After the first successful laparoscopic cholecystectomy by Mühe in 1987, open cholecystectomy has become virtually obsolete, and is currently performed in <5% of all cases, usually as a result of conversion secondary to severe inflammation. Indeed, within a decade of this seminal event, many previously open procedures have followed the same course. The rapid rise to becoming a gold standard procedure was, however, not without problems, as there was a transient but noticeable rise in the rates of common bile duct injuries in cases of laparoscopic cholecystectomy.3–5
Parallel with these developments was the introduction and popularization of laparoscopic hernia repair, which began in 1989.12
In some Western countries such as Australia, in 2010, laparoscopic (total extraperitoneal and transabdominal preperitoneal) inguinal hernia repair represented 44% of all inguinal hernias repaired (www.medicareaustralia.gov.au
), and this therefore represents the most commonly performed procedure, compared with other open procedures, including the Lichenstein, Bassini, Shouldice, Kugel, mesh plug, and others. Indeed, nationally 48% of surgeons in Australia profess to performing laparoscopic inguinal hernia repair. In fact, in the states of New South Wales and Queensland, the proportion of surgeons performing laparoscopic inguinal hernia repair is currently 51%. While reasonably accurate data exist for laparoscopic inguinal hernia repair, because of specific item numbers assigned to open and laparoscopic inguinal hernia repair, there are no accurate data for laparoscopic ventral hernia repair in the Western world, including Australia. However, it has been estimated that LVHR is being used for only 10% of ventral/incisional hernias being repaired. One of the reasons for the poor uptake for LVHR is the feared complication of enterotomy, which can occur among up to 2% of all patients, even in high-volume centers.13,14
At least some of the unrecognized enterotomies are due to inadvertent perforation by dissecting instruments, which are usually introduced “out-of-sight” during LVHR, because the surgeon forgets to look at the secondary trocar sites with each instrument insertion. Furthermore, some of these injuries are due to the introduction of sharp secondary trocars. Indeed, in a study of 37 000 gynecologic procedures,15
0.03% of all bowel injuries were caused by sharp secondary trocars. This equates to an excess of 120 cases of avoidable bowel injuries. Such injuries should no longer occur, with the introduction of single ports like SILS and Triport, because these involve no sharp trocars. Furthermore, because the dissecting instruments and the laparoscope are parallel, this should negate the risks of bowel injuries from intraperitoneal introduction of instruments.
The main objection to the use of LESS procedures is the relative loss of triangulation. However, this has largely been overcome by the use of a smaller and longer laparoscope, which, apart from increasing the range of movements within the port, will also minimize the clashing of the heads of the dissecting instruments with the side arm of the scope. In addition, modified dissection techniques, such as “inline” and “vertical/chopsticks,” will further enhance safe and efficient dissection, even with standard straight dissecting instruments.10
Unlike the dissection repertoire of a TEP repair where the maneuvers can be quite broad in distance between the tips of the dissecting instruments, adhesiolysis, especially when it involves bowels, occurs in millimeters, a scale quite suited to LESS dissection techniques, which further diminish the argument regarding relative loss of triangulation.
There is no doubt that LESS represents the most significant innovation in the field of laparoscopic surgery for the last 2 decades. In the area of hernia surgery, enormous efforts have been made in the area of mesh prosthetics and these have resulted in the current situation where currently some 270 different meshes are available. The introduction of LESS has reinvigorated the industry to participate in an exciting area of surgical innovations in the field of optics (eg, flexible laparoscopes), in instrumentation (eg, angulated/roticulated dissecting instruments) and, increasingly, in robotics (eg, robotic Freehand), with the primary focus being on optimizing LESS and hence make it more surgeon friendly and hopefully increase patient safety and acceptability.16–18
In the end, one should never forget the fact that the best instruments are the surgeon's hands.
There are currently very few reports on LESS LVHR, with most reports consisting of single-case reports.19
Roy et al20
reported a series of 4 selected cases of LESS LVHR, with defect sizes measuring 4cm to 5cm in diameter in half of the cases (umbilical hernias) and Swiss cheese defects measuring up to 6cm to 7cm maximum. This would mean that the mesh size based on a 5-cm clearance of the defect of some 225cm2
for the umbilical hernias repaired and 289cm2
for the largest of incisional hernias repaired. We have concluded that LESS LVHR is feasible, based on this study of 22 unselected patients, representing one of the largest series of LESS LVHR reported to date.
Our patients presented with a spectrum of abdominal wall hernias, including multiply recurrent inguinal, suprapubic, ventral/incisional, and parastomal hernias. Although the number is relatively small, compared with published series on conventional LVHR, our operative time of 125 minutes, compared favorably with these series, given that the mean mesh size for our patients is 460cm2, or the equivalent of a 20cm to 23cm mesh. Given the unselected nature (except for 1 patient) in the cohort, the mean body mass index of 31.5kg/m2 represents more closely the general obesity of the Australian population, which was made worse by the inability of our patients to engage in vigorous physical activities to reduce their weight because of the hernia. In fact, we have seen anecdotal evidence of significant weight loss, in some of our patients, after their operation. Two of the patients, whose operations occurred early in the morning, went home on the same day, while the remaining except for 1, went home 1 day after their operation, even for the 2 patients with LESS parastomal hernia repair with the modified Sugarbaker technique. This is impressive given that their mean operation time was 270minutes. There was no mortality, no morbidities, and no recurrence with a follow-up of 6 months to 18 months. All of our patients were highly satisfied with their operation, with a mean satisfaction score of 2.7, with no patients being dissatisfied with the procedure.
Due to single ports being relatively new, and their acceptance limited to a few centers, the cost of the ports represents an additional $150 per procedure relative to conventional ports. However, compared with LESS inguinal hernia repair, LESS LVHR is potentially and usually much more complex, time-consuming, and expensive, overall; therefore, this additional cost of the single port would only represent a small percentage of the overall cost. Furthermore, like most new devices, the price always comes down with increasing competition and popularity. This is based on the assumption that it can be shown that LESS outperforms conventional multiport laparoscopy in terms of cost effectiveness, safety, efficacy, patient acceptability, and improved cosmesis. However, the exploding development of ancillary devices, such as roticulated instruments and flexible endoscopes, may threaten the viability and propagation of a potentially beneficial technique by making LESS procedures economically “unviable”, at worst, or confined to few centers, at best. This is the case with the radical prostatectomy performed with the da Vinci Robotic system (Intuitive Surgical, Sunnyvale, CA).20
While a few studies have demonstrated the feasibility of LESS LVHR in select cases,18,19
this study is the first to demonstrate the safety and efficacy of LESS LVHR in an unselected patient population with various types of ventral hernias in a general surgical practice. The general applicability of LESS in LVHR, demonstrated in this study, should serve as an important milestone in the quest to demonstrate whether LESS is superior to conventional multiport hernia repair. This awaits evidence from large, multicenter, prospective, randomized controlled studies.