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  3. Laparoscopic Hernia Surgery: An Operative Guide (Arnold Publication). Karl A. LeBlanc
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Recurrence is the complication that this operation is known to have reduced its incidence. The choice of biomaterial may influence this complication, but there are many very good prostheses available today Table 2. Fixation is the paramount concern to assure that the intraabdominal pressure does not dislodge the biomaterial from its attachments. The current recommendation is that of a fixation device supplemented by the use of transfascial sutures. These are spaced approximately 1cm and 5cm apart respectively along the periphery of the biomaterial.

Admittedly, however, these sutures may be used less frequently. The most important fact should be that the surgeon is both comfortable and confident in the chosen method of fixation. Most of the immediate complications, such as pain, fever, and an ileus, cannot be prevented. Pain should be treated as usual but the use of ketorolac may diminish it in many patients. We prefer to place an abdominal binder upon all of our patients while they are still on the operating table, because this greatly aids in pain control.

It has not resulted in respiratory embarrassment in any patient. The frequent and early use of an incentive spirometer will help prevent the postoperative atelectatic fever that is seen rather frequently. This may be difficult because of the short length of stay in the hospital, if at all. The development of a prolonged ileus should not truly be considered a complication, but, in most reports, this is listed as such.

Generally, this cannot be prevented, especially in those with extensive adhesions involving significant portions of intestinal contents, particularly if these were incarcerated. As in most surgical procedures, early ambulation and the allowance of oral intake at an early stage may offer considerable benefit.

The majority of complications known to occur with the laparoscopic approach are not different from that of the open repair Table 1. A few complications, such as an unrecognized enterotomy, can have a significant mortality rate. Intraoperative hemorrhage can occur at the outset of the operation during insertion of the first trocar and is, therefore, not unique to incisional hernia repair.

The exact incidence of this is not known, as this type of injury is rarely reported because it is generally of no consequence and can be readily controlled. The use of an entry method that does not use a cutting trocar may provide an increased margin of safety. If hemorrhage does occur, it can be stopped in one of a variety of ways. The trocar can be removed and replaced with a larger one to tamponade the bleeding vessels. The insertion of a balloon-tipped trocar can also be used to tamponade the bleeding site.

Alternatively, the trocar can be removed and the site cauterized, or a transabdominal suture can be placed before or after its removal. Hemorrhage can occur during the most challenging portion of the procedure, the adhesiolysis. This will usually originate from one of the vessels within the omentum and can be managed with electrocautery or the ultrasonic shears. If this method is chosen, the surgeon must be especially cautious to ensure that there is no adjacent intestine at that site so a lateral burn will not occur.

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This type of injury may not become apparent until a few days later when that site necroses and perforates see below. Alternatively, the use of hemoclips, looped sutures, or suture ligation can be effective for this problem. Another common occurrence of hemorrhage is that which results during the fixation of the prosthetic biomaterial. Any of the metal devices or the transfascial sutures that are placed can puncture or lacerate small abdominal wall vessels or the inferior epigastric vessels.

This will be easily identified because either brisk bleeding will be seen or a hematoma will form rapidly. One must be quick to apply direct pressure at that site and then place one or more transfascial sutures with one of the devices designed for that purpose. This is the most feared of the potential complications. The serosal injury that occurs during the dissection of the intestine can be managed as one would during any bowel surgery.

If the lumen has not been violated, one may elect to leave this injury untouched, or the surgeon can close this with either sutures or with the application of endoscopic staples. In our series of patients, we used all of these choices without any adverse events. The management of a recognized enterotomy is currently somewhat controversial. In many centers, if this event occurs, the hernia procedure is terminated. The surgeon will repair the injury either laparoscopically or by conversion to laparotomy.

In the latter instance, the intestinal repair is completed but the hernia repair is delayed. The patient will be returned to the operative suite 2 to 4 days later whence the laparoscopic hernioplasty will be performed. This delay will allow any contamination to be eliminated, and this short time span will not allow the formation of dense adhesions that would make the second operation quite tedious.

A delay of several weeks or longer should be considered if a significant spillage of intraluminal contents has occurred. Antibiotics are generally continued in the intervening period. More recently, reports have shown that the simultaneous repair of this recognized small bowel injury and the hernia may be safe. This enterotomy should not be associated with a large amount of spillage of the intestinal contents. Some series 20,23 have repaired this injury and proceeded to repair the hernia laparoscopically with insertion of a prosthetic biomaterial. Others 24 have resected gangrenous bowel and completed the hernia repair.

In these few reports, an adverse consequence did not occur. Because the risk can be significant, this choice must be made carefully. Intestinal necrosis secondary to an electrosurgical injury is frequently underestimated. When that injury is oversewn, there may be an extension of the necrosis and subsequent development of an intraabdominal abscess. This would then require a formal laparotomy, resection, and repair of the involved intestine and removal of the prosthesis. The use of this latter biomaterial has not been proven to prevent the redevelopment of another hernia in the future, however.

More data are needed on the use of these products in these circumstances. An injury to the colon carries a much greater potential for complications if the hernia repair is completed as planned. The majority of surgeons will simply repair the injury and repair the hernia by a laparotomy and primary closure. The use of a polypropylene or collagen-based prosthesis may be required if the fascial defect is very large, because primary closure may not be possible.

If this is not used, then closure of the skin alone and a planned repair of the hernia at a later time may be undertaken. A few have reported that the hernia repair can be performed with a simultaneous colon resection as a preplanned operation with an adequately prepared colon. In either case, the injury will not be manifest in the initial hours following the procedure, in most instances. The usual postoperative course of LIVH patients is a rapid discharge from the hospital, usually less than 24 to 48 hours. The complete blood count can be obtained on a daily basis, if necessary. In many cases, the total white blood cell count will be normal, but an increase in the level of immature cells left shift will be an early indication that there might be an unrecognized bowel injury.

Following the LIVH, there should not be any significant accumulation of intraperitoneal fluid. Free air should have been resorbed before the third postoperative day. This can be both diagnostic and therapeutic. If the findings appear benign, then no further therapy is needed. If significant contamination is found, open laparotomy will generally be required with resection of the involved intestine and excision of the prosthesis.

The abdomen could be closed primarily with or without retention sutures. However, if there is a concern of an abdominal compartment syndrome, the prosthesis could be left in place to allow the expansion of the abdomen. The status of the biomaterial should be closely monitored, and sequential removal of this could be electively planned as the condition of the patient stabilizes. Alternatively, a vacuum-assist device can be used over the unclosed abdominal wall. Injury to a solid organ, such as the liver, is not common even in the most complex procedures.

Cautery or a hemostatic agent can be used successfully in nearly every case. The bladder is at risk during pelvic dissection such as in the repair of parapubic hernias. One may fill the bladder with cc of saline that is colored with dye, if desired, and clamp the drainage catheter.

This will provide easy identification of the bladder. If a bladder injury occurs, primary sutured repair with absorbable sutures and drainage with the catheter will be sufficient to treat this problem. This entity is not an entirely unexpected phenomenon given the degree of dissection of the intestine and intraabdominal organs, as well as the surgical hemorrhage that occurs. The concern in the patient with an ileus is the possibility of an unrecognized enterotomy. The risk, of course, is that this is not acknowledged or diagnosed until several days later at which time there is a significant incidence of sepsis and subsequent death.

If there is suspicion of bowel injury, the appropriate workup should be instituted see above. The development of a seroma is so common after this procedure that many surgeons do not believe it to be a real complication. This occurrence should be expected, because the peritoneum within the hernia sac is not removed. The fluid secreted by that surface will result in fluid collection. The disparity between this report and that of the published series is related to the definition of the seroma.

Many authors do not list this as a complication unless this is persistent for greater than 6 weeks. It is virtually impossible to prevent seroma formation with certainty. Kirshtein 32 attempted to pierce the biomaterial with the Veress needle but found that omitting this step did not have any appreciable effect on the incidence of seromas. The use of other biomaterials that are macroporous, such as those that are polypropylene based, does not eliminate the occurrence of these fluid collections either.

Some surgeons have tried to use preemptive measures such as the argon beam coagulator to scarify the peritoneum of the hernia sac. The application of electrocautery and the ultrasonic scalpel with the use of a single suture in the center of the hernia defect to fixate the prosthetic biomaterial has also been used. A prospective randomized study used a central suture in one group of patients and added the application of the energy source in a second group. It is precisely the larger hernias that are most likely to develop notable fluid accumulations postoperatively. There is a potential risk of the excessive application of the electrosurgical energy to the thin area of the hernia itself, which could result in a full-thickness necrosis of the thin subcutaneous tissue and skin.

This could result in slough of the tissue and exposure of the prosthetic biomaterial, which will increase the risk of infection. Therefore, the use of this technique should be carefully chosen. In an effort to inhibit or diminish the development of these known problems, many surgeons will place an abdominal binder on the patient while the patient is still on the operating table. This will be worn for up to 6 weeks postoperatively, depending on the initial size of the protruding hernia. The size of the binder, the length of time that its use is recommended, and whether a bulky dressing is used have not been standardized.

Once the seroma is confirmed, the management of this problem is controversial. Most surgeons believe that these will resolve if given enough time to do so. This will usually occur within 12 weeks. Carbajo 20 aspirated all of the We do not attempt to aspirate seromas unless the patient remains symptomatic for longer than 6 months and there is no ultrasonic evidence of any significant resolution.

Occasionally, if the patient is symptomatic with a noteworthy degree of pain, seroma aspiration will be necessary at an earlier time. One or two aspirations will usually suffice. Aspiration is avoided because bacteria can be introduced into the fluid collection, resulting in an infection. An ultrasonic examination of the fluid collection before aspiration is recommended to ensure that a recurrent hernia is not misdiagnosed as a seroma.

This will avoid an inadvertent puncture of the bowel during the procedure. This test will also identify the presence of a multiloculated fluid collection that will be difficult to aspirate. If this is found, ultrasonically directed aspiration or even incision and drainage would be necessary to adequately treat this seroma. This is rarely necessary, however. A CT scan can also be used to evaluate the hernia sac.

This can be another effective tool to verify whether the content of the former hernia site is a recurrent hernia or a seroma. Interestingly, one study noted that some of the postoperative fluid collections contained air as late as 6 days to 12 days postoperatively. Therefore, clinical and laboratory correlation is of utmost importance. LIVH can be associated with significantly more abdominal pain than the initial laparotomy that eventuated in the incisional hernia.

This is probably based on the use of the fixation devices that are needed to secure the prosthesis to the wall of the abdomen. It is plausible that transfascial sutures will incorporate the subcutaneous nerves as well as the muscle tissue, which increases the degree and persistence of the postoperative pain. Because the average length of the hospital stays of these procedures is approximately 1 day to 2 days, it must be assumed that the acute postoperative pain is quite manageable with oral analgesics.

It can be exacerbated by movement, deep breathing, or coughing. If this type of condition appears to be present, one should first evaluate the hernia site with ultrasonography or CT scanning.

Laparoscopic Hernia Surgery: An operative guide (Arnold Publication) …

This will be needed to affirm that there is no persistent seroma or a recurrent hernia that is actually causing the pain. If none is found, an initial attempt at treatment should be with either nonsteroidal anti-inflammatory agents or a short duration of steroids. This, of course, could be initiated at any point in the evaluation of this problem.

If this does not result in improvement, injection at the site of the complaint with bupivacaine may result in complete resolution of the symptoms. This actually should be done at the outset of this complaint due to its high rate of success. If successful, only 1 injection or 2 injections are usually required. If significant pain persists, laparoscopy may become necessary. It is important to have the patient localize the site of pain while on the operating table to provide direction during the operative procedure.

Adhesions can be lysed and any sutures or tacks at the site of the apparent pain could be cut, or removed, or cut and removed, at that time. While very seldomly required, this is very effective in eliminating the pain in nearly every patient in the experience of these and other authors. The suture can then be excised, but this is usually difficult in patients with a large amount of subcutaneous tissue. Additionally, the suture may have slipped below the initial fascial layer of the abdominal wall, making its location very difficult to identify.

A notable benefit of LIVH is the decrease in the frequency of wound complications. Paul, MN , prophylactic antibiotics, and the choice of a biomaterial that contains an antimicrobial agent. Infections following LIVH can be classified into minor and major infections. Infections that occur at a trocar site or at one of the transfascial suture incisions should usually be of a minor degree. These will usually present as erythema or drainage at one of these locations. This can be successfully managed with local care and parenteral antibiotics providing gram-positive coverage.

If this treatment regimen fails, the possibility of a major infection exists and further workup should be instituted. A major infection directly involves the prosthetic biomaterial. This can present rather subtly in some cases and can manifest itself by drainage from one of the trocar sites. Therefore, lack of a quick favorable response to the above treatment should lead one to evaluate this with a CT scan. A major infection will usually but not always result in leukocytosis, an elevation of the sedimentation rate and C-reactive protein level. If this infection is confirmed, a short-term attempt at parenteral antibiotics with subsequent drainage has been successful in a very limited number of cases.

Not surprisingly, removal of the mesh nearly always results in a recurrence of the hernia. A particularly difficult situation exists in the patient with an infected biomaterial that requires excision who had a very large fascial defect. Once this prosthesis is explanted, an attempt to repair this with a primary tissue repair is fraught with failure due to the large size of the hernia and the tension that results.

Laparoscopic Hernia Surgery An operative guide Arnold Publication

Additionally, a tissue repair will predispose the patient to a significant risk of pulmonary complications due to the results of the excision of the biomaterial and the repair of the hernia. Two options are anecdotally reported in this situation. If the patient is not septic, one may elect to excise the central portion of the patch sequentially. The remaining material will then be sewn together to reapproximate the prosthesis. The patient will then be returned to the operating room several days later usually 2 to 5 days for another partial excision of the central portion of the patch.

During that time, local wound care, dressing changes, or vacuum-assisted treatment and parenteral antibiotics will be continued. Usually, within 2 weeks to 3 weeks, the fascial edges will be approximated enough so that a primary sutured repair can be accomplished without the concern of an abdominal compartment syndrome. There is still a high risk of recurrence, but this may be lower and less uncertain than an initial closure of the infected hernia defect.

At the time of the reapproximation of the fascial defect, one may use either a collagen-based mesh as an underlay or a polypropylene product as an onlay or both to bolster the strength of the repair. These biomaterials have been successfully used in infected fields. An alternative to the above is the closure of the midline after the mesh has been excised with the use of a component separation technique. In that procedure, the external oblique aponeurosis is cut, allowing the rectus sheath to slide medially, and generally primary closure of the midline can be successfully accomplished. This can be under some tension so that some authors will add the use of collagen-based or synthetic biomaterials, or both unpublished data.

Laparoscopic Hernia Surgery: An Operative Guide (Arnold Publication). Karl A. LeBlanc

Finally, it is important for the surgeon to be aware that there is an appearance of the skin overlying the hernia defect that is normal, despite the fact that there is significant erythema. This can appear after several days following the operation Figure 1. This condition has not been adequately described in the literature but can be a source of significant concern due to the suspicion that an infection exists or is developing.

This condition is unassociated with fever, pain, or leukocytosis. This does not require treatment and will usually resolve in 4 weeks to 6 weeks. However, it can persist for several months in extreme cases. If there is concern of an infection, early use of imaging modalities and laboratory testing is recommended. This is an uncommon event following LIVH. A patient with this condition may exhibit the signs and symptoms of an ileus, obstruction, or an acute surgical abdomen. Diagnosis and treatment must be both rapid and accurate.

As noted above, a significant number of patients will develop an ileus that will usually resolve with conservative management. Those who do not should be investigated further to rule out a true obstruction or a missed enterotomy. The usual radiologic tests may normally be adequate, but one should be swift to obtain a CT scan to investigate the appearance of the entire abdominal cavity.

This may be the only test that will reveal fluid-filled distended loops of small intestine, air fluid levels or significant free air in the abdominal cavity. This complication has been reported in only a few series but has ranged from 0. Although the exact distance of the placement of the fixation devices was not stated, one might infer that these devices were too far apart to prevent this complication. This reiterates the recommendation that transfascial sutures should be placed no more than 5cm apart, and the additional tacks or constructs should be placed at 1-cm to 1.

In one of these cases, an associated colonic erosion was present due to a polypropylene mesh that was inserted 23 months prior to the event. If there is no indication of a bowel injury or the presence of gangrenous obstruction, nasogastric suction and hydration are reasonable treatments. If the condition of the patient deteriorates, surgical intervention will be necessary. Either laparoscopy or laparotomy could be used to access the abdominal cavity and deal with the problem in the required manner.

If the patient has ascites from hepatic or renal disease, the entry into the abdominal cavity should attempt to minimize the leakage of this fluid from the abdomen. One should try to locate the trocars in the upper abdomen, if possible. This is rarely a problem that requires intervention, but if this is necessary then sutured closure of the offending site via an open approach is the most reasonable method in which to manage the complication.

The current cumulative recurrence rate of the laparoscopic repair in the published literature is approximately 4. It should be acknowledged that these series are obtained with a follow-up that usually is only about 3 years, but this is the time frame in which most recurrences are seen with both the open and laparoscopic repairs. Based on this experience, the use of 2 methods of fixation that include sutures is an integral part of the procedure in all patients.


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At least 6 publications have compared the open and the laparoscopic repair. In all but one of these comparison studies, the laparoscopic repair was associated with a lower rate of recurrence. That series represented the early experience of the surgeons. Another study compared the open repair with and without the use of a mesh prosthesis, and the laparoscopic repair. A summary of several large series that all have more than patients is shown in Table 4.

In our own series, we noted that the lack of transfascial sutures, the use of too small a prosthesis, or infection lead to a recurrence. The second patients in our series had recurrences that were due to different causes than the first , usually infections that required excision of the prosthesis. Two other recurrences in the latter group were due to a suture fracture or a new hernia that appeared below the prior repair. As shown in this table, the average recurrence was still an acceptable 4.

The avoidance of the development of a recurrent hernia should be the goal of all surgeons. Even in this procedure, this has not been achieved, nor is it expected to eliminate any recurrence. Some factors, such as advanced age, obesity, pulmonary or hepatic insufficiency, and steroid use cannot be avoided. However, the surgeon can address some issues to minimize the risk of recurrence, such as provision of adequate exposure of the defect so that all of the prosthetic biomaterial contacts fascia rather than preperitoneal fat.

The interposition of adipose tissue will impede the ingrowth process and predispose to a recurrence. Whatever biomaterial is used, it must overlap the defect by a minimum of 3cm. This distance has been shown to decrease the recurrence rate. The larger overlap is preferred in the hernias that are located very high or very low on the abdominal wall, very large hernias, and in significantly obese individuals. This large overlap of the biomaterial reduces tension on the repair, which will assist in the prevention of recurrence. Additionally, the more difficult areas of fixation, such as those mentioned above, would benefit from a larger surface area to allow ingrowth of fibroblasts and collagen and to allow for the contraction of the tissues that could result in a decrease in the surface area of the product.

It is also recommended to place a large enough piece of biomaterial so that as much of the incision that developed the hernia is covered to prevent the development of a later hernia above or below the current repair. One of the most critical aspects of this repair is the assurance that the biomaterial is adequately fixed to the abdominal wall to ensure an effective repair. This fixation should include transfascial sutures. As noted earlier, we demonstrated the effectiveness of this technique in our first patients by eliminating a recurrence with an average follow-up of 51 months in these patients.

Our preference is to place these sutures at no more than 5cm apart along the periphery of the patch using a suture-passing instrument. Others place these 4cm to 6cm apart. Not all authors share the view that there is a need for these transfascial sutures. Berger et al 18 use sutures merely to position the prosthesis and do not tie them. They believe that sutures increase postoperative pain.

Their recurrence rate was only 2. Twenty-seven of the patients were subsequently excluded from the study for various reasons or were lost to follow-up. Thus, entered the analysis phase of the trial Fig. Values in parentheses are numbers of patients. Because the DC mesh-fixation method uses an extra circle of tacks, repairs in which this technique was employed required significantly more tacks than were necessary in either AS or NS procedures.

Operative and postoperative characteristics, according to mesh-fixation group a. The scores in the three groups were similar at all times, as was the extent of change in scores. A separate analysis of the VAS scores in the DC group found no significant correlation between the number of tacks used and postoperative pain correlation coefficient 0. Because the number of TAS used was predominantly eight, no statistical analysis could be performed on the relation between TAS and postoperative pain. VAS scores for pain at various assessment times, according to mesh-fixation group a.

The patient who was readmitted to hospital after surgery required help in performing activities of daily living. Five patients in the study one each in the AS and DC groups and three in the NS group required reoperation for chronic pain that did not resolve with conservative treatment. Two of the patients with mesh removal and one with TAS removal became symptom free.

The two other patients, one with non-absorbable sutures and one with double-crown fixation, remain with pain symptoms. Complications of surgery and Dindo complication grade, according to mesh-fixation group a. During the 3-month follow-up period in the study, no patient had hernia recurrence. Secure fixation of the mesh and adequate overlap of all hernia margins with the prosthetic material are crucial to the success of LVIHR. However, fixation of the mesh to the abdominal wall also appears to be the most important source of postoperative pain.

The importance of this problem was indicated by the recent study of Eriksen et al.


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As is the case with mesh repair of inguinal hernias, an increasing number of clinicians and researchers now consider postoperative pain, rather than recurrence, the most important adverse effect of LVIHR. The finding that injections of local anaesthetics at TAS sites frequently result in pain resolution [ 9 ] supports this assumption. However, Carbajo et al. Bageacu et al. Both a review by LeBlanc [ 18 ] and a case-controlled study by Nguyen et al. The aim of the current randomized trial was to provide more reliable data on the relation between pain after LVIHR and the method used to fix the mesh.

The only significant difference among the groups was that operating time was shorter in the DC group compared with the AS group, probably because it takes longer to place TAS around the perimeter of the mesh than to insert a second circle of tacks [ 20 ]. Our results indicate that the most commonly used methods to secure the mesh during LVIHR have a similar association with postoperative pain and that none of these techniques can be considered to have a pain-reduction advantage over the others.

In addition, only minimal intergroup differences in postoperative QoL measures were observed. It is possible that the use of DC and NS mesh fixation in LVIHR provides mesh fixation that is more secure than is necessary to prevent recurrence, while increasing the risk of postoperative pain. Therefore, in this study, we also included a group of patients in whom absorbable TAS were employed to affix the mesh, speculating that, if postoperative pain is due to the presence of a permanent mesh-fixation device, the potential for such pain might decrease over time in patients in whom an absorbable material is used instead.

These results are similar to those in a previous study that failed to detect any significant difference between mesh fixation using absorbable TAS and fixation using nonabsorbable TAS with regard to postoperative pain after Lichtenstein inguinal hernia repair [ 21 ]. To minimize systematic and random errors, we analyzed only two outcomes: postoperative pain and QoL. To reduce the number of prognostic variables, the same type of mesh, tacks and nonabsorbable or absorbable TAS were used in all operative procedures, which were performed by one of two experienced surgeons, who used a standardized technique.

This protocol made introduction of performance bias unlikely. Certain modifications to the LVIHR procedure have potential to influence the severity of postoperative pain. For example, closing the hernia defect before placement of the mesh has been proposed. However, most surgeons including us do not close the defect. Probably they assume, as we do, that the resulting traction may contribute to the onset or severity of postoperative pain. Moreover, in two large case series in which defect closure was performed, the rates of chronic pain 2. Some recent research has focused on new, possibly less pain-inducing, mesh-fixation techniques.

Olmi et al.

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In a randomized controlled trial in pigs, Eriksen et al. Substantial additional research is required to ascertain whether the use of such techniques will decrease the rate or severity of pain after LVIHR while resulting in the same low recurrence rate. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author s and source are credited. National Center for Biotechnology Information , U. Surgical Endoscopy. Surg Endosc. Published online Dec Author information Article notes Copyright and License information Disclaimer.

Eelco Wassenaar, Email: ude. Corresponding author. Received May 18; Accepted Oct This article has been cited by other articles in PMC. Abstract Background Persistent, activity-limiting pain after laparoscopic ventral or incisional hernia repair LVIHR appears to be related to fixation of the implanted mesh. Methods A total of patients undergoing non-urgent LVIHR in our unit between August and July were randomly assigned to one of three mesh-fixation groups: absorbable sutures AS with tacks; double crown DC , which involved two circles of tacks and no sutures; and nonabsorbable sutures NS with tacks.

Conclusion In this trial, the three mesh-fixation methods were associated with similar postoperative pain and QoL findings. Methods Patients The protocol for this study was approved by the ethics committee of Medisch Spectrum Twente Enschede, The Netherlands and the local ethics committee.

PDF Laparoscopic Hernia Surgery: An operative guide (Arnold Publication) {Free Books|Online

Operative techniques All patients were given low-molecular-weight heparin subcutaneously to provide prophylaxis for thrombosis, and all were placed under general anaesthesia for operation. Results A total of patients met the inclusion criteria and were initially randomly assigned to one of the three mesh-fixation groups. Open in a separate window. Complication Mesh-fixation group No. AS absorbable sutures, DC double crown, NS nonabsorbable sutures a Values are numbers of patients unless otherwise indicated b Twenty-nine complications were observed in the study complication rate, Discussion Secure fixation of the mesh and adequate overlap of all hernia margins with the prosthetic material are crucial to the success of LVIHR.

References 1. Laparoscopic incisional hernia repair: a review of the literature. Am J Surg. Laparoscopic ventral hernia repair: a systematic review. Laparoscopic ventral and incisional hernia repair: an year experience. Recurrences after laparoscopic repair of ventral and incisional hernia: lessons learned from repairs.

Laparoscopic repair of recurrent ventral hernias. Am Surg. Complications and their management. In: LeBlanc KA, editor. Laparoscopic hernia surgery: an operative guide.