterm follow--up necessaryup necessary(min. 3 years)(min. 3 years)

•• 10 RCT10 RCT

•• Almost 1000 patientsAlmost 1000 patients

•• ClinicalClinical• Hernia size/location

• Surgical technique• Open:

• onlay, sublay• fascial closure

• Laparoscopic: • mesh overlap• mesh fixation

• Learning curve effect

= IPOM

Large heterogeneity in the different Large heterogeneity in the different trialstrials

Large heterogeneity in the different Large heterogeneity in the different trialstrials

•• MethodologicalMethodological

randomisation process

(primary outcome parameter)

Operation timeOperation time

Results too heterogenous to be pooled

ComplicationsComplications

Any complicationAny complication

Major vs. minor complicationsMajor vs. minor complications•• MinorMinor

• Wound infection• Seroma formation: problem of definition• Hematoma• Acute and chronic pain

•• MajorMajor• (Missed) enterotomy• Mesh removal• Reoperation• Mortality

EnterotomyEnterotomy

recognised and unrecognisedrecognised and unrecognised

No results extractable on ICU admission

No mortality(described)

HematomaHematoma--seromaseroma

Seroma vs. open mesh placementSeroma vs. open mesh placement

Wound infectionWound infection

Wound infection vs. Wound infection vs. open mesh placementopen mesh placement

Hospital stayHospital stay

Significantly shorter in 6/9 trialsSignificantly shorter in 6/9 trialsBut large heterogeneityBut large heterogeneity

Hospital stayHospital stay

ShortShort--term pain term pain

Hernia recurrenceHernia recurrence

Follow-up > 2 years in only 3 trials

3.3%

0%

0%

EBM based conclusionsEBM based conclusions

•• Large heterogeneity in the different trialsLarge heterogeneity in the different trials

•• Laparoscopic incisional hernia repairLaparoscopic incisional hernia repair• Is safe • Benefit of decreased wound infections and shorter

hospital stay• No increased recurrence rates with medium-term

follow-up

• The key to succes is a careful adhesiolysis and avoiding/immediate treatment of enterotomy

• No decrease in acute pain

My personal conclusions My personal conclusions ••Excellent indication inExcellent indication in

• Obese patients – diabetics• Lateral hernias• Parastomal hernias

••Beware for patients withBeware for patients with• Wide hernias or a diffuse bulge• Hernias close to bony edges: extraperitoneal mesh

••Careful patient selection in learning curveCareful patient selection in learning curve• Eg. umbilical hernia/trocar site hernia in obese patient• Exploration of the whole scar

rectus muscle

posterior rectus sheath/peritoneum

Miserez and Penninckx, Surg Endosc 2002; 16: 1207-1213



684434-684445

implanteerbaar netje voor herstel van breuk of eventratie.

Y2 per 10 cm2


a-a’ netje voor herstel van abdominaal wanddefect of voor herstel van liesbreuk of voor bescherming van orgaan tot 300cm2

U5 per 10 cm2

b-b’ netje voor herstel van abdominaal wanddefect of voor herstel van liesbreuk of voor bescherming van orgaan vanaf 300cm2

U4 per 10 cm2

c-c’ netje voor herstel van abdominaal wanddefect (exclusief herstel van liesbreuk) en ontworpen voor intraperitoneale plaatsing met orgaancontact tot 300cm2

U30 per 10 cm2

d-d’ netje voor herstel van abdominaal wanddefect (exclusief herstel van liesbreuk) en ontworpen voor intraperitoneale plaatsing met orgaancontact vanaf 300cm2

U20 per 10 cm2

e-e’ voorgevormd netje voor herstel van liesbreuk U195 aandeel patient 25%

f-f’ voorgevormd netje voor herstel van abdominaal wanddefect (exclusief herstel van liesbreuk)

U195 aandeel patient 25%


• c-c’/d-d’/e-e’/f-f’ limitative list• criterium:

– at least one prospective study with at least 1 year follow-up published in a peer-reviewed journal, with an outcome showing equivalency on safety and efficacy compared to the gold standard


Documents

Laparoscopic abdominal wall surgery - 56k · Laparoscopic abdominal wall surgery Marc Miserez UZ Leuven Filip Muysoms AZ Maria Middelares Gent 8th edition “Warm‐up Package”