Loop Ileostomy Closure: Comparison of Cost Effectiveness between Suture and Stapler

Background: Closure of loop ileostomy can be safely performed using sutures or staplers. The aim of the present study was to compare the cost effectiveness of three different techniques. Methods: A total of 128 consecutive patients who underwent closure of loop ileostomy between January 2002 and December 2008 were analyzed retrospectively. The primary outcome parameter was operative cost. Results: Closure of ileostomy was performed in 66 patients with hand-sewn anastomosis, in 25 patients with stapler only, and in 37 patients with a combination of stapler and suture. There were no differences in terms of early and late postoperative complications. Operative time was significantly longer for "suture only” (101.4±26min) than for "stapler/suture” (−4.9min) and "stapler only” (−17.8min); the difference between the three groups is significant (p=0.05). Duration of hospital stay was not different among the three groups. Operative costs with "stapler/suture” (1,755.9±355.6 EUR) were significantly higher than with "suture only” (−254 EUR; p=0.001) and "stapler only” (−236 EUR; p=0.005). Conclusions: Operative time using the stapler only is significantly shorter than with hand-sewn anastomosis or combinations of stapler and suture. Operative costs are significantly higher for a procedure that includes suture and staple

Long-term Follow-up of Open and Laparoscopic Repair of Large Incisional Hernias

Background: Long-term results after laparoscopic repair of large incisional hernias remain to be determined. The aim of this prospective study was to compare early and late complications between laparoscopic repair and open repair in patients with large incisional hernias. Methods: Only patients with a hernia diameter of ≥5cm were included in this study and were prospectively followed. We compared 56 patients who underwent open incisional hernia repair with 69 patients who underwent laparoscopic repair. Median follow-up in the laparoscopic group was 32.5months (range 1-62months) and in the open group 65months (range 1-80months). Results: The demographic parameters were not significantly different between the two groups. However, the median hospital stay (6.0days, range 1-23days vs. 7.0days, range 1-67days; p=0.014) and incidence of surgical site infections (SSIs) (5.8% vs. 26.8%; p=0.001) were significantly lower in the laparoscopic group than in the open surgery group. Bulging of the implanted mesh was observed in 17.4% in the laparoscopic group and in 7.1% in the open group (p=NS). The recurrence rate was 18% in the open group and 16% in the laparoscopic group (p=NS). Multivariate analysis revealed that width of the hernia ≥10cm, SSI, and BMI ≥30kg/m2 were significant risk factors for hernia recurrence. Conclusions: The incidence of SSIs was significantly lower after laparoscopic incisional hernia repair. At long-term follow-up, the recurrence rate was not different between the two techniques. Abdominal bulging is a specific problem associated with laparoscopic repair of large incisional hernias. Size of the hernia, BMI, and SSI are risk factors for hernia recurrence irrespective of the techniqu

Postoperative hypoesthesia and pain: qualitative assessment after open and laparoscopic inguinal hernia repair

Background: Chronic pain is an important outcome variable after inguinal hernia repair that is generally not assessed by objective methods. The aim of this study was to objectively investigate chronic pain and hypoesthesia after inguinal hernia repair using three types of operation: open suture, open mesh, and laparoscopic. Methods: A total of 96 patients were included in the study with a median follow-up of 4.7 years. Open suture repair was performed in 40 patients (group A), open mesh repair in 20 patients (group B), and laparoscopic repair in 36 patients (group C). Hypoesthesia and pain were assessed using von Frey monofilaments. Quality of life was investigated with Short Form 36. Results: Pain occurring at least once a week was found in 7 (17.5%) patients of group A, in 5 (25%) patients of group B, and in 6 (16.6%) patients of group C. Area and intensity of hyposensibility were increased significantly after open nonmesh and mesh repair compared to those after laparoscopy (p = 0.01). Hyposensibility in patients who had laparoscopic hernia repair was significantly associated with postoperative pain (p = 0.03). Type of postoperative pain was somatic in 19 (61%), neuropathic in 9 (29%), and visceral in 3 (10%) patients without significant differences between the three groups. Conclusions: The incidence of hypoesthesia in patients who had laparoscopic hernia repair is significantly lower than in those who had open hernia repair. Hypoesthesia after laparoscopic but not after open repair is significantly associated with postoperative pain. Von Frey monofilaments are important tools for the assessment of inguinal hypoesthesia and pain in patients who had inguinal hernia repair allowing quantitative and qualitative comparison between various surgical technique

Laparoscopic incisional hernia repair is feasible and safe after liver transplantation

Background: Incisional hernia is a common complication after liver transplantation. The current study evaluated incidence and risk factors for incisional hernia and compared laparoscopic and open hernia repair in terms of feasibility and outcome. Methods: A cohort of 225 patients was prospectively investigated. The median follow-up period was 61months (range, 6-186months). The study cohort had 31 patients who underwent open repair and 13 who underwent laparoscopic repair. Results: Incisional hernia, found in 57 patients (25%), had occurred after a median of 17months (range, 5-138months). The significant risk factors were male gender (p = 0.001) and body mass index (BMI) greater than 25kg/m2 (p = 0.002). A trend toward a lower recurrence rate (15% vs 35%; p = 0.28) and fewer surgical complications (15% vs 19%; p = 0.99) was found in the laparoscopic group. Conclusions: Incisional hernia is a frequent complication after liver transplantation. Associated risk factors are male gender and a BMI greater than 25kg/m2. Laparoscopic hernia repair for such patients is feasible and saf

Mesh shrinkage and pain in laparoscopic ventral hernia repair: a randomized clinical trial comparing suture versus tack mesh fixation

Background: Mesh fixation during laparoscopic ventral hernia repair can be performed using transfascial sutures or metal tacks. The aim of the present study is to compare mesh shrinkage and pain between two different techniques of mesh fixation in a prospective randomized trial. Methods: A randomized trial was performed. Patients with ventral hernia of maximal diameter 8cm were assigned to mesh fixation using either transfascial nonabsorbable sutures or metal tacks for fixation of a parietene composite mesh. The borders of the mesh were marked using clips, and radiological images in prone position were used for assessment of mesh size and location. The primary endpoint was mesh shrinkage; secondary endpoints included postoperative pain, mesh dislocation, and surgical morbidity. Results: Demographic parameters were similar in both groups. A total of 40 patients were randomized, and 36 patients were available for follow-up. There was one hernia recurrence in each group. Pain was significantly higher following suture fixation after 6weeks, but no difference was found after 6months. Mesh shrinkage after 6months was significantly higher using tacks for mesh fixation. Conclusions: Transfascial sutures are associated with more pain within the first 6 postoperative weeks and less mesh shrinkage after 6months compared with mesh fixation using metal tack

Intraperitoneal Mesh Implantation for Fascial Dehiscence and Open Abdomen

Background: Postoperative fascial dehiscence and open abdomen are severe postoperative complications and are associated with surgical site infections, fistula, and hernia formation at long-term follow-up. This study was designed to investigate whether intraperitoneal implantation of a composite prosthetic mesh is feasible and safe. Methods: A total of 114 patients with postoperative fascial dehiscence and open abdomen who had undergone surgery between 2001 and 2009 were analyzed retrospectively. Contaminated (wound class 3) or dirty wounds (wound class 4) were present in all patients. A polypropylene-based composite mesh was implanted intraperitoneally in 51 patients, and in 63 patients the abdominal wall was closed without mesh implantation. The primary endpoint was incidence of incisional hernia, and the incidence of enterocutaneous fistula was a secondary endpoint. Results: The incidence of enterocutaneous fistulas after wound closure post-fascial dehiscence (13% vs. 6% without and with mesh, respectively) or post-open abdomen (22% vs. 28% without and with mesh, respectively) was not significantly different. The incidence of incisional hernia was significantly lower with mesh implantation compared with no-mesh implantation in both contaminated (4% vs. 28%; p=0.025) and dirty abdominal cavities (5% vs. 34%; p=0.01). Conclusions: Intra-abdominal contamination is not a contraindication for intra-abdominal mesh implantation. The incidence of enterocutaneous fistula is not elevated despite the presence of contamination. The rate of incisional hernias is significantly reduced after intraperitoneal mesh implantation for postoperative fascial dehiscence or open abdome