Background: Many ventral hernia repair methods have been described among surgeons. The traditional primary repair entails a laparotomy with suture approximation of strong fascial tissue on each side of the defect. However, recurrence rates after this procedure range from 12% to 24% during long-term follow-up. Laparoscopic ventral hernia repair (LVHR) is a well recognized minimally invasive surgical technique for repair of different types of abdominal wall ventral hernias. However, the best method of mesh fixation during LVHR is still a subject ofdebate. Patients & Methods: In the present study, 50 patients were presented with ventral hernia between June 2012 and October 2013. Demographics of the patients were recorded. All patients were submitted to LVHR with mesh fixation by “Double Crown” of tackers. The first crown was placed on the mesh periphery with 1 cm between each 2 successive tackers and the second crown around the edges of the defect. Operative complications, VAS scale, post-operative complications, and length of hospital stay were reported. Results: The mean age was 40.08 years. Female to male ratio was 3:2. The mean BMI was 32.3. The diameter of the hernial defect was <5 cm in 64%, while, the defects larger than 15 cm were excluded. LVHR was successfully completed in all the patients with no conversion. Only 1 patient had intra-operative bleeding from omental vessels that was successfully controlled. The mean operative time was 79 minutes. Post-operatively, the mean VAS was 3.96, 2.12, and 0.24 at 24 hours, 2 weeks, and 4 weeks, respectively. Two patients developed post-operative ileus that was treated conservatively and 1 patient developed persistent seroma that was treated by repeated aspiration. The mean length of hospital stay was 3.08 days. Conclusion: “Double Crown” tackers mesh fixation in LVHR seems to be a safe and effective surgical technique with favorable outcome. However, further randomized studies are needed on larger numbers of patients to validate these results.
Ventral hernia is a common surgical disorder. It may be either primary (including umbilical, para-umbilical, epigastric, and Spigelian hernia) or secondary which is commonly known as incisional hernia [
Laparoscopic ventral hernia repair (LVHR) with intra-peritoneal mesh placement to cover the defect was first described by LeBlanc and Booth in 1993 [
The introduction of new generation of light weight bilaminar meshes has encouraged more surgeons to use LVHR technique as it is believed that this veneer facing the bowel is safer and less likely to create erosion or fistulization [
On the other hand, other surgeons prefer to fix the mesh with only tackers without any transracial sutures [
Morales-Conde et al. [
Between June 2012and October 2013, fifty patients presented with ventral hernia were submitted to laparoscopic repair (LVHR) in Hamad Medical Corporation (HMC), Doha, Qatar. The study protocol was fully approved by legal ethical approval number: HMC 41020027. Demographics of the patients were recorded. Exclusion criteria included patients with hernial defect larger than 15 cm, and patients with hernias close to bony structures as the mesh in these hernias cannot be fixed by tackers only.
The surgical technique was discussed with each patient and informed consent was taken. All the patients received prophylactic antibiotics in the form of 1 gm Cefotaxime Sodium with the induction of anesthesia and it was continued 12 hourly post-operatively for 24 hours. Surgery was performed with the patient placed in supine position. The surgeon and the assistant are on the side of the patient which is opposite to the ventral hernia. If the hernia is in the midline, the surgeons stood on the left side. The trocars were inserted as lateral as possible from the hernial defect. Open technique was used to introduce 12 mm trocar at the level of the umbilicus to create artificial pneumoperitoneum with insertion of 30 degrees scope. Then, two 5 mm trocars were inserted under vision cephalic and caudal to the first trocar. Another 5 mm port was inserted in the opposite side of the abdomen in some cases where we found difficulty in dissection or fixation of the mesh.
Adhesiolysis was performed by taking down the omentum and bowel adhesions using the scissors trying to avoid the use of diathermy as much as possible to minimize the risk of thermal injury. Adhesiolysis was continued till the edges of the defect were completely and clearly exposed to a distance of at least 5 cm. Any adjacent small defects that might be non-obvious pre-operatively must be also exposed to be covered by the mesh (
We used Parietex Optimized Composite (PCO) mesh (Covidien, USA) which is polyester knit mesh from one side and the other side is covered by absorbable collagen barrier to prevent visceral adhesions. The mesh has 2 prolene stitches that help in mesh orientation and fixation. The mesh was rolled up and introduced through the 12 mm trocar. Then, it was oriented to make the non-adherent face toward the bowel and to overlap the defect edges by 5 cm in different directions. Two small incisions (each is about 1 mm) were made in the abdominal wall at 6 and 12 o’clock. The endo-close was passed through these incisions to take the prolene sutures fixed to the mesh and pull them out through the abdominal wall. These 2 sutures help to keep the mesh hanged up on the abdominal wall and centered on the defect while fixing it. The mesh was fixed to the abdominal wall by double crown of Securestrap Tackers (Ethicon, USA) which is absorbable tackers measuring 6.7 mm in length. It become completely absorbed in 12 months after critical tissue integration has occurred. The first crown was applied on the mesh periphery with 1 cm between each 2 successive tackers (
The second crown was applied around the edge of the defect (
At the end, the 2 prolene stitches hanging the mesh were cut. The ports were removed and the sheath at the site of 12-mm port was closed under vision. Pressure dressing was applied at the site of the hernia to reduce the incidence of seroma formation.
Post-operatively, the patients were kept on Pethidine 50 mg intra-muscularly every 8 hours and started oral intake once the bowel sounds became audible. The patients were discharged once they tolerated full oral intake,
no fever, no or mild pain that can be controlled by oral analgesics in the form of Ibuprofen 400 mg twice daily.
All the patients were reviewed in the out-patient clinic 2 weeks, 4 weeks, 3 months, 6 months and 1 year.
Fifty patients with ventral hernias were enrolled in the study and were submitted to LVHR. The age of the patients ranged between 25 & 59 years with the mean of 40.08 years (
Twenty eight patients (56%) had para-umbilical hernia (
The operative time ranged between 68 and 133 minutes with a mean of 79 minutes.
Intra-operative complications included hemorrhage from omental vessels in 1 patient (2%) that was controlled by cautery and clips, serosal tears of the small bowel in 3 patients (6%) during adhesiolysis and it didn’t need any repair. No full thickness bowel injury was reported. All the cases were successfully completed laparoscopically with no need to conversion to open surgery.
Length of hospital stay ranged between 2 and 6 days with a mean of 3.08 days.
Post-operatively, VAS score was recorded for all the patients. The mean VAS score 24 hour post-operatively was 3.96. It was 2.12 and 0.24 at 2 weeks and 4 weeks respectively. At 3 months, only 6 patients (12%) had VAS score equal or more than 1.
Post-operative ileus was recorded in 2 patients (4%) who couldn’t tolerate oral intake with vomiting and abdominal distention. They were treated by naso-gastric tube and IV fluids. They were discharged 5 & 6 days respectively. During the follow-up period, no wound infection was recorded. Mild asymptomatic seroma was observed in 8 patients (16%) and it resolved spontaneously without aspiration. Persistant seroma more than 8 weeks was recorded in only 1 patient (2%) and it was treated by repeated aspiration. No hernia recurrence recorded in any patient during the follow-up period that ranged between 12 and 22 months (
Patients’ demographics | Value |
---|---|
Mean age | 40.08 years |
Female/male | 3/2 |
Mean BMI | 32.3 |
Hernia characteristic | No. of the patients (%) |
---|---|
Type: | |
Para-umbilical | 28 (56) |
Epigastric | 12 (24) |
Incisional | 10 (20) |
Defect size: | |
Less than 5 cm | 32 (64) |
5 - 10 cm | 14 (28) |
10 - 15 cm | 4 (8) |
Outcome result | (Mean ± SD) |
---|---|
Operative time min | 79 ± 36.1 |
Hospital stay day | 3.08 ± 1.2 |
Postoperative morbidity | Patients (n%) |
Ileus | 2 (4%) |
Wound infection | 0 (0%) |
Prolonged seroma (>8 weeks) | 1 (2%) |
Prolonged pain (>3 months) | 6 (0%) |
Hernia recurrence | 0 (0%) |
Laparoscopic ventral hernia repair is nowadays a widely accepted surgical technique after the publication of many systemic reviews over the last few years [
The mean age of the patients in our study was 40.08 years which was younger in compared with other studies as Sasse et al. [
In our study the mean BMI was 32.3 which was matched with other studies as In a study by Sasse et al. [
As regard the width of the hernia, in the present study, 32 hernias (64%) are less than 5 cm, 14 hernias (28%) are 5 - 10 cm, and 4 hernias (8%) are 10 - 15 cm in diameter. Chevrel and Rath [
PCO mesh (Covidien, USA) was used in all of our patients that was fixed by Securestarp tackers (Ethicon, USA) which are absorbable with no exposed sharp edges. The classic polypropylene meshes can’t be used in LVHR because many cases of intestinal erosions and fistulization were reported with these meshes in different studies [
The old metal tackers should not be used anymore as they can induce ileus and bowel injury due to direct contact of the bowel with these exposed metallic tackers [
The need of mesh fixation by stitches is still a matter of debate. Heniford et al. [
The crucial point in “Double Crown” mesh fixation without transfacial stitches is that a larger overlap of the mesh beyond the edges of the defect is needed. Three cm overlap was generally accepted recommendation at the start of LVHR. However, current recommendation requires a minimum overlap of 5 cm specially in patients with hernial defects more than 5 cm in diameter [
In our study, the mean operative time was 79 minutes. Intra-operatively, 1 patient had bleeding from omental vessels that was successfully controlled and 3 patients had serosal bowel tears. No conversion to open technique was needed. The mean length of hospital stay was 3.08 days. These results are comparable with results of other studies. Baccari et al. [
The post-operative pain is of great concern in LVHR as it increases consumption of pain killers, increases the incidence of post-operative ileus and subsequently prolongs the length of hospital stay [
Post-operative complications in the present study were post-operative ileus in 2 patients and persistent seroma in 1 patient. No wound infection was reported. No recurrence was encountered during a mean follow-up of 20.56 months. These results compare favorably with results of other studies. Colon et al. [
It is not surprising that the incidence of surgical site infection seems to be much lesser after LVHR if compared to the open approach because LVHR, unlike the open approach, involved almost no dissection of the subcutaneous tissue, and the incisions are smaller, making bacterial migration to the subcutaneous space less likely [
Seroma formation is one of the commonest complications after LVHR [
According to our knowledge, no previous series published short-term follow-up in “Double Crown” Tackers Mesh Fixation in Laparoscopic Ventral Hernia Repair, our period of follow-up (12 - 24 months with mean of 12.4 month) was almost short in comparison with other series as Sasse et al. [
In conclusion, results of this study suggest that LVHR is a safe and feasible technique. It is associated with low rates of complications and hernia recurrence. It provides the patient a good quality of life. However, further randomized studies with longer follow-up period are needed to assess the validity of these results.