UMBILICAL HERNIA REPAIR WITH IPOM TECHNIQUE

Samuel Szomstein, MD, FACS, FASMBSAssociate Director, Bariatric and Metabolic Institute

and Division of Minimally Invasive SurgeryDirector, Advance Laparoscopy and Bariatrics

Fellowship ProgramDirector, Bariatric Endoscopy

Disclosures

Nothing to disclose

IPOM and IPOM Plus• IPOM = INTRA PERITONEAL ONLAY MESH• IPOM Plus = Defect closure with suture + IPOM

Angelica Garcia SST, Abraham Abdemur MD, Luciano Poggi MD, Samuel Szomstein MD, FACS, Raul Rosenthal MD, FACS

The Bariatric & Metabolic Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL, USA

Method:

Results:

Conclusions:

NEW SIMPLIFIED TECHNIQUE FOR CLOSURE OF HIATAL HERNIAS USING QUILLä SUTURE.

Introduction:Closure of diaphragmatic hiatal defects in patients with Paraesophageal herniasis one of the most demanding procedures in Laparoscopic surgery. The usesof non-absorbable suture in combination with pledgets, absorbable andnon-absorbable mesh have been advocated to achieve low recurrence rates.

We present a new technique of hiatal closure using a Quillä KnotlessTissue-Closure Device suture Angiotech (Vancouver, CA).

A new type of suture material thatwas originally developed to be usedfor wound closure in orthopedic andplastic surgery was utilized.Quilläsuture contains barbs alongits length. This feature makespossible bidirectional fixation thatprovides distribution of the tensionacross the two edges of the tissueand eliminates the need to tie knotsmaintaining tight tissueapproximation.

We demonstrate the closure of a hiatalhernia defect with a 2/0 proleneQuillärunning suture. The operativetime dedicated to this part of theprocedure decreased significantly anddid not require advanced skills.

Closure of the hiatal hernia with running Quills suture isfeasible and enhances patient safety, operative time, as wellas technical considerations.

VIDEO

VIDEO

Technique and Pearls1. Verres needle or Hassan open entry or direct view trocar entry (L subcostal)2. Diagnostic laparoscopy 3. Adhesiolysis and reduction of contents4. Measure defect with low IAP 5. Choose mesh size (I go small)

• Heniford BT, Park A, Ramshaw BJ, Voeller G (2003) Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg 238:391-399; discussion 399-400

Technique and Pearls7. Sac “bite” to prevent seroma8. Defect closure at low pneumoperitoneum (9-11)9. Suture defect-non absorbable barbed suture 10. Mesh deployment and fixation (Low PNU+protacks)11. Centering stitch (PDS)12. Omentum between mesh and bowel

• Heniford BT, Park A, Ramshaw BJ, Voeller G (2003) Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg 238:391-399; discussion 399-400

Pros and ConsIPOM Plus Centering

Stitches on Mesh Tackers

Pros

-RestoreFunctionality of abdominal wall

Cons

-Repair under tension-Large defects suture cut through

Pros

-AdequatePositioning-umbilicusshaping

Cons

-Can get Infected as it’s sub-cutaneous*8

Pros

-Non absorbableLess pain, adhesions

Cons

-Only 2mm penetration

• Jenkins ED, Yom V, Melman L, Brunt LM, Eagon JC, Frisella MM, Matthews BD (2010) Prospective evaluation of adhesion characteristics to intraperitoneal mesh and adhesiolysis-related complications during laparoscopic re-exploration after prior ventral hernia repair. Surg Endosc 24:3002-3007

Indications of IPOM

• Umbilical/Epigastric/Paraumbilical• Incisional/Ventral• Recurrent primary hernia • Obese/Diabetic/Smoker• Size up to 5 cm

Contraindications

LeBlanc KA, Elieson MJ, Corder JM, 3rd (2007) Enterotomy and mortality rates of laparoscopic incisional and ventral hernia repair: a review of literature. JSLS 11:408-414

To laparoscopy in general

• Shock• Cardiopulmonary compromise • Pregnancy

ContraindicationsSpecific to IPOM• Large defect with Loss of Domain (LOD)• Abdominal skin grafts• Need to remove large prosthetic mesh• Active entero-cutaneous fistula• Gangrenous bowel• Fecal peritonitis• Intra-abdominal sepsis• Cirrhosis with caput medusae

• Aura T, Habib E, Mekkaoui M, Brassier D, Elhadad A (2002) Laparoscopic tension-free repair of anterior abdominal wall incisional and ventral hernias with an intraperitonealGore-Tex mesh: prospective study and review of the literature. J Laparoendosc Adv Surg Tech A 12:263-267

• Perrone JM, Soper NJ, Eagon JC, Klingensmith ME, Aft RL, Frisella MM, Brunt LM (2005) Perioperative outcomes and complications of laparoscopic ventral hernia repair. Surgery 138:708-715; discussion 715-706

Complications

• Trocar injury (vascular, hollow viscus)• Seroma• Recurrence • Wound infection • Intestinal obstruction • Port site hernia

Table 1: Cohort volume and prior repairs

National Cleveland Clinic Florida

NProcedure category N (%)

Umbilical (primary hernia) 518 (100) 67 (100)

Primary or recurrent hernia N (%)Primary 494 (95) 58 (87)

Recurrent 24 (5) 9 (13)

Number of prior repairs N (%)1 19 (79) 6 (67)2 3 (12) 2 (22)3 2 (8) 1 (11)4 0 (0) 0 (0)5+ 0 (0) 0 (0)

Table 2: Surgeon and site volume

Surgeons contributing data N 82 2

Sites contributing data N 71 1

Primary surgeon affiliation N (%)

Academic 288 (56) 2 (100)

Private 194 (37) 0 (0)

Private practice with academic affiliation 36 (7) 0 (0)

Age (years; capped at 90)N 518 67Mean 52 52.91SD 13 11.54Q1 43 45Median 52 52Q3 61 60

Female N (%) 159 (31) 32 (48)

Race N (%)American Indian or Alaskan Native 0 (0) 0 (0)Asian or Pacific Islander 3 (1) 2 (3)Black, not of Hispanic origin 61 (12) 4 (6) Hispanic 30 (6) 13 (19)Middle Eastern 3 (1) 1 (2)White, not of Hispanic origin 411 (81) 47 (70)

BMI (kg/m2; capped at 15, 60)N 518 67Mean 35 34.545SD 7 9.687Q1 30 28.2Median 34 33Q3 39 37

BMI categories N (%)< 30 139 (27) 20 (30) >= 30 379 (73) 47 (70)

ASA class N (%)1 44 (8) 6 (9)2 278 (54) 41 (61)3 188 (36) 20 (30) 4 8 (2) 0 (0)5 0 (0) 0 (0)Non assigned 0 (0) 0 (0)Wound class distribution N (%)

Clean (Class 1) 509 (98) 63 (94)Clean-contaminated (Class 2) 9 (2) 4 (6)Contaminated (Class 3) 0 (0) 0 (0)Dirty/Infected (Class 4) 0 (0) 0 (0)

Hernia Grade (VHWG) N (%)Grade 1 110 (21) ???Grade 2 397 (77)Grade 3 11 (2)Hernia width (cm)

N 517 67Mean 3 3.664SD 2 2.247Q1 2 2Median 2 3Q3 3 4

Hernia length (cm)N 517 67Mean 3 3.813SD 2 2.356Q1 2 2Median 2 3Q3 3 4

Table 3: Patient and Hernia Characteristics

Mesh width (cm)N 518 67Mean 12 12.9SD 3 3.67Q1 10 10Median 12 12Q3 15 15

Mesh length (cm)N 518 67Mean 13 13.113SD 4 3.67Q1 11 10.8Median 12 12Q3 15 15

Functional Status N (%)Independent 506 (99) 67Partially Dependent 3 (1) 0Totally Dependent 0 (0) 0Unknown 3 (1) 0

Table 4: Comorbidities

Prevalence of comorbidities N (%) 323 (62) 67 (100)Comorbidities N

Immunosuppressant 14 0Smoking (within 1 year) 73 7Nicotine use (within 1 year) 78 23Hypertension 216 29Diabetes mellitus 79 9Dyspnea 15 0COPD 22 1History of abdominal wall surgical site infection 2 1History of component separation 0 0History of open abdomen 16 16Current steroid use 7 0

Operative time N (%)

0-59 222 (43) 15 (22)

60-119 242 (47) 34 (51)

120-179 43 (8) 13 (20)

180-239 8 (2) 4 (6)

240+ 3 (1) 1 (1)

Planned concomitant procedure N (%) 50 (10) 10 (15)

Any concomitant procedure N (%) 50 (10) 10 (15)

Concomitant procedurescata N

Hernia 26

Foregut/Endocrine 2

Hepatobiliary/Pancreatic 2

Small intestine 0

Colorectal 0

Obstetric/Gynecologic 12

Urologic 5

Vascular 1

Soft tissue/plastics 4

Fascial closure 347 (67) 54Myofascial release 0 (0) 0 (0)Mesh used 518 (100) 67 (100)

Mesh type (4) N (%)Permanent Synthetic 513 (99) 66 (99)Resorbable Synthetic 4 (1) 0 (0)Biological tissue-derived 1 (<1) 1 (1)Other/Unknown 0 (0) 0 (0)

Mesh location N (%)Inlay 0 (0) 0 (0)Onlay 0 (0) 0 (0)Sublay 518 (100) 67 (100)

Mesh fixation (among repairs using mesh) 511 (99) 66 (99)

Mesh fixation typecata NAdhesives 0 0 (0)Staples 3 0 (0)Sutures 307 67 (100)Tacks 492 67 (100)

Length of stay (days)

N 448 67

Mean 1 0.64

SD 2 1.64

Q1 0 0

Median 0 0

Q3 1 1

Conversion to open 2 (<1) 0 (0)

Table 5: Operative characteristics

Table 6: Intra-operative complications

Any intra-op complications 1 (<1) 0 (0)

Specific complicationscata N (%)Hemorrhage requiring transfusion 0 0Peritoneal access injury 0 0Bowel injury 1 0Bladder injury 0 0Liver injury 0 0Gastric injury 0 0Major vascular injury requiring intervention 0 0

Other 0 0

Subjects reporting any complication 57 (13) 4 (4)

Specific non-wound/other complication NPulmonary embolism 0 0Stroke 0 0DVT 2 1Sepsis 0 0Septic shock 0 0MI 1 0Cardiac arrest 0 2UTI 2 0Renal insufficiency 0 0Acute renal failure 2 0Pneumonia 0 0Respiratory failure requiring intubation 1 0Ventilator > 48 hrs 0 0Coma > 24 hrs 0 0Peripheral nerve injury 0 0Post-op bleeding transfusion 0 0Graft/prosthesis/flap failure 0 0Pain requiring intervention 1 0Other 6 4

Table 7: Post-operative complications, mortality, follow-up

Death 30 days N (%)

Actively following 518 (100) 67 (100)

Follow up ended 0 (0) 0 (0)

Death after 30 days 0 (0) 0 (0)

Death (no date reported) 0 (0) 0 (0)

Death within 30 days 0 (0) 0 (0)

Surgical site infection (SSI) 6 (1) 1 (1)

Infection type NSuperficial SSI 5 1Deep incisional SSI 0 0Organ space SSI 1 0

Surgical site infection requiring treatment 6 (1) 1 (1)

Surgical site infection requiring procedural intervention 2 (<1) 6 (0)

Treatments administered for SSIcata NOral antibiotics 4 0IV antibiotics 1 0Wound opening 0 0Wound debridement 0 0Suture excision 0 1Percutaneous drainage 1 0Partial mesh removal 0 0Complete mesh removal 1 0

Surgical site occurrences exclusive of SSI (SSO-EI) 38 (8) 6 (9)

SSO-EI complication typecata NChronic sinus drainage 0 0Contaminated biologic mesh 0 0Contaminated synthetic mesh 0 0Enterocutaneous fistula 1 0Exposed biologic mesh 0 0Exposed synthetic mesh 0 0Fascial disruption 0 0Hematoma 1 0Infected biologic mesh 0 0Infected hematoma 0 0Infected seroma 0 4Infected synthetic mesh 0 0Localized stab wound infection 0 1Mucocutaneous anastomosis disruption 0 0Nonhealing incisional wound 0 0Seroma 32 0Skin/soft tissue ischemia 1 0Skin/soft tissue necrosis 0 0Stitch abscess 0 0Wound cellulitis 1 0Wound purulent drainage 0 0Wound serous drainage 0 0Unspecified 0 0

Table 8: SSI/SSO outcomes

SSO-EI requiring treatment 9 (2) 6 (9)

SSO-EI requiring procedural intervention 6 (1) 2 (3)

Treatments administered for SSO-EIcata NOral antibiotics 3 3IV antibiotics 1 2Wound opening 0 0Wound debridement 1 0Suture excision 0 1Percutaneous drainage 4 0Partial mesh removal 0 1Complete mesh removal 1 0

Table 9: Post-operative through 30 day outcomes

Subject re-encounterscata N (%)Clinic 136 (30) -Emergency room 26 (6) -

Re-admission within 30 days 13 (3) 5 (7)Reported reasons for re-admissioncata N

Pain 3 2Prosthetic related complication 0 0Wound complication 0 0Bleeding complication 0 0Thrombotic complication (non-cardiac) 1 1Gastrointestinal complication 6 1

Reoperation 2 (<1) 0 (0)Reoperation typecata N

Unrecognized bowel injury 1 0Major wound complication 2 0Postoperative bleeding 0 0Early recurrence 0 0Bowel obstruction 0 0Mesh excision 0 0Unrelated intraabdominal pathology 0 0

Hernia recurrence 1 (<1) 1 (1)

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