- Email: [email protected]
Morbidity associated with laparoscopic repair of suprapubic hernias
The American Journal of Surgery (2008) 196, 983–988
The Southwestern Surgical Congress
Morbidity associated with laparoscopic repair of suprapubic hernias Brandon Varnell, M.D.a, Sharon Bachman, M.D.b, Jacob Quickb, Michelle Vitamvas, R.N.a, Bruce Ramshaw, M.D.b, Dmitry Oleynikov, M.D.a,* a
University of Nebraska Medical Center, Department of General Surgery, 983280 Nebraska Medical Center, Omaha, NE 68198 –3280, USA; bUniversity of Missouri-Columbia, Department of General Surgery, Columbia, MO 65212, USA KEYWORDS: Suprapubic; Hernia; Morbidity; Ventral; Incisional; Laparoscopic
Abstract BACKGROUND: Laparoscopic suprapubic hernia repair (LSHR) is frequently a technically difficult procedure. This is often due to extensive adhesions from multiple previous operations, the necessary wide pelvic dissection, and adequate mesh coverage with transfascial suture fixation. The aim of the current study was to document the complications and morbidity associated with the repair of suprapubic hernias. METHODS: A retrospective review of patients with complex suprapubic ventral hernias undergoing laparoscopic repair between 2003 and 2007 at 2 university-based practices by 1 surgeon at each facility was conducted. The operative techniques were similar and included dissection into the space of Retzius to mobilize the dome of the bladder, intraperitoneal onlay of mesh using a barrier mesh, careful tack fixation to the pubic bone and Cooper’s ligaments, and extensive transfascial suture fixation of the mesh. RESULTS: A total of 47 patients were reviewed, 29 women and 18 men, with a mean age of 54 years. Patients averaged 3.5 previous abdominal surgeries (SD ⫾2.3) and had a mean body mass index (BMI) of 35.1 (SD ⫾7.5). Previous ventral hernia repairs had been performed in 57% of patients. Average defect size was 139.8 cm2 (SD ⫾126) and average mesh size was 453.8 (SD ⫾329.0), with an average hernia-to-mesh ratio of 3.2. Median length of stay was 3 days with a mean follow-up of 2.6 months (SD ⫾3.1). There were 18 complications (38%): symptomatic seroma (n ⫽ 4), prolonged ileus (n ⫽ 2), chronic pain (n ⫽ 2), postoperative urinary retention (n ⫽ 2), enterotomy (n ⫽ 1), intraoperative bladder injury (n ⫽ 1), postoperative urinary tract infection (n ⫽ 1), mesh infection (n ⫽ 1), rapid ventricular rate (n ⫽ 1), small bowel obstruction (n ⫽ 1), pulmonary embolism (n ⫽ 1), and pneumonia (n ⫽ 1). One patient required conversion to open ventral hernia repair, no injury was identified. Recurrence occurred in 3 patients (6.3%). The mechanisms of recurrence included reherniation at the level of the pubic tubercle, a lateral mesh recurrence in a patient with a high BMI and small abdominal excursion, and in a pregnant patient who developed a fixation suture hernia. CONCLUSIONS: Laparoscopic suprapubic hernia repair is safe and effective with a relatively low recurrence rate, considering the complexity of the repair. © 2008 Elsevier Inc. All rights reserved.
The incidence of incisional hernias associated with laparotomy wounds is approximately 20%. The introduction of * Corresponding author. Tel.: ⫹1-402-559-7733; fax: ⫹1-402-559-6749. E-mail address: [email protected] Manuscript received May 3, 2008; revised manuscript August 1, 2008
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.08.006
prosthetic mesh for hernia repair decreased the recurrence rate compared with primary repair alone by nearly 50% (32% vs 63%).1 Based on the modified Rives-Stoppa open technique, laparoscopic repair allows a wide coverage of the fascial defect with fewer recurrences, decreased hospital stay, improved cosmesis, reduced risk of infection, and
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decreased narcotic use.2– 6 With laparoscopic techniques, ventral hernia recurrence is reported to be about 5%.2– 4 The term “suprapubic” hernia is used to describe a hernia defect located within 3– 4 cm above the symphysis pubis.7,8 Suprapubic hernias may occur following low midline, Pfannenstiel, Maylard, and Cherney incisions, at trocar sites, or suprapubic catheterization insertions.7–12 The specific technical difficulty of suprapubic hernia repairs rests in the complexity of dissection and close proximity of these hernias to bony, vascular, and nerve structures. We present our 4-year experience with laparoscopic suprapubic hernia repair (LSHR) and discuss the complications and morbidity associated with the repair of suprapubic hernias.
Methods A retrospective review of patients with suprapubic ventral hernias undergoing laparoscopic repair between 2003 and 2007 at 2 university-based practices by 1 surgeon at each facility was conducted. Institutional review board approval was received from both institutions before acquiring data. Data collected included patient characteristics and demographics, history of hernia repair, defect size, mesh size, operative time, length of stay, complications, and recurrences. Data were entered into an Excel Database (Microsoft Corp, Redmond, WA) and descriptive statistics were calculated.
Operative technique Operative techniques employed were similar in their evolution at each facility, due to the continued academic interaction and communication between each surgeon. A Foley catheter was placed in all patients to decompress the bladder and allow for retrograde distension of bladder or infusion of methylthioninium chloride in the event of a difficult dissection or possible bladder injury. Each procedure began with the placement of 3 or 4 laparoscopic ports. These ports were typically placed in the lateral quadrant furthest from the palpable defect and tailored once the defect was ascertained. Extensive lysis of adhesions was then performed. When the anterior abdominal wall was cleared, the patient was placed in Trendelenburg position, to allow for ease of access to the pelvis. A peritoneal flap was created by incising the peritoneum below the umbilicus, and clearing off the preperitoneal fat. This flap was extended down into the suprapubic portion of the hernia as the hernia contents were reduced and adhesiolysis completed with sharp dissection. The peritoneal flap allowed for safe reduction of hernia contents without injuring unrecognized herniated bladder by staying in the prevesicular space of Retzius. This flap included the hernia sac, which was left in situ. As this flap was extended inferiorly and laterally, it mobilized the dome of the bladder from the pubic bone, allowing direct visualization of the posterior aspect of the
Figure 1 Peritoneal flap extended inferiorly with reduction of hernia contents, mobilization of bladder from pubic bone, and bilateral exposure of Cooper’s ligaments, inferior epigastric vessels, and iliac vessels.
pubic bone, and bilaterally exposing Cooper’s ligaments, inferior epigastric vessels, and iliac vessels (Fig. 1). This dissection is similar to that used in transabdominal preperitoneal (TAPP) inguinal hernia repair. The hernia defect was then measured intracorporeally and a barrier mesh designed for intraperitoneal use was then sized, allowing at least a 4-cm overlap of the defect and allowing at least 5 cm of inferior overlap extending inferior to the pubis. Four permanent sutures were then placed in the mesh. Two techniques were used. If a “4-corner” technique was applied, the most inferior corner sutures were placed about 2 cm above the edge of the mesh, allowing for midline overlap upon the pubis. Alternatively, sutures were placed at the 4 cardinal positions, with the suture at the 6 o’clock position back at least 5 cm away from the edge of the mesh to allow for pelvic coverage. The mesh was then rolled and placed into the abdominal cavity, unfurled and oriented. The stay sutures were then retrieved transabdominally using the suture Passer and tagged. As the placement of the suprapubic sutures were most critical, they were externalized first. The externalized sutures were pulled taught to insure adequate overlap of the defect and the pelvis. These sutures were then tied. Circumferential fixation was completed using spiral tacks at approximately 1-cm intervals to prevent interstitial herniation of bowel at the mesh edges. The first tacks were placed inferiorly at the posterior pubis in the midline and bilaterally in Cooper’s ligaments until the femoral canal was reached. Tacks were also placed laterally at or above the iliopubic tract. Transabdominal sutures were then placed every 3 cm using the suture Passer (Fig. 2). Great care was taken to avoid the placement of sutures or tacks below the iliopubic tract. The peritoneal flap, with included bladder and hernia sac, was either left in place or elevated and tacked to cover the inferior border of the mesh and underlying Cooper’s
B. Varnell et al.
Morbidity of laparoscopic suprapubic hernia repair
Figure 2 Circumferential fixation of fashioned barrier mesh using tacks and transfascial sutures with adequate overlap of the defect and overlap inferior to pubis.
ligaments and neurovascular structures below the iliopubic tract. All patients were offered an abdominal binder in the immediate postoperative course for abdominal comfort.
Results A total of 47 patients undergoing LSHR were reviewed, 29 women and 18 men. This cohort had a mean age of 54 years (range 28 – 84). Patients averaged 3.5 previous abdominal surgeries (SD ⫾2.3), which included surgeries for ventral hernia (n ⫽ 51), gynecology (n ⫽ 42), laparotomy (n ⫽ 26), appendectomy (n ⫽ 15), colorectal (n ⫽ 12), urology (n ⫽ 8), and umbilical hernia (n ⫽ 4). Patients had a mean body mass index (BMI) of 35.1 kg/m2 (SD ⫾7.5). Previous ventral hernia repairs had been performed in 27 (57%) of patients with an average of 2.1 previous attempted repairs each. Mean defect size was 139.8 cm2 (SD ⫾126) and mean mesh size was 453.8 (SD ⫾329.0), with an average hernia-to-mesh ratio of 3.2. The barrier mesh used included: (1) Gore-Tex Dual Mesh (n ⫽ 26) (W.L. Gore, Flagstaff, AZ, USA), which is a dual-sided expanded polytetrafluoroethylene (ePTFE) with a macroporous and microporous side; (2) Proceed (n ⫽ 11) (Johnson & Johnson, Cincinnati, OH, USA), which is a polypropylene mesh with an absorbable oxidized regenerated cellulose barrier; and (3) Parietex Composite (n ⫽ 10) (Covidien, Mansfield, MA, USA), which is a polyester mesh with an absorbable collagen and polyethylene glycol barrier. Operative times ranged from 50 minutes to 270 minutes (mean 130 minutes). Length of stay was 1–20 days (median 3 days) with a mean follow-up of 2.6 months (SD ⫾3.1). There were 18 patients who developed a total of 18 complications (38%): symptomatic seroma (n ⫽ 4), prolonged ileus (n ⫽ 2), chronic pain (n ⫽ 2), postoperative
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urinary retention (n ⫽ 2), enterotomy (n ⫽ 1) with delayed mesh placement, intraoperative bladder injury (n ⫽ 1), postoperative urinary tract infection (n ⫽ 1), mesh infection (n ⫽ 1), postoperative rapid ventricular rate (n ⫽ 1), small bowel obstruction (n ⫽ 1), postoperative pulmonary embolism (n ⫽ 1), and postoperative pneumonia (n ⫽ 1). One patient required conversion to open ventral hernia repair secondary to inability to reduce herniated small bowel contents; no injury was identified. Patient demographics, medical comorbidities (hypertension, tobacco use, pulmonary disease, steroid use, diabetes, cardiovascular disease), American Society of Anesthesiologists (ASA) classification, and number of previous abdominal surgeries all did not significantly differ between those patients with complications and those without. Patients with a greater number of previous surgeries above the average of 3.5 had an increased risk of complications (50% vs 29%); however, this difference was not statistically significant (P ⫽ .226). Patients with complications had a larger defect size above the average of 140 cm2 (52% vs 29%), but the difference was not statistically significant (P ⫽ .131). Those with an ASA greater than 2 were noted to have an increased risk of complications (47% vs 24%), but the difference was not significant (P ⫽ .135). Patients with previous hernia repair had a slight increased risk (44% vs. 30%), not statistically significant (P ⫽ .374). Those patients with complications were noted to have an increased average BMI (37.4 kg/m2 vs 33.7 kg/m2), although not statistically significant (P ⫽ .075). Recurrence occurred in 3 patients (6.3%). Suprapubic recurrence occurred in only 1 patient (2.1%) with re-herniation at the level of the pubic tubercle 34 months after initial repair. A lateral mesh recurrence developed in a patient with a high BMI and small abdominal excursion 14 months following initial repair. Lastly, a patient developed a fixation suture hernia after becoming pregnant 4 months after repair.
Comments The development of the Rives-Stoppa technique with placement of the mesh in a retrorectus position decreased recurrence rates down to 5%, and is considered the open hernia repair gold standard; the laparoscopic approach is thought to have similar recurrence rates due to the intraperitoneal location of the mesh.4 – 6 As laparoscopic placement of mesh necessitates the direct contact between mesh and intra-abdominal contents, the routine use of a barrier mesh reduces the risk of adhesion formation and bowel ingrowth into the prosthetic material.4,13–15 A vital aspect of laparoscopic ventral hernia repair includes the adequate overlap of mesh over the hernia defect onto intact fascia, which improves rates of recurrence.4,16,17 The abdominal oblique aponeurosis, rectus abdominus, and rectus sheath insert upon the symphysis pubis. Incisions near this insertion allow potential hernia formation due to relatively weak tissue and due to inadequate tissue approx-
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imation inferiorly during primary closure. Standard ventral hernia repair techniques apply equally to suprapubic hernia repair in regards to safe and extensive adhesiolysis using sharp dissection, counter-traction, and prevention or immediate recognition of enterotomies. The laparoscopic approach allows superior evaluation of the extent and number of fascial defects to allow proper overlap in hopes of decreasing recurrence due to a “missed” defect. The use of laparoscopy in ventral hernia repair is associated with less pain, better cosmesis, lower risk of mesh and wound infections, and lower recurrence rates.2,4 Increased risk of postoperative morbidity and recurrence is often associated with mesh fixation, mesh overlap, multiple previous abdominal surgeries, previous hernia recurrence, size of hernia defect, and obesity.4,7,18 –21 Development of a preperitoneal plane in patients with previous lower abdominal surgeries has proven to be safe and efficient.22,23 Incising the peritoneum and creating a flap to enter the space of Retzius (similar to the approach in the TAPP inguinal hernia repair) exposes the posterior aspect of the pubic bone, Cooper’s ligaments, and inferior epigastric vessels bilaterally.7,8,10 The proper repair of suprapubic hernias requires development of this preperitoneal plane; this allows the bladder to be dropped safely into the pelvis to prevent inadvertent injury. Additionally, overlap of the mesh into the pubis covers the myopectineal orifice and allows secure fixation of the mesh to the pubis and Cooper’s ligaments at a location of stress.7,9,10,24 The inferior overlap of mesh and its fixation in suprapubic hernias is particularly difficult. There is mounting evidence to support the use of transabdominal sutures as a means of ensuring mesh fixation.1,4,15,16,18 Transabdominal fixation with adequate overlap of mesh inferiorly within the pelvis is limited by the pelvic bony structures. Therefore, further inferior fixation of mesh is required. There is also support for the inferior placement of transabdominal sutures through the periosteum in addition to tacks upon the pubis and Cooper’s ligaments for further inferior mesh fixation.7 Elevation of the peritoneum flap with the bladder covers the inferior mesh edge and corresponding Cooper’s ligaments and neurovascular structures, and allows the bladder to resume anatomic position.9,18 In our series, recurrences occurred in 3 patients (6.3%), which is comparative to the 0%–5.8% cited in the literature.7–9 Only 1 of our patients recurred at the suprapubic location. Increased intra-abdominal pressure was present in both of the other recurrences; elevated BMI led to a lateral mesh recurrence in 1 patient, and the pressure of an enlarging uterus in a second patient placed tension upon 1 of the fixation sutures, causing it to pull through the fascia. This was repaired laparoscopically in the postpartum period. Women of childbearing age must be counseled about the increased risk of recurrence due to the increased abdominal wall pressure presented during pregnancy. Bioabsorbable mesh may play a role in these repairs; however, recurrence would still be increased.
The complication rate of 38% in our series is higher than the 16.6%–29.4% reported in the literature and is attributed to many factors including multiple previous abdominal surgeries, multiple previous attempted repairs, large size of hernia defect, and relative obesity within this subset of patients.7,8,17 Of our patients with previous ventral hernia repairs, there were a total of 55 previous repairs of which 17 involved mesh repair. Four of our patients were noted to have intra-abdominal placement of mesh, with 1 noted to be a nonbarrier type mesh that required removal after extensive lysis of severe adhesions. Seroma was found to be our greatest complication, occurring in 4 patients. Three of these seromas were simply observed and found to resolve within 6 months. One of the seromas was surgically drained 16 days after surgery secondary to the appearance of infection with cellulitis; the seroma wound cultures were negative and the wound healed without further complication. Chronic pain lasting greater than 6 months remained relatively low despite the extensive dissection and fixation in the pelvis. This greatly emphasizes avoidance of suture or tack fixation below the iliopubic tract due to fear of nerve entrapment and chronic pain. One enterotomy occurred in this series, which was recognized immediately and repaired with no mesh placed at that time. One patient suffered an unrecognized bladder injury that was diagnosed on the first postoperative day when hematuria was noted. Cystoureterogram confirmed contained extravasation of contrast into the preperitoneal space; conservative treatment with Foley drainage and re-evaluation on the 12th postoperative day verified no leak. One pulmonary embolism occurred in a patient on the forth postoperative day. This patient had received only sequential compression devises as deep venous thrombosis prophylaxis during the perioperative period and received heparin bridge with coumadin therapy once the embolism was diagnosed. Keys to limiting morbidity include extensive preoperative history and physical (elicit possible etiology behind hernia occurrence/recurrence and assure optimization of comorbidities), perioperative antibiotic prophylaxis, deep vein thrombosis prophylaxis (low molecular weight heparin, sequential compression device, early mobilization), safe entry into the abdominal cavity with adequate visualization, tedious and extensive lysis of adhesions with sharp dissection, exposure and surveillance of entire dissection area (immediate recognition of enterotomies, bladder injuries, vascular injuries, or nerve entrapment), close monitoring of incisions, and early ambulation (improved bowel, pulmonary, and cardiovascular function). There has been shown a significant relationship between postoperative morbidity and hernia location inferior to the umbilicus.17
Conclusions Considering the complexity of the repair, laparoscopic suprapubic hernia repair is safe with few major complications, and is effective with a relatively low recurrence at the
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pubis. Surgeons attempting this technique need to be comfortable with laparoscopic exposure of pelvic structures.
References 1. Burger JWA, Luijendijk RW, Hop WCJ, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578 – 85. 2. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998;124:816 –21. 3. Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 1999;65:827–31. 4. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg 2003;238:391–9. 5. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545–54. 6. Rives J, Pire JC, Flament JB, et al. Treatment of large eventrations: new therapeutic indications apropos of 322 cases. Chirurgie 1985;111: 215–25. 7. Carbonell AM, Kercher KW, Matthews BD, et al. The laparoscopic repair of suprapubic ventral hernias. Surg Endosc 2005;19:174 –7. 8. Palanivelu C, Rangarajan M, Parthasarathi R, et al. Laparoscopic repair of suprapubic incisional hernias: suturing and intraperitoneal composite mesh onlay. A retrospective study. Hernia 2008;12:251– 6. 9. McKay R, Haupt D. Laparoscopic repair of low abdominal wall hernias by tack fixation to the cooper ligament. Surg Laparosc Endosc Perc Tech 2006;16:86 –90. 10. Hirasa T, Pickleman J, Shayani V. Laparoscopic repair of parapubic hernia. Arch Surg 2001;136:1314 –7. 11. Lobel RW, Sand PK. Incisional hernia after suprapubic catheterization. Obstet Gynecol 1997;89:844 – 6. 12. Pena AA, Bermejo CE, Thompson IM. Ventral bladder hernia following tubal ligation. J Urol 2002;168:1502. 13. Gonzalez R, Rodeheaver GT, Moody DL, et al. Resistance to adhesion formation: a comparative study of treated and untreated mesh products placed in the abdominal cavity. Hernia 2004;8:213–9. 14. Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose. Surg Clin North Am 2008;88:101–12. 15. Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic intraperitoneal onlay mesh repair of incisional hernia. Surg Laparosc Endosc 1998;8:360 –2. 16. Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: a personal series and review of the literature. Journal of the Society of Laparoendoscopic Surgeons 1999;3:293–304. 17. Moreno-Egea A, Torralba JA, Girela E, et al. Immediate, early, and late morbidity with laparoscopic ventral hernia repair and tolerance to composite mesh. Surg Laparosc Endosc Perc Tech 2004;14: 130 –5. 18. LaBlanc KA. The critical technical aspects of laparoscopic repair of ventral and incisional hernias. Am Surg 2001;67:809 –12. 19. Tsereteli Z, Pryor BA, Heniford BT, et al. Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia 2008;12:233– 8. 20. Novitsky YW, Cobb WS, Kercher KW, et al. Laparoscopic ventral hernia repair in obese patients: A new standard of care. Arch Surg 2006;141:57– 61. 21. Rosen M, Brody F, Ponsky J, et al. Recurrence after laparoscopic ventral hernia repair. Surg Endosc 2003;17:123– 8. 22. Paterson HM, Casey JJ, Nixon SJ. Totally extraperitoneal laparoscopic hernia repair in patients with previous lower abdominal surgery. Hernia 2005;9:228 –30. 23. Singhal T, Balakrishnan S, Grandy-Smith S, et al. Consolidated five year experience with laparoscopic inguinal hernia repair. Surg 2007; 5:137– 40. 24. Bendavid R. Incisional parapubic hernias. Surgery 1990;108:898 –901.
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Discussion Dr. John Moore (Denver, CO): Ventral incisional hernia is, as we all know, a formidable clinical problem for practicing surgeons and our patients. Unfortunately, as long as laparotomies are performed, unless our population characteristics dramatically change or our techniques for closure change, we can expect the incidents that you describe. To repair these hernias through traditional open procedures, even with the use of mesh, has significant morbidities. It only makes sense for us to continue to look and analyze the new methods that have become available to us in regards to accomplishing the repair. We know that most hernias do not recur until approximately the third year following repair, so I’d like that addressed. In addition, I have several other questions. What was the average time spent in the performance of the procedure? What type of barrier mesh did you utilize and was it standard across all the procedures in both institutions? What was your port placement strategy and were any changes made or modified during the performance of the multiple procedures to accomplish better visualization? Also, in regards to the Revis-Stoppa technique, did you leave the sac in place? Did you perform the adhesiolysis in reduction before opening the flap in regards to the placement of the mesh? And lastly, I wonder if you would comment on the apparent low incidence of chronic pain in this group even though you are using such extensive fixation in the periosteum of the pubis where we know a lot of pain occurs. Dr. Shanu Kothari (La Crosse, WI): Do you have any information on the demographics of these patients? Were these all from C-sections, hysterectomies, prostatectomies, emergent versus elective, or are these just in the inferior edge of a laparotomy incision? Dr. Brandon Varnell (Omaha, NE): In regards to our follow up, that is very true. When you look in the literature on laparoscopic ventral hernia repair or even the few reports there are on suprapubic ventral hernia repair, the average follow-up is typically 46 months, whereas ours was only 2.6 months across the board. For the average operative time, our mean operative times were 180 minutes across the board from all of our hernia repairs. The mesh used was actually split almost 50 –50 with the use of extended PTFE or dual mesh by Gore and Covidian, which was the Pryotex composite mesh or polyester with the collagen-based. Most of our approaches were that through the left lower quadrant or left lateral quadrant. With regards to our hernia sac dissection, typically if these were only suprapubic component, then we would actually begin our dissection very similar to a TAPP repair by making excision in the peritoneum and umbilical fold and continuing that flap down to the actual fascial defect and hernia defect and then subsequently reduce the hernia defects from there. Now often if these were ventral hernias, then a lot of times, the defect started much higher than that, and so as the hernia
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defect was reduced, then we would cut the peritoneal flap and extend it laterally from there to further expose things. In regards to pain, it was a big issue. As you could see, we had 2 patients that had chronic pain which we considered greater than 6 weeks. As far as Dr Kothari’s question for demographics, we did look at our demo-
graphics and the types of procedures. Probably the breakdown was about 40% from lower midline procedures. Some of these were colorectal procedures, some were urological or gynecologic procedures or exploratory laparotomies. If I remember right, only about 10% were emergent cases, the remaining were elective cases.
The Southwestern Surgical Congress
Morbidity associated with laparoscopic repair of suprapubic hernias Brandon Varnell, M.D.a, Sharon Bachman, M.D.b, Jacob Quickb, Michelle Vitamvas, R.N.a, Bruce Ramshaw, M.D.b, Dmitry Oleynikov, M.D.a,* a
University of Nebraska Medical Center, Department of General Surgery, 983280 Nebraska Medical Center, Omaha, NE 68198 –3280, USA; bUniversity of Missouri-Columbia, Department of General Surgery, Columbia, MO 65212, USA KEYWORDS: Suprapubic; Hernia; Morbidity; Ventral; Incisional; Laparoscopic
Abstract BACKGROUND: Laparoscopic suprapubic hernia repair (LSHR) is frequently a technically difficult procedure. This is often due to extensive adhesions from multiple previous operations, the necessary wide pelvic dissection, and adequate mesh coverage with transfascial suture fixation. The aim of the current study was to document the complications and morbidity associated with the repair of suprapubic hernias. METHODS: A retrospective review of patients with complex suprapubic ventral hernias undergoing laparoscopic repair between 2003 and 2007 at 2 university-based practices by 1 surgeon at each facility was conducted. The operative techniques were similar and included dissection into the space of Retzius to mobilize the dome of the bladder, intraperitoneal onlay of mesh using a barrier mesh, careful tack fixation to the pubic bone and Cooper’s ligaments, and extensive transfascial suture fixation of the mesh. RESULTS: A total of 47 patients were reviewed, 29 women and 18 men, with a mean age of 54 years. Patients averaged 3.5 previous abdominal surgeries (SD ⫾2.3) and had a mean body mass index (BMI) of 35.1 (SD ⫾7.5). Previous ventral hernia repairs had been performed in 57% of patients. Average defect size was 139.8 cm2 (SD ⫾126) and average mesh size was 453.8 (SD ⫾329.0), with an average hernia-to-mesh ratio of 3.2. Median length of stay was 3 days with a mean follow-up of 2.6 months (SD ⫾3.1). There were 18 complications (38%): symptomatic seroma (n ⫽ 4), prolonged ileus (n ⫽ 2), chronic pain (n ⫽ 2), postoperative urinary retention (n ⫽ 2), enterotomy (n ⫽ 1), intraoperative bladder injury (n ⫽ 1), postoperative urinary tract infection (n ⫽ 1), mesh infection (n ⫽ 1), rapid ventricular rate (n ⫽ 1), small bowel obstruction (n ⫽ 1), pulmonary embolism (n ⫽ 1), and pneumonia (n ⫽ 1). One patient required conversion to open ventral hernia repair, no injury was identified. Recurrence occurred in 3 patients (6.3%). The mechanisms of recurrence included reherniation at the level of the pubic tubercle, a lateral mesh recurrence in a patient with a high BMI and small abdominal excursion, and in a pregnant patient who developed a fixation suture hernia. CONCLUSIONS: Laparoscopic suprapubic hernia repair is safe and effective with a relatively low recurrence rate, considering the complexity of the repair. © 2008 Elsevier Inc. All rights reserved.
The incidence of incisional hernias associated with laparotomy wounds is approximately 20%. The introduction of * Corresponding author. Tel.: ⫹1-402-559-7733; fax: ⫹1-402-559-6749. E-mail address: [email protected] Manuscript received May 3, 2008; revised manuscript August 1, 2008
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.08.006
prosthetic mesh for hernia repair decreased the recurrence rate compared with primary repair alone by nearly 50% (32% vs 63%).1 Based on the modified Rives-Stoppa open technique, laparoscopic repair allows a wide coverage of the fascial defect with fewer recurrences, decreased hospital stay, improved cosmesis, reduced risk of infection, and
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decreased narcotic use.2– 6 With laparoscopic techniques, ventral hernia recurrence is reported to be about 5%.2– 4 The term “suprapubic” hernia is used to describe a hernia defect located within 3– 4 cm above the symphysis pubis.7,8 Suprapubic hernias may occur following low midline, Pfannenstiel, Maylard, and Cherney incisions, at trocar sites, or suprapubic catheterization insertions.7–12 The specific technical difficulty of suprapubic hernia repairs rests in the complexity of dissection and close proximity of these hernias to bony, vascular, and nerve structures. We present our 4-year experience with laparoscopic suprapubic hernia repair (LSHR) and discuss the complications and morbidity associated with the repair of suprapubic hernias.
Methods A retrospective review of patients with suprapubic ventral hernias undergoing laparoscopic repair between 2003 and 2007 at 2 university-based practices by 1 surgeon at each facility was conducted. Institutional review board approval was received from both institutions before acquiring data. Data collected included patient characteristics and demographics, history of hernia repair, defect size, mesh size, operative time, length of stay, complications, and recurrences. Data were entered into an Excel Database (Microsoft Corp, Redmond, WA) and descriptive statistics were calculated.
Operative technique Operative techniques employed were similar in their evolution at each facility, due to the continued academic interaction and communication between each surgeon. A Foley catheter was placed in all patients to decompress the bladder and allow for retrograde distension of bladder or infusion of methylthioninium chloride in the event of a difficult dissection or possible bladder injury. Each procedure began with the placement of 3 or 4 laparoscopic ports. These ports were typically placed in the lateral quadrant furthest from the palpable defect and tailored once the defect was ascertained. Extensive lysis of adhesions was then performed. When the anterior abdominal wall was cleared, the patient was placed in Trendelenburg position, to allow for ease of access to the pelvis. A peritoneal flap was created by incising the peritoneum below the umbilicus, and clearing off the preperitoneal fat. This flap was extended down into the suprapubic portion of the hernia as the hernia contents were reduced and adhesiolysis completed with sharp dissection. The peritoneal flap allowed for safe reduction of hernia contents without injuring unrecognized herniated bladder by staying in the prevesicular space of Retzius. This flap included the hernia sac, which was left in situ. As this flap was extended inferiorly and laterally, it mobilized the dome of the bladder from the pubic bone, allowing direct visualization of the posterior aspect of the
Figure 1 Peritoneal flap extended inferiorly with reduction of hernia contents, mobilization of bladder from pubic bone, and bilateral exposure of Cooper’s ligaments, inferior epigastric vessels, and iliac vessels.
pubic bone, and bilaterally exposing Cooper’s ligaments, inferior epigastric vessels, and iliac vessels (Fig. 1). This dissection is similar to that used in transabdominal preperitoneal (TAPP) inguinal hernia repair. The hernia defect was then measured intracorporeally and a barrier mesh designed for intraperitoneal use was then sized, allowing at least a 4-cm overlap of the defect and allowing at least 5 cm of inferior overlap extending inferior to the pubis. Four permanent sutures were then placed in the mesh. Two techniques were used. If a “4-corner” technique was applied, the most inferior corner sutures were placed about 2 cm above the edge of the mesh, allowing for midline overlap upon the pubis. Alternatively, sutures were placed at the 4 cardinal positions, with the suture at the 6 o’clock position back at least 5 cm away from the edge of the mesh to allow for pelvic coverage. The mesh was then rolled and placed into the abdominal cavity, unfurled and oriented. The stay sutures were then retrieved transabdominally using the suture Passer and tagged. As the placement of the suprapubic sutures were most critical, they were externalized first. The externalized sutures were pulled taught to insure adequate overlap of the defect and the pelvis. These sutures were then tied. Circumferential fixation was completed using spiral tacks at approximately 1-cm intervals to prevent interstitial herniation of bowel at the mesh edges. The first tacks were placed inferiorly at the posterior pubis in the midline and bilaterally in Cooper’s ligaments until the femoral canal was reached. Tacks were also placed laterally at or above the iliopubic tract. Transabdominal sutures were then placed every 3 cm using the suture Passer (Fig. 2). Great care was taken to avoid the placement of sutures or tacks below the iliopubic tract. The peritoneal flap, with included bladder and hernia sac, was either left in place or elevated and tacked to cover the inferior border of the mesh and underlying Cooper’s
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Figure 2 Circumferential fixation of fashioned barrier mesh using tacks and transfascial sutures with adequate overlap of the defect and overlap inferior to pubis.
ligaments and neurovascular structures below the iliopubic tract. All patients were offered an abdominal binder in the immediate postoperative course for abdominal comfort.
Results A total of 47 patients undergoing LSHR were reviewed, 29 women and 18 men. This cohort had a mean age of 54 years (range 28 – 84). Patients averaged 3.5 previous abdominal surgeries (SD ⫾2.3), which included surgeries for ventral hernia (n ⫽ 51), gynecology (n ⫽ 42), laparotomy (n ⫽ 26), appendectomy (n ⫽ 15), colorectal (n ⫽ 12), urology (n ⫽ 8), and umbilical hernia (n ⫽ 4). Patients had a mean body mass index (BMI) of 35.1 kg/m2 (SD ⫾7.5). Previous ventral hernia repairs had been performed in 27 (57%) of patients with an average of 2.1 previous attempted repairs each. Mean defect size was 139.8 cm2 (SD ⫾126) and mean mesh size was 453.8 (SD ⫾329.0), with an average hernia-to-mesh ratio of 3.2. The barrier mesh used included: (1) Gore-Tex Dual Mesh (n ⫽ 26) (W.L. Gore, Flagstaff, AZ, USA), which is a dual-sided expanded polytetrafluoroethylene (ePTFE) with a macroporous and microporous side; (2) Proceed (n ⫽ 11) (Johnson & Johnson, Cincinnati, OH, USA), which is a polypropylene mesh with an absorbable oxidized regenerated cellulose barrier; and (3) Parietex Composite (n ⫽ 10) (Covidien, Mansfield, MA, USA), which is a polyester mesh with an absorbable collagen and polyethylene glycol barrier. Operative times ranged from 50 minutes to 270 minutes (mean 130 minutes). Length of stay was 1–20 days (median 3 days) with a mean follow-up of 2.6 months (SD ⫾3.1). There were 18 patients who developed a total of 18 complications (38%): symptomatic seroma (n ⫽ 4), prolonged ileus (n ⫽ 2), chronic pain (n ⫽ 2), postoperative
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urinary retention (n ⫽ 2), enterotomy (n ⫽ 1) with delayed mesh placement, intraoperative bladder injury (n ⫽ 1), postoperative urinary tract infection (n ⫽ 1), mesh infection (n ⫽ 1), postoperative rapid ventricular rate (n ⫽ 1), small bowel obstruction (n ⫽ 1), postoperative pulmonary embolism (n ⫽ 1), and postoperative pneumonia (n ⫽ 1). One patient required conversion to open ventral hernia repair secondary to inability to reduce herniated small bowel contents; no injury was identified. Patient demographics, medical comorbidities (hypertension, tobacco use, pulmonary disease, steroid use, diabetes, cardiovascular disease), American Society of Anesthesiologists (ASA) classification, and number of previous abdominal surgeries all did not significantly differ between those patients with complications and those without. Patients with a greater number of previous surgeries above the average of 3.5 had an increased risk of complications (50% vs 29%); however, this difference was not statistically significant (P ⫽ .226). Patients with complications had a larger defect size above the average of 140 cm2 (52% vs 29%), but the difference was not statistically significant (P ⫽ .131). Those with an ASA greater than 2 were noted to have an increased risk of complications (47% vs 24%), but the difference was not significant (P ⫽ .135). Patients with previous hernia repair had a slight increased risk (44% vs. 30%), not statistically significant (P ⫽ .374). Those patients with complications were noted to have an increased average BMI (37.4 kg/m2 vs 33.7 kg/m2), although not statistically significant (P ⫽ .075). Recurrence occurred in 3 patients (6.3%). Suprapubic recurrence occurred in only 1 patient (2.1%) with re-herniation at the level of the pubic tubercle 34 months after initial repair. A lateral mesh recurrence developed in a patient with a high BMI and small abdominal excursion 14 months following initial repair. Lastly, a patient developed a fixation suture hernia after becoming pregnant 4 months after repair.
Comments The development of the Rives-Stoppa technique with placement of the mesh in a retrorectus position decreased recurrence rates down to 5%, and is considered the open hernia repair gold standard; the laparoscopic approach is thought to have similar recurrence rates due to the intraperitoneal location of the mesh.4 – 6 As laparoscopic placement of mesh necessitates the direct contact between mesh and intra-abdominal contents, the routine use of a barrier mesh reduces the risk of adhesion formation and bowel ingrowth into the prosthetic material.4,13–15 A vital aspect of laparoscopic ventral hernia repair includes the adequate overlap of mesh over the hernia defect onto intact fascia, which improves rates of recurrence.4,16,17 The abdominal oblique aponeurosis, rectus abdominus, and rectus sheath insert upon the symphysis pubis. Incisions near this insertion allow potential hernia formation due to relatively weak tissue and due to inadequate tissue approx-
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imation inferiorly during primary closure. Standard ventral hernia repair techniques apply equally to suprapubic hernia repair in regards to safe and extensive adhesiolysis using sharp dissection, counter-traction, and prevention or immediate recognition of enterotomies. The laparoscopic approach allows superior evaluation of the extent and number of fascial defects to allow proper overlap in hopes of decreasing recurrence due to a “missed” defect. The use of laparoscopy in ventral hernia repair is associated with less pain, better cosmesis, lower risk of mesh and wound infections, and lower recurrence rates.2,4 Increased risk of postoperative morbidity and recurrence is often associated with mesh fixation, mesh overlap, multiple previous abdominal surgeries, previous hernia recurrence, size of hernia defect, and obesity.4,7,18 –21 Development of a preperitoneal plane in patients with previous lower abdominal surgeries has proven to be safe and efficient.22,23 Incising the peritoneum and creating a flap to enter the space of Retzius (similar to the approach in the TAPP inguinal hernia repair) exposes the posterior aspect of the pubic bone, Cooper’s ligaments, and inferior epigastric vessels bilaterally.7,8,10 The proper repair of suprapubic hernias requires development of this preperitoneal plane; this allows the bladder to be dropped safely into the pelvis to prevent inadvertent injury. Additionally, overlap of the mesh into the pubis covers the myopectineal orifice and allows secure fixation of the mesh to the pubis and Cooper’s ligaments at a location of stress.7,9,10,24 The inferior overlap of mesh and its fixation in suprapubic hernias is particularly difficult. There is mounting evidence to support the use of transabdominal sutures as a means of ensuring mesh fixation.1,4,15,16,18 Transabdominal fixation with adequate overlap of mesh inferiorly within the pelvis is limited by the pelvic bony structures. Therefore, further inferior fixation of mesh is required. There is also support for the inferior placement of transabdominal sutures through the periosteum in addition to tacks upon the pubis and Cooper’s ligaments for further inferior mesh fixation.7 Elevation of the peritoneum flap with the bladder covers the inferior mesh edge and corresponding Cooper’s ligaments and neurovascular structures, and allows the bladder to resume anatomic position.9,18 In our series, recurrences occurred in 3 patients (6.3%), which is comparative to the 0%–5.8% cited in the literature.7–9 Only 1 of our patients recurred at the suprapubic location. Increased intra-abdominal pressure was present in both of the other recurrences; elevated BMI led to a lateral mesh recurrence in 1 patient, and the pressure of an enlarging uterus in a second patient placed tension upon 1 of the fixation sutures, causing it to pull through the fascia. This was repaired laparoscopically in the postpartum period. Women of childbearing age must be counseled about the increased risk of recurrence due to the increased abdominal wall pressure presented during pregnancy. Bioabsorbable mesh may play a role in these repairs; however, recurrence would still be increased.
The complication rate of 38% in our series is higher than the 16.6%–29.4% reported in the literature and is attributed to many factors including multiple previous abdominal surgeries, multiple previous attempted repairs, large size of hernia defect, and relative obesity within this subset of patients.7,8,17 Of our patients with previous ventral hernia repairs, there were a total of 55 previous repairs of which 17 involved mesh repair. Four of our patients were noted to have intra-abdominal placement of mesh, with 1 noted to be a nonbarrier type mesh that required removal after extensive lysis of severe adhesions. Seroma was found to be our greatest complication, occurring in 4 patients. Three of these seromas were simply observed and found to resolve within 6 months. One of the seromas was surgically drained 16 days after surgery secondary to the appearance of infection with cellulitis; the seroma wound cultures were negative and the wound healed without further complication. Chronic pain lasting greater than 6 months remained relatively low despite the extensive dissection and fixation in the pelvis. This greatly emphasizes avoidance of suture or tack fixation below the iliopubic tract due to fear of nerve entrapment and chronic pain. One enterotomy occurred in this series, which was recognized immediately and repaired with no mesh placed at that time. One patient suffered an unrecognized bladder injury that was diagnosed on the first postoperative day when hematuria was noted. Cystoureterogram confirmed contained extravasation of contrast into the preperitoneal space; conservative treatment with Foley drainage and re-evaluation on the 12th postoperative day verified no leak. One pulmonary embolism occurred in a patient on the forth postoperative day. This patient had received only sequential compression devises as deep venous thrombosis prophylaxis during the perioperative period and received heparin bridge with coumadin therapy once the embolism was diagnosed. Keys to limiting morbidity include extensive preoperative history and physical (elicit possible etiology behind hernia occurrence/recurrence and assure optimization of comorbidities), perioperative antibiotic prophylaxis, deep vein thrombosis prophylaxis (low molecular weight heparin, sequential compression device, early mobilization), safe entry into the abdominal cavity with adequate visualization, tedious and extensive lysis of adhesions with sharp dissection, exposure and surveillance of entire dissection area (immediate recognition of enterotomies, bladder injuries, vascular injuries, or nerve entrapment), close monitoring of incisions, and early ambulation (improved bowel, pulmonary, and cardiovascular function). There has been shown a significant relationship between postoperative morbidity and hernia location inferior to the umbilicus.17
Conclusions Considering the complexity of the repair, laparoscopic suprapubic hernia repair is safe with few major complications, and is effective with a relatively low recurrence at the
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pubis. Surgeons attempting this technique need to be comfortable with laparoscopic exposure of pelvic structures.
References 1. Burger JWA, Luijendijk RW, Hop WCJ, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004;240:578 – 85. 2. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998;124:816 –21. 3. Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 1999;65:827–31. 4. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg 2003;238:391–9. 5. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545–54. 6. Rives J, Pire JC, Flament JB, et al. Treatment of large eventrations: new therapeutic indications apropos of 322 cases. Chirurgie 1985;111: 215–25. 7. Carbonell AM, Kercher KW, Matthews BD, et al. The laparoscopic repair of suprapubic ventral hernias. Surg Endosc 2005;19:174 –7. 8. Palanivelu C, Rangarajan M, Parthasarathi R, et al. Laparoscopic repair of suprapubic incisional hernias: suturing and intraperitoneal composite mesh onlay. A retrospective study. Hernia 2008;12:251– 6. 9. McKay R, Haupt D. Laparoscopic repair of low abdominal wall hernias by tack fixation to the cooper ligament. Surg Laparosc Endosc Perc Tech 2006;16:86 –90. 10. Hirasa T, Pickleman J, Shayani V. Laparoscopic repair of parapubic hernia. Arch Surg 2001;136:1314 –7. 11. Lobel RW, Sand PK. Incisional hernia after suprapubic catheterization. Obstet Gynecol 1997;89:844 – 6. 12. Pena AA, Bermejo CE, Thompson IM. Ventral bladder hernia following tubal ligation. J Urol 2002;168:1502. 13. Gonzalez R, Rodeheaver GT, Moody DL, et al. Resistance to adhesion formation: a comparative study of treated and untreated mesh products placed in the abdominal cavity. Hernia 2004;8:213–9. 14. Bachman S, Ramshaw B. Prosthetic material in ventral hernia repair: how do I choose. Surg Clin North Am 2008;88:101–12. 15. Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic intraperitoneal onlay mesh repair of incisional hernia. Surg Laparosc Endosc 1998;8:360 –2. 16. Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: a personal series and review of the literature. Journal of the Society of Laparoendoscopic Surgeons 1999;3:293–304. 17. Moreno-Egea A, Torralba JA, Girela E, et al. Immediate, early, and late morbidity with laparoscopic ventral hernia repair and tolerance to composite mesh. Surg Laparosc Endosc Perc Tech 2004;14: 130 –5. 18. LaBlanc KA. The critical technical aspects of laparoscopic repair of ventral and incisional hernias. Am Surg 2001;67:809 –12. 19. Tsereteli Z, Pryor BA, Heniford BT, et al. Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia 2008;12:233– 8. 20. Novitsky YW, Cobb WS, Kercher KW, et al. Laparoscopic ventral hernia repair in obese patients: A new standard of care. Arch Surg 2006;141:57– 61. 21. Rosen M, Brody F, Ponsky J, et al. Recurrence after laparoscopic ventral hernia repair. Surg Endosc 2003;17:123– 8. 22. Paterson HM, Casey JJ, Nixon SJ. Totally extraperitoneal laparoscopic hernia repair in patients with previous lower abdominal surgery. Hernia 2005;9:228 –30. 23. Singhal T, Balakrishnan S, Grandy-Smith S, et al. Consolidated five year experience with laparoscopic inguinal hernia repair. Surg 2007; 5:137– 40. 24. Bendavid R. Incisional parapubic hernias. Surgery 1990;108:898 –901.
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Discussion Dr. John Moore (Denver, CO): Ventral incisional hernia is, as we all know, a formidable clinical problem for practicing surgeons and our patients. Unfortunately, as long as laparotomies are performed, unless our population characteristics dramatically change or our techniques for closure change, we can expect the incidents that you describe. To repair these hernias through traditional open procedures, even with the use of mesh, has significant morbidities. It only makes sense for us to continue to look and analyze the new methods that have become available to us in regards to accomplishing the repair. We know that most hernias do not recur until approximately the third year following repair, so I’d like that addressed. In addition, I have several other questions. What was the average time spent in the performance of the procedure? What type of barrier mesh did you utilize and was it standard across all the procedures in both institutions? What was your port placement strategy and were any changes made or modified during the performance of the multiple procedures to accomplish better visualization? Also, in regards to the Revis-Stoppa technique, did you leave the sac in place? Did you perform the adhesiolysis in reduction before opening the flap in regards to the placement of the mesh? And lastly, I wonder if you would comment on the apparent low incidence of chronic pain in this group even though you are using such extensive fixation in the periosteum of the pubis where we know a lot of pain occurs. Dr. Shanu Kothari (La Crosse, WI): Do you have any information on the demographics of these patients? Were these all from C-sections, hysterectomies, prostatectomies, emergent versus elective, or are these just in the inferior edge of a laparotomy incision? Dr. Brandon Varnell (Omaha, NE): In regards to our follow up, that is very true. When you look in the literature on laparoscopic ventral hernia repair or even the few reports there are on suprapubic ventral hernia repair, the average follow-up is typically 46 months, whereas ours was only 2.6 months across the board. For the average operative time, our mean operative times were 180 minutes across the board from all of our hernia repairs. The mesh used was actually split almost 50 –50 with the use of extended PTFE or dual mesh by Gore and Covidian, which was the Pryotex composite mesh or polyester with the collagen-based. Most of our approaches were that through the left lower quadrant or left lateral quadrant. With regards to our hernia sac dissection, typically if these were only suprapubic component, then we would actually begin our dissection very similar to a TAPP repair by making excision in the peritoneum and umbilical fold and continuing that flap down to the actual fascial defect and hernia defect and then subsequently reduce the hernia defects from there. Now often if these were ventral hernias, then a lot of times, the defect started much higher than that, and so as the hernia
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defect was reduced, then we would cut the peritoneal flap and extend it laterally from there to further expose things. In regards to pain, it was a big issue. As you could see, we had 2 patients that had chronic pain which we considered greater than 6 weeks. As far as Dr Kothari’s question for demographics, we did look at our demo-
graphics and the types of procedures. Probably the breakdown was about 40% from lower midline procedures. Some of these were colorectal procedures, some were urological or gynecologic procedures or exploratory laparotomies. If I remember right, only about 10% were emergent cases, the remaining were elective cases.