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General Surgery
Perspective on Hernias (A) Laparoscopic Incisional Hernia
Built from Maingot's Abdominal Operations
What’s inside
8 sections · 62 slides
The problem being solved
What an incisional hernia is, and how the keyhole repair began
- Definition of an incisional hernia
- Burden of incisional hernia in surgical practice
- Terms used in ventral and incisional hernia repair
- First report of laparoscopic incisional hernia repair
- Scope of the term laparoscopic ventral hernia repair
- State of the evidence after two decades
- Minimally invasive operating setup
Rationale for the laparoscopic approach
Why surgeons expected the keyhole route to do better
- Original rationale for the laparoscopic approach
- Patient-related causes of repair failure
- Missed fascial defects as a technical cause of failure
- Causes of incisional hernia repair failure
- Sequence from missed defect to recurrence
- View of the fascial defect from inside the abdomen
- Layers of the anterior abdominal wall
- Incidental findings during peritoneoscopy
- Avoiding dissection through a deeply scarred incision
- Mesh delivery through a clean field after prior wound infection
Drawbacks of the laparoscopic repair
What the keyhole route gives up, and where it can go wrong
- Dead space and seroma formation
- Cosmetic outcome after repair of large defects
- Severe adhesions and hazardous adhesiolysis
- Inadvertent bowel injury and mesh infection
- Sequence from adhesiolysis to mesh infection
- Sites where transfascial fixation is not possible
- Pros and cons of laparoscopic ventral hernia repair
- Balance of advantages against drawbacks
Technique
Mesh choice, fixation and the mistakes that follow the learning curve
- Mesh versus suture repair in open surgery
- Role of mesh in the laparoscopic repair
- Risks of mesh placed in contact with viscera
- Dual-sided mesh prostheses
- Evidence behind adhesion-preventing coatings
- Requirements common to both operations
- What the laparoscopic route substitutes for open dissection
- The invasiveness paradox
- Postoperative pain and quality of life in trials
- Mesh fixation technique and postoperative pain
- Bowel injury rates compared with open surgery
- 1.78%
- The learning curve in laparoscopic repair
- Sizing the mesh with the abdomen deflated
- Transfascial sutures and tacks
- Abdominal binders after repair
- Steps of the laparoscopic repair
Postoperative results
Complications, wound problems, hospital stay and return to work
- Postoperative pain compared with other laparoscopic operations
- Overall postoperative complication rates
- Wound infection and mesh removal
- 31.5% vs 47.9%
- Hospital stay and return to work
- Summary of short-term outcomes
Long-term follow-up
Recurrence, the outcome that decides whether a repair worked
- Recurrence as the key long-term outcome
- Effect of mesh on long-term recurrence in open repair
- 63%
- Recurrence after laparoscopic versus open repair
- Limitations of the long-term evidence
- Surgeon experience and recurrence
Cost and benefit
What the technique adds to the bill, and what is not yet known
- Cost drivers in laparoscopic hernia repair
- State of the cost-effectiveness evidence
Conclusion
Where the laparoscopic repair belongs in practice
- Conclusion of the authors
- Take-home points
- References
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition