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   Table of Contents - Current issue
July-September 2022
Volume 5 | Issue 3
Page Nos. 103-158

Online since Thursday, September 1, 2022

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Robotic transversus abdominis release for ventral hernia repairs p. 103
Tiffany Nguyen, Kristina Kunes, Christine Crigler, Conrad Ballecer
Background: Robotic transversus abdominis release (roboTAR) is a minimally invasive surgical approach for ventral hernia repairs that builds on the concepts developed by Rives and Stoppa. The Rives–Stoppa procedure incorporates Rives’ retromuscular repair and Stoppa’s concept of giant prosthetic reinforcement of the visceral sac (GPRVS).[1] In an effort to mitigate the limitations of the Rives–Stoppa procedure, Novitsky et al. developed the open transversus abdominis release (TAR). The TAR approach is favorable when repairing large ventral hernia defects, as it provides myofascial advancement to reconstitute linea alba, preserves the neurovascular bundles of the medial abdominal wall, and creates a large extraperitoneal space to allow for mesh reinforcement. Methods: The three main technical components of the roboTAR include the following: bottom-up, Novitsky method, and top-down approach. An understanding of the anatomy and technique involved in the three techniques is critical for performing roboTAR. Results: Within the authors’ practice, the average hernia defect size is 115 cm2. With a n = 200, approximately 1% of our patients has had a surgical site complication. Recurrences are rare and occur in very large complex hernias. The average operative time is approximately 400 min with an average length of stay being 1.2 days. This is consistent with others. Conclusion: Utilizing a minimally invasive approach, as seen in roboTAR, provides additional advantages, including shorter length of hospital stay, reduced wound morbidity, reduced postoperative pain, and expedited return to work and activities of daily living. This article is a comprehensive review of the pertinent anatomy, preoperative evaluation, operative technique, and the postoperative course of roboTAR.
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Repair of giant incisional hernias: Comparison of separation technique with and without mesh Highly accessed article p. 110
Suat Benek, Şevki Pedük, Yasin Duran
BACKGROUND: Incisional hernias are one of the most common postoperative complications encountered by surgeons in daily practice. In our study, we compared the component separation technique (CST) with and without synthetic mesh in large incisional hernia surgery. MATERIALS AND METHODS: The files of 79 patients who underwent surgery for giant incisional hernia between January 2016 and November 2020 were reviewed retrospectively. The patients were divided into two groups: CST with mesh reinforcement (mesh+ group) and CST without mesh reinforcement (non-mesh group). The groups were compared in terms of recurrence, complications, and other clinical features. RESULTS: There were 36 patients in the mesh+ group and 38 patients in the non-mesh group. There was no significant difference between the two groups in terms of demographic parameters and clinical features. There was a statistically significant difference between the groups in terms of recurrence rate (P = 0.007, OR = 0.17). In addition, there was a significant difference between the two groups in terms of mean operation times (2.8 h and 1.9 h for mesh+ and non-mesh, respectively) (P = 0.000, 95% CI). Regardless of the use of mesh, recurrence was significantly higher in the presence of high body mass index (BMI) (P = 0.003, 95% CI) and comorbidity (P = 0.031, OR = 3.4). CONCLUSION: Repair of giant incisional hernias with mesh-reinforced CST is superior to the non-mesh technique in terms of hernia recurrence. Although CST without mesh reinforcement seems advantageous in terms of complications and operation time, we believe that the mesh-reinforced CST should be applied in suitable patients when the total cost, recurrence, and patient satisfaction are taken into account.
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Feasibility of robotic repair of parastomal hernias p. 116
Kyle M Schmitt, Vance L Albaugh, Karl LeBlanc
BACKGROUND: Parastomal hernias present a common complex surgical problem that has a severe clinical impact on quality of life. Several techniques for repair have been described with open or minimally invasive techniques, although recurrence and reoperation continue to be common problems. In the following, a case series utilizing a technique for a minimally invasive repair using the Di Vinci robotic platform for a mesh-reinforced, modified Sugarbaker repair is described. STUDY DESIGN: This study is a retrospective review of 24 cases of robotic-assisted parastomal hernia repairs performed by a single surgeon from 2014 to 2020. Primary endpoints of interest were operative times and length of stay, as well as postoperative complications. RESULTS: Twenty-four patients were included in the study. The average operative time was 194.8 min (range: 95–378 min) and the average console time was 149.5 min (range: 72–319 min). The average length of stay was 3.9 days. No patients required conversion to either a laparoscopic or an open procedure, although two complications required reoperation. Twelve patients developed minor complications, including four who developed a postoperative seroma, but none of them required surgical intervention. CONCLUSIONS: This is the first and largest series describing a technique for a robotic-assisted parastomal hernia repair. This shows that this procedure can be reliably undertaken with the robotic platform with consistent and reproducible results and few complications. Further long-term research will be needed as new robotic techniques evolve and patients will need follow-up regarding recurrence rates and any late complications evaluated.
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To compare the outcome of inguinal hernia repair under local and spinal anesthesia p. 122
Naveen K Maurya, Shadab Asif, Saleem Tahir, Kumar Aishwarya, Swarnlata Shiromani
INTRODUCTION: The most frequent form of hernia is inguinal hernia, affecting around 15% of adult males. The optimal surgical anesthetic method for ambulatory inguinal hernia repair is unknown at the moment, and there is no consensus on the procedure. The goal of this study was to examine the outcome of inguinal hernia repair under local anesthesia compared with spinal anesthesia. MATERIALS AND METHODS: In this prospective observational study, 80 patients were randomly assigned into two groups by the SNOSE method with a different mode of anesthesia: group SA (n = 40) and group LA (n = 40). Lichtenstein tension-free hernioplasty was done in all patients. Pre- and post-OP clinical examinations (3rd day) were looked for complications. RESULTS: There were no significant demographic differences between the two groups. When compared with the SA group, the LA group experienced much less post-operative pain. With local anesthesia, post-operative ambulation was substantially faster. The use of a local anesthetic allowed for a shorter stay in the hospital and a speedy return to regular activity. In general, local anesthesia was linked to less post-operative complications in the early aftermath. CONCLUSION: Local anesthesia is a preferable choice to spinal anesthesia for short stay or daycare surgery, particularly for patients who are unable to tolerate spinal anesthesia. As a result, Lichtenstein’s hernioplasty performed under local anesthesia is attracting considerable interests in the field of groin hernia repair.
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Enhancing safety in ventral patch repair for umbilical hernia by utilizing a hybrid technique p. 129
Ruchir Jhaveri, Vishakha Kalikar, Rajan Modi, Roy Patankar
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.
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Robotic transabdominal preperitoneal morgagni hernia repair technique: A case report p. 135
Courtney Janowski, Natasha Sioda, Siwen Liu, Alissa Sabatino, Conrad Ballecer
Robotic transabdominal preperitoneal Morgagni hernia repair: A step-wise approach. Morgagni hernia (MH) is an atypical and rare type of diaphragmatic hernia that presents surgical challenges given its location and proximity to vital structures. Classically, these hernias have been repaired either open or laparoscopically with the use of an intraperitoneal onlay mesh without defect closure. Borrowing from the groups’ excellent experience in robotic transabdominal preperitoneal hernia repair (rTAPP) ventral and atypically located hernias, this approach has shown promise in repairing MHs in albeit a small cohort of patients. The rTAPP technique in our opinion overcomes many of the challenges and pitfalls associated with atypical hernias, including those of the diaphragm, providing excellent visualization and facilitating wide preperitoneal dissection with a complete reduction of the hernia sac located in the anterior mediastinum. The wide preperitoneal exposure allows for directed diaphragmatic closure, minimizing the risk of injury to mediastinal structures, placement of a large uncoated mesh sandwiched in between layers of the abdominal wall, and safely targeted fixation at cardinal points. Preperitoneal mesh allows for the use of a more cost-effective uncoated mesh that is not exposed to the viscera. It also allows for minimal and targeted fixation without the use of tacks, leading to decreased postoperative pain and complications. In this article, we are detailing the rTAPP approach in managing MHs.
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A simple technique for definite closure of full thickness abdominal wall defect in open abdomen after temporary applied split thickness graft: A case report p. 140
Michael Lorentziadis, Moustafa Mahmoud Nafady Hego, Hanan Al-Jurini
Open abdomen (OA) has gained a wide acceptance in the management of abdominal surgical catastrophes. Definite reconstruction of OA is an operative challenge as various methods are used. Dynamic techniques are preferred for the closure of OA. If other methods fail to close the OA, then temporary split thickness skin graft can be applied and refer the definite closure for later. We used a modification of an existing technique, in a 47-year-old female patient with a big midline incisional hernia due to temporary closure of OA with partial-thickness skin graft, who was operated for permanent closure of the defect. In order to avoid complications from extensive dissection, we invaginated the grafted area and realigned the recti muscles with on lay mesh reinforcement with excellent outcome. This technique of inverting the previous grafted area when it can be applied is an easy and safe method with rewarding results.
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A combined laparoscopic and open delayed repair of a rare traumatic abdominal wall hernia: A case report p. 145
Dries Dorpmans, Anne Dams
Introduction: Traumatic abdominal wall hernias (TAWHs) are uncommon and result from a high-energetic blunt trauma to the abdomen. These hernias are not always apparent in initial trauma evaluation. No consensus exists regarding optimal timing and surgical approach. Case Presentation: A 68-year-old Caucasian woman was involved as a passenger in a high-energetic head-on collision motor vehicle accident. In the initial assessment a sternal fracture, four rib fractures, a small pneumothorax, and a medial malleolus fracture were found. A small abdominal wall hernia was missed. Six months later she presents with a painful mass in her left flank. Computed tomography (CT) showed a large hernia containing colon. An elective hybrid repair was done. Laparoscopically, a preperitoneal mesh was placed. Afterward, using open access, the abdominal wall musculature was re-fixated on the iliac crest. Discussion: Emergent surgical management of TAWH is often preferred due to high incidence of associated intra-abdominal lacerations. These settings are not always favorable for mesh placement. Some data suggest a higher recurrence rate for hernias without mesh augmentation and repair within the acute posttraumatic period. Conservative management poses the risk of incarceration and hernia defect enlargement. A delayed repair can be considered if the patient is hemodynamically stable, no associated visceral lacerations are present and the defect is large enough to reduce the risk of incarceration. It has the advantage of mesh placement in healthy tissue.Conclusions: A delayed laparoscopic repair seems a safe and valid option allowing larger mesh placement. Additional fascia closure of muscle fixation can be done granting more reinforcement and smaller incision needs and thus less postoperative pain.
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When hernia mesh erodes into the bowel: A “bezoar” case p. 150
Ishwarya Nair, Kellee Slater
Incisional hernia repair surgery is commonly performed by using a synthetic mesh; due to its low complication rate. This article describes the management of a patient with mesh erosion into the small bowel, a rare complication of mesh-based ventral hernia repair. Fatigue secondary to iron-deficiency anemia and disfigurement from his hernia were his only symptoms. The patient was conservatively managed for several years due to the risks associated with restorative surgery. Eventually, due to deterioration of his health as well as advances in the techniques of abdominal wall reconstruction, the patient underwent surgery. The patient made excellent recovery. The complications associated with the synthetic mesh are likely to be very underreported. This article discusses the factors leading to mesh erosion, including mesh type, fixation methods, mesh migration, and mesh position, and it emphasizes the importance of reporting and following up hernia patients to advance the science behind mesh technology and surgical techniques surrounding ventral hernia repair.
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Is there a link between mesh implantation and systematic autoimmune disease? p. 154
Junsheng Li, Xiangyu Shao, Tao Cheng, Zhenling Ji
Autoimmune/autoinflammatory syndrome induced by adjuvants (ASIA)/“Shoenfeld’s syndrome” corresponds to a spectrum of immune-mediated diseases triggered by exposure to various materials. Polypropylene (PP) mesh has become the standard for nearly all kinds of hernia repair. There are conflicting reports on the link between ASIA and PP mesh implantation for hernia repair. We reported a typical ASIA/“Shoenfeld’s syndrome” after inguinal hernia repair with PP mesh, and the patient's systematic syndrome was completely alleviated after mesh removal. The present case highlights that there is a link between ASIA/“Shoenfeld’s syndrome” and hernia repair with PP mesh, although not frequently. Both surgeons and patients should bear in mind this disease, and patients should be fully informed before surgery, and registry is an important and possible tool to evaluate and determine the frequency of ASIA after hernia repairs with PP meshes.
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