International Journal of Abdominal Wall and Hernia Surgery

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Component separation technique (CST) allows the mobilization of large musculofascial flaps of the abdominal wall and was developed for the treatment of very large, primary and incisional abdominal wall hernias. The classic open anterior CST first published by Albanese and later by Ramirez is associated with high complication rates. According to a recent literature review, CST without mesh should no longer be performed because of high recurrence rates. Classic anterior CST is associated with high rates of surgical-site occurrences and infections and should only be performed as endoscopic- and perforator-sparing anterior CST. The unfavorable results of classic CST resulted in the development of numerous new anterior and posterior CST modifications, several of them were minimally invasive. The posterior CST with transversus abdominis muscle (TAM) release (TAR) published by Novitsky et al. is an extension of the original retrorectus Rives operation and Stoppa procedure. The technique avoids vast skin flaps and allows the closure of large abdominal wall defects and insertion of very large retromuscular alloplastic standard sublay meshes without damaging the vessels and intercostal nerves. The TAR procedure is one of the major advances of abdominal wall surgery of the last decades. Several new promising minimally invasive modifications including robotic-assisted TAR have been published recently. The indications and technique of the TAM (TAR) procedure and its minimally invasive modifications are described.

BACKGROUND: Posterior component separation through transversus abdominis muscle release (TAR) is an increasingly accepted technique worldwide for complex ventral hernia repair. Recently, researchers have attempted to perform the TAR procedure using minimally invasive approaches. In this study, we present our experience of laparoscopic TAR (Lap-TAR). The procedure will be described in detail and its feasibility evaluated. PATIENTS AND METHODS: To learn and be proficient in the procedure through soft cadaver workshop practice, we accumulated the necessary knowledge and minimally invasive surgery skills for the Lap-TAR procedure. We selected an appropriate patient and performed a Lap-TAR operation to treat complex ventral hernia. RESULTS: The Lap-TAR operation was successfully performed in a 73-year-old female patient with a giant lower abdominal incisional hernia, without open conversion. The estimated blood loss was 60 mL and the operative time was 365 min. The postoperative pain was mild, and the visual analog pain scale score was 3 on postoperative day (POD) 2. The patient was discharged on POD 7. All subfascial drains were removed before patient discharge. On an initial follow-up period of 3 months, there was no evidence of wound complication, bulging, or hernia recurrence. CONCLUSIONS: The Lap-TAR operation is technically feasible with a deliberate preparation. It could be an alternative for complex abdominal wall reconstruction with the potential to reduce pain, facilitate recovery, and decrease the length of hospital stay of patients.

The open approach to inguinal hernia repair has several distinct advantages in the management of both primary and recurrent groin hernia repairs. A variety of repair techniques are available to suite the patient's condition. Both pure tissue and mesh techniques in a tailored fashion may be employed, rather than the cookie-cutter approach where the mesh is used in the same fashion in every case. Most patients with preexisting comorbidities may have repair carried out under local or regional anesthesia instead of general anesthesia as required by laparoscopy. Studies have demonstrated the efficacy of open preperitoneal mesh placement in the treatment of recurrent inguinal and femoral hernia repair, where hernia recurrence rates, postoperative complications, and long-term patient outcomes are equivalent to laparoscopic repair. The use of robots has yet to demonstrate any advantage over manual repairs either open or laparoscopic, with extended operating time and extreme cost. Return to normal daily activity is advocated in 3–7 days whichever technique is used.

INTRODUCTION: The superiority of laparoscopic approach for a ventral and incisional hernia has been well documented over the traditional open repair. However, there is a paucity of literature comparing the outcomes of laparoscopic repair of primary ventral hernias versus incisional hernias. The objective of our study was to compare the operative variables and short-term outcomes of laparoscopic repair of primary ventral hernia as compared to incisional hernia in our setup. MATERIALS AND METHODS: We reviewed the clinical data of 159 patients who underwent laparoscopic ventral and incisional hernia repair from January 2014 to December 2015. Demographics, operative variables, and short-term outcomes were compared between the two groups. Comparison of outcome variables was done using independent sample t- test for continuous variables and Chi-square test for categorical variables. RESULTS: Of 159 patients, 90 (57%) had primary ventral hernia repair and 69 (43%) underwent incisional hernia repair. Both groups were similar in terms of age, body mass index, comorbid conditions, and high preponderance of females. The number (P < 0.006) and size (P < 0.000) of the hernia defect were significantly higher in the incisional hernia group. The operating time (P < 0.000) and extent of adhesiolysis (P < 0.011) were significantly higher in patients with incisional hernia. There was no statistically significant difference in intraoperative and postoperative complications in the two groups. The duration of postoperative hospital stay was longer in the incisional hernia group (P < 0.001). CONCLUSIONS: The patients in the incisional hernia group had higher frequency of complex and large hernias. Laparoscopic repair of incisional hernia was associated with extensive adhesiolysis, longer operating time, and longer hospital stay as compared to primary ventral hernias.

BACKGROUND: In spite of their wide use, clinical studies on intraperitoneal ventral patches are rare, especially for Ventralex^TM ST (VST), recently released. MATERIALS AND METHODS: Two-year results of 108 patients operated on from a ventral hernia with VST were assessed using a patient-reported outcome measures concept. RESULTS: One hundred and eight patients (59.9 ± 14.65 years; body mass index 29.72 ± 8.14; wound healing risk factor in 49 patients) were prospectively registered. Surgery was clean in 105 (97%) or clean contaminated in 3 (3%). The defect was <4 cm in diameter in 81% of primaries and <4 cm in width in 91% of incisional ventral hernias. No postoperative complication occurred except one benign subcutaneous seroma. At 2 years, 15 patients could not be reached by the independent clinical research assistant, despite five attempts at different moments, while 93 (86%) completed the phone questionnaire. None declined to answer. Only one reoperation was mentioned. Three recurrences (two not reoperated) were identified. No bowel obstruction, wound sinus, or mesh migration was identified. Only three patients had pain, mild and less bothering than their treated hernia. Compared with the preoperative quality of life, evaluated with the same questionnaire, the improvement in these 93 patients was highly statistically significant (P < 0.001). CONCLUSION: Despite potential underestimation of recurrences and rare long-term complications, this study, the first one on this new patch, suggests that VST could be safe and effective in the treatment of small primary or incisional ventral hernias. However, further studies are needed to confirm these preliminary results.

Online since 26^th Feb, 2018