Endoscopic-assisted repair of combined ventral hernias and diastasis recti: minimizing seroma incidence by quilting.

BACKGROUND: To reduce the incidence of seromas, we have adapted the quilting procedure used in open abdominoplasty to the endoscopic-assisted repair of concomitant ventral hernia (VH) and diastasis recti (DR). The aim of this study was to describe the technique and assess its efficacy by comparing two groups of patients operated on with the same repair technique before and after introducing the quilting. METHODS: This retrospective study included data prospectively registered in the French Club Hernie database from 176 consecutive patients who underwent surgery for concomitant VH and DR via the double-layer suturing technique. Patients were categorized into two groups: Group 1 comprised 102 patients operated before introducing the quilting procedure and Group 2 comprised 74 operated after introducing the quilting. To carry out comparisons between groups, seromas were classified into two types: type A included spontaneously resorbable seromas and seromas drained by a single puncture and type B included seromas requiring two or more punctures and complicated cases requiring reoperation. RESULTS: The global percentage of seromas was 24.4%. The percentage of seromas of any type was greater in Group 1 (27.5%) than in Group 2 (20.3%). The percentage of Type B seromas was greater in Group 1 (19.6%) than in Group 2 (5.4%), when the percentage of Type A seromas was greater in Group 2 (14.9) than in Group 1 (7.9%). Differences were significant (p = 0.014). The operation duration was longer in Group 2 (83.9 min) than in Group 1 (69.9 min). Four complications requiring reoperation were observed in Group 1: three persistent seromas requiring surgical drainage under general anesthesia and one encapsulated seroma. CONCLUSION: Adapting the quilting technique to the endoscopic-assisted bilayer suturing technique for combined VH and DR repair can significantly reduce the incidence and severity of postoperative seromas.

Minimally invasive bilayer suturing technique for the repair of concomitant ventral hernias and diastasis recti.

BACKGROUND: According to EHS guidelines, mesh repair is recommended in case of concomitant diastasis recti (DR) and ventral hernia more than 1 cm in diameter. Since in this situation, the higher risk of hernia recurrence may be attributed to the weakness of aponeurotic layers, in our current practice, for hernias up to 3 cm, we use a bilayer suture technique. The study aimed at describing our surgical technique and evaluating the results of our current practice. METHODS: The technique combines suturing repair of the hernia orifice and diastasis correction by suture, and includes an open step through periumbilical incision and an endoscopic step. The study is an observational report on 77 cases of concomitant ventral hernias and DR. RESULTS: The median diameter of the hernia orifice was 1.5 cm (0.8-3). The median inter-rectus distance was 60 mm (30-120) at rest and 38 mm (10-85) at leg raise at tape measurement and 43 mm (25-92) and 35 mm (25-85) at CT scan respectively. Postoperative complications involved 22 seromas (28.6%), 1 hematoma (1.3%) and 1 early diastasis recurrence (1.3%). At mid-term evaluation, with 19 (12-33) months follow-up, 75 (97.4%) patients were evaluated. There were no hernia recurrences and 2 (2.6%) diastasis recurrences. The patients rated the result of their operation as excellent or good in 92% and 80% of the cases at global and esthetic evaluations, respectively. The result was rated bad at esthetic evaluation in 20% of the cases because the skin appearance was flawed, due to discrepancy between the unchanged cutaneous layer and the narrowed musculoaponeurotic layer. CONCLUSION: The technique provides effective repair of concomitant diastasis and ventral hernias up to 3 cm. Nevertheless, patients should be informed that the skin appearance can be flawed, because of the discrepancy between the unchanged cutaneous layer and the narrowed musculoaponeurotic layer.

Mid-term results of VTEP (Ventral hernia repair by Totally ExtraPeritoneal approach).

BACKGROUND: Techniques of retromuscular repair of ventral hernias aim at avoiding complications linked to intraperitoneal patch. Aim of the study was to evaluate results of the VTEP technique. METHODS: On 187 patients who underwent a VTEP, evaluation was carried out on 128 patients with a minimum follow-up of 1 year. The surgical technique consisted of creating connection between both retro-rectus spaces, by division of the medial edges of the posterior sheath and deploying the patch in the retromuscular patch without fixation. The posterior sheath was repaired in 16 cases. The patients were sent a questionnaire and invitation to have physical examination by the surgeon. RESULTS: The mean hernia and patch size were 9 (1-50) and 225 (50-500) cm2, respectively. The mean follow-up was 21.2 (12-35) months; 120 (93.7%) patients were evaluated, 21 by physical examination, 41 by questionnaire, 58 by telephone and 8 (6.3%) were lost to follow-up. Hundred (83%) patients felt no pain at rest, and 88 (73%) during effort. Among patients who felt some degree of pain, the mean VAS value was 2 (1-4) at rest and 2.6 (1-7) during effort. Two recurrences occurred, 3 patients were worried about a persisting diastasis bulging at the upper border of the patch and 8 patients in which the posterior sheath was not repaired complained they felt that their upper abdomen was somewhat distended or swollen. CONCLUSION: The VTEP procedure provides a low level of chronic pain but can entail some drawbacks, such as the swollen abdomen, which can be attributed to the absence of repair of the posterior sheath. It may be that restoring or preserving structural integrity of the abdominal belt formed by the posterior sheath constitutes a key point in retromuscular techniques.

Stapled VTEP (sVTEP), diastasis and the "swollen abdomen".

BACKGROUND: In the VTEP series, some patients declared that their abdomen was "somewhat swollen", and the authors suggested that this might be related to disruption of the posterior sheath due to the crossing. Following this observation, we decided to evaluate the systematic repair of the posterior sheath. METHODS: In 50 consecutive patients operated for ventral hernias, the VTEP procedure was modified, using the linear stapler to perform simultaneous division and closure of the posterior sheath. Perioperative data and short-term results were prospectively assessed. RESULTS: Six (12%) complications occurred: one hematoma, one sudden death at home five days after surgery in a man with history of cardiac disease, and 4 cases of dehiscence of the staple line, which were successively reoperated by suture of the gap and posterior sheath release incision (PSR). With a mean follow-up of 7.5 months (4-12) there were no recurrences and 2 cases of "swollen abdomen", in patients who undergone PSR. The "swollen abdomen" did not occur when the posterior sheath was repaired without PSR. Preoperative diastasis bulging present in 11 cases, was totally or partially corrected in 8 and 1 cases, respectively, and unchanged in 2 cases. CONCLUSION: The sVTEP procedure, can contribute to prevent the swollen abdomen and to diastasis correction. The PSR can prevent staple line disruption or permit tension-free repair of the dehiscence, but then, the newly created lateral gaps can finally entail the same drawback. Search for the best solution to treat the gap in the posterior sheath requires further studies.

Ventral hernia repair by totally extraperitoneal approach (VTEP): technique description and feasibility study.

BACKGROUND: The repair of ventral hernias by intra-peritoneal patch (IPOM) involves a risk of pain due to stapling as well as intestinal adhesions. Extraperitoneal placement of the patch without fixation can prevent these drawbacks. Techniques of endoscopic preperitoneal repair were previously described by others. The aim of this article is to describe our technique and to evaluate the feasibility and short-term results. METHODS: The totally endoscopic technique consists of dividing the median aponeurotic structures, while preserving the proper linea alba, to create a unique retro-muscular space, in which the patch is deployed without any fixation. Hundred twelve consecutive patients were operated on for ventral hernias (82 umbilical, 20 epigastric, 10 combined). Perioperative data including duration of operation, technical problems, conversions and complications, as well as postoperative pain, time to resume daily activities and time off work were prospectively assessed. RESULTS: 98 (87.5%) patients were operated in ambulatory surgery, and 14 (12.5%) in overnight stay. The mean sizes of the hernia and the patch were 9 (1-50) cm2 and 225 (50-500) cm2, respectively. The mean operation duration was 75 (30-270) min. The peritoneum was opened in 43 (38.4%) cases and closed by suture in 41 instances. There were 5 (4.5%) conversions to IPOM and 4 (3.6%) complications (1 seroma, 1 urine retention, 1 transitory ileus, and 1 intestinal obstruction) which were reoperated. The mean VAS value of postoperative pain was 2.45 (0-8), pain was scored 0 by 17 (15%) patients. The mean times to resume daily activity and work were 4 (1-15) days and 11.5 (1-30) days, respectively. CONCLUSION: Our results suggest that VTEP is safely feasible by surgeons skilled in laparoscopy, and might contribute to minimize pain, though this must be established by comparative studies.

Transinguinal preperitoneal patch (TIPP) under local anesthesia with sedation.

Transinguinal preperitoneal placement of the patch (TIPP) combines the advantages of the preperitoneal patch and the simplicity of the inguinal approach. The aim of the study was to evaluate the feasibility of TIPP under local anesthesia (LA) with sedation on a series of unselected patients. All 161 patients referred to one of us for inguinal hernia repair were included in a prospective evaluation; they were operated on for 169 inguinal hernias, in LA with sedation. TIPP was the routine method and was used in all but a few particular cases. TIPP was performed in 139 cases out of 169 (82.2%). In 21 cases (12.4%) another method was chosen, due to the patient's age, the patient's request, or the type of the hernia. In nine cases (5.3%) another technique was used because preperitoneal dissection was not possible, due to a previous preperitoneal surgery. In the 139 cases where a TIPP was performed, general anesthesia was used in four cases at the patient's request and spinal anesthesia in two cases of large irreducible scrotal hernias in old, frail patients. TIPP was begun under LA in 133 cases and conversion to general anesthesia was necessary in one case only. Therefore, TIPP under LA was possible in 132 cases out of 139 (95%). These results suggest that TIPP can be performed under LA in most cases. The expected advantages of combining preperitoneal patch repair and local anesthesia are worth being confirmed by comparative studies.