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We report an incarcerated internal hernia in a huge irreducible parastomal hernia-"hernia within hernia." A 70-year-old obese woman with diabetes who underwent an abdomino-perineal resection 20 years ago was admitted to our hospital with 20 years history of a huge irreducible bulge, 25 cm in diameter. An internal hernia due to an adhesive band extending from the sac wall to proximal colon was found in the parastomal hernia sac during an emergency laparotomy. We cut off the distal colon and relocated the colostomy stoma. The patient was discharged uneventfully 2 weeks after the surgery and was readmitted to have a further laparoscopic hernia repair 8 months later. Unfortunately, an unrecognized enterotomy occurred during the secondary surgery that led to an additional laparotomy during which the mesh was not contaminated by the bowel contents and was kept in place. At 22-month follow-up, there were no evidences of recurrence.

Spontaneous rupture of an abdominal hernia is very rare and usually occurs in incisional or recurrent groin hernia. The rupture of abdominal hernia demands emergency surgery, to prevent further obstruction, strangulation of bowel and to cover its contents. The hernial contents can be covered primarily by mesh repair if the general condition of the patient and local condition of the operative site allows or can be covered by skin followed by delayed mesh repair. We report a case of spontaneous rupture of incisional hernia in a 60 years old lady who had developed incisional hernia following tubectomy and managed by mesh repair.

Background:

It has been more than a decade, since the introduction of laparoscopic management of ventral and incisional hernia. The purpose of this article was to systematically review the literature, analyze the results of Laparoscopic repair of ventral and incisional hernia and to ascertain its role.

Materials and Methods:

Pubmed was used for identifying the original articles. Both incisional and ventral hernia repair were included. Out of 145 articles extracted from Pubmed, 34 original studies were considered for review. More than three thousand patients were included in the review. Variables analyzed in the review were inpatient stay, defect size, mesh size, hematoma, seroma, wound infection, bowel perforation, obstruction, ileus, recurrence and pain. Qualitative analysis of the variables was carried out.

Results:

Seromas (5.45%) and post operative pain (2.75%) are the two common complications associated with this procedure. Recurrence rate was found to be 3.67%. Overall complication rate was 19.24%, with two deaths reported.

Conclusion:

The results suggest laparoscopic repair of ventral and incisional hernia as an effective procedure. Faster recovery and shorter in patient stay - makes it a feasible alternative to open repair.

Incisional hernias remain one of the most common surgical complications with a long-term incidence of 10–20%. Increasing evidence of impaired wound healing in these patients supports routine use of an open prefascial, retromuscular mesh repair. Basic pathophysiologic principles dictate that for a successful long-term outcome and prevention of recurrence, a wide overlap underneath healthy tissue is required. Particularly in the neighborhood of osseous structures, only retromuscular placement allows sufficient subduction of the mesh by healthy tissue of at least 5 cm in all directions. Preparation must take into account the special anatomic features of the abdominal wall, especially in the area of the Linea alba and Linea semilunaris. Polypropylene is the material widely used for open mesh repair. New developments have led to low-weight, large-pore polypropylene prostheses, which are adjusted to the physiological requirements of the abdominal wall and permit proper tissue integration. These meshes provide the possibility of forming a scar net instead of a stiff scar plate and therefore help to avoid former known mesh complications.

Morbidly obese patients (MOPs) are predisposed to developing abdominal wall hernias with the potential complication of small bowel obstruction and other morbidity. We report our experience in treating morbidly obese patients. Hernia prophylaxis has been attempted as a means of decreasing the incisional hernia risk associated with weight loss surgery. The controversy regarding the optimal time and method of repair of abdominal wall hernias in patients undergoing open or laparoscopic gastric bypass is discussed with emphasis placed on either a simultaneous repair or splits of the omentum, and of leaving a plug in the hernia defect, to allow time to perform a delayed repair.

Background / Aim: Incisional hernia is still relatively common in our practice. The aim of the study was to identify risk factors associated with incisional hernia in our region. The setting is the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria during a period when prosthetic mesh was not readily available. Patients and Methods: All the women who presented with incisional hernia between 1996 and 2005 were prospectively studied using a standard form to obtain information on pre-hernia (index) operations and possible predisposing factors. They all had open surgical repair and were followed up for 18–60 months. Results: Forty-four women were treated during study period. The index surgeries leading to the hernias were emergency caesarian section 26/44 (59.1%), emergency exploratory laparotomy 6/44 (13.6%), and elective surgeries 12/44 (27.3%). Major associated risk factors were the use of wrong suture materials for fascia repair, midline incisions, wound sepsis, and overweight. Conclusion: For elective surgeries, reduction of weight should be encouraged when appropriate, and transverse incisions are preferred. Absorbable sutures, especially chromic catgut, should be avoided in fascia closure. Antibiotics should be used for complicated obstetric cases.

This report suggests that Spigelian hernia in an emergency setting may be easily and quickly repaired with an intraperitoneal onlay method using composite mesh.

Background and Objectives:

Spigelian hernia is a rare cause of incarcerated ventral abdominal hernia that may pose a diagnostic dilemma. However, with the increasing utilization of double contrast computed tomography (CT) for undiagnosed small bowel obstruction in a virgin abdomen, more such cases are being diagnosed with increasing confidence. Furthermore, with the rapid expansion of the indications for minimal access surgery in emergency situations, these rare emergencies are increasingly tackled using a laparoscopic approach leading to swift patient recovery and discharge.

Methods:

We present the case of an emergency intraperitoneal onlay mesh (IPOM) repair of Spigelian hernia, causing acute small bowel obstruction in a 55-year-old man with liver disease and ascites that was diagnosed using a CT scan. We conducted a search of Medline, Embase, Science Citation Index, Current Contents, PubMed, and the Cochrane Database to review the history of laparoscopic repair of Spigelian hernia and its various advancements, which are briefly presented here.

Results:

The hernia was successfully reduced using laparoscopy, revealing a moderate-size defect in the linea semilunaris. The hernial defect was repaired with a composite mesh that was tacked into position. The patient was discharged from the hospital on the second postoperative day.

Conclusions:

Spigelian hernia in an emergency setting can be easily and swiftly repaired using the IPOM method utilizing a composite mesh.

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.

Appendicitis and incarcerated hernia are frequently encountered reasons of emergency surgery for acute abdomen. The treatment in early stages of each condition is generally simple, but when these conditions are combined, the symptoms become slightly complicated, obscuring specific symptoms. Especially the lack of symptoms for appendicitis leads to delayed diagnosis, resulting in high morbidity. Amyand hernia, which contains appendix in its inguinal hernia sac, is perhaps more familiar to the general surgeons than De Garengeot hernia, which is an incarcerated femoral hernia with an appendix in its sac. We report the case of a 90-year-old female with incarcerated femoral hernia who underwent emergency hernioplasty only to reveal an inflamed appendix in its sac. The patient underwent both appendectomy and hernia repair simultaneously with synthetic mesh and was discharged on postoperative day 7 without any complications. We will also discuss the physical and radiological findings of De Garengeot hernia.

Background and objectives:

Trocar-site incisional hernia following laparoscopic ventral hernia repair is reported to have a relatively high incidence. The main reasons are trocar diameter and design, pre-existing fascial defects, and some operation- and patient-related factors. The aim of this article to show a new technique of ventral hernia repair that could prevent trocar site incisional hernia.

Methods:

After establishing the pneumoperitoneum, three 5-mm ports are inserted in positions according to the site and size of the hernia. The procedure begins by dissection of the adhesions of bowel loops or omentum (if any) from the hernia to clear a good margin for mesh coverage. Then a single 10-mm to 15-mm port (mesh insertion port) is inserted in the center of the ventral hernia depending on the size of the mesh. The mesh is fixed in position with a 5-mm tacker. The peritoneum and underlying superficial fascia are carefully closed before closing the skin.

Results:

A total of 35 patients were recruited for this method. The mean hospital stay was 1.5 days, the mean age was 50.35 years and the mean operative time was 40 minutes. In all patients, 10x15-cm ePTFE was used. No single incidence of trocar-site incisional hernia occurred during a mean follow-up of 2 years. Three (8.57%) patients developed complications and no mortality was reported.

Conclusion:

The mesh introduction through the port, which is situated at the center of the hernia defect is a simple, cost-effective technique and will prevent trocar-site incisional hernia.

Spontaneous evisceration is a very rare and potentially fatal complication of abdominal-wall incisional hernia. Here the authors present a case report of spontaneous evisceration in an incisional hernia in a 45-year-old female patient. Management of the condition using prosthetic mesh repair risks mesh infection, while the use of non-prosthetic repair risks recurrence of the hernia due to the absence of stout natural tissues. Use of a biological mesh for the condition seems quite plausible. Thorough saline washes of the eviscerated organ; excision of redundant/unhealthy skin and strict adherence to the fundamental principles of hernia repair is desired in managing the condition.

In an attempt to reduce the high recurrence rate after repair of parastomal hernia, a technique was devised in which non-absorbable mesh was used to provide a permanent closure of the gap between the emerging bowel and abdominal wall. Seven patients were treated during the period 1990-1992. Five-year follow-up has given disappointing results, with recurrent hernia in 29% of cases and serious complications, including obstruction and dense adhesions to the intra-abdominal mesh, in 57% and a mesh-related abscess in 15% of cases. This study highlights a dual problem--failure of a carefully sutured mesh to maintain an occlusive position, and complications of the mesh itself. The poor results obtained with this technique together with the disappointing results with other methods described in the literature confirms that parastomal hernia presents a continuing challenge.

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Background

The repair of incisional hernias remains a challenge for the general surgeon. Indications for surgery are severe bowel obstruction, as well as aesthetic problems. There are various surgical methods to correct these hernias, with varying results. However, the gold standard has not yet been found. Both laparoscopic repair and the component separation technique (CTS) have proven to be acceptable techniques; however, they are not always suitable for resolving the more complicated abdominal wall defects, i.e. after open-abdomen treatment or fascial necrosis. In our hospital, we developed a new onlay technique which we have evaluated in the following research.

Patients and methods

During a period of 10 years (1996–2007), 101 patients with an incisional hernia were corrected with the new onlay technique. A Marlex mesh of dimensions at least 10 × 20 cm was used, overlapping the fascia by at least 5 cm on each side. This mesh was stapled onto the fascia with skin staples. Of the 101 patients, there were 45 men and 56 women, with a mean age of 55 years. Nine patients died and 13 were lost during follow-up. Of the remaining 79 patients, eight refused to participate. The mean follow-up time was 64 months (normal distribution, standard deviation [SD] 34 months). This cohort of 101 patients was studied retrospectively.

Results

Seventy-one of the 101 patients were evaluated at our out-patient clinic. For 24 patients (25%), the operation was for a recurrence after an incisional hernia correction in the past. Twenty-one patients (20%) had an open-abdomen treatment in their medical history. The surgical procedure was technically possible in all patients and the mean operation time was 63 min. The median admission time was 4.5 days (quartiles 3–6.25). The mean follow-up time was 64 months (SD 35 months). A seroma was reported in 27 of 101 patients (27%) and a wound infection in 22 patients (21%), of which seven patients had to be re-operated. Only if a patient was evaluated at our out-patient clinic could reherniation have been scored; this occurred in 11 of 71 patients (16%).

Conclusion

This technique is an effective and simple procedure to correct incisional hernias with acceptable complication rates and is feasible even in the more complicated hernias.

BACKGROUND:

Incarceration and strangulation are the most feared complications of inguinal hernia. Till date, incarcerated hernias have traditionally been treated by conventional open repair. Reports are now available for the feasibility of laparoscopic repair of incarcerated inguinal hernia. Here, we described our experience with the transperitoneal approach for incarcerated hernias.

MATERIALS AND METHODS:

Between January 2008 and May 2008, four patients were presented with a history of irreducible hernia, abdominal distention and vomiting. All the patients had right-sided inguinal hernia. Reductions of the hernia contents were not possible in any patient. The patients were treated on emergency basis with laparoscopic transabdominal preperitoneal hernia repair. Retrospective analyses of all the patients were done.

RESULTS:

Reduction of the bowel was achieved in all but one patient, who required the division of the internal ring on lateral side. Transperitoneal mesh repair was performed. No major complications were encountered. One patient developed seroma formation that was treated conservatively.

CONCLUSION:

Laparoscopic transperitoneal approach has the advantage of observation of the hernia content for a longer period of time. The division of the internal ring can be done under direct vision. Other intra-abdominal pathology and opposite side hernia can be diagnosed and treated at the same time..

'On-table' pneumoperitoneum before repair of 'complicated' incisional hernias has been used in eight patients considered to be at high risk of recurrence. In four patients the procedure revealed the presence of occult defects. The procedure was uncomplicated and a primary repair without the need for a prosthetic implant was possible in all cases. Six patients remain well with no sign of recurrence at a median follow-up of 96 months (range 22-120 months). Two patients died from conditions unrelated to the method of repair; acute necrotising pancreatitis on the 10th postoperative day and lobar pneumonia 2 months postoperatively. Peroperative pneumoperitoneum is a simple procedure which obviates the need for a prosthetic implant in selected patients. It is therefore particularly useful in the management of incisional hernias associated with sepsis, stomas or in patients requiring synchronous bowel resection.

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Introduction

A vermiform appendix in an inguinal hernia, inflamed or not, is known as Amyand's hernia. Here we present a case series of four men with Amyand's hernia.

Case presentations

We retrospectively studied 963 Caucasian patients with inguinal hernia who were admitted to our surgical department over a 12-year period. Four patients presented with Amyand's hernia (0.4%). A 32-year-old Caucasian man had an inflamed vermiform appendix in his hernial sac (acute appendicitis), presenting as an incarcerated right groin hernia, and underwent simultaneous appendectomy and Bassini suture hernia repair. Two patients, Caucasian men aged 36 and 43 years old, had normal appendices in their sacs, which clinically appeared as non-incarcerated right groin hernias. Both underwent a plug-mesh hernia repair without appendectomy. The fourth patient, a 25-year-old Caucasian man with a large but not inflamed appendix in his sac, had a plug-mesh hernia repair with appendectomy.

Conclusion

A hernia surgeon may encounter unexpected intraoperative findings, such as Amyand's hernia. It is important to be prepared and apply the appropriate treatment.

Spigelian hernia is a rare hernia of the ventral abdominal wall accounting for 1–2% of all hernias. Incarceration of a Spigelian hernia has been reported in 17–24% of the cases. We herein describe an extremely rare case of a colonic obstruction secondary to an incarcerated Spigelian hernia in a severely obese patient. Physical examination was inconclusive and diagnosis was established by computed tomography scans. The patient underwent an open intraperitoneal mesh repair. A high level of suspicion and awareness is required as clinical findings of a Spigelian hernia are often nonspecific especially in obese patients. Computed tomography scan provides detailed information for the surgical planning. Open mesh repair is safe in the emergent surgical intervention of a complicated Spigelian hernia in severely obese patients.

Introduction

Incisional hernias are a common complication following abdominal surgery and they represent about 80% of all ventral hernia. In uncomplicated postoperative follow-up they can develop in about eleven percent of cases and up to 23% of cases with wound infections or other forms of wound complications. Localisation and size of the incisional hernia can vary according to the causal abdominal scar. Conservative treatment (e. g. weight reduction) is only available to relieve symptoms while operative treatments are the only therapeutic treatment option for incisional hernia. Traditionally, open suture repair was used for incisional hernia repair but was associated with recurrence rates as high as 46%. To strengthen the abdominal wall and prevent the development of recurrences the additional implantation of an alloplastic mesh is nowadays commonly used. Conventional hernia surgery as well as minimally invasive surgery, introduced in the early 90s, make use of this mesh-technique and thereby showed marked reductions in recurrence rates. However, there are possible side effects associated with mesh-implantation. Therefore recommendations remain uncertain on which technique to apply for incisional hernia repair and which technique might, under specific circumstances, be associated with advantages over others.

Objectives

The goal of this HTA-Report is to compare laparoscopic incisional hernia repair (LIHR) and conventional incisional hernia repair with and without mesh-implantation in terms of their medical efficacy and safety, their cost-effectiveness as well as their ethical, social und legal implications. In addition, this report aims to compare different techniques of mesh-implantation and mesh-fixation as well as to identify factors, in which certain techniques might be associated with advantages over

others.

Methods

Relevant publications were identified by means of a structured search of databases accessed through the German Institute of Medical Documentation and Information (DIMDI) as well as by a manual search. The former included the following electronic resources:

SOMED (SM78), Cochrane Library – Central (CCTR93), MEDLINE Alert (ME0A), MEDLINE (ME95), CATFILEplus (CATLINE) (CA66), ETHMED (ED93), GeroLit (GE79), HECLINET (HN69), AMED (CB85), CAB Abstracts (CV72), GLOBAL Health (AZ72), IPA (IA70), Elsevier BIOBASE (EB94), BIOSIS Previews (BA93), EMBASE (EM95), EMBASE Alert (EA08), SciSearch (IS90), Cochrane Library – CDSR (CDSR93), NHS-CRD-DARE (CDAR94), NHS-CRD-HTA (INAHTA) as well as NHSEED (NHSEED).

The present report includes German and English literature published until 31.08.2005. The search parameters can be found in the appendix. No limits were placed on the target population. The methodological quality of the included clinical studies was assessed using the criteria recommended by the “Scottish Intercollegiate Guidelines Network Grading Review Group“. Economic studies were evaluated by the criteria of the German Scientific Working Group Technology Assessment for Health Care.

Results

The literature search identified 17 relevant medical publications. One of these studies compared laparoscopic and conventional surgery with and without mesh for incisional hernia repair, while 16 studies compared laparoscopic and conventional surgery with mesh for incisional hernia repair. Among these studies were 14 primary studies (one randomised controlled trial (RCT), two systematic reviews and one HTA-Report. The only study comparing laparoscopic and conventional surgery without mesh found substantial differences in terms of baseline characteristics between treatment groups. The outcome parameters showed decreased recurrence rates for the laparoscopic repair and similar safety of the procedures. Studies comparing laparoscopic and conventional surgery with mesh found similar outcome in terms of medical efficacy and safety. However, there was a trend towards lower recurrence rates, length of hospital stay, and postoperative pain as well as decreased complication rates for laparoscopic repair in the majority of studies. The impact of the technique of mesh-implantation and -fixation as well as the impact of certain factors on the choice of technique has not been systematically assessed in any of the studies.

Discussion

All identified studies suffer from significant methodological weaknesses, such as differences between treatment groups, mainly due to the non-randomised study design, small treatment groups causing low case numbers and lack of statistical power as well as the neglect of important risk factors or adjustment for those. Therefore, no conclusive differences could be identified concerning compared operative techniques, mesh-implantation and -fixation techniques or certain risk factors. Only the comparison of laparoscopic and conventional technique with mesh provides some evidence for a trend towards similar or slightly improved outcome in terms of medical efficacy and safety for the laparoscopic technique. However, there is still a great need for further research to investigate these questions.

Basically, there is no full economic evaluation focussing on the relevant alternatives. Cost compareisons were available, even though only briefly attached to clinical research results. None of the studies primarily aimed to investigate costs or even cost-effectiveness.

Conclusion

When deciding on the choice of operative technique for incisional hernia repair, surgeons take various considerations into account, including patient characteristics, hernia characteristics and their own experience. The studies included in this HTA did not provide conclusive evidence to answer the research questions. Nonetheless, laparoscopic surgery demonstrated a trend towards similar or slightly improved outcome following incisional hernia repair. However, for more conclusive recommendations on the choice of operative technique, high quality trials are required

From the economic perspective, alternative methods are not yet assessed. Only five of the studies involve a cost analysis, though in an insufficient manner. None of the studies identified were laid out as a health economic evaluation. Hence, further research is strongly recommended.

Background

Incarceration of inguinal, umbilical and cicatricial hernias is a frequent problem. However, little is known about the relationship between the use of mesh and outcome after surgery. The goal of this study was to describe the relationship between the use of mesh in incarcerated hernia and the clinical outcome.

Patients and methods

Correspondence, operation reports and patient files between January 1995 and December 2005 of patients presented at one academic and one teaching hospital in Rotterdam were searched for the following keywords: incarceration, strangulation and hernia. The patient characteristics, clinical presentation, pre-operative findings and clinical course were scored and analysed.

Results

A total of 203 patients could be identified: 76 inguinal, 52 umbilical, 39 incisional, 14 epigastric, 14 femoral, five trocar and three spigelian hernias. In the statistical analysis, epigastric, femoral, trocar and spigelian hernias were pooled, due to their small group sizes. One patient was excluded from the analysis because the hernia was not corrected during operation. In total, 99 hernias were repaired using mesh versus 103 primary suture repairs.

Twenty-five wound infections were registered (12.3%). One mesh was removed during a reintervention for anastomotic leakage, although no signs of wound infection were present. Nine patients died, none of them due to wound-related problems [one cardiovascular, one ruptured aneurysm, two anastomotic leakage, two sepsis e causa incognita (e.c.i.), three pulmonary complications]. Univariate analysis showed that female patients (P = 0.007), adipose patients (P = 0.016), patients with an umbilical hernia (P = 0.01) and patients who underwent a bowel resection (P = 0.015) had a significantly higher rate of wound infections. The type of repair (e.g. primary suture or mesh), use of antibiotic prophylaxis, gender, ASA class and age showed no significant relation with post-operative wound infection. After logistic regression analysis, only bowel resection (P = 0.020) showed a significant relation with post-operative wound infection.

Conclusions

Wound infection rates are high after the correction of acute hernia, but clinical consequences are relatively low. Mesh correction of an acute hernia seems to be safe and should be considered in every incarcerated hernia.

Objective:

Laparoscopic repair of ventral incisional hernias is feasible and safe. Polypropylene mesh is often preferred because of its ease of handling and lower cost. Complications like adhesion and fistula formation can occur. The goal of this study was to determine whether bowel adhesions and their attendant complications could be prevented by interposition of omentum.

Methods:

Thirty patients underwent laparoscopic ventral incisional hernias repair with polypropylene mesh. Omentum was always positioned over the loops of bowel for protection. At a mean follow-up of 14 months, 20 patients underwent ultrasonic examination using the previously described visceral slide technique to detect adhesions.

Results:

The mean size of the hernias in the study was 50.3 cm2, and the mean size of the mesh applied was 275 cm2. Thirteen patents (65%) had no sonographically detectable adhesions. Five patients demonstrated adhesions between the mesh and omentum, 1 patient developed adhesions between the left lobe of the liver and the mesh, and only 1 case of bowel adhesion to the edge of the mesh was found.

Conclusion:

Laparoscopic ventral incisional hernias repair with polypropylene mesh and omental interposition is not associated with visceral adhesions in the majority of patients. Polypropylene mesh can be used safely when adequate omental coverage is available.

Background:

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.

Methods:

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.

Results:

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.

Conclusion:

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.

Objectives:

Laparoscopic ventral incisional hernia repair involves intraabdominal placement of a synthetic mesh, and the possibility of formation of severe visceral adhesions to the prosthesis is a principal concern. Little clinical information based on reoperative findings is available about adhesions to biomaterials placed intraabdominally. We conducted a multiinstitutional study of adhesions to implanted expanded polytetrafluoroethylene (ePTFE) mesh at reoperation in patients who had previously undergone laparoscopic incisional hernia repair done with the same mesh implantation technique.

Methods:

Nine surgeons retrospectively assessed the severity of adhesions to ePTFE mesh at reoperation in 65 patients. For each case, adhesions were assigned a score of 0 to 3, with 0 indicating no adhesions and 3 severe adhesions.

Results:

The mean time from mesh implantation to reoperation was 420 days (range, 2 to 1739 days). No adhesions were observed in 15 cases. Forty-four cases received an adhesion score of 1, and 6 cases a score of 2; no scores of 3 were assigned. Thus, 59 patients (91%) had either no or filmy, avascular adhesions. No enterotomies occurred during adhesiolysis.

Conclusions:

In this large series of reoperations after laparoscopic incisional hernia repair, no or minimal formation of adhesions to implanted ePTFE mesh was observed in 91% of cases, and no severe cohesive adhesions were found. Comparative analyses of newer materials based on clinical reoperative findings are warranted to assess the safety of intraabdominally placed meshes.

The iliac crest is a common donor site for autogenous bone grafts. Among the reported complications, lumbar hernias occur infrequently with a reported incidence of 5% to 9%. Surgical repair is advocated secondary to the risk of incarceration or strangulation. Computed tomography is the diagnostic study of choice. Various transabdominal, retroperitoneal, and laparoscopic approaches have been described for the repair of lumbar hernias. We describe a case of successful lumbar incisional hernia repair after iliac crest bone graft harvesting that used prosthetic mesh.

Background

The surgical treatment of large midline incisional hernias remains a challenge. The aim of this report is to present the results of a new technique for large midline incisional hernia repair which combines the components-separation technique with a double-prosthetic-mesh repair.

Methods

The records of all consecutive patients who received a double-mesh combined with the components-separation technique for ventral hernia repair were reviewed. The clinical, surgical, and follow-up data were analyzed.

Results

Nine patients [3 women, 6 men; median age = 62 years (range = 26–77)] were included in the study. Median transverse defect size was 20 cm (range = 15–25). The median duration of hospital stay was 8 days (range = 5–17). Postoperative complications occurred in 66% (6/9). Follow-up [median = 13 months (range = 3–49)] showed no recurrent hernias, but one patient had a small hernia after a relaparotomy for colon carcinoma recurrence. The overall occurrence of wound infections was 44% (4/9). There was no mortality.

Conclusion

The components-separation technique in combination with a double-mesh has shown a low recurrence rate in the short-term follow-up. However, there is a considerable occurrence of postoperative wound infections. Long-term results of the hernia recurrence rate have to be awaited.

Background

We determined the rate of incarceration of inguinal hernia among infants and young children waiting for elective surgery and examined the relation to wait times. We also explored the relation between wait times and the use of emergency department services before surgery.

Methods

We used linked data from administrative databases to identify infants and children less than 2 years of age who underwent surgical repair of an inguinal hernia between Apr. 1, 2002, and Mr. 31, 2004. We determined the rate of hernia incarceration during the wait for surgery and stratified the risk by patient age and sex. We used logistic regression analysis to examine factors associated with hernia incarceration and wait times.

Results

A total of 1065 infants and children less than 2 years old underwent surgical repair of an inguinal hernia during the study period. The median wait time was 35 days (interquartile range 17–77 days). Within 30 days after diagnosis, 126 (11.8%) of the patients had at least 1 emergency department visit; 23.8% of them presented with hernia incarceration. The overall rate of hernia incarceration was 11.9%. The rate was 5.2% with a wait time of up to 14 days (median time from diagnosis to first emergency department visit), as compared with 10.1% with a wait time of up to 35 days (median wait time to surgery) (p < 0.001). Factors associated with an increased risk of incarcerated hernia were age less than 1 year (odds ratio [OR] 2.07, 95% confidence interval [CI] 1.32–3.23), female sex (OR 1.75, 95% CI 1.04–2.93) and emergency department visits (1 visit, OR 2.73, 95% 1.65–4.50; ≥ 2 visits, OR 3.77, 95% CI 1.89–7.43). Children less than 1 year old who waited longer than 14 days had a significant 2-fold risk of incarcerated hernia (OR 1.92, 95% CI 1.11–3.32).

Interpretation

A wait time for surgery of more than 14 days was associated with a doubling of the risk of hernia incarceration among infants and young children with inguinal hernia. Our data support a recommendation that inguinal hernias in this patient population be repaired within 14 days after diagnosis.