Trans-cutaneous Closure of Central Defects (TCCD) in laparoscopic ventral hernia repairs (LVHR).

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) has been reported to have lower recurrence rates, fewer surgical site infections, and shorter hospital stays compared to open repair. Despite improved surgical outcomes with standard LVHR (sLVHR), seroma formation, eventration (or bulging of mesh or tissue), and hernia recurrence remain common complications. Our objective was to evaluate outcomes with trans-cutaneous closure of central defects in LVHR compared to sLVHR. METHODS: A retrospective review of 176 patients who underwent elective LVHR between January 2007 and December 2010 was performed. Of the 176 patients, 36 (20.5 %) had the LVHR-TCCD (trans-cutaneous closure of central defects) procedure and 140 (79.5 %) had sLVHR. The LVHR-TCCD cases were compared to a 1:1 case-matched control (n = 36). The case control group was matched by hernia type (primary versus secondary), hernia size, Ventral Hernia Working Group (VHWG) grade, institution, and follow-up duration. Patient demographics, co-morbidities, hernia characteristics, operative details, imaging data, and complications were collected. Patient satisfaction (using a 10-point, Likert-type scale), late postoperative pain (using the visual analogue scale), and patient functional status (using the Activities Assessment Scale; AAS) were analyzed. Continuous data were analyzed with either the unpaired Student's t test or the Mann-Whitney U-test, while Fischer's exact test was used to compare categorical data. RESULTS: Patient demographics, co-morbidities, hernia size, hernia type, mesh type, and surgical histories were similar between the LVHR-TCCD group and the case control group. The LVHR-TCCD patients had significantly lower rates of seroma formation (5.6 % versus 27.8 %; p = 0.02), mesh eventration (0.0 % versus 41.4 %; p = 0.0002), tissue eventration (4.0 % versus 37.9 %; p = 0.003), clinical eventration (8.3 % versus 69.4 %; p = 0.0001), and hernia recurrence (0.0 % versus 16.7 %; p = 0.02) when compared to the sLVHR case control. Postoperative infectious complications and early complications classified by the Dindo-Clavien system were similar between the groups. Median follow-up was 24 months (range: 7-34 months) for both groups. Compared to the case control group, patients having undergone LVHR-TCCD had higher patient satisfaction scores (8.8 ± 0.4 versus 7.0 ± 0.5; p = 0.008), cosmetic satisfaction scores (8.8 ± 0.4 versus 7.0 ± 0.6; p = 0.01), and AAS functional status scores (79.1 ± 1.9 versus 71.3 ± 2.3; p = 0.002). There was no difference in worst pain scores or the prevalence of chronic pain. CONCLUSIONS: The incidence of seroma, mesh and tissue eventration, and hernia recurrence was significantly lower following LVHR-TCCD when compared to sLVHR. Subjective improvement in overall patient satisfaction, cosmetic satisfaction, and functional status was reported with closing the central defect. The LVHR-TCCD technique may be superior for treating ventral hernias due to lower complication rates and higher patient satisfaction and functional status.

Laparoscopic ventral hernia repair: primary versus secondary hernias.

BACKGROUND: Most studies regarding laparoscopic ventral hernia repair (LVHR) have merged primary hernias (PHs) and secondary (incisional) hernias (SHs) into one group of ventral hernias. This grouping could produce falsely favorable results for LVHR. Our objective was to review and compare the outcomes of laparoscopic repair of PHs and SHs. METHODS: A retrospective chart review of patients from 2000 to 2010 identified the cases of LVHR at two affiliated institutions. The demographics, comorbidities, type of hernia (PH versus SH), and short- and long-term complications were analyzed. The postoperative pain, cosmetic satisfaction, and Activities Assessment Scale scores were assessed by telephone survey. RESULTS: A total of 201 cases of LVHR were identified: 73 PHs (36%) and 128 SHs (64%). No difference was found in the mean age between the two groups. The PH group had a greater percentage of black patients (34% versus 14%; P < 0.05), and the SH group had a greater percentage of white patients (85% versus 65%; P < 0.05). More female patients had SHs (34% versus 14%; P < 0.05), and more male patients had PHs (86% versus 66%; P < 0.05). More patients in the SH group had chronic obstructive pulmonary disease (19% versus 7%; P < 0.05) and prostate disease (32% versus 9%; P < 0.05). Overall, the SHs were larger (37.9 ± 4.9 cm(2)versus 11.5 ± 1.9 cm(2); P < 0.01). No differences were found in early postoperative complications, including pneumonia, urinary tract infection, surgical site infection, and seromas between the two groups. However, those with SHs had a greater incidence of recurrence (16% versus 5%; P < 0.05) and mesh explantation (7% versus 0%; P < 0.05). The patients who also underwent SH repairs had greater postoperative pain scores when followed up for a median of 25 mo than those who underwent PH repairs when followed up for a median of 24 mo (3.5 ± 0.4 versus 1.8 ± 0.4; P < 0.05). More patients in the SH group had chronic pain issues (26% versus 5%; P = 0.0003) and had lower satisfaction scores (7.5 ± 0.3 versus 8.6 ± 0.3; P < 0.05). Overall, the Activities Assessment Scale scores were not significantly different. CONCLUSIONS: Our data have demonstrated that PHs and SHs are different. LVHR of SHs is associated with increased recurrence, greater postoperative pain scores, chronic pain issues, and lower patient satisfaction scores. We recommend that future studies evaluate LVHR for PHs separate from those for SHs.

Patient Satisfaction, chronic pain, and functional status following laparoscopic ventral hernia repair.

BACKGROUND: Ventral hernia repairs are one of the most common surgeries performed. Symptoms are the most common motivation for repair. Unfortunately, outcomes of repair are typically measured in recurrence and infection rather than patient focused results. We correlated factors associated with decreased patient satisfaction, chronic pain, and diminished functional status following laparoscopic ventral hernia repair (LVHR) METHODS: A retrospective study of 201 patients from two affiliated institutions was performed. Patient satisfaction, chronic abdominal pain, pain scores, and Activities Assessment Scale results were obtained in 122 patients. Results were compared with univariate and multivariate analysis. RESULTS: Thirty-two (25.4%) patients were dissatisfied with their LVHR while 21 (17.2%) patients had chronic abdominal pain and 32 (26.2%) patients had poor functional status following LVHR. Decreased patient satisfaction was associated with perception of poor cosmetic outcome (OR 17.3), eventration (OR 10.2), and chronic pain (OR 1.4). Chronic abdominal pain following LVHR was associated with incisional hernia (OR 9.0), recurrence (OR 4.3), eventration (OR 6.0), mesh type (OR 1.9), or ethnicity (OR 0.10). Decreased functional status with LVHR was associated with mesh type used (OR 3.7), alcohol abuse (OR 3.4), chronic abdominal pain (OR 1.3), and age (OR 1.1). CONCLUSIONS: One-fourth of patients have poor quality outcome following LVHR. These outcomes are affected by perception of cosmesis, eventration, chronic pain, hernia type, recurrence, mesh type, and patient characteristics/co-morbidities. Closing central defects and judicious mesh selection may improve patient satisfaction and function. Focus on patient-centered outcomes is warranted.

Mesh shift following laparoscopic ventral hernia repair.

INTRODUCTION: Traditionally, laparoscopic ventral hernia repair (LVHR) is performed by placing the trocars on one side of the abdomen. Tacking the mesh on the operative side can be challenging. We hypothesized that mesh shift may occur as a result of this approach. We define mesh shift as any mesh off-center, where the center is the hernia defect. Our objectives were to evaluate whether mesh shift occurs after LVHR, and to develop a grading system to describe this phenomenon. METHODS: We conducted a retrospective review of patients who underwent LVHR from 2000 to 2010. We examined patient demographics, comorbidities, radiographic data, surgical data, and outcomes. Using analysis of variance, we analyzed continuous data; we used Chi squared to analyze categorical data. Of the 201 patients, we reviewed 78 postoperative computed tomography (CT) scans. Two surgeons measured mesh overlap of the fascia bilaterally at the level of the hernia defect. We compared a ratio of the two sides of overlap (least overlap/greatest overlap) and classified patients into four grades: grade I, no mesh shift (ratio of 0.5-1.00); grade II, mild mesh shift (ratio of 0.20-0.49); grade III, moderate mesh shift (>0-0.19); and grade IV, major mesh shift with recurrence (<0). Any recurrence was classified as a grade IV shift. RESULTS: A total of 48% of patients had mesh shift (grade II = 23%; grade III = 10%; and grade IV = 17%). In 92% of the patients with mesh shift, the mesh migrated away from the port placement site, resulting in decreased mesh/fascial overlap. Patients in the four groups had similar demographics, comorbid conditions, hernia characteristics, operative technique, and outcomes (excluding recurrences, which were all grade IV by definition). Whereas differences in time to follow-up CT scan in the different grades were not statistically significant, there was a trend toward increasing shift with time (mean: grade I, 20 mo; grade II, 38 mo; grade III, 50 mo; and grade IV, 26 mo; P = 0.07). A total of 26 patients (33%) had multiple postoperative CT scans. With time, it appears that mesh tended to shift with time (grade I, 68%-46%; grade II, 12%-19%; grade III, 12%-8%, and grade 4, 8%-23%). CONCLUSIONS: Mesh can shift from the ideal central placement after LVHR. Mesh tends to shift away from the operative side and recurrences tend to occur on the operative side. Mesh shift may be a precursor to hernia recurrence. Recurrence may be a two-step process, beginning first with intra-operative mesh shift followed by additional factors (such mesh contraction) that may accentuate the shift and lead to recurrence. Potential solutions include increasing mesh overlap (≥ 6 cm), performing transcutaneous closure of central defect, securing trans-fascial sutures before tacking, placing operative side tacks first, and consider placing contralateral ports to secure the mesh.