Minimally invasive hernia surgery

Minimally invasive laparoscopic and open tension-free techniques have been evolved during the 1990's. Different laparoscopic techniques have been used, where the totally extraperitoneal hernioplasty (TEP) is a technically demanding but probably a better approach to minimally invasive hernia surgery than the transabdominal preperitoneal technique (TAPP), which may increase the risk of adhesions and postoperative intestinal obstruction. TEP has been criticized because of expensive disposable equipment. The standard polypropylene mesh used in tension-free operations induces a strong foreign tissue reaction with potentially harmful effects. A mesh with less polypropylene could possibly be beneficial. The aim of this thesis was to evaluate and compare different minimally invasive techniques and meshes for inguinal hernia. In three randomized controlled multi-center studies 1212 patients were randomized and included in follow-up: TEP with or without the use of a dissection balloon (322 patients); TEP using only reusable instruments, mesh-plug or Lichtenstein (299 patients); Lichtenstein with Prolene or Vyproll (which contains less polypropylene) mesh (591 patients). In the last study all randomization and entering of data was performed online in a database through the Internet, which facilitated the completion of the trial. More than 80% of all patients in the studies were operated on in day- surgery. There were more conversions to TAPP or an open technique if a balloon not was used. However the majority of the conversions occurred early in the learning curve, which indicates that the use of a dissection balloon can be helpful during the learning curve, but in experienced hands it just adds costs to the operation, without offering additional benefits The operation time was shorter in the mesh-plug group compared to Lichtenstein and TER Postoperative pain was diminished after TEP compared to open repair. The time to return to work was shorter after TEP than Lichtenstein (5 vs. 7 days). The time of rehabilitation was shorter after TEP than mesh-plug or Lichtenstein (14 vs. 24.5 vs. 28.5 days). There was a tendency of more pain after Lichtenstein than after TEP or mesh-plug at follow-up. Laparoscopic hernioplasty (TEP) is superior to tension-free open herniorrhaphy with Mesh-plug and patch or Lichtenstein's operation in terms of postoperative pain and rehabilitation. There was no significant difference between Lichtenstein with Prolene or Vyproll concerning postoperative pain, complications, rehabilitation or quality of life. All patients (n=33 275) with a unilateral primary inguinal or femoral hernia with only one operation recorded in the Swedish Hernia Register 1992-2000 were linked to the Swedish Inpatient Register and the Swedish Death Register for the period 1987-2000. The highest adjusted relative risk (RR) of postoperative intestinal obstruction was found in patients with previous multiple admissions for abdominal operations/inflammations, including intestinal obstruction, 58.99. The RR was 2.79 with TAPP and 0.57 with TEP compared to Lichtenstein operated patients

PHaLIR: prevent hernia after loop ileostomy reversal—a study protocol for a randomized controlled multicenter study

Abstract Background Rectal cancer is a common cancer worldwide. Surgery for rectal cancer with low anterior resection often includes the formation of a temporary protective loop ileostomy. The temporary ostomy is later reversed in a separate operation. One complication following stoma closure is the development of a hernia at the former stoma site, and this has been reported in 7–15% of patients. The best method to avoid hernia after stoma closure is unclear. The most common closure is by suturing only, but different forms of mesh have been tried. Biological mesh has in a randomized trial halved hernia incidence after stoma reversal. Biosynthetic mesh and retromuscular mesh are currently being evaluated in ongoing studies. Methods The present multicenter, double-blinded, randomized, controlled study will compare standard suture closure of the abdominal wall in loop ileostomy reversal with retromuscular synthetic mesh at the stoma site. The study has been approved by the Regional Ethical Review board in Stockholm. Patients aged 18–90 years, operated on with low anterior resection and a protective loop ileostomy for rectal cancer and planned for ileostomy reversal, will be considered for inclusion in the study. Randomization will be 1:1 on the operation day with concealed envelopes. The estimated sample size is intended to evaluate the superiority of the experimental arm and to detect a reduction of hernia occurrence from 12 to 3%. The operation method is blinded to the patients and in the chart and for the observer at the 30-day follow-up. The main outcome is hernia occurrence at the stoma site within 3 years postoperatively, diagnosed through CT with strain. Secondary outcomes are operation time, length of hospital stay, pain, and 30-day complications. Discussion This double-blinded randomized controlled superiority study will compare retromuscular synthetic mesh during the closure of loop ileostomy to standard care. If this study can show a lower frequency of hernia with the use of prophylactic mesh, it may lead to new surgical guidelines during stoma closure. Trial registration ClinicalTrials.gov NCT03720262. Registered on October 25, 2018

Clinical And Patient-Reported Outcomes After Absorbable Strap Fixation For Ventral Hernia Repair

RESULTS: Patients were enrolled at 16 centers. Data was available on 100 of the 203 patients at six months and on 119 patients at 12 months. Demographics: mean age of 52.7 (13.2 standard deviation[ SD]); mean body mass index (BMI) of 33.2 (7.5 SD) kg/m2; 64.3% having a BMI over 30kg/m2; male patients 47.4%; 16.7% for recurrent hernias. Mesh fixation with straps alone in 48.3% of cases or straps and sutures in 51.7% of cases. Percentage of patients with symptomatic pain decreased slightly from baseline to one month (70.0 vs. 60.6, p=0.0782) and significantly from one month to six months (60.6% symptomatic vs. 23.2%; p=0.0004). From six months to twelve months, the change in percentage of symptomatic patients was not significant (23.2% vs. 28.7%; p=0.8084). Similar results were observed with symptomatic CCS movement limitations. Overall recurrence rate at 12 months was 4.72% (2.39%-9.22%)

Short-term Outcomes for Open and Laparoscopic Midline Incisional Hernia Repair: A Randomized Multicenter Controlled Trial: The ProLOVE (Prospective Randomized Trial on Open Versus Laparoscopic Operation of Ventral Eventrations) Trial.

OBJECTIVE:: The aim of the trial was to compare laparoscopic technique with open technique regarding short-term pain, quality of life (QoL), recovery, and complications. BACKGROUND:: Laparoscopic and open techniques for incisional hernia repair are recognized treatment options with pros and cons. METHODS:: Patients from 7 centers with a midline incisional hernia of a maximum width of 10 cm were randomized to either laparoscopic (LR) or open sublay (OR) mesh repair. Primary end point was pain at 3 weeks, measured as the bodily pain subscale of Short Form-36 (SF-36). Secondary end points were complications registered by type and severity (the Clavien-Dindo classification), movement restrictions, fatigue, time to full recovery, and QoL up to 8 weeks. RESULTS:: Patients were recruited between October 2005 and November 2009. Of 157 randomized patients, 133 received intervention: 64 LR and 69 OR. Measurements of pain did not differ, nor did movement restriction and postoperative fatigue. SF-36 subscales favored the LR group: physical function (P < 0.001), role physical (P < 0.012), mental health (P < 0.022), and physical composite score (P < 0.009). Surgical site infections were 17 in the OR group compared with 1 in the LR group (P < 0.001). The severity of complications did not differ between the groups (P < 0.213). CONCLUSIONS:: Postoperative pain or recovery at 3 weeks after repair of midline incisional hernias does not differ between LR and OR, but the LR results in better physical function and less surgical site infections than the OR does. (ClinicalTrials.gov Identifier: NCT00472537)

Management of Diastasis of the Rectus Abdominis Muscles : Recommendations for Swedish National Guidelines

Background: Diastasis of the rectus abdominis muscle is a common condition. There are no generally accepted criteria for diagnosis or treatment of diastasis of the rectus abdominis muscle, which causes uncertainty for the patient and healthcare providers alike. Methods: The consensus document was created by a group of Swedish surgeons and based on a structured literature review and practical experience. Results: The proposed criteria for diagnosis and treatment of diastasis of the rectus abdominis muscle are as follows: (1) Diastasis diagnosed at clinical examination using a caliper or ruler for measurement. Diagnostic imaging by ultrasound or other imaging modality, should be performed when concurrent umbilical or epigastric hernia or other cause of the patient's symptoms cannot be excluded. (2) Physiotherapy is the firsthand treatment for diastasis of the rectus abdominis muscle. Surgery should only be considered in diastasis of the rectus abdominis muscle patients with functional impairment, and not until the patient has undergone a standardized 6-month abdominal core training program. (3) The largest width of the diastasis should be at least 5 cm before surgical treatment is considered. In case of pronounced abdominal bulging or concomitant ventral hernia, surgery may be considered in patients with a smaller diastasis. (4) When surgery is undertaken, at least 2 years should have elapsed since last childbirth and future pregnancy should not be planned. (5) Plication of the linea alba is the firsthand surgical technique. Other techniques may be used but have not been found superior. Discussion: The level of evidence behind these statements varies, but they are intended to lay down a standard strategy for treatment of diastasis of the rectus abdominis muscle and to enable uniformity of management.First published online: September 28, 2020</p