|Year : 2022 | Volume
| Issue : 3 | Page : 129-134
Enhancing safety in ventral patch repair for umbilical hernia by utilizing a hybrid technique
Ruchir Jhaveri, Vishakha Kalikar, Rajan Modi, Roy Patankar
Department of digestive diseases, Zen Hospital, Mumbai, India
|Date of Submission||22-Jun-2022|
|Date of Decision||23-Jul-2022|
|Date of Acceptance||25-Jul-2022|
|Date of Web Publication||01-Sep-2022|
Department of digestive diseases, Zen Hospital, Zen hospital, 10th road, AB near sandu garden, Chembur [E], Mumbai-400071
Source of Support: None, Conflict of Interest: None
BACKGROUND: Both suture and mesh repairs are used for smaller (1-3 cm) umbilical hernias. But primary repair has a higher recurrence rate in literature. The use of mesh repairs has become the way to go for small and medium sized ventral hernias. Ventral patch placement is a simple and effective procedure for the repair of umbilical hernias of 1–3 cm size. We demonstrate the safety and efficacy of the ventral patch for the same with our modification of the technique in 100 consecutive patients. We would initially insert the patch as described by the company, but had one patient presenting with intestinal obstruction, who on diagnostic laparoscopy had a small bowel loop entrapped between the patch and the anterior abdominal wall. This brought about a change in the original technique at our institute, which we adopted for all patients thereafter. MATERIALS AND METHODS: A single centre retrospective analysis of prospectively collected data was done. Our modified technique was done in 100 consecutive patients with umbilical hernia defect size ranging from 1 cm to 2.5 cm, from January 2017 to January 2021. Demographics, post-operative pain, duration of hospital stay, surgical site occurrences (early and late), post-operative complications and recurrences were noted. RESULTS: A total of 100 patients were included in the study. Two patients had superficial surgical site infection which was managed conservatively. We did not record any other major complications or recurrence. Visual analogue scale for pain was recorded at 24 hours. Majority (95%) of the patients had none to mild pain and were discharged at 24 hours. Five patients experienced moderate pain and were discharged at 36–48 hours. No patient experienced chronic pain at follow up. CONCLUSION: The hybrid technique of the ventral patch placement is a safe way for optimum visualization for the correct mesh placement and may improve results, decrease complications and recurrences.
Keywords: Hernia, modification, patch, ventral, zen
|How to cite this article:|
Jhaveri R, Kalikar V, Modi R, Patankar R. Enhancing safety in ventral patch repair for umbilical hernia by utilizing a hybrid technique. Int J Abdom Wall Hernia Surg 2022;5:129-34
| Introduction|| |
Ventral patch placement is a simple and effective procedure for the repair of umbilical hernias of 1–3 cm size.,, In early days (2015 to 2017) of our experience with the patch, when we had adhered to the recommended surgical technique, we encountered a complication. One of the patients treated with the ventral patch developed intestinal obstruction. The cause was found to be an ileal loop stuck between the patch and anterior abdominal wall. This incident revealed a problem with this technique: occasionally some space remains between the patch and the anterior abdominal wall, which essentially exposes the polypropylene mesh to the abdominal cavity and is one of the major causes of complications. This led to a modification of the surgical technique at our institute. Here we describe this modified method of placement of the patch, and our experience with the same in 100 consecutive patients.
| Materials and Methods|| |
A single centre retrospective analysis was done of prospectively collected data. Our modified technique was done in 100 consecutive patients with umbilical hernia defect size ranging from 1 cm to 2.5 cm, from January 2017 to January 2021. Demographics, post-operative pain, duration of hospital stay, surgical site occurrences (early and late), post-operative complications and recurrences were noted.
- Primary umbilical hernias up to 2.5 cm
- Trocar site umbilical hernias
- Supraumbilical hernias up to 2.5 cm
- Patients unfit for spinal or general anaesthesia
- Defects larger than 3 cm
- Incisional/recurrent umbilical hernia
- History of Previous midline laparotomy
Patient in supine position with arms by the side, under general anaesthesia. A small curvilinear infraumbilical incision is taken. Length of the incision is 3 cm to 4 cm. The sac is dissected, and sheath is defined up to 1 cm around the defect. Contents are reduced and redundant sac is excised. A 10 mm port is introduced through the defect, and pneumoperitoneum is created. A 5 mm viewing port is inserted at Palmer’s point under vision [Figure 1]. The camera is now inserted through the 5 mm port and a thorough visualization of the abdomen is done for any adhesions. The prosthesis is then soaked in normal saline. After evacuation of pneumoperitoneum, the patch is folded in half with the polypropylene side facing inwards and introduced through the defect [Figure 2]. The mesh is folded into half along the ring provided and then inserted into the defect. This prevents the mesh being in contact with the wound. Only the straps of the mesh remain exposed to the surroundings and as they are held in traction to stabilize the mesh, thus further minimizing contact with skin. As the ring can break thus, rendering the mesh unfit for further use it is not possible to put the mesh through a 10 mm trocar. The two polypropylene straps are gently pulled up [Figure 3]. Placement of the patch is checked laparoscopically, and once satisfactory placement is seen, each polypropylene strap of the patch is sutured to the sheath using a nonabsorbable monofilament suture material. The defect is closed with continuous sutures using a 1-0 nonabsorbable monofilament material.
|Figure 3: Positioning the patch and applying optimal tension on the strap|
Click here to view
Two trans fascial sutures are taken at 3 and 9 o’ clock positions through the same incision using a 20-gauge spinal needle and a suture passer with a 1-0 monofilament non absorbable material [Figure 4].
|Figure 4: Trans fascial suture using a spinal needle through the same umbilical incision|
Click here to view
Pneumoperitoneum is evacuated. Incision is closed in layers and skin with absorbable subcuticular sutures. A waterproof dressing is done. The operating time was between 50 to 80 minutes. The cost of the patch is 351.7 USD.
In all patients, the patch used was an 8 cm composite patch consisting of a polypropylene mesh, a Polydioxanone memory ring, and a Hydrogel barrier reinforced by polyglycolic acid fibres [Figure 5].
The mesh is folded into half along the ring provided and then inserted into the defect. This prevents the mesh being in contact with the wound. Only the straps of the mesh remain exposed to the surroundings and as they are held in traction to stabilize the mesh, thus further minimizing contact with skin. As the ring can break thus, rendering the mesh unfit for further use it is not possible to put the mesh through a 10 mm trocar.
Outcomes were recorded in terms of postoperative pain (VAS at 24 hours), complications, and recurrence. Mean follow up period was 2 years (range 6 months to 5 years). In patients who were unable to come for the long-term physical follow up, a telephonic follow up was done, and direct questions about recurrence, pain, or any other complaints were asked, and the responses noted.
| Ethics committee approval|| |
It was not applicable for this article.
| Results|| |
100 consecutive patients who underwent surgery in this manner were included in the study [Table 1]. The study population comprised of 42 male and 58 female patients. Mean age was 48 years (range 19–79). 36 patients had comorbidities (American society of anaesthesiologist’s grade (ASA) I: 64 patients, ASA II: 26 patients, ASA III: 10 patients). Mean Body mass index was 29 (range 20–35).
31 patients had a history of previous abdominal surgeries, of which 26 patients had an umbilical port inserted (port site hernia). Patients with previous major laparotomy or contaminated surgery were not selected for this procedure, as in these cases, significant adhesions were expected, and were posted for Laparoscopic intraperitoneal onlay mesh (IPOM) plus procedure. Size of the umbilical hernia defect was between 1 cm and 2.5 cm (mean 1.65 cm). In 18 of the cases, the hernia was irreducible.
Two patients developed superficial surgical site infection in the form of minimal seropurulent discharge from the wound which was managed conservatively. This was a superficial wound surgical site occurrence. The probable method to prevent this would be to close the subcutaneous space in 2 layers instead of one and obliterate the dead space. A thorough wash with normal saline and change of gloves before wound closure could be considered to minimize SSIs. No wound breakdown was noted. Intravenous injection of third generation cephalosporin, is given at induction. Oral antibiotics (cefuroxime) are then continued for 3 days post-surgery. We didn’t have to incise the hernia ring in any patient. The mesh directly is deployed into the defect without any contact with the skin. No viscera related complications were noted. No recurrences were recorded.
Post operatively majority of the patients 95% experienced none to mild pain, and 5% had moderate pain (VAS 4–5). No patients experienced chronic pain. Tablet diclofenac 50 mg twice a day was given for 3 days, and VAS scores were taken at 24 hours post-surgery.
| Discussion|| |
Ventral patch repair is a good, well-established method of umbilical hernia repair for defect sizes less than 3 cm. A wide range of recurrence rates were noted in the various studies (0%–14.8%).,,,, Tinelli et al. found good results when patch deployment was monitored under laparoscopic vision – they commented that only sweeping the finger for checking adhesions is often inadequate and therefore patch placement is inadequate, if not monitored laparoscopically [Figure 7].
Another study monitored the deployment of the ventral patch laparoscopically, and found that patch was inadequately deployed in a large proportion of patients leading to an unacceptable rate of recurrence (14.8%). Some studies have commented that the tension on the positioning straps at the time of fixing the patch must be just optimal; too much tension will lead to a “cupping” or bending effect [Figure 6], and too little will lead to inadequate approximation with the anterior abdominal wall., This has been implicated as the cause of many of the complications. When done blind, there is no reliable way to avoid giving too much or too little traction on the bands. Here, laparoscopic monitoring gives a fool-proof way of ensuring just the right amount of tension on the bands.
|Figure 6: Bending of the patch due to excessive tension on the positioning straps|
Click here to view
Wasssenberg et al. have described a study with proceed ventral patch for umbilical hernias both small and medium sized in obese patients with acceptable result. Popescu RC et al. have mentioned a series of 93 patients with repair of ventralex ST patch is simpler and more cost effective than regular laparoscopic ipom meshes for small to medium sized umbilical hernias.
Berrevoet et al. noted that there is a seemingly higher recurrence rate (8.3%) due to “less controllable” mesh deployment. Many studies have evaluated the outcomes of the self-expanding ventral patch repair for small ventral hernias.
Our modification comes from our own experience of a single patient who came to us with intestinal obstruction after ventral patch repair. On diagnostic laparoscopy a loop of the ileum was entrapped between the mesh and the anterior abdominal wall leaving the polypropylene side exposed to the bowel. To minimize chances of the same we decided to visualize the mesh deployment and take additional trans fascial sutures for a more secure fixation through the same incision.
The two extra steps in our modification have distinct functions. Laparoscopic vision ensures absence of adhesions, and perfect deployment of the patch. The trans fascial sutures at 3 and 9 o’ clock positions help secure the patch to the abdominal wall very effectively and obviate the possibility of “cupping” or bending deformity of the patch.
Limitations of this new technique are, that it requires a laparoscopic camera set up. Another limitation is that trans fascial suturing has a learning curve (albeit short) and may lead to visceral injury if not done properly. Trans fascial sutures can also be an added factor for increased post-operative pain.
There are various other alternatives for the repair of an umbilical hernia which include a pre peritoneal placement of mesh. Yang et al. described a case of PPOM (pre peritoneal onlay mesh) as an adjunct to IPOM so that the disadvantages of adhesion formation, enterocutaneous fistulae were abbreviated.
Endoscopic totally pre peritoneal approach (ETPA) for midline hernias is another technique for small to midline hernias. Possible concomitant repair of diastasis could be done in this. Another new repair is called PUMP (Pre peritoneal umbilical hernia meshplasty) described by Kohler et al. for small to medium sized umbilical hernias where they describe it to have lower recurrence rates than a suture repair. But the pre peritoneal dissection can be cumbersome in addition to mesh deployment.
Belyanksi et al. also discussed a novel approach for ETPA for midline hernias where they have made suggestions about varied port placements for easier dissection and large placement of mesh. The disadvantage being that in the hands of newer surgeons’ injuries maybe more and the long operating time along with wide dissection for smaller hernias. The EMILOS (mini/less open sublay repair) was another method introduced for abdominal wall hernias where the advantage of laparoscopy was offered and disadvantages of open surgery, like long incisions, longer hospital stay were avoided. Schroeder AD et al. described laparoscopic transperitoneal sublay repair for ventral hernias. They compared a group to open sublay repair where, laparoscopy group had lesser hospital stay but the long-term chronic pain, foreign body sensation, recurrences were similar in both groups.
Trials are on to compare the outcomes in view of pain control, adhesions, recurrence of hernia, abdominal wall specific quality of life, wound events, surgeon related intra operative work load between ETEP and IPOM.
| Conclusion|| |
The hybrid technique of the of ventral patch placement is a safe way for optimum visualization for the correct mesh placement and may improve results, decrease complications and recurrences.
Bard for the provision of the 8 cm ventralex patch.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
- Ruchir Jhaveri: First draft
- Vishakha Kalikar: final draft and technical procedure
- Rajan Modi: Technical procedure
- Roy Patankar: approving the final draft
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]