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Laparoscopic Ventral Hernia Repair: 5-mm Port Technique and Alternative Mesh Insertion Method
SURGEON AT WORK
Laparoscopic Ventral Hernia Repair: 5-mm Port Technique and Alternative Mesh Insertion Method Abdelrahman A Nimeri, MD, L Michael Brunt, MD Laparoscopic ventral hernia repair (LVHR) is becoming the preferred technique for repair of ventral hernias at many institutions.1,2 LVHR is associated with low conversion rates to open operation, short hospital stays, low recurrence rates, and is suitable for repair of complicated hernias. The standard approach to LVHR involves mesh insertion through a 10- to 12-mm or larger port site.3 Studies have shown that port sites ⬎ 5 mm lead to port-site hernias if the fascia is not sutured.4 The 10- to 12-mm or larger port site created must be sutured closed to minimize chance of developing a port-site hernia.4 Suturing the port site can be a source of persistent postoperative pain.1 We describe our technique for LVHR using 5-mm ports only and an alternative method for mesh insertion. This technique eliminates the need for a large fascial defect and can decrease incidence of postoperative pain and port-site hernias.
Operative technique
After administration of general anesthesia, a urinary catheter, sequential compression devices, and an orogastric tube were placed. A closed Veress needle insertion was used to gain access to the peritoneal cavity away from previous scars, surgical sites, and lateral to the hernia defect; two to three additional 5-mm ports were placed laterally as well (Fig. 1). Adhesiolysis was performed using a 5-mm 30° laparoscope and sharp dissection. The mesh was introduced into the peritoneal cavity by making a 2- to 2.5-cm incision over the center of the hernia defect. The mesh was rolled and inserted through the sac into the peritoneal cavity (Fig. 2). Pneumoperitoneum was reestablished after either applying towel clips to the skin or closing the hernia sac and skin with running sutures to prevent leak of the pneumoperitoneum. The mesh was then unrolled intraperitoneally, positioned, and anchored with a standard technique using 5-mm spiral tacks (Protack; US Surgical Corp) and transfascial sutures (Fig. 3). No fascial closure of port sites was needed.
METHODS Data from a prospectively collected database of patients undergoing LVHR repair using 5-mm ports at the Washington University School of Medicine were reviewed. Patient demographics and intraoperative and postoperative data were collected. All LVHRs were performed by one senior surgeon (LMB) between March 2002 and March 2005. This study was approved by the Human Studies Committee at the Washington University School of Medicine. On the first postoperative day, oral liquids were started, the urinary catheter was removed, and patients were ambulated. Patients were discharged home when they were tolerating a regular diet and their pain was controlled. Data are expressed as mean ⫾ SD (for even distribution) along with ranges where appropriate.
RESULTS Seventeen consecutive patients underwent LVHR using only 5-mm ports with the mesh inserted through the hernia defect. Mean patient age was 59.7 ⫾ 10.1 years, and there were 10 women and 7 men. Mean body mass index was 33.5 ⫾ 7.5 (calculated as kg/m2) and mean American Society of Anesthesiology score was 2.2 ⫾ 0.5. Hernia location was midline in 15 patients and flank in 2 patients. Nine (53%) of the hernias repaired were recurrent. Mean operative time was 156 ⫾ 45 minutes; concomitant procedures were performed in 5 patients, and included 2 umbilical hernia repairs, epigastric hernia repair, superficial groin abscess drainage, and laparoscopic adrenalectomy. Mean defect size was 128 ⫾ 124 cm2 (range 9 to 494 cm2), and mean mesh size used was 364 ⫾ 184 cm2 (range 150 to 825 cm2). There were no conversions to open repair and no enterotomies created during adhesiolysis. Median postoperative length of stay was 2.3 days. Mean followup period was 8.1 ⫾ 9.2 months (range
Competing Interests Declared: None. Received November 30, 2005; Accepted December 9, 2005. From the Department of Surgery and Institute for Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO. Correspondence address: L Michael Brunt, MD, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8109, St Louis, MO 63110. email: [email protected]
© 2006 by the American College of Surgeons Published by Elsevier Inc.
708
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2005.12.013
Vol. 202, No. 4, April 2006
Nimeri and Brunt
Laparoscopic Ventral Hernia Repair
709
Figure 1. Intraoperative photograph showing port placement. Note the lateral position of the 5-mm ports.
0.7 to 21.6 months). In followup, 5 (29.4%) patients developed a seroma; 1 required aspiration once, and the rest resolved spontaneously. One patient required mesh removal on postoperative day 14 because of Candida peritonitis that developed secondary to a urinary source. This patient was the only patient to develop a recurrent hernia during followup, for a recurrence rate of 5.9%. DISCUSSION Current techniques of LVHR typically use a 10- to 12-mm or larger port for mesh insertion.4 This fascial defect used for mesh insertion must be sutured closed, and that can produce postoperative pain or be the site for a postoperative hernia.4 Advantages of the 5-mm port
Figure 2. Intraoperative photograph showing insertion of the mesh through the hernia sac and defect to be repaired. The mesh has been rolled and sutures have been tied around it to keep it from unrolling during insertion. Clamps are used to hold the edges of the hernia sac apart. Nonabsorbable sutures placed in the mesh for future transfascial fixation can also be seen coming out the end of the rolled mesh.
Figure 3. Intraoperative photograph showing the transfixion sutures in place to secure the mesh. Note the three 5-mm ports and central transverse incision over the repaired hernia defect that was used for mesh insertion.
technique with hernia-site mesh insertion are that it eliminates need for placement of a large trocar through the lateral abdominal wall and obviates need for fascial closure of any port site. Use of the hernia site for mesh insertion also facilitates the introduction of large pieces of mesh, because the mesh is being passed through pliable superficial abdominal skin, SC tissue, and hernia sac, and not through a rigid trocar or full-thickness abdominal wall musculature. This approach can also reduce postoperative pain at the conventional 10- to 12-mm port site. Because all ports are 5 mm in size, access to the peritoneal cavity is achieved using a closed technique and with a Veress needle and optically guided placement of the initial 5-mm port. Almost all patients undergoing LVHR have had previously open abdominal operations. For patients to be candidates for this approach they should have at least one quadrant of the abdomen that is expected to be untouched from earlier operations; otherwise, an open insertion technique (with a 10- to 12-mm port) should be used. Use of the hernia site for mesh insertion should also probably be avoided in any patient who has had a prior wound infection at that site. The incidence of laparoscopic port-site hernias has been reported to be 2.8%.5 This problem has not been well studied in patients undergoing laparoscopic ventral hernia repair. Anecdotally, we have already repaired sizable port-site hernias in patients who have previously undergone LVHR. Port-site hernias, as classified by Tonouchi and colleagues,5 are of three types: early onset, late onset, and special type
710
Nimeri and Brunt
Laparoscopic Ventral Hernia Repair
(dehiscence of the whole abdominal wall). Although incidence of this problem is low, it can lead to considerable morbidity and even intestinal strangulation because of the small size of the fascial defect if the diagnosis is not suspected.4 These hernias are most commonly associated with 10to 12-mm or larger ports, but can also occur at 5-mm port sites that have been actively manipulated or stretched during the operative procedure as for mesh insertion.5 In addition, port-site hernias have been reported in standard and bladeless trocars.4 Other factors that can increase risk for developing a port-site hernia include enlarging the fascial defect, effect of CO2 pneumoperitoneum pushing the viscera through the fascial defect, periumbilical, or midline ports, obesity, and postoperative wound infection.5 Current recommendations are to close the fascia at all port sites ⬎ 5 mm in diameter, and to close any 5-mm site that has been manipulated or stretched during operation.5 Fascial closure under direct vision can be difficult through a 10- to 12-mm skin incision, especially in obese patients, and use of a fascial closure device or suture passer under direct laparoscopic vision is recommended to ensure that margins of the fascia are well approximated. Also, patients with incisional hernias have already shown a predisposition to hernia formation and can be at increased risk for herniation at the port sites. Although port-site herniation does not appear to be a common problem after LVHR, the exclusive 5-mm port approach has the potential to eliminate this problem entirely. Postoperative pain after LVHR is most commonly a result of mesh fixation and, in particular, use of transfascial sutures.6 Another potential advantage of the 5-mm port technique is elimination of the port site as a source of increased or prolonged postoperative pain. None of the patients in the present series reported increased or prolonged postoperative pain at any of the port sites. Additional studies to differentiate suture fixation pain from port-site pain are needed to address this issue. In this study we were able to perform LVHR in obese patients, patients with large hernia defects, and those who required large pieces of mesh using only 5-mm ports. None of the patients developed wound infections at either the port sites or the mesh-insertion site. In one patient, Candida sepsis and peritonitis developed from an apparent urinary source and required mesh removal, constituting the only infection and hernia recurrence in this study. Whether the infection in this patient had any
J Am Coll Surg
relationship to the mesh-insertion site is unknown, but appears unlikely. One of the most common consequences of LVHR is development of a seroma at the hernia site. Incidence of postoperative seroma in large series of LVHR has been 11.4%.1 Most of these are asymptomatic and do not require aspiration or other therapy. In the present series, 4 patients (24%) developed postoperative seromas, which is similar to the incidence of seroma (19.8%) reported previously by our group before using the 5-mm port technique; there was no incidence of wound infection in these 4 patients.7 In addition, there was no leakage of seroma fluid or wound breakdown at the site of mesh insertion. In summary, we report a new technique for LVHR using 5-mm ports only and an alternative method for mesh insertion. This technique appears to be safe, can decrease incidence of postoperative port-site hernias, and is applicable to most patients undergoing LVHR. This technique should be evaluated in larger numbers of patients to assess its advantages and evaluate outcomes. Author Contributions Study conception and design: Brunt Acquisition of data: Nimeri, Brunt Analysis and interpretation of data: Nimeri, Brunt Drafting of manuscript: Nimeri, Brunt Critical revision: Nimeri, Brunt Acknowledgment: This study is supported by the Washington University Institute for Minimally Invasive Surgery. REFERENCES 1. Cobb WS, Kercher KW, Heniford BT. Laparoscopic repair of incisional hernias. Surg Clin N Am 2005;58:91–103. 2. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000;190:645–650. 3. Kirshtein B, Lantsberg L, Avinoach E, et al. Laparoscopic repair of large incisional hernias. Surg Endosc 2002;16:1717–1719. 4. Boughey JC, Nottingham JM, Walls AC. Richter’s hernia in the laparoscopic era: four case reports and review of the literature. Surg Laparosc Endosc Percutan Tech 2003;13:55–58. 5. Tonouchi H, Ohmori Y, Kabayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004;139:1248–1256. 6. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias. Nine years’ experience with 850 consecutive hernias. Ann Surg 2003;238:391–400. 7. Perrone J, Soper NJ, Eagon CJ, et al. Perioperative outcomes and complications of laparoscopic ventral hernia repair. Surgery 2005; 138:708–716.
Laparoscopic Ventral Hernia Repair: 5-mm Port Technique and Alternative Mesh Insertion Method Abdelrahman A Nimeri, MD, L Michael Brunt, MD Laparoscopic ventral hernia repair (LVHR) is becoming the preferred technique for repair of ventral hernias at many institutions.1,2 LVHR is associated with low conversion rates to open operation, short hospital stays, low recurrence rates, and is suitable for repair of complicated hernias. The standard approach to LVHR involves mesh insertion through a 10- to 12-mm or larger port site.3 Studies have shown that port sites ⬎ 5 mm lead to port-site hernias if the fascia is not sutured.4 The 10- to 12-mm or larger port site created must be sutured closed to minimize chance of developing a port-site hernia.4 Suturing the port site can be a source of persistent postoperative pain.1 We describe our technique for LVHR using 5-mm ports only and an alternative method for mesh insertion. This technique eliminates the need for a large fascial defect and can decrease incidence of postoperative pain and port-site hernias.
Operative technique
After administration of general anesthesia, a urinary catheter, sequential compression devices, and an orogastric tube were placed. A closed Veress needle insertion was used to gain access to the peritoneal cavity away from previous scars, surgical sites, and lateral to the hernia defect; two to three additional 5-mm ports were placed laterally as well (Fig. 1). Adhesiolysis was performed using a 5-mm 30° laparoscope and sharp dissection. The mesh was introduced into the peritoneal cavity by making a 2- to 2.5-cm incision over the center of the hernia defect. The mesh was rolled and inserted through the sac into the peritoneal cavity (Fig. 2). Pneumoperitoneum was reestablished after either applying towel clips to the skin or closing the hernia sac and skin with running sutures to prevent leak of the pneumoperitoneum. The mesh was then unrolled intraperitoneally, positioned, and anchored with a standard technique using 5-mm spiral tacks (Protack; US Surgical Corp) and transfascial sutures (Fig. 3). No fascial closure of port sites was needed.
METHODS Data from a prospectively collected database of patients undergoing LVHR repair using 5-mm ports at the Washington University School of Medicine were reviewed. Patient demographics and intraoperative and postoperative data were collected. All LVHRs were performed by one senior surgeon (LMB) between March 2002 and March 2005. This study was approved by the Human Studies Committee at the Washington University School of Medicine. On the first postoperative day, oral liquids were started, the urinary catheter was removed, and patients were ambulated. Patients were discharged home when they were tolerating a regular diet and their pain was controlled. Data are expressed as mean ⫾ SD (for even distribution) along with ranges where appropriate.
RESULTS Seventeen consecutive patients underwent LVHR using only 5-mm ports with the mesh inserted through the hernia defect. Mean patient age was 59.7 ⫾ 10.1 years, and there were 10 women and 7 men. Mean body mass index was 33.5 ⫾ 7.5 (calculated as kg/m2) and mean American Society of Anesthesiology score was 2.2 ⫾ 0.5. Hernia location was midline in 15 patients and flank in 2 patients. Nine (53%) of the hernias repaired were recurrent. Mean operative time was 156 ⫾ 45 minutes; concomitant procedures were performed in 5 patients, and included 2 umbilical hernia repairs, epigastric hernia repair, superficial groin abscess drainage, and laparoscopic adrenalectomy. Mean defect size was 128 ⫾ 124 cm2 (range 9 to 494 cm2), and mean mesh size used was 364 ⫾ 184 cm2 (range 150 to 825 cm2). There were no conversions to open repair and no enterotomies created during adhesiolysis. Median postoperative length of stay was 2.3 days. Mean followup period was 8.1 ⫾ 9.2 months (range
Competing Interests Declared: None. Received November 30, 2005; Accepted December 9, 2005. From the Department of Surgery and Institute for Minimally Invasive Surgery, Washington University School of Medicine, St Louis, MO. Correspondence address: L Michael Brunt, MD, Department of Surgery, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8109, St Louis, MO 63110. email: [email protected]
© 2006 by the American College of Surgeons Published by Elsevier Inc.
708
ISSN 1072-7515/06/$32.00 doi:10.1016/j.jamcollsurg.2005.12.013
Vol. 202, No. 4, April 2006
Nimeri and Brunt
Laparoscopic Ventral Hernia Repair
709
Figure 1. Intraoperative photograph showing port placement. Note the lateral position of the 5-mm ports.
0.7 to 21.6 months). In followup, 5 (29.4%) patients developed a seroma; 1 required aspiration once, and the rest resolved spontaneously. One patient required mesh removal on postoperative day 14 because of Candida peritonitis that developed secondary to a urinary source. This patient was the only patient to develop a recurrent hernia during followup, for a recurrence rate of 5.9%. DISCUSSION Current techniques of LVHR typically use a 10- to 12-mm or larger port for mesh insertion.4 This fascial defect used for mesh insertion must be sutured closed, and that can produce postoperative pain or be the site for a postoperative hernia.4 Advantages of the 5-mm port
Figure 2. Intraoperative photograph showing insertion of the mesh through the hernia sac and defect to be repaired. The mesh has been rolled and sutures have been tied around it to keep it from unrolling during insertion. Clamps are used to hold the edges of the hernia sac apart. Nonabsorbable sutures placed in the mesh for future transfascial fixation can also be seen coming out the end of the rolled mesh.
Figure 3. Intraoperative photograph showing the transfixion sutures in place to secure the mesh. Note the three 5-mm ports and central transverse incision over the repaired hernia defect that was used for mesh insertion.
technique with hernia-site mesh insertion are that it eliminates need for placement of a large trocar through the lateral abdominal wall and obviates need for fascial closure of any port site. Use of the hernia site for mesh insertion also facilitates the introduction of large pieces of mesh, because the mesh is being passed through pliable superficial abdominal skin, SC tissue, and hernia sac, and not through a rigid trocar or full-thickness abdominal wall musculature. This approach can also reduce postoperative pain at the conventional 10- to 12-mm port site. Because all ports are 5 mm in size, access to the peritoneal cavity is achieved using a closed technique and with a Veress needle and optically guided placement of the initial 5-mm port. Almost all patients undergoing LVHR have had previously open abdominal operations. For patients to be candidates for this approach they should have at least one quadrant of the abdomen that is expected to be untouched from earlier operations; otherwise, an open insertion technique (with a 10- to 12-mm port) should be used. Use of the hernia site for mesh insertion should also probably be avoided in any patient who has had a prior wound infection at that site. The incidence of laparoscopic port-site hernias has been reported to be 2.8%.5 This problem has not been well studied in patients undergoing laparoscopic ventral hernia repair. Anecdotally, we have already repaired sizable port-site hernias in patients who have previously undergone LVHR. Port-site hernias, as classified by Tonouchi and colleagues,5 are of three types: early onset, late onset, and special type
710
Nimeri and Brunt
Laparoscopic Ventral Hernia Repair
(dehiscence of the whole abdominal wall). Although incidence of this problem is low, it can lead to considerable morbidity and even intestinal strangulation because of the small size of the fascial defect if the diagnosis is not suspected.4 These hernias are most commonly associated with 10to 12-mm or larger ports, but can also occur at 5-mm port sites that have been actively manipulated or stretched during the operative procedure as for mesh insertion.5 In addition, port-site hernias have been reported in standard and bladeless trocars.4 Other factors that can increase risk for developing a port-site hernia include enlarging the fascial defect, effect of CO2 pneumoperitoneum pushing the viscera through the fascial defect, periumbilical, or midline ports, obesity, and postoperative wound infection.5 Current recommendations are to close the fascia at all port sites ⬎ 5 mm in diameter, and to close any 5-mm site that has been manipulated or stretched during operation.5 Fascial closure under direct vision can be difficult through a 10- to 12-mm skin incision, especially in obese patients, and use of a fascial closure device or suture passer under direct laparoscopic vision is recommended to ensure that margins of the fascia are well approximated. Also, patients with incisional hernias have already shown a predisposition to hernia formation and can be at increased risk for herniation at the port sites. Although port-site herniation does not appear to be a common problem after LVHR, the exclusive 5-mm port approach has the potential to eliminate this problem entirely. Postoperative pain after LVHR is most commonly a result of mesh fixation and, in particular, use of transfascial sutures.6 Another potential advantage of the 5-mm port technique is elimination of the port site as a source of increased or prolonged postoperative pain. None of the patients in the present series reported increased or prolonged postoperative pain at any of the port sites. Additional studies to differentiate suture fixation pain from port-site pain are needed to address this issue. In this study we were able to perform LVHR in obese patients, patients with large hernia defects, and those who required large pieces of mesh using only 5-mm ports. None of the patients developed wound infections at either the port sites or the mesh-insertion site. In one patient, Candida sepsis and peritonitis developed from an apparent urinary source and required mesh removal, constituting the only infection and hernia recurrence in this study. Whether the infection in this patient had any
J Am Coll Surg
relationship to the mesh-insertion site is unknown, but appears unlikely. One of the most common consequences of LVHR is development of a seroma at the hernia site. Incidence of postoperative seroma in large series of LVHR has been 11.4%.1 Most of these are asymptomatic and do not require aspiration or other therapy. In the present series, 4 patients (24%) developed postoperative seromas, which is similar to the incidence of seroma (19.8%) reported previously by our group before using the 5-mm port technique; there was no incidence of wound infection in these 4 patients.7 In addition, there was no leakage of seroma fluid or wound breakdown at the site of mesh insertion. In summary, we report a new technique for LVHR using 5-mm ports only and an alternative method for mesh insertion. This technique appears to be safe, can decrease incidence of postoperative port-site hernias, and is applicable to most patients undergoing LVHR. This technique should be evaluated in larger numbers of patients to assess its advantages and evaluate outcomes. Author Contributions Study conception and design: Brunt Acquisition of data: Nimeri, Brunt Analysis and interpretation of data: Nimeri, Brunt Drafting of manuscript: Nimeri, Brunt Critical revision: Nimeri, Brunt Acknowledgment: This study is supported by the Washington University Institute for Minimally Invasive Surgery. REFERENCES 1. Cobb WS, Kercher KW, Heniford BT. Laparoscopic repair of incisional hernias. Surg Clin N Am 2005;58:91–103. 2. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000;190:645–650. 3. Kirshtein B, Lantsberg L, Avinoach E, et al. Laparoscopic repair of large incisional hernias. Surg Endosc 2002;16:1717–1719. 4. Boughey JC, Nottingham JM, Walls AC. Richter’s hernia in the laparoscopic era: four case reports and review of the literature. Surg Laparosc Endosc Percutan Tech 2003;13:55–58. 5. Tonouchi H, Ohmori Y, Kabayashi M, Kusunoki M. Trocar site hernia. Arch Surg 2004;139:1248–1256. 6. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias. Nine years’ experience with 850 consecutive hernias. Ann Surg 2003;238:391–400. 7. Perrone J, Soper NJ, Eagon CJ, et al. Perioperative outcomes and complications of laparoscopic ventral hernia repair. Surgery 2005; 138:708–716.