Incisional hernia is the most frequently seen long term complication after laparotomy causing much morbidity and even mortality. The overall incidence remains 11-20%, despite studies attempting to optimize closing techniques. Two patient groups, patients with abdominal aortic aneurysm and obese patients, have a risk for incisional hernia after laparotomy of more than 30%. These patients might benefit from mesh augmented midline closure as a means to reduce incisional hernia incidence.
The PRImary Mesh Closure of Abdominal Midline Wound (PRIMA) trial is a double-blinded international multicenter randomized controlled trial comparing running slowly absorbable suture closure with the same closure augmented with a sublay or onlay mesh. Primary endpoint will be incisional hernia incidence 2 years postoperatively. Secondary outcomes will be postoperative complications, pain, quality of life and cost effectiveness.
A total of 460 patients will be included in three arms of the study and randomized between running suture closure, onlay mesh closure or sublay mesh closure. Follow-up will be at 1, 3, 12 and 24 months with ultrasound imaging performed at 6 and 24 months to objectify the presence of incisional hernia. Patients, investigators and radiologists will be blinded throughout the whole follow up.
The use of prosthetic mesh has proven effective and safe in incisional hernia surgery however its use in a prophylactic manner has yet to be properly investigated. The PRIMA trial will provide level 1b evidence whether mesh augmented midline abdominal closure reduces incisional hernia incidence in high risk groups.
Clinical trial.gov NCT00761475.
Several randomized controlled trials have compared different suture materials and techniques for abdominal wall closure with respect to the incidence of incisional hernias after midline laparotomy and shown that it remains, irrespective of the methods used, considerably high, ranging from 9% to 20%. The development of improved suture materials which would reduce postoperative complications may help to lower its frequency.
This is a historically controlled, single-arm, multi-centre, prospective trial to evaluate the safety of MonoMax® suture material for abdominal wall closure in 150 patients with primary elective midline incisions. INSECT patients who underwent abdominal closure using Monoplus® and PDS® will serve as historical control group. The incidences of wound infections and of burst abdomen are defined as composite primary endpoints. Secondary endpoints are the frequency of incisional hernias within one year after operation and safety. To ensure adequate comparability in surgical performance and recruitment, the 4 largest centres of the INSECT-Trial will participate. After hospital discharge, the investigators will examine the enrolled patients again at 30 days and at 12 ± 1 months after surgery.
This historically controlled, single-arm, multi-centre, prospective ISSAAC trial aims to assess whether the use of an ultra-long-lasting absorbable monofilament suture material is safe and efficient.
The implantation of a polymer mesh is considered as the standard treatment for incisional hernia. It leads to lower recurrence rates compared to suture techniques without mesh implantation; however, there are also some drawbacks to mesh repair. The operation is more complex and peri-operative infectious complications are increased. Yet it is not clear to what extent a mesh implantation influences quality of life or leads to chronic pain or discomfort. The influence of the material, textile structure and size of the mesh remain unclear. The aim of this study was to evaluate if a non-absorbable, large pore-sized, lightweight polypropylene (PP) mesh leads to a better health outcome compared to a partly absorbable mesh.
In this randomised, double-blinded study, 80 patients with incisional hernia after a median laparotomy received in sublay technique either a non-absorbable mesh (Optilene® Mesh Elastic) or a partly absorbable mesh (Ultrapro® Mesh). Primary endpoint was the physical health score from the SF-36 questionnaire 21 days post-operatively. Secondary variables were patients' daily activity score, pain score, wound assessment and post-surgical complications until 6 months post-operatively.
SF-36, daily activity and pain scores were similar in both groups after 21 days and 6 months, respectively. No hernia recurrence was observed during the observation period. Post-operative complication rates also showed no difference between the groups.
The implantation of a non-absorbable, large pore-sized, lightweight PP mesh for incisional hernia leads to similar patient-related outcome parameters, recurrence and complication rates as a partly absorbable mesh.
Incisional hernia; Lightweight mesh; Patient-reported outcome; Quality of life
Incisional hernia is a serious complication after abdominal surgery and occurs in 11–23% of laparotomies. Repair can be done, for instance, with a direct suture technique, but recurrence rates are high. Recent literature advises the use of mesh repair. In contrast to this development, we studied the use of a direct suture repair in a separate layer technique. The objective of this retrospective observational study is to assess the outcomes (recurrences and complications) of a two-layered open closure repair for primary and recurrent midline incisional hernia without the use of mesh.
In an observational retrospective cohort study, we analysed the hospital and outpatient records of 77 consecutive patients who underwent surgery for a primary or recurrent incisional hernia between 1st May 2002 and 8th November 2006. The repair consisted of separate continuous suturing of the anterior and posterior fascia, including the rectus muscle, after extensive intra-abdominal adhesiolysis.
Forty-one men (53.2%) and 36 women (46.8%) underwent surgery. Sixty-three operations (81.8%) were primary repairs and 14 (18.2%) were repairs for a recurrent incisional hernia. Of the 66 patients, on physical examination, three had a recurrence (4.5%) after an average follow-up of 2.6 years. The 30-day postoperative mortality was 1.1%. Wound infection was seen in five patients (6.5%).
A two-layered suture repair for primary and recurrent incisional hernia repair without mesh with extensive adhesiolysis was associated with a recurrence rate comparable to mesh repair and had an acceptable complication rate.
Ventral hernia; Abdominal hernia; Suture repair; Direct repair; Recurrence
Burst abdomen and incisional herniation are continuing problems for the general surgeon. A prospective study was carried out to define the extent of the problem. Over five years from 1975 to 1980 a total of 1129 major laparotomy wounds in adults were assessed at regular intervals for 12 months after operation. There were 19 burst abdomens (1.7%) and 84 incisional hernias (7.4%). The introduction of the mass-closure technique reduced the incidence of burst abdomen from over 3% in 1975 to 0.95% in 1979. It did not, however, improve the rate for incisional hernias, which was 7.6% in 1979. Many factors are associated with incisional herniation: old age, male sex, obesity, bowel surgery, type of suture, chest infection, abdominal distension, and, most important, wound infection. More work is needed to find the ideal method of wound closure, and efforts should be made to eliminate wound infection.
Randomised controlled trials with a long term follow-up (3 to 10 years) have demonstrated that mesh repair is superior to suture closure of incisional hernia with lower recurrence rates (5 to 20% versus 20 to 63%). Yet, the ideal size and material of the mesh are not defined. So far, there are few prospective studies that evaluate the influence of the mesh texture on patient's satisfaction, recurrence and complication rate. The aim of this study is to evaluate, if a non-absorbable mesh (Optilene® Mesh Elastic) will result in better health outcomes compared to a partly absorbable mesh (Ultrapro® Mesh).
In this prospective, randomised, double blind study, eighty patients with incisional hernia after a midline laparotomy will be included. Primary objective of this study is to investigate differences in the physical functioning score from the SF-36 questionnaire 21 days after mesh insertion. Secondary objectives include the evaluation of the patients' daily activity, pain, wound complication and other surgical complications (hematomas, seromas), and safety within six months after intervention.
This study investigates mainly from the patient perspective differences between meshes for treatment of incisional hernias. Whether partly absorbable meshes improve quality of life better than non-absorbable meshes is unclear and therefore, this trial will generate further evidence for a better treatment of patients.
On the hypothesis that incisional defects occur soon after operation but the resulting hernia may not be diagnosed until months or years later, we attached three to five pairs of stainless steel haemostatic clips to the cut edges of the anterior aponeurosis during the closure of 59 major laparotomy incisions and X-rayed the abdomen one month later. Three patients were withdrawn and the remaining 56 were examined with special reference to incisional herniation at their six-month follow-up visit. The senior author subsequently arranged a series of extra clinics for surviving patients up to three years later (median 30 months after operation). He had no knowledge of the results of the abdominal X-rays when assessing whether or not the patient had a hernia. Six patients were found to have incisional hernias, and correlation with the measurements on the one-month X-rays showed separation of pairs of clips ranging from 12-70 mm (median 40). Three of the six hernias were discovered within seven months, the remaining three at 13, 28 and 29 months. In contrast none of the 50 patients without incisional hernias had more than 9 mm of separation of any pair of clips on the one-month X-ray. We conclude that the origins of incisional hernias can be traced back to events during the first month after operation and that they are not the result of later weakening of a well-healed laparotomy wound.
Annually approximately 100.000 patients undergo a laparotomy in the Netherlands. About 15,000 of these patients will develop an incisional hernia. Both open and laparoscopic surgical repair have been proven to be safe. However, the most effective treatment of incisional hernias remains unclear. This study, the ‘INCH-trial’, comparing cost-effectiveness of open and laparoscopic incisional hernia repair, is therefore needed.
A randomized multi-center clinical trial comparing cost-effectiveness of open and laparoscopic repair of incisional hernias. Patients with a symptomatic incisional hernia, eligible for laparoscopic and open incisional hernia repair. Only surgeons, experienced in both open and laparoscopic incisional hernia repair, will participate in the INCH trial. During incisional hernia repair, a mesh is placed under or on top of the fascia, with a minimal overlap of 5 cm. Primary endpoint is length of hospital stay after an incisional hernia repair. Secondary endpoints are time to full recovery within three months after index surgery, post-operative complications, recurrences, mortality and quality of life.
Our hypothesis is that laparoscopic incisional hernia repair comes with a significant shorter hospital stay compared to open incisional hernia repair. A difference of two days is considered significant. One-hunderd-and-thirty-five patients are enrolled in each treatment arm. The economic evaluation will be performed from a societal perspective. Primary outcomes are costs per patient related to time-to-recovery and quality of life.
The main goal of the trial is to establish whether laparoscopic incisional hernia repair is superior to conventional open incisional hernia repair in terms of cost-effectiveness. This is measured through length of hospital stay and quality of life. Secondary endpoints are re-operation rate due to post-operative complications or recurrences, mortality and quality of life.
The difference in time to full recovery between the two treatment strategies is thought to be in favor of laparoscopic incisional hernia repair. Laparoscopic incisional hernia repair is therefore expected to be a more cost-effective approach.
Netherlands Trial register: NTR2808
Incisional hernia is a frequent complication in abdominal surgery. This article describes the development of a prospective randomized clinical trial designed to determine whether watchful waiting is an acceptable alternative to surgical repair for patients with oligosymptomatic incisional hernia.
This clinical multicenter trial has been designed to compare watchful waiting and surgical repair for patients with oligosymptomatic incisional hernia. Participants are randomized to watchful waiting or surgery and followed up for two years. The primary efficacy endpoint is pain/discomfort during normal activities as a result of the hernia or hernia repair two years after enrolment, as measured by the hernia-specific Surgical Pain Scales (SPS). The target sample size of six hundred thirty-six patients was calculated to detect non-inferiority of the experimental intervention (watchful waiting) in the primary endpoint. Sixteen surgical centers will take part in the study and have submitted their declaration of commitment giving the estimated number of participating patients per year. A three-person data safety monitoring board will meet annually to monitor and supervise the trial.
To date, we could find no published data on the natural course of incisional hernias. To our knowledge, watchful waiting has never been compared to standard surgical repair as a treatment option for incisional hernias. A trial to compare the outcome of the two approaches in patients with oligosymptomatic incisional hernias is urgently needed to provide data that can facilitate the choice between treatment options. If watchful waiting was equal to surgical repair, the high costs of surgical repair could be saved. The design for such a trial is described here.
This multicenter trial will be funded by the German Research Foundation (DFG). The ethics committee of the Charité has approved the study protocol. Approval has been obtained from ten study sites at time of this submission. The electronic Case Report Forms have been created. The first patient was to be randomized November 14th, 2011. An initiation meeting took place in Berlin January 9th, 2012.
oligosymptomatic incisional hernia; watchful waiting; surgical repair; prospective randomized trial
Many thousand laparotomy incisions are created each year and the failure rate for closure of these abdominal wounds is between 10–15%, creating a large problem of incisional hernia. In the past many of these hernias have been neglected and treated with abdominal trusses or inadequately managed with high failure rates. The introduction of mesh has not had a significant impact because surgeons are not aware of modern effective techniques which may be used to reconstruct defects of the abdominal wall. This review will cover recent advances in incisional hernia surgery which affect the general surgeon, and also briefly review advanced techniques employed by specialist surgeons in anterior abdominal wall surgery.
Incisional hernia; Abdominal wall; Repair
To determine whether a transverse incision is an alternative to a midline incision in terms of incisional hernia incidence, surgical site infection, postoperative pain, hospital stay and cosmetics in cholecystectomy.
Summary background data
Incisional hernias after midline incision are commonly underestimated but probably complicate between 2 and 20% of all abdominal wall closures. The midline incision is the preferred incision for surgery of the upper abdomen despite evidence that alternatives, such as the lateral paramedian and transverse incision, exist and might reduce the rate of incisional hernia. A RCT was preformed in the pre-laparoscopic cholecystectomy era the data of which were never published.
One hundred and fifty female patients were randomly allocated to cholecystectomy through midline or transverse incision. Early complications, the duration to discharge and the in-hospital use of analgesics was noted. Patients returned to the surgical outpatient clinic for evaluation of the cosmetic results of the scar and to evaluate possible complications such as fistula, wound dehiscence and incisional hernia after a minimum of 12 months follow-up.
Two percent (1/60) of patients that had undergone the procedure through a transverse incision presented with an incisional hernia as opposed to 14% (9/63) of patients from the midline incision group (P = 0.017). Transverse incisions were found to be significantly shorter than midline incisions and associated with more pleasing appearance. More patients having undergone a midline incision, reported pain on day one, two and three postoperatively than patients from the transverse group. The use of analgesics did not differ between the two groups.
In light of our results a transverse incision should, if possible, be considered as the preferred incision in acute and elective surgery of the upper abdomen when laparoscopic surgery is not an option.
Cholecystectomy; Hernia abdominal; Abdominal wall
Aim. Three incisional ventral abdominal wall hernias were repaired by placing a 20 × 30 cm composite mesh via single incision of 2 cm.
Methods. All three cases had previous operations and presented with giant incisional defects clinically. The defects were repaired laparoscopically via single incision with the placement of a composite mesh of 20 × 30 cm. Nonabsorbable sutures were needed to hang and fix the mesh only in the first case. Double-crown technique was used in all of the cases to secure the mesh to the anterior abdominal wall.
Results. The mean operation time was 120 minutes. The patients were mobilized and led for oral intake at the first postoperative day. No morbidity occurred.
Conclusion. Abdominal incisional hernias can be repaired via single incision with a mesh application in experienced centers.
Postoperative pain control after laparoscopic ventral hernia repairs remains a significant clinical problem. We sought to determine the pain-sparing efficacy of local anesthetic infiltrated into the abdominal wall wounds created by the placement of transabdominal sutures used to ensure adequate fixation of the mesh during laparoscopic ventral hernia repair.
Patients undergoing laparoscopic ventral/incisional hernia repair were randomized to receive local anesthesia (0.25% bupivacaine with epinephrine) into all layers of the abdominal wall to the level of the parietal peritoneum at suture fixation sites immediately before suture placement (Group I; n=9) or no local anesthesia (Group II, control; n=9). The anesthetic technique was otherwise standard for both groups. Postoperatively, pain was assessed with a 10-point visual analogue scale (VAS) at 1, 2, 4, and 24 hours. Analgesic use and hospital stay were also recorded.
The groups were similar in age, sex, ASA, and size of hernia defect. The operative times were not statistically different between the 2 groups (Group I, 118±12 minutes; Group II, 144±21 minutes; P>0.05). Group I had a statistically significant decrease in the pain scores compared with Group II (2.2±0.8 vs. 6.4±0.9; P<0.05) at 1 hour postoperatively. At 2 and 4 hours, the mean pain scores were decreased but not statistically different. Similarly, the cumulative consumption of pain medication at 1, 2, and 4 hours postoperatively as well as the average hospital stay (Group I, 2.0±0.4; Group II, 2.4±0.4 days) were lower but not statistically significant in patients in Group I compared with those in Group II.
This small, randomized study demonstrates that infiltration of suture fixation sites is effective in reducing early postoperative pain but not analgesic consumption following laparoscopic incisional and ventral hernia repairs. A larger study is required to investigate this strategy on later postoperative pain and hospital stay.
Local anesthesia; Laparoscopic ventral hernia repair
Persistent, activity-limiting pain after laparoscopic ventral or incisional hernia repair (LVIHR) appears to be related to fixation of the implanted mesh. A randomized study comparing commonly used fixation techniques with respect to postoperative pain and quality of life has not previously been reported.
A total of 199 patients undergoing non-urgent LVIHR in our unit between August 2005 and July 2008 were randomly assigned to one of three mesh-fixation groups: absorbable sutures (AS) with tacks; double crown (DC), which involved two circles of tacks and no sutures; and nonabsorbable sutures (NS) with tacks. All operations were performed by one of two experienced surgeons, who used a standardized technique and the same type of mesh and mesh-fixation materials. The severity of the patients’ pain was assessed preoperatively and at 2 weeks, 6 weeks and 3 months postoperatively by using a visual analogue scale (VAS). Quality of life (QoL) was evaluated by administering a standard health survey before and 3 months after surgery. Results in the three groups were compared.
The AS, DC, and NS mesh-fixation groups had similar patient demographic, hernia and operative characteristics. There were no significant differences among the groups in VAS scores at any assessment time or in the change in VAS score from preoperative to postoperative evaluations. The QoL survey data showed a significant difference among groups for only two of the eight health areas analyzed.
In this trial, the three mesh-fixation methods were associated with similar postoperative pain and QoL findings. These results suggest that none of the techniques can be considered to have a pain-reduction advantage over the others. Development of new methods for securing the mesh may be required to decrease the rate or severity of pain after LVIHR.
Incisional hernia; Ventral hernia; Laparoscopic surgery; Pain; Quality of life; Mesh fixation
Incisional hernia is one of the most common complications of abdominal surgery, with a reported occurrence rate of up to 20% after laparotomy. The high incidence of hernia formation significantly contributes to both patient morbidity and health care costs. Although a variety of approaches have been described to repair these defects, historically the results have been disappointing. Recurrence rates after primary repair have been reported to range from 24% to 54%. The recent advent of laparoscopic ventral hernia repair (LVHR) has offered promising outcomes by combining tension-free repair using a prosthesis with minimally invasive techniques, lowering reported recurrence rates to <10%. This review discusses standardized, well-researched techniques that have contributed to the success of LVHR. We also discuss how these techniques have been modified for laparoscopic repair of suprapubic lumbar hernias, hernias near the iliac crest, and parastomal hernias. In addition, we review our own experience with LVHR in the context of the principles discussed.
A prospective randomized controlled clinical trial is reported which compares midline with lateral paramedian incisions in relation to the development of incisional hernias at one year. Of 431 patients randomized, 329 were available for assessment one year later. Two patients suffered burst abdomen, both being in the lateral paramedian group. Twenty-two incisional hernias occurred, 2 in the lateral paramedian group and 20 in the midline group (P less than 0.001). Of the two types of incision, the lateral paramedian incision takes longer to perform, requires a longer incision, rarely results in dehiscence, and does confer protection against incisional hernia.
We compared fascial wounds repaired with non-cross-linked intact porcine-derived acellular dermal matrix versus primary closure in a large-animal hernia model. Incisional hernias were created in Yucatan pigs and repaired after 3 weeks via open technique with suture-only primary closure or intraperitoneally placed porcine-derived acellular dermal matrix. Progressive changes in mechanical and biological properties of porcine-derived acellular dermal matrix and repair sites were assessed. Porcine-derived acellular dermal matrix–repaired hernias of additional animals were evaluated 2 and 4 weeks post incision to assess porcine-derived acellular dermal matrix regenerative potential and biomechanical changes. Hernias repaired with primary closure showed substantially more scarring and bone hyperplasia along the incision line. Mechanical remodeling of porcine-derived acellular dermal matrix was noted over time. Porcine-derived acellular dermal matrix elastic modulus and ultimate tensile stress were similar to fascia at 6 weeks. The biology of porcine-derived acellular dermal matrix–reinforced animals was more similar to native abdominal wall versus that with primary closure. In this study, porcine-derived acellular dermal matrix–reinforced repairs provided more complete wound healing response compared with primary closure.
Incisional hernia; biologic mesh; biologic tissue matrix; Strattice; fascial wounds
A classification of parastomal hernias (PH) is needed to compare different populations described in various trials and cohort studies, complete the previous inguinal and ventral hernia classifications of the European Hernia Society (EHS) and will be integrated into the EuraHS database (European Registry of Abdominal Wall Hernias).
Several members of the EHS board and invited experts gathered for 2 days to discuss the development of an EHS classification of PH. The discussions were based on a literature review and critical appraisal of existing classifications.
The classification proposal is based on the PH defect size (small is ≤5 cm) and the presence of a concomitant incisional hernia (cIH). Four types were defined: Type I, small PH without cIH; Type II, small PH with cIH; Type III, large PH without cIH; and Type IV, large PH with cIH. In addition, the classification grid includes details about whether the hernia recurs after a previous PH repair or whether it is a primary PH. Clinical validation is needed in the future to assess if the classification allows us to differentiate the treatment strategy and if the classification impacts outcome in these different subgroups.
A classification of PH divided into subgroups according to size and cIH was formulated with the aim of improving the ability to compare different studies and their results.
Parastomal; Hernia; Classification
The incidence of incisional hernia depends on many factors factors including old age, sex, obesity, bowel surgery, suture type, chest infection, abdominal distension and wound infection.
A 55 years old woman presented at out institute, she had an operation 19 years ago – elsewhere – to remove a branched stone from her right kidney and admitted for two months into the hospital at this time as she had troubles with her surgical wound and she had repeated secondary sutures. The hernia is in the right lumbar region, has a smooth surface, shows expansile impulse on coughing, there are some dilated veins on its surface, there is no tenderness, it has a uniform consistency, mobile, there are no pulsations, it contains large and small intestine, partially reducible, the defect is about 10 cm in diameter and there are no complications. This woman had left nephrectomy two years ago as a treatment for painful non functioning kidney and she is living now with only functioning right kidney with serum creatinine 1.1 mg % and blood urea 38 mg %.
Incisional hernia is a very common complication of wound healing after surgery. Good care and precautions are very important to avoid its development.
Incisional hernias can be a significant problem after open abdominal surgery. Laparoscopic incisional hernia repair (LIHR) is conceptually appealing: a large, abdominal wall re-incision with potential wound-related ill effects is avoided and an intra-peritoneal onlay mesh is expected to provide security that is equivalent to open, retro-muscular mesh repair. As such, LIHR has gained substantial popularity despite sparse, randomised clinical data to compare with conventional, open repair.
To enumerate and discuss important, controversial issues in patient-selection, technique and early post-operative care for LIHR.
Materials and Methods:
Pragmatic summary of comprehensive review of English language literature, discussion with experts and personal experience.
Six important areas of some dispute were identified: 1. Size of abdominal-wall defect that is suitable for LIHR: Generally, defect-diameter > 10 cm is better served by open retromuscular repair with tension-free re-approximation of the edges of the defect. 2. Extent of adhesiolysis: Complete division of adhesions to the anterior abdominal wall may identify sub-clinical “Swiss-cheese” defects but incurs some risk of additional complications. 3. Intra-operative recognition of enterotomy: Possible options are either laparoscopic suture of bowel injury and simultaneous completion of LIHR, or staged LIHR or conversion to open suture-repair. 4. Choice of mesh: “Composite” meshes are regarded as the current standard of care but there is paucity of data regarding potential dangers of intra-peritoneal polypropylene mesh. 5. Technique of mesh-fixation: Trans-parietal sutures are more secure than tacks, with limited data to correlate with post-operative pain. 6. Alarm over post-operative pain: Unlike other advanced laparoscopic operations, the specificity of pain as a marker of intra-abdominal sepsis after LIHR remains unclear.
Recognition of and attention to controversial issues will promote increased success of LIHR.
Intra-peritoneal onlay mesh; ventral hernia repair; composite mesh; dual-sided mesh
The closure of the abdomen after median laparotomy is still a matter of debate among surgeons. Further well designed and performed randomised controlled trials determining the optimal method of abdominal fascial closure are needed.
This is a three armed, multi-centre, intra-operatively randomised, controlled, patient blinded trial. Over 20 surgical departments will enrol 600 patients who are planned for an elective primary abdominal operation. The objective of this study is to compare the frequency of abdominal incisional hernias between two continuous suture techniques with different, slowly absorbable monofilament materials and an interrupted suture using an absorbable braided suture material at one year postoperatively.
This trial will answer the question whether the continuous abdominal wall closure with a slowly absorbable material with longitudinal elasticity is superior to the continuous suture with a material lacking elasticity and to interrupted sutures with braided thread.
The optimal strategy for abdominal wall closure has been an issue of ongoing debate. Available studies do not specifically enroll patients who undergo emergency laparotomy and thus do not consider the distinct biological characteristics of these patients. The present randomized controlled trial evaluates the efficacy and safety of two commonly applied abdominal wall closure strategies in patients undergoing primary emergency midline laparotomy.
The CONTINT trial is a multicenter, open label, randomized controlled trial with a two-group parallel design. Patients undergoing a primary emergency midline laparotomy are enrolled in the trial. The two most commonly applied strategies of abdominal wall closure after midline laparotomy are compared: the continuous, all-layer suture technique using slowly absorbable monofilament material (two Monoplus® loops) and the interrupted suture technique using rapidly absorbable braided material (Vicryl® sutures). The primary endpoint within the CONTINT trial is an incisional hernia within 12 months or a burst abdomen within 30 days after surgery. As reliable data on this primary endpoint is not available for patients undergoing emergency surgery, an adaptive interim analysis will be conducted after the inclusion of 80 patients, allowing early termination of the trial if necessary or modification of design characteristics such as recalculation of sample size.
This is a randomized controlled multicenter trial with a two-group parallel design to assess the efficacy and safety of two commonly applied abdominal wall closure strategies in patients undergoing primary emergency midline laparotomy.
Natural orifice surgery has evolved from a preclinical setting into a common occurrence at the University of California San Diego (UCSD). With close to 40 transvaginal cases, we have become comfortable with this technique and are exploring other indications. One of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation. Patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites. In addition, patients with recurrent incisional hernias may, likewise, be at increased risk. We believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias. Here, we describe what we believe to be the first natural orifice transluminal endoscopic surgical (NOTES) approach to the repair of an abdominal wall hernia.
The patient is a 38-year-old female with a painful recurrent umbilical hernia, previously repaired 8 years prior with a polypropylene-based mesh. The patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.
The patient had no intraoperative or postoperative complications. At 5 months follow up, the patient had no complaints, no evidence of hernia recurrence, and was very pleased with her result.
The repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible, and the result of our initial case was exceptional. However, there are still significant obstacles which must be addressed before this approach can be widely utilized. These obstacles include safe entrance into the abdominal cavity via a transvaginal approach, the proper mesh to be placed during the repair, and the risk of infection.
Transvaginal; Incisional hernia; NOTES; Natural orifice; Hernia
Results of this study suggest that laparoscopic herniorrhaphy with a 2-port technique may allow a safe, efficient repair of ventral and incisional hernias.
Various ventral and incisional hernia repair techniques exist and have largely replaced the open ones. The purpose of this study was to document the 2-port technique and demonstrate that it is feasible, efficient, and safe. To our knowledge, this is the largest report on this topic to date in the English-language literature.
Forty patients with ventral hernias (VH) or incisional hernias (IH) underwent laparoscopic repair with a 2-port technique. The technique involves insertion of one 10-mm to 12-mm balloon port and one 5-mm port, usually on the left side as laterally as possible. A mesh is inserted through the balloon port site and secured to the abdominal wall by using either 4 peripheral or 1 central Prolene suture. Helical fasteners are used to attach the mesh to the abdominal wall.
Forty patients with 47 hernias underwent repair. Operating time ranged from 15 minutes to 70 minutes. Early complications were seen in 5 patients and included 1 small bowel enterotomy, 2 small bowel obstructions (SBO) with bowel adhering to the visceral side of the mesh, 1 wound infection, and 1 seroma. Late postoperative complications occurred in 8 patients (20%) who experienced persistent abdominal pain that resolved without any treatment. There was one recurrence during a mean follow-up of 23.5 months.
Laparoscopic herniorrhaphy with the 2-port technique offers an efficient, safe, and effective repair for ventral and incisional hernias.
Laparoscopy; Ventral hernia; Two-port technique
BACKGROUND: Incisional hernias develop in up to 13% of laparotomy incisions: the most difficult to repair are complex, multiply recurrent hernias with significant loss of domain (>15-20% of the abdominal contents). METHODS: Retrospective analysis by standard proforma of a series of 52 patients operated on at a single institution between 1996 and 2002. All patients received pre-operative CT and anaesthetic assessment. Patients with significant tissue loss were assessed by a plastic surgeon. Cardiorespiratory status was optimised and trophic skin ulcers treated before operation. RESULTS: Sublay repair was applied in 33 patients, onlay in 16 patients, one patient received inlay repair and two patients the Ramirez abdominoplasty. Additional procedures of stoma closure, muscle flap or abdominoplasty were carried out in 7 patients. Complications occurred in 18 (34.6%) patients, 5 of whom required further surgery for haematoma, infection or fistulisation. One patient died from pulmonary embolism after postoperative complications. Three recurrences were apparent after follow-up of 6 months to 6 years. CONCLUSIONS: Complex incisional hernias are a challenging surgical problem. Careful patient selection and surgical technique with a team involving anaesthetists and plastic surgeons is required. Post-operative management may require facilities in HDU and ITU. Clinical trials are required to identify techniques and materials which give the best results.