Cabry, F

Campanelli, M

Grande, M

Grande, S

Lisi, G

Nigro, C

Venditti, D

Villa, M

Archivio della Ricerca - Università di Roma Tor vergata

B
ackground: Minimal access surgery for incisional hernia repair is still debated, especially for giant wall
defects. Laparoscopic repair may reduce pain and hospital stay. This study was designed to evaluate the
feasibility of the laparoscopic technique in giant hernia.
Materials and Methods: From 2007 to 2013, 35 consecutive patients with giant ventral hernia, according to the
Chevrel classification, underwent laparoscopic repair. Fourteen patients were obese, with a body mass
index>30 and in 21 patients the mean BMI was 24 (range 22–28). In all patients, the wall defect was larger
than 20 cm.
Results: Mean operative time was 159±30 minutes, and, for defects larger than 25 cm, it was 210±20 minutes.
Patient conversion did not occur. In 29 patients, the mean wall defect was 20 x 25 cm, and in six patients mean
wall defect was 26x31 cm, and, as measured from within the peritoneal cavity, the mean overlap was 5 cm
Laparoscopic Treatment of Giant Ventral
Hernia: Experience of 35 Patients
- 1 -
#807-Lisi-Galley - 01
ABSTRACT
Hernia Repair
SURGICAL TECHNOLOGY INTERNATIONAL Volume 30
MICHELE GRANDE, MD
ASSISTANT PROFESSOR
DEPARTMENT OF SURGERY
UNIVERSITY HOSPITAL OF TOR VERGATA
ROME, ITALY
GIORGIO LISI, MD
RESIDENT
DEPARTMENT OF SURGERY
UNIVERSITY HOSPITAL OF BORGO ROMA
VERONA, ITALY
MICHELA CAMPANELLI, MD
RESIDENT
DEPARTMENT OF SURGERY
UNIVERSITY HOSPITAL OF MODENA
MODENA, ITALY
SIMONA GRANDE
INTERN
DEPARTMENT OF SURGERY
UNIVERSITY HOSPITAL OF MESSINA
MESSINA, ITALY
DARIO VENDITTI, MD
ASSISTANT PROFESSOR
DEPARTMENT OF SURGERY
UNIVERSITY HOSPITAL OF TOR VERGATA
ROME, ITALY
CASIMIRO NIGRO, MD
ASSISTANT PROFESSOR
DEPARTMENT OF SURGERY
UNIVERSITY HOSPITAL OF TOR VERGATA
ROME, ITALY
FRANCESCA CABRY, MD
RESEARCHER
DEPARTMENT OF SURGERY
UNIVERSITY HOSPITAL OF MODENA
MODENA, ITALY
MASSIMO VILLA, MD, PHD
ASSISTANT PROFESSOR
DEPARTMENT OF SURGERY
UNIVERSITY HOSPITAL OF TOR VERGATA
ROME, ITALY
- 2 -
Incisional hernia occurs after laparo-
tomy in 2–20% of patients, generally
within three years after surgery, more
frequently after long median abdominal
incisions were created for aor tic
aneurysm and peritonitis. Incisional her-
nias have been classified by Chevrel et
al.1 as small (< 5 cm), medium (5 – 10
cm), large (> 10 cm), and giant or very
large (> 20 cm), based on the diameter
of the wall. The surgical management of
incisional hernias before the use of pros-
thesis meshes had a 12–54% rate of
recurrence, but in the last two decades
the use of meshes has dramatically
reduced the recurrence rate.2 The open
approach is the standard technique for
repair of ventral hernias. However, the
rate of hernia recurrence is high, espe-
cially if the hernia defect has been
repaired with sutures. The laparoscopic
repair of ventral hernias is an emerging
technique that has been applied with
potential to replace open repair.
Laparoscopic ventral hernia repair
(LVHR) was first introduced in 1993 by
LeBlanc and Booth.3 Recurrence rates
have been reported to be similar to open
repair with mesh, but with shorter hospi-
tal stay as it does not require the wide
dissection area or routinely require the
subcutaneous drains which accompany
open repair. A summary of the evidence
of the efficacy, safety, and cost-effective-
ness of laparoscopic repair compared
with open repair is lacking.4 It is unclear
whether laparoscopic technique may be
more appropriate for giant incisional
hernia and if the severity and types of
complications differ or are similar than
open approach.5 Indications for laparo-
scopic surgery for the so-called giant
hernias are controversial, as well as in
obese patient. The aim of this study is to
analyze the outcomes of the laparoscopic
incisional hernia repair (LIHR) for fascial
defect larger than 20 cm.
Materials and Methods
Between February 2007 and April
2013, a total of 35 patients underwent
LVHR in our institution for primary inci-
sional hernia. According to the Chevrel
classification,1 we defined giant as a fas-
cial defect with a diameter > 20. The
hernia size was measured in an outpa-
tient clinic however this may led to mis-
interpretation of defects. Therefore, all
patients underwent pre-operative CT
scan to identify those fit for this study.
The demographics are shown in Table I.
Comorbidities affected many patients
in this study and included hypertension
(n=10), insulin-independent diabetes
mellitus (n=28), and chronic cardiac dis-
ease (n=16). None of the patients had
chronic bronchopneumopathy. As many
as 14 patients in this series were obese
(40%), with a body mass index (BMI) >
30 kg/m2, in 21 patients the mean BMI
was 24 kg/m2 (range 22–28). The mean
BMI was 28.4 kg/m2.
The general conditions were classified
according to the criteria of the American
Society of Anaesthesiology (ASA), and
the score was ASA I in 13 patients, ASA
II in 17 patients, and ASA III in five
patients. Patients with recurrent incision-
al ventral hernia were excluded from the
study. Once discharged, the patients
were monitored by clinical examination
with echography (with a 7.5 MHz probe)
on the 10th, 30th, and 60th postoperati-
ve day. Later, they were followed-up by
clinical examination or telephone call.
The study was approved by the local
ethics committee. All patients were
asked for consent before minimal access
surgical repair and all patients were
treated by the same surgeon (MG). 
Statistical Analysis
The data were collected retrospecti-
vely from the database of 35 patients
according to the BMI of the patients.
Analysis of the data was done using the
#807-Lisi-Galley - 01
Laparoscopic Treatment of Giant Ventral Hernia: Experience of 35 Patients
GRANDE/LISI/CAMPANELLI/GRANDE/VENDITTI/NIGRO/CABRY/VILLA
INTRODUCTION 
MATERIALS AND METHODS
(range 3–6). Short-term antibiotic prophylaxis consisted of Cefazolin 2 g IV (intravenous) the day of surgery.
All patients were discharged within 72–96 hrs. The mean follow-up was 24 months. No infection occurred and
no chronic pain was recorded. However, three seroma were observed (outpatient treatment) and two
xiphoid recurrences were observed. 
Conclusions: Laparoscopic hernia repair is technically feasible and is safe in patients with giant fascial defects
as well as obese patients. This operation decreases postoperative pain, hastens the recovery period, and
reduces postoperative morbidity and recurrence. This approach should be reserved for patients with no
history of previous hernia repair. Further studies are expected to confirm these promising results
Table I 
Demographics
Variable N = 35
Gender M/F 25-oct.
Age (years) 57.5 (range 40 – 75)
BMI kg/m2 28.4 (range 21.89 – 35)
ASA 2.1 (range 1 – 3)
N number of patients; BMI Body Mass Index; ASA American Society of Anesthe-
siologist
STATISTICAL ANALYSIS
- 3 -
SPSS 11.0 statistical analysis software
package (SPSS Inc., Chicago, IL). For
continuous variables, student’s t test
was used and the χ2 test was used for
discrete variables. A variable of p <
0.05 was considered statistically signi-
ficant.
Results
Thir ty-five patients underwent
laparoscopic ventral hernia repair for
primary incisional hernia (Table II).
Shor t-term antibiotic prophylaxis
consisted of Cefazolin 2 g IV the day
of surgery. Covidien Parietex™ Com-
posite Mesh (Medtronic Inc., Min-
neapolis, Minnesota) was used in all
patients, although, in the literature,
different types of ventral hernia mesh
have been used, it was the prosthesis
suppl ied to our hospita l . In 29
patients, the mean wall defect was 20
x 25 cm, and in six patients mean wall
defect was 26x31 cm—as measured
from within the peritoneal cavity—
and there was no difference with the
CT measurement. The mean operative
time was 159±30 minutes for defects
larger than 20 cm, and it was 210±20
minutes for defects larger than 25 cm.
Zero patient conversions occurred.
The mean overlap was 5 cm (range
3–6). All patients were discharged
home within 72–96 hours.
None of the patients returned to
work until one month after surgery.
All patients used a compression dress-
ing for six months after surgery. Mor-
bidity in the other 14 obese patients
(40%), and in 21 non-obese patients
(60%), showed no statistically rele-
vant difference with the χ2 test (p >
0.05). 
During the follow-up, no mesh
infections occurred. No chronic pain
was recorded; however, two very
small xiphoid recurrences (<2 cm)
were obser ved. The di f ferences
between outcomes in obese and non-
obese patients were not statistically
relevant (p > 0.05). 
Seroma superficial to the mesh
were seen in three patients (8.5%)
during immediate postoperative fol-
low-up. In no case was surg ical
drainage of the seroma required, but a
needle aspirat ion was eventual ly
repeated in time with pressure dress-
ing (Table III).
#807-Lisi-Galley - 01
Hernia Repair
SURGICAL TECHNOLOGY INTERNATIONAL Volume 30
RESULTS
Table II
Characteristics, operative and postoperative data 
of 35 patients
Patient Age (Years) Sex ASA BMI OT (min) Morbidity
Hospital 
Stay
(days)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
40
43
47
40
51
69
41
70
67
69
75
71
49
48
51
57
68
62
61
56
45
41
44
72
64
67
52
59
68
75
40
44
49
57
61
M
M
M
M
F
M
F
M
F
M
F
M
M
M
M
M
F
M
F
M
F
M
M
F
M
F
M
F
M
M
M
M
M
M
M
2
2
2
2
3
3
3
2
2
2
3
3
2
2
2
2
3
3
2
3
2
2
3
2
3
2
2
2
2
3
3
3
3
2
2
21.8
22
22.4
21.5
25.7
26.8
35.4
33.2
27.2
22.2
34.5
32.8
28.6
29.5
27.5
23.9
31.3
34.5
29.7
33.3
27.4
24.8
32.8
24.2
33.9
31.5
22.1
27.6
23.9
31.2
32.5
33.6
31.6
23.1
26.7
160
170
159
161
209
199
230
221
175
160
188
190
173
189
164
189
191
201
169
230
168
153
185
153
226
199
161
163
200
192
229
230
187
157
153
Seroma
Recurrence
Seroma
Recurrence
Seroma
4
4
4
2
4
4
4
4
4
4
3
3
3
2
4
3
3
4
4
3
4
4
4
3
3
3
4
3
3
4
4
3
3
4
4
ASA American Society of Anesthesiologist; BMI Body Mass Index; OT Operative
Time
- 4 -
Discussion
The management of giant incisional
ventral hernia using laparoscopy is still
controversial, and the diameter of the
wall defect seems to be the main limita-
tion preventing this procedure from
gaining wider acceptance.6,7 The indica-
tions for the laparoscopic approach in
large incisional hernias included having
enough abdominal surface to insert tro-
cars, enough working chamber, and
adequate overlap (a minimum of 5
cm).8 Obesity does not seem to be a
contraindication for a minimal access
approach for treating incisional hernia,9
and, in our study, 14 patients were
obese. Laparoscopic division of adhe-
sions represents a very important step
in incisional hernia repair. Intestinal
injury during adhesiolysis ranges from
0–6%, and such a complication is more
frequent during the learning phase and
can jeopardize the procedure when not
recognized intraoperatively.10,11 We cur-
rently use laparoscopic scissors and
avoid coagulation by both ultrasonic
scalpel and bipolar forceps close to the
intestinal loops. 
The overall mean duration of
surgery was 159 minutes; comparable
with other studies that included smaller
sized hernias. All patients were dis-
charged home within 72–96 hours, so
the mean hospital stay was consistent
with the stay from 0–64 days reported
in the literature. In the present study,
we have had two xiphoid recurrences
(5.7%). According to the literature, the
recurrence rate with open intraperi-
toneal underlay is equal to the recur-
rence rate of intraperitoneal LVHR,
that is, approximately 4.5%.12-14
The existing literature does not doc-
ument the superiority of any one mesh
fixation technique in relation to recur-
rence. Concerning the side of the
recurrence (xyphoid), some authors15
used a mesh overlap of at least 5 cm. In
the present study, we have used a mean
overlap of 4 cm.
Conze et al.16 stressed the impor-
tance of the appropriate landmarks for
dissection of the retroxiphoidal space.
In agree with Conze et al., we believed
these techniques may be useful to have a
sufficient overlap. 
We have had three cases of seroma
(8.5%). There is no agreement in the
literature about the need for draining a
seroma. A seroma does need to be drai-
ned in case of infection or symptoms, or
if it still be present after six to eight
weeks.17,18 Seroma were not routinely
aspirated and were noted to resolve in
the early postoperative period. Three
patients underwent seroma outpatient
aspiration because of prolonged discom-
fort at the site. Postoperative seroma
formation in the previous defect site has
been well documented in other
studies.19-21
The International Endohernia Soci-
ety (IEHS) guidelines22 reported an
incidence of seroma after LVHR from
3–100%. In this article, Bittner et al.,
suggested to attempt cauterization of
the hernia sac to prevent seroma forma-
tion, Bingener et al.23 showed a
decrease from 25% to 4% when cauter-
izing the hernia sac by electrocautery or
ultrasonic energy. However, despite
these promising results, there are no
randomized studies confirming this
hypothesis and there is no consensus
about it. In our group of patients, we
have not systematically applied this
technique, however, we have observed
that the seroma was formed indepen-
dently of the cauterization of the hernia
sac. But, since our sample was not
numerically consistent and we were not
particularly focused on this issue, we
did not feel able to express our own
assessment about it.
It should also be emphasized how
LVHR, in contrast with traditional
surgery, has the advantage of identifying
small wall defects, which may be missed
during open repair.24,25 Therefore, it is
possible, as indeed we have found in our
experience in three cases, that a defect
in the wall considered large has become
giant during surgery for the detec-
tion—especially in the case of median
laparotomy xipho-pubic—of small
defects on the line etching. Despite
these improvements resulting from use
of LVHR, most surgeons still prefer to
repair giant incisional hernias with an
open approach.26
This study seems to confirm the
validity of a minimal access approach
for management of defect size > 20 cm
in transverse dimension. However, to
date, giant incisional hernias are consid-
ered a contraindication to minimal inva-
sive surgery, but, in this study, wall
defects larger than 20 cm were success-
fully repaired by laparoscopy with
noticeable short-term results.
Conclusions
Laparoscopic ventral hernia repair
seems to be a safe procedure in the
management of giant incisional hernias,
and this approach could be reserved for
patients with no history of previous
laparoscopic hernia repair. Further
studies with a longer follow-up, and
with a greater number of patients, are
necessary to confirm this promising
result.
Acknowledgments
Michele Grande: manuscript prepa-
ration, interpretation of data and criti-
cal review.
Giorgio Lisi: acquisition data and
drafting the manuscript.
Michela Campanelli: acquisition and
processing data.
Simona Grande: acquisition and pro-
cessing data.
Dario Venditti: acquisition data and
literature review.
Casimiro Nigro: acquisition data and
literature review.
Francesca Cabry: acquisition data
#807-Lisi-Galley - 01
Laparoscopic Treatment of Giant Ventral Hernia: Experience of 35 Patients
GRANDE/LISI/CAMPANELLI/GRANDE/VENDITTI/NIGRO/CABRY/VILLA
Table III
Laparoscopic worldwide experience with giant 
ventral hernia repair
Author [ref] Pts Mean FU(months)
Recurrence
(%)
Complications
(%)
Present study
Ferrari et al.4
Ferrari et al.5
Kirshtein et al.6
35
25
36
103
24
24
28
26
2 (5.7)
3 (12)
3 (8)
4 (3.9)
3 (8.5)
12 (48)
3 (8)
2 (1)
Pts Patients; FU Follow up
DISCUSSION
STI
CONCLUSION
ACKNOWLEDGMENTS
- 5 -
and literature review.
Massimo Villa: literature review and
manuscript preparation.
All authors read and approved the
final version of the manuscript.
Authors’ Disclosures
All authors have no conflicts of inte-
rest to disclose.
References
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Laparoscopic treatment of abdominal incision-
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#807-Lisi-Galley - 01
Hernia Repair
SURGICAL TECHNOLOGY INTERNATIONAL Volume 30
REFERENCES
AUTHORS’ DISCLOSURES


Laparoscopic Treatment of Giant Ventral Hernia:Experience of 35 Patients

Cineca Institutional Research Information System

Background: Minimal access surgery for incisional hernia repair is still debated, especially for giant wall defects. Laparoscopic repair may reduce pain and hospital stay. This study was designed to evaluate the feasibility of the laparoscopic technique in giant hernia.

Materials and methods: From 2007 to 2013, 35 consecutive patients with giant ventral hernia, according to the Chevrel classification, underwent laparoscopic repair. Fourteen patients were obese, with a body mass index (BMI) &gt; 30 and in 21 patients the mean BMI was 24 (range 22-28). In all patients, the wall defect was larger than 20 cm.

Results: Mean operative time was 159±30 minutes, and, for defects larger than 25 cm, it was 210±20 minutes. Patient conversion did not occur. In 29 patients, the mean wall defect was 20x25 cm, and in six patients the mean wall defect was 26x31 cm, and, as measured from within the peritoneal cavity, the mean overlap was 5 cm (range 3-6). Short-term antibiotic prophylaxis consisted of Cefazolin 2 g IV (intravenous) the day of surgery. All patients were discharged within 72-96 hrs. The mean follow-up was 24 months. No infection occurred and no chronic pain was recorded. However, three seroma were observed (outpatient treatment) and two xiphoid recurrences were observed.

Conclusions: Laparoscopic hernia repair is technically feasible and is safe in patients with giant fascial defects as well as obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence. This approach should be reserved for patients with no history of previous hernia repair. Further studies are expected to confirm these promising results

Laparoscopic Treatment of Giant Ventral Hernia:Experience of 35 Patients

Abstract

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Archivio della Ricerca - Università di Roma Tor vergata

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