Laparoscopy Today

Postoperative Pain After Laparoscopic Ventral Hernia Repair: a Prospective Comparison of Sutures Versus Tacks

PICK FROM JSLS, JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS

SCOTT Q. NGUYEN, MD, CELIA M. DIVINO, MD, KERRI E. BUCH, FNP, JESSICA SCHNUR, MD, KAARE J. WEBER, MD, L. BRIAN KATZ, MD, MARK A. REINER, MD, ROBERT A. ALDOROTY, MD, DANIEL M. HERRON, MD

INTRODUCTION

Laparoscopic ventral hernia repair has grown in popularity since it was first reported in the early 1990s. Numerous studies have found it to have many advantages over traditional open repair [1-3]. Lower recurrence rates, fewer complications, and shorter hospital stays have led some to believe that it sets the new standard of care for ventral hernia repair [1,2]. Controversy exists regarding the optimal method to fix the prosthetic mesh to the anterior abdominal wall. Currently, the 2 most popular methods of mesh fixation are via transabdominal sutures and laparoscopic tacks. Sutures pass through all layers of the fascia and muscle of the anterior abdominal wall, while tacks secure the mesh to the innermost millimeters of the peritoneal cavity.

Most controversy in laparoscopic repair centers on the tensile strength of the mesh fixation method. Recurrence is thought to be the result of inadequate or failed fixation. Postoperative pain produced by the securing methods is another consideration in deciding between sutures and tacks. Sutures are felt to cause worse and more persistent pain [3,4].  However, no comparative studies investigate which method truly causes more discomfort. This study compares these 2 methods and examines the consequential pain that occurs after each type of fixation.

METHODS

From 2004 through 2006, patients undergoing laparoscopic ventral hernia repair by 8 different surgeons at the Mount Sinai Medical Center were prospectively enrolled in the study. Patients undergoing other simultaneous procedures were excluded. The patients were sorted into 2 groups: (1) those undergoing hernia repairs primarily with transabdominal sutures (Sutures Group) and (2) those undergoing hernia repairs primarily with tacks (Tacks Group). Patients in the Sutures Group had repairs with transabdominal sutures placed circumferentially approximately 2 cm to 3 cm apart. These patients typically had 10 to 20 sutures placed, depending on the size of hernia. Patients in the Tacks Group included those with hernias completely repaired with only tacks and repairs that may have involved 4 stay sutures with the rest of the mesh secured to the anterior abdominal wall with tacks. The patients were not randomized into these groups. Choice of repair was made by surgeon preference, including type of mesh and type of tacks.
Patients’ demographics and clinical data were prospectively recorded. Telephone follow-up was used to determine verbal pain scores at 1 week, 1 month, and 2 to 3 months postoperatively (0=pain free, 10=excruciating pain/worse pain ever). In addition, patients were asked regarding time to return to work and need for narcotic pain medications. Informed consent was obtained, and this study was approved by the institutional review board. We needed to enroll 50 patients into the study to detect a 50% difference in pain scores (Power 80%, Level of significance P=0.05).

RESULTS

Fifty patients were enrolled in this study. Twenty-nine were in the Sutures Group and 21 in the Tacks Group. Demographics and clinical characteristics of the 2 groups are outlined in Table 1. Both groups were of similar age and body mass index (BMI). More females were in the Sutures Group. No significant difference was found between the groups in terms of proportion of patients with recurrent hernias, multiple hernia defects, and total defect size. The type of mesh used was surgeon dependent and was variable across both groups.

Table 2 shows the operative and postoperative characteristics of the 2 groups. Both groups were similar in operative time. The Tacks Group had a longer length of postoperative hospital stay (2.4 vs 1.7 days); however, this difference was not statistically significant. There was no early recurrence during the follow-up period. The Tacks Group had a higher morbidity rate (19% vs 4%). The most common complications between the 2 groups were pneumonia and urinary retention.

Verbal pain scores as reported via telephone interview are shown in Figure 1. No difference was reported in mean pain scores between the 2 groups at 1 week, 1 month, and 3 months (P>0.05). On a scale of 0 to 10, patients from both groups had moderate pain 1 week after the operation. Pain scores in both groups decreased at 1 month and were minimal by 2 to 3 months. In addition, use of narcotic pain medications during the postoperative period was similar in both groups (Table 3). A similar proportion of both groups required such pain medications at 1 week. Time to return to work was also similar between the groups. No patients required local anesthetic injection for chronic, persistent pain in either group.

DISCUSSION

The preferred method of mesh fixation during laparoscopic ventral hernia is controversial. Many proponents of the use of transabdominal sutures cite lower recurrence rates due to higher tensile holding strengths of sutures in comparison to tacks [5,6]. Other authors [6-8] argue that the use of tacks reduces surgical time considerably while maintaining similar recurrence rates. These authors also argue that the use of tacks significantly reduces postoperative pain. To date, most studies of mesh fixation during laparoscopic ventral hernia repair focus on the risk of recurrence. However, this is the only study that compares postoperative pain after hernia repair with sutures versus tacks.

Anecdotally, pain is generally worse after repair with sutures than with tacks. Sutures penetrate through the full thickness of abdominal wall musculature and fascia. This has been theorized to cause local muscle ischemia resulting in severe pain postoperatively [7]. In addition, numerous sutures are typically needed around the perimeter of the hernia defect. Because mesh overlap on normal muscular fascia is usually aimed for around 3 cm to 5 cm, the circumference around which sutures must be secured becomes quite large. We found no difference in postoperative pain in patients undergoing hernia repair with sutures or tacks. Both groups had moderate pain at one week and minimal pain on further follow-up. It is possible that early pain caused by multiple tacks penetrating the parietal peritoneum is equivalent to the pain caused by transfascial sutures. In the long-term, both repairs seem to level off in terms of discomfort.

Cobb et al [12] has also proposed that intercostal nerves may become entrapped within the transabdominal sutures causing chronic, persistent neuropathic pain. Series of repairs using transfascial sutures report persistent pain and discomfort in 1% to 6% of patients [1-3,8,9]. Most authors feel oral anti-inflammatory medications or injections of a local anesthetic can alleviate the symptoms in the majority of cases [1,3,10,11]. Others have reported re-explorations for persistent pain, finding immediate relief after the release of a suture from the site of symptoms [12]. None of the patients in our study had persistent pain severe enough to undergo local anesthetic injection or reoperation. The reports of persistent cases of pain seem to be isolated at one particular suture site, supporting the nerve entrapment theory. Pain from muscle ischemia would seem to be more generalized at all of the suture sites. Our data suggest that both methods of mesh fixation are generally not different in terms of their resultant postoperative pain. However, because our study only included 50 patients, occasional episodes of chronic persistent pain due to nerve entrapment are certainly possible if more patients were followed. Our findings are somewhat consistent with those of LeBlanc et al, [17] whose study noted that patients in the earlier half of their series had more pain. These patients had fewer sutures used, suggesting the use of these sutures was unrelated to postoperative pain.

Though the use of laparoscopic tackers may seem to be simpler and faster, we did not find a significant difference in operative time between the 2 fixation methods. This is contrary to the general opinion that the use of tacks reduces surgical time [1,4]. Operative time during laparoscopic ventral hernia repair significantly involves extensive adhesiolysis and dissection of peritoneal contents from the anterior abdominal wall. Conceivably, surgeons may misinterpret the amount of time spent on the different phases of the operation and focus on time spent on mesh fixation. In our study, we did not specifically look at operative time during different components of the operation. Moreover, no other prospective studies compare operative time in laparoscopic ventral hernia repair. Therefore, the assumption that repair with transabdominal sutures takes longer than tack repair remains largely unproven.

The limitations of this study center on the sample size. Fifty patients were followed, and comparisons were made between the 2 groups. Small differences in pain scale between the groups may be difficult to assess. However, large differences should be found. Considering that most anecdotal evidence suggests a large difference in pain experience, we feel our conclusions are still valid. In addition, although data were prospectively recorded, the patients in this study were not randomized to treatment arms. The type of repair was based on surgeon preference, as each had his or her own strong feeling regarding the best method of fixation. Larger controlled trials may be necessary to optimally determine which method contributes to the most pain.

CONCLUSION

Patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experience similar overall postoperative pain. Symptoms are moderate by the end of the first postoperative week and mild by 1 month. Occasional episodes of chronic, persistent suture site pain are possible and have been reported. Postoperative pain should be a minor factor when deciding between repair with sutures or tacks in laparoscopic ventral hernia repair.

Figure 1.  Mean postoperative pain scores at 1 week, 1 month, and 2 to 3 months after laparoscopic ventral hernia repair. No difference in pain score existed between groups (P>0.05, 2-tailed Student t test).

Reprinted from JSLS, Journal of the Society of Laparoendoscopic Surgeons. 2008;12(2):113-116.

Department of Surgery, Mount Sinai School of Medicine, New York, New York, USA (all authors).

Correspondence: Celia Divino, MD, Department of Surgery, Mount Sinai School of Medicine, 5 E 98th St, Box 1259, 15th Floor, New York, NY 10029, USA. Telephone: 212 241 6509, Fax: 212 410 0111, E-mail: celia.divino@mountsinai.org

References

1.  McGreevy JM, Goodney PP, Birkmeyer CM, Finlayson SRG, Laycock WS, Birkmeyer JD.   A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs.  Surg Endosc.  2003;17:1778-1780.

2.  DeMaria EJ, Moss JM, Sugerman HJ.  Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia.  Surg Endosc.  2000;14:326-329.

3. Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13:250-252.

4. Heniford B, Park A, Ramshaw BJ, Voller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg. 2000;190:645-650.

5. Eid GM, Prince JM, Mattar SG, Hamad G, Ikrammudin SI, Schauer PR. Medium-term follow-up confirms the safety and durability of laparoscopic ventral hernia repair with PTFE. Surgery.  2003;143:599-604.

6. Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic approach to incisional hernia. Lessons learned from 270 patients over 8 years. Surg Endosc. 2003;17:118-122.

7. Gillian GK, Geis WP, Grover G. Laparoscopic incisional and ventral hernia repair (LIVH): an evolving outpatient technique. JSLS. 2002;6:315-322.

8. Berger D, Bientzle M, Muller A. Postoperative complications after laparoscopic incisional hernia repair. Surg Endosc.  2002;16:1720-1723.

9. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias. Nine years’ experience with 850 consecutive hernias. Ann Surg.  2003;238:391-400.

10. van’t Riet M, van Steenwijk PJ, Kleinrensink GJ, Steyerberg EW, Bonjer HJ. Tensile strength of mesh fixation methods in laparoscopic incisional hernia repair. Surg Endosc. 2002;16:1713-1716.

11. Franklin ME, Gonzalez Jr JJ, Glass JL, Manjarrez A. Laparoscopic ventral and incisional hernia repair:  An 11-year experience. Hernia.  2004;8:23-27.

12.  Cobb WS, Kercher KW, Heniford BT. Laparoscopic repair of incisional hernias. Surg Clin N Am. 2005;85:91-103.

13. Parker 3rd HH, Nottingham JM, Byone RP, Yost MJ. Laparoscopic repair of large incisional hernias.  Am Surg.  2002;68:530-533.

14. Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience with the “four-before” laparoscopic ventral hernia repair. Am Surg. 2002;66:465-468.

15. LeBlanc KA, Whitaker JM. Management of chronic postoperative pain following incisional hernia repair with Composix mesh:  a report of two cases. Hernia.  2002;6:194-197.

16. Carbonell AM, Harold KL, Mahmutovic AJ, et al. Local injection for the treatment of suture site pain after laparoscopic ventral hernia repair. Am Surg. 2003;69:688-691.

17. LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK. Laparoscopic incisional and ventral hernioplasty:  lessons learned from 200 patients. Hernia. 2003;7:118.

Enterotomy and Mortality Rates of Laparoscopic Incisional and Ventral Hernia Repair: a Review of the Literature

PICK FROM JSLS, JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS

KARL ANDREW LEBLANC, MD, MBA, MELVIN JOSEPTH ELIESON, MD, JAMES M. CORDER III, MD

INTRODUCTION

The use of the laparoscopic technique to repair incisional and ventral hernias (LIVH) has increased significantly throughout the world. The outcomes of LIVH repair have generally been shown to be superior to the open method of hernia repair. This is particularly true of open hernia repairs performed without mesh. As with all surgical interventions, certain risks can be disastrous if they occur. One such associated disaster is that of an enterotomy. The incidence of this complication has been reported to be from 0% to 14%. The current published data were reviewed to determine the incidence of enterotomy during laparoscopic incisional and ventral hernia repair and its associated mortality rate.

Little has been published to date to aid in the decision-making process when bowel injury occurs during LVIH repair. The rational concern of placing a prosthetic biomaterial into a contaminated field following bowel injury leads many surgeons to perform a compromised operation–opting to perform an open primary sutured hernia repair that has a significantly higher recurrence rate to avoid the risk of having an infected prosthetic biomaterial with its associated sequelae. The current published literature was also reviewed to ascertain the experience of surgeons and the results encountered when an enterotomy occurred.

METHODS

A literature search was conducted using the PubMed and Medline indices. Articles that involved laparoscopic incisional and ventral hernia repair were identified. Of those identified, case series with more than 50 patients in a series were included. Studies that compared open and laparoscopic techniques were also included to determine whether a true difference existed in the rates of bowel injury between the 2 approaches. Only the most recent article of any single author was included if it appeared that the series was reported earlier with the same patient cohorts. Retrospective, prospective, and randomized studies were all evaluated with the same methodology.

For the purposes of this research, an enterotomy was defined as a transmural injury that required suture closure, either laparoscopically or via a laparotomy. Nonsignificant serosal injuries were not considered an enterotomy for this study. An analysis was made to address the total number of patients who actually underwent the laparoscopic operation, including those who were converted to an open operation if an enterotomy occurred. Those who were converted for some other reason were not included in the totals to obtain a more accurate determination of the true incidence of this event. These were then divided into those that were recognized and those that were missed at the original operation. The repair of both the enterotomy and the hernia was also evaluated. Finally, the mortality related to the operation itself was recorded.

RESULTS

The results as shown in Table 1 [1-34] and include all studies that were identified as defined above. The comparative series are relatively easily identified from those of Holzman [22] and those that follow his series in Table 1. These generally had a smaller patient sample than the series preceding them. It is interesting to note that of the 21 published noncomparative series, only 5 of them reported no enterotomies. Only 2 of these 5 had an experience that exceeded 100 patients. The 13 comparative series, in contrast, had 6 series that experienced an enterotomy. It should be noted that the average number of patients included in these latter comparative series was only 39 patients.

The incidence of incidental enterotomy in 3925 laparoscopic incisional and ventral hernia repairs was determined to be 1.78%. It was further determined that 82% of these injuries will be noted at the time of the operation, representing an incidence of 1.50% of the total number of patients. The more critical fact is that an enterotomy will not be recognized 18% of the time that it occurs. The overall incidence of unrecognized enterotomy is 0.33% in over 3900 patients. Unfortunately, this devastating complication (recognized or unrecognized) will result in the death of 2.8% of patients in which it occurs. It is somewhat reassuring to note, however, that the overall mortality of this procedure is only 0.05% in these series. Given the fact that many of these patients have had multiple prior procedures and comorbidities, this is a very low rate.

The management of recognized enterotomies and the method of hernia repair following the recognition of an enterotomy were also examined (Table 2) [2,3,5,7-10,12,13,15-17,20,22,24,29,30]. Several of the articles were unclear as to the management of enterotomies (ie, conversion to laparotomy or laparoscopic repair) or the method of hernia repair following enterotomy. Therefore, Table 2 lists only those studies in which these could be determined. It is somewhat surprising that only 43% of the cases listed in Table 2 were converted to an open method to facilitate repair of the intestinal injury. The subsequent method of hernia repair was not always influenced by a conversion to a laparotomy. In 3 instances, an intestinal injury was repaired with the open method, then the intestine was returned to the abdominal cavity and the hernia was repaired laparoscopically as planned either immediately or after an interval delay [7,10,17].

A frequent factor used to determine whether to proceed with repair of the hernia with a laparoscopically placed prosthesis following bowel injury was the presence or absence of gross spillage of intestinal contents. If there was minimal to no contamination, the hernia repair was performed as planned [5,15,20,24]. Large bowel injury represented 6/72 or 8.3% of these intestinal injuries. Of these 6 colonic injuries, 4 of these were repaired primarily, and the hernia repair was completed as planned [10,12]. One of the 2 other colonic injuries was converted to laparotomy for repair of the colotomy and hernia [17]. The sixth injury was unrecognized initially and was later treated with laparotomy, ileostomy, and patch removal with primary hernia repair (this hernia repair later failed in the follow-up period) [13].

Definitive laparoscopic hernia repair, following repair of enterotomy (whether repaired laparoscopically or open) was delayed 16% of the time. Most commonly, this delay was between 3 days to14 days, although it was as long as several months in a few instances. None of the articles offered evidence to support the interval of time delayed before hernia repair.

The unrecognized enterotomy is the most problematic event during this procedure. As noted earlier, this will occur in 18% of these injuries, representing an incidence of 0.33% in total number of patients at risk (Table 1). The detection of this complication can be difficult, but it is usually noted on either the first or second postoperative day and based upon clinical suspicion, sometimes tachycardia alone. Occasionally, a computed tomographic (CT) scan was used to confirm the diagnosis [21]. Generally, not unexpectedly, the management was laparotomy, repair of the injury, and removal of the prosthetic biomaterial [6,9,13,17,21,24,30]. Even immediate recognition of a bowel injury and prompt repair during the initial operation did not always prevent further problems. Two series (ie, Berger and Ramshaw) had one patient each who required reoperation because the initial repair performed at the time of the hernia repair became insecure and subsequently leaked intestinal contents into the abdominal cavity. Both repairs were performed laparoscopically during the original hernia repair [10,24].

The comparison studies revealed enterotomies in both the open and laparoscopic patients (Table 3). As in Table 2, only those series that incurred an injury are listed. The numbers in the individual cells of the table indicate whether the enterotomy occurred via the open method and whether it was recognized or not. In other words, Holzman had only one enterotomy. This occurred in the laparoscopic group, therefore under “lap” and “recognized” the “1/1” indicates that he only had one and it was recognized. Under “lap” and “unrecognized”, the “0/1” indicates that zero of the one enterotomies were unrecognized. He did not have a recognized or unrecognized enterotomy in the open group; therefore, “0/0” is indicated for each. The other series follow this same pattern. Overall, in these comparative series, the incidence of recognized enterotomy was 1.0% for the open procedure and 1.9% for the laparoscopic method. The unrecognized injuries occurred in 0.2% and 0.9% of the cases, respectively. As shown in the table, little difference existed in the percentage of enterotomies that were recognized and unrecognized in all of the comparative series based on the method of repair (eg, 83% vs 67% and 17% vs 33%). There were more in the laparoscopic group, but there was no statistical difference between the incidence of either the recognized or the unrecognized injuries between these 2 methods (P=0.44, Fisher’s exact test). The only death in these series, however, occurred following an unrecognized laparoscopic enterotomy [30].   

DISCUSSION

The original intent of this literature review was to establish the true incidence of enterotomy and its associated outcomes during the laparoscopic repair of incisional and ventral hernias. As shown in the data, this occurred in 1.78% of 3925 cases. Surgeon experience did not influence the rate of enterotomy, as expected. Some of the smaller series had the lowest rate of enterotomy. This would indicate that the statistical probability of enterotomy increases with larger numbers of patients. This inversely proportional complication rate with surgeon experience might be due in part to the fact that the more experienced surgeons will likely attempt to manage more difficult patients thereby increasing the risk of this occurrence. The comparative series had relatively more enterotomies. This is likely due to the fact that these were early in the experience of the surgeons. Therefore, not surprisingly, inexperience probably plays a significant role in this complication as well. Consequently, surgeon experience may play a role in these procedures in the early stages of the learning curve but may not be as important with greater numbers of cases as these will undoubtedly be more difficult. In other words, this risk is always present and unavoidable but for potentially different reasons.

As anticipated, the small bowel proved to be the most frequently affected organ and was the site of injury 92% of the time. The method chosen to repair either the colon or small intestine was generally determined by the extent of the injury and the skill level of the surgeon. If one were proficient in performing a laparoscopic repair of the affected organ, then proceeding laparoscopically would be prudent. If not, then the obvious course should be to perform a laparotomy to repair the injury. Regardless of the method of enterotomy repair, only 2 patients in a single series had any adverse outcomes subsequent to concomitant laparoscopic hernia repair [10]. However, in both of these patients, the subsequent complications were not related to proceeding with repair of the hernia. Rather, one repair leaked postoperatively and the other was repaired open but had a second unrecognized injury to the small intestine that was initially missed laparoscopically and still missed following conversion to open. Therefore, if an enterotomy is recognized, either colonic or small bowel, and a sound repair can be effected either open or laparoscopically, these data suggest that the prosthetic repair of the hernia can safely proceed as intended. This, of course, would be contingent on the lack of any significant contamination. However, the small number of cases in these series makes such a firm statement difficult. Caution must be exercised if this course of action is taken. On the other hand, if significant contamination does exist, the repair can either be performed by the open tissue repair method at the initial operation or laparoscopically with the placement of a prosthetic biomaterial after delaying for several days. No scientific basis has been offered for the chosen number of days delayed before hernia repair following enterotomy with contamination. The usual time frame reported was generally within one week. The patient should probably be maintained on antibiotics during that time; however, there was only brief discussion regarding this recommendation in the literature [17]. We have preferred to wait just 3 days to 4 days to return to the operating theater to avoid the development of dense intestinal adhesions. In the few cases that this has been done, no adverse sequelae developed.

Most active laparoscopic surgeons hold the opinion that a colonic injury poses a threat of infection too great to proceed with placement of a prosthetic biomaterial to repair the hernia. However, in those series in which a recognized colonic injury occurred, some were repaired primarily with concomitant hernia repair as planned [10,12,17]. Others, however, chose to repair the colonic injury and performed either a primary tissue repair or a delayed laparoscopic repair of the hernia [16,17]. Based on these data, it may be permissible to repair the hernia with a prosthesis even in the presence of a colonic injury if an antimicrobial-impregnated prosthesis is used. However, as with small intestinal injuries, one must be certain that no contamination exists. But as noted earlier, more study in this area is warranted before any strong recommendations can be made regarding this approach, because only a small number of these patients heretofore have been reported.

Of the 34 intestinal repairs performed in association with a prosthetic hernia repair, whether repaired open or laparoscopically, only 2 patients experienced adverse consequences (Tables 2 and 3 ) [10,24]. Although even one anastomotic failure might be considered too many, it is somewhat comforting that a failure rate of 6%, as seen in these case series is within the range of expectation of such an intestinal repair. Unfortunately, one of these injuries resulted in the death of the patient [10]. There were, however, no adverse consequences (ie, mesh infection) related to concomitant hernia repair with a prosthetic biomaterial in any patient.

The only other death in these series was the result of an unrecognized enterotomy [30]. The causes of both deaths in these series were similar in that both patients experienced leakage of bowel content postoperatively. It can be said that the major cause of death following this procedure will be a consequence of enterotomy, whether it be colonic or small intestine, recognized or unrecognized. The mortality rate of this procedure (0.05%) is quite near that of other laparoscopic procedures, such as cholecystectomy. However, when an enterotomy does occur, the mortality increases to 2.8%. The mortality of a recognized enterotomy is 1.7% (1/59); however, the mortality rate of an unrecognized enterotomy is 7.7% (1/13), 4 and 1/2 times higher. Although this injury cannot be avoided in all cases, the surgeon should perform an inspection of the intestine and abdominal cavity following adhesiolysis and again upon completion of the herniorrhaphy in an effort to identify any missed injuries.

The comparative series did show that enterotomy will occur with both techniques and that some will be missed even with the open method. In these series, the only mortality was in the laparoscopic group. Due to the low rate of this event, a larger number of patients is needed to draw a firm conclusion as to the difference in the death rates between these 2 techniques.

We would be remiss if we did not acknowledge the fact that there are probably a few, or possibly, many deaths that are unreported subsequent to an unrecognized enterotomy during this procedure. There are undoubtedly numerous surgeons with varying degrees of experience that have not reported their personal series in the literature. Therefore, the true rate of enterotomy and mortality probably exists at a higher level than this literature review reports. The results of this analysis should serve to provide the reader with a synopsis of the currently published data upon which to base surgical decision-making. Although careful technique will not avoid all complications, vigilance and early identification of unrecognized enterotomies will minimize fatal results.

A thorough review of the current literature has revealed that the occurrence of an injury to the intestine during laparoscopic incisional and ventral hernia stands at 1.78%. Should this occur, the hernia repair could be completed laparoscopically (or open) with the use of a prosthetic biomaterial. The use of an antimicrobial impregnated product and systemic antibiotics is recommended. The overall mortality of patients undergoing this procedure is 0.05%. If an enterotomy occurs, the mortality increases to 2.8%. A recognized enterotomy is associated with a mortality rate of 1.7%, but an unrecognized enterotomy is associated with a rate of 7.7%. As always, careful and skillful technique should be performed. Despite excellent surgical skill, vast experience, and careful dissection, laparoscopic incisional and ventral hernia repair carries with it the risk of morbidity and mortality.

Reprinted from JSLS, Journal of the Society of Laparoendoscopic Surgeons. 2007;11(4):408–414.

Minimally Invasive Surgery Institute, Baton Rouge, Louisiana, USA (all authors).

Correspondence: Karl A. LeBlanc, MD, MBA, FACS, Director, Minimally Invasive Surgery Institute, Baton Rouge, LA, and Clinical Associate Professor, Surgery, Louisiana State University School of Medicine, New Orleans, LA, 7777 Hennessy Blvd, Ste 612, Baton Rouge, LA 70808, USA. Telephone: 225 769 5656, Fax: 225 766 6996, E-mail: docmba2@aol.com.

References

1.    Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of laparoscopic ventral hernioplasty. Surg Endosc. 1998;12:955-959.

2.    Kyzer S, Alis M, Aloni Y, Charuzi I. Laparoscopic repair of postoperation ventral hernia. Surg Endosc. 1999;13:928-931.

3.    Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic incisional/ventral herniorraphy: a five year experience. Hernia. 1999;4:209-214.

4.    Chowbey PK, Sharma A, Khullar R, Mann V, Baijal M, Vashistha A. Laparoscopic Ventral Hernia Repair. J Laparoendosc Adv Surg Tech. 2000;10(2):79-84.

5.    Birgisson G, Park A, Mastrangelo MJ, et al. Obesity and laparoscopic repair of ventral hernias. Surg Endosc. 2001;15:1419-1422.

6.    Moreno-Egea A, Castillo JA, Girela E, Canteras M, Aguayo JL. Outpatient Laparoscopic Incisional/Ventral Hernioplasty: Our Experience in 55 Cases. Surg Lap Endo & Perc Tech. 2002;12(3):171-174.

7.    Parker HH, Nottingham JM, Bynoe RP, Yost MJ. Laparoscopic repair of large incisional hernias. Am Surg. 2002;68(6):530-534.

8.    Bageacu S, Blanc P, Breton C, et al. Laparoscopic repair of incisional hernia. A retrospective study of 159 patients. Surg Endosc. 2002;16:345-348.

9.    Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia. Surg Endosc. 2002;16:785-788.

10.    Berger D, Bientzle M, Müller A. Postoperative complications after laparoscopic incisional hernia repair. Surg Endosc. 2002;16:1720-1723.

11.    Aura T, Habib E, Mekkaoui M, et al. Laparoscopic tension-free repair of anterior abdominal wall incisional and ventral hernias with an intraperitoneal Gore-tex® mesh: Prospective study and review of the literature. J Laparoendo & Adv Surg Tech. 2002;12(4):263-267.

12.    Gillian GK, Geis WP, Grover G. Laparoscopic incisional and ventral hernia repair (LIVH): an evolving outpatient technique. JSLS. 2002;6:315-322.

13.    Eid GM, Prince JM, Mattar SG, et al. Medium-term followup confirms the safety and durability of laparoscopic ventral repair with PTFE. Surgery. 2003;134:599-604.

14.    Chelala E, Gaede F, Douillez V, et al. The suturing concept for laparoscopic mesh fixation in ventral and incisional hernias: Preliminary results. Hernia. 2003;7:191-196.

15.    Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic approach to incisional hernia. Surg Endosc. 2003;17:118-122.

16.    LeBlanc KA, Whitaker JM, Rhynes VK, et al. Laparoscopic incisional and ventral hernioplasty: lessons learned from 200 patients. Hernia. 2003;7:118-124.

17.    Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic repair of ventral hernias, nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238(3):391-400.

18.    Bower CE, Reade CC, Kirby W, et al. Complications of laparoscopic incisional-ventral hernia repair. Surg Endosc. 2004;18:672-675.

19.    Sánchez LJ, Bencini L, Moretti R. Recurrences after laparoscopic ventral hernia repair: results and critical review. Hernia. 2004;8:138-143.

20.    Franklin ME, Gonzales JJ, Glass JL. Laparoscopic ventral and incisional hernia repair: An 11-year experience. Hernia. 2004;8:23-27.

21.    Frantzides CT, Carlson MA, Zografakis JG, et al. Minimally invasive incisional herniorrhaphy. Surg Endosc. 2004;18:1488-1491.

22.    Holzman MD, Purut CM, Reintgen K Eubanks S, Pappas TN. Laparoscopic ventral and incisional hernioplasty. Surg Endosc. 1997;11:32-35.

23.    Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery. 1998;124(4):816-822.

24.    Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg. 1999;65:827-832.

25.    Carbajo MA, Martín del Olmo JC, Blanco JI, et al. Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13:250-252.

26.    DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Surg Endosc. 2000;14:326-329.

27.    Zanghi A, Di Vita M, Lomenzo E, De Luca A, Cappellani A. Laparoscopic repair v sopen surgery for incisional hernias: a comparison study. Ann Ital Chir. 2000;LXXI(6):663-668.

28.    Chari R, Chari V, Eisenstat M, Cheng R. A case controlled study of laparoscopic incisional hernia repair. Surg Endosc. 2000;14:117-119.

29.    Robbins SB, Pofahl WE, Gonzalez RP. Laparoscopic ventral hernia repair reduces wound complications. Am Surg. 2001;67(9):896-900.

30.    Wright BE, Niskanen BD, Peterson DJ, et al. Laparoscopic ventral hernia repair: are there comparative advantages over traditional methods of repair?Am Surg. 2002;68(3):291-296.

31.    Moreno-Egea A, Carrasco L, Girela E, Martin J-G, Aguayo JL, Canteras M. Open vs laparoscopic repair of Spigelian hernia. Arch Surg. 2002;137:1266-1268.

32.    Gonzalez R, Mason E, Duncan T, Wilson R, Ramshaw BJ. Laparoscopic versus open umbilical hernia repair. JSLS. 2003;7:323-328.

33.    Raftopoulos I, Vanuno D, Khorsand J, Kouraklis G, Lasky P. Comparison of open and laparoscopic prosthetic repair of large ventral hernias. JSLS. 2003;7:227-232.

34.    McGreevy JM, Goodney PP, Birkmeyer CM, et al. A prospective study comparing the complication rates between laparoscopic and open ventral hernia repairs. Surg Endosc. 2003;17:1778-1780.

Infections in Laparoscopic Surgery

EXCERPT FROM NEW TEXTBOOK
Prevention and Management of Laparoendoscopic Surgical Complications, 2nd Edition

MICHAEL S. KAVIC, MD, GAYETTE F. GRIMM, MD, JOHN THOMAS, MD

INTRODUCTION

A common complication of surgery is infection, which can range from minor wound infections to large, complex intraabdominal catastrophes, as well as infections distant to the site of surgery. The purpose of this chapter is to synthesize current clinical and basic science knowledge of laparoscopic infections and collate that knowledge into a set of coherent principles. This will be done by using laparoscopic hernioplasty as a conceptual framework of a sound approach to management of prosthetic infections.

GRAFT INFECTION

Most cases of surgical infection are due to deficiencies in surgical technique (including breaks in sterile technique) or failure to control the bacterial milieu of a surgical wound. For instance, delicate handling of tissues, gentle dissection, and meticulous homeostasis are time-honored surgical principles that diminish the potential for infection [10]. Thus, any surgical technique that minimizes the amount of contamination and decreases the amount of devitalized tissue at the operative site will decrease the incidence of surgical-site infection by decreasing the quantity of nutrients available to potential pathogens.

Distinct differences exist between laparoscopic procedures in gaining access to the operative site. In general, laparoscopic surgery has smaller skin incisions, less dissection (especially in the subcutaneous tissues), and incisions that are often distant from the operative field. This causes less traumatized tissues overall and provides fewer nutrients for pathogens as discussed above. In addition, it is thought that the smaller incisions grant fewer opportunities for introduction of bacteria into an operative site and thereby reduce the chance of infection.

Sutures or tacking materials also make a great difference in the incidence of surgical infection. As previously noted, the presence of suture material in a wound decreases the minimum bacterial concentration needed to produce clinical infection [1]. Braided sutures compound this problem due to the presence of very small interstices between the braided strands that provide a “safe harbor” for bacteria. But even monofilament suture can have interstices, such as between the throws of a knot, that can harbor bacteria [13, 11, 12]. Thus, the use of any suture can increase the risk of infection. In some laparoscopic procedures, especially laparoscopic hernia repairs, inert, metal-anchoring tacks or clips are used. These devices are minimally reactive and have no interstices, thus providing little place for bacteria to hide and cause infection.

Finally, the presence of mesh in a surgical site also increases the chance of infections by reducing the threshold numbers of bacteria required for infection and increasing the virulence factor of bacteria [6]. In the presence of a synthetic graft, bacteria bind to the prosthesis via microbial surface components recognizing adhesive matrix molecules (MSCRAMMs) that are elaborated by the bacteria themselves [11]. These adhesion molecules recognize and bind to elements of the host’s interstitial matrix. The binding process then leads to an elaboration of a glycoprotein layer that impedes the entrance of host bactericidal elements. In addition, traumatized tissues have surfaces devoid of a protective cellular layer, competent protective extracellular polysaccharide (glycocalyx), and a basement membrane, all of which promote bacterial growth [11,13].

The type of mesh chosen for hernia repair can also affect the chance of infection because macrophages and neutrophils require larger pores for admission than bacteria do. Synthetic mesh can be classified by pore size into 4 groups:

Type I—Prostheses with pores greater than 75 microns. Examples: Marlex, monofilament polypropylene meshes [8,14,15];

Type II—Prostheses with pore sizes less than 10 microns in at least 1 of their 3 dimensions. Examples: ePTFE, Dual Mesh, surgical membrane;

Type III—Macroporous prosthesis with multifilamentous or microporous components. Examples: braided Dacron, braided polypropylene;

Type IV—Biomaterial with submicron pore size. Example: silastic.

The completely macroporous materials (all pores >10 microns) will allow for admission of macrophages, fibroblasts, blood vessels, and collage fibers into the mesh, thus providing a lesser chance of infection.

In summary, current techniques of laparoscopic hernia surgery have optimized conditions to make bacterial infection of the prosthetic materials less likely. Reducing the potential inoculum with small incisions remote from the operative site minimizes bacterial contamination overall and especially to the operative site. Laparoscopic dissection is typically more meticulous than open methods due to the magnification of laparoscopic imaging, thus the amount of devitalized tissue available for bacteria to bind and utilize as nutrition is reduced. Common use of Type I biomaterials and fixation with staples or other inert tacking devices eliminates interstices less than 10 microns. The result of using the laparoscopic method and these materials is a hernia repair that is quite resistant to infection with infection rates reported as 0% to 0.1% [10,16,22,23].

DIAGNOSIS AND TREATMENT OF MESH INFECTIONS

Complications of laparoscopic hernioplasty can occur, and any deviation from normal postoperative recovery should raise suspicion of a problem. In general, the complications are similar to those of open hernioplasty, and the differential diagnosis should include hernia recurrence, hematoma, seroma, orchitis, neuralgia, “mesh inguinodynia,” and mesh infection.

Two distinct types of prosthetic infection have been described. The first type is an uncomplicated infection caused by contamination of the prosthetic material at the time of operation. This contamination may be from endogenous or exogenous sources. In uncomplicated infections, the source of sepsis is localized and not ongoing. The second type of prosthetic infection, a complicated prosthetic infection, usually results from mesh migration and erosion into adjacent viscera. In these instances, an ongoing source of sepsis is present from the eroded organ [10,16-21].

Uncomplicated infection can frequently be treated by local measures without removal of the prosthesis (particularly if a Type I mesh with large pores constructed of monofilament material has been utilized) [12]. Graft migration, however, requires surgical intervention for removal of the mesh and management of the enteric source of sepsis [11,16,18-20]. Distinguishing between these 2 types of compilations is essential for successful management. Their clinical signs and symptoms, however, are not necessarily specific to mesh infection and may be indistinguishable from each other as well as from other postherniorrhaphy complications.

For example, hernia recurrence after laparoscopic inguinal hernia repair can present with swelling at the operative site, pain, obstructive symptoms, and skin discoloration. The presentation of recurrence may be early or delayed. Differentiating recurrence from other types of complications is important because successful treatment of mesh infections depends on the results of bacteriologic studies of fluid aspirated or drained from the operative site. Aspiration or incision and drainage of the visceral content of a recurrent hernia, however, could prove disastrous. Ultrasound and computed tomography are useful to rule out early hernia recurrence as a cause for prolonged groin swelling or pain. Radiographic evidence of recurrence does not rule out infection, but does mandate reoperation.

Once recurrence is eliminated, the differential includes infection, seroma, hematoma, and orchitis along with neuralgia. A diagnosis of postoperative neuropathy is established if the patient describes pain in the distribution of the ilioinguinal, iliohypogastric, genitofemoral, or lateral femoral cutaneous nerve that has arisen since surgery. In addition, there must be no systemic signs or symptoms of sepsis (ie, fever, leukocytosis, elevated erythrocyte sedimentation rate) and radiographic imaging is normal. Delayed presentations of postoperative neuropathy have been reported. Confirmation of neuralgia is aided when infiltration of the involved nerve with local anesthetic relieves pain. Treatment may require medication such as amitriptyline, local injection with steroid, or mesh removal with or without neurectomy of the iliohypogastric, ilioinguinal, and genitofemoral nerves.

Swelling from hematoma, seroma, and orchitis must be differentiated from swelling caused by mesh infection, as the treatment of these conditions is quite different. Seroma and hematoma can be managed expectantly with resolution expected within 6 weeks to 12 weeks. Orchitis is usually painless and associated with an indurated testicle that slowly subsides with or without antibiotics and can result in an atrophic testicle, usually within a year. Mesh infections often have the universal signs of infection: pain, redness, swelling, warmth, and possibly fever and leukocytosis.

Occasionally, persistent draining sinus tracts have been described with complicated and uncomplicated mesh infections and may herald a stitch abscess or a more severe infection [8,11,16,19,20]. Once infection is suspected and recurrence is ruled out, aspiration of fluid with appropriate bacteriologic studies should be done. Additionally, cultures of any drainage from chronic sinus tracts should be performed. Aspirations of purulent fluid should prompt open drainage and administration of broad-spectrum antibiotics [11]. Polymicrobial infections or growth of enteric organisms should raise the suspicion of a visceral injury and prompt radiographic investigation with computed tomography or fistulography [11,18-20].

Infections that are not the result of an enteric source and involve Type I mesh are generally treatable by exposure of the prosthesis and removal of suture and unincorporated mesh, along with local wound care. Good results usually follow [11,12]. Vacuum system dressings have been used for infected wounds to reduce the effect of wound secretions and encourage tissue ingrowth. Early experience with these systems suggests that they may have utility in conservative management of open infected abdominal wall grafts (Figures 1 and 2).

Figure 1. Graft. 

Figure 2. Vacuum System Dressing.

Type II prostheses typically need to be removed, as tissue incorporation is impaired in the presence of infection. A trial of conservative management with antibiotic, exposure, and local wound care, however, is warranted before removal. On the other hand, enteric fistulas will not respond well to local care and require removal of the mesh as well as repair of the fistula independent of the type of mesh used [18-20]. The operative approach for mesh removal and fistula repair may require open incision and drainage of the groin followed by laparotomy. Alternatively, a laparoscopic intervention may be attempted if the operator has sufficient skill and experience. With infection, mesh usually becomes unincorporated from the operative site and is not difficult to remove. The operator’s experience and judgment guide the choice or approach (open or laparoscopic).

SUBSEQUENT REPAIR

As described above, it is rare for mesh to be removed because of an infectious complication. In addition, when mesh is removed after hernioplasty, recurrence seems to be infrequent [12]. However, when mesh must be replaced because of infection, care must be taken to avoid recurrent infection. Deysine [11] has outlined an approach to this problem based on orthopedic experience with implantable prostheses. Essentially, this investigator advocates aspiration of any infected material to test for residual bacteria. If percutaneous microbiological wound sampling is positive, remove the prosthesis and treat the infection. Once cultures are negative, repair with a new prosthesis is possible; otherwise perform wound exploration with secondary closure (Figure 3).

Figure 3. Algorithm for Treatment of Postherniorrhaphy Infection.

CONCLUSION

In summary, infection related to laparoscopic surgery is not much different from that of conventional surgery, and all the same principles of good surgical practice hold true. The major difference is that infection seems to be much reduced with laparoscopy when compared with conventional surgery. This is likely due to a multitude of reasons, such as smaller incisions, less trauma to tissues, and use of inert foreign bodies. But, some studies suggest that physiological reasons, such as less immune system depression, may exist that account for the lower infection rates. In general, infections that do occur after a laparoscopic procedure can be treated in a similar fashion to conventional surgical infections. 

Michael S. Kavic, MD, is Director of Education, General Surgery for the St. Elizabeth Health Center; Professor of Surgery and Vice Chair, Department of Surgery for the Northeastern Ohio Universities College of Medicine; and an Adjunct Professor of Surgery, Department of Surgery at the University of Pittsburgh School of Medicine. He is a founding member of the SLS and is Editor-in-Chief of JSLS, Journal of the Society of Laparoendoscopic Surgeons. Dr Kavic has written and published numerous book chapters, journal articles, and editorials and has lectured nationally and internationally on laparoscopic surgery. He is a past president of both SLS and the American Hernia Society.

Gayette F. Grimm, MD, is a general surgeon at Gundersen Lutheran Clinic in Prairie du Chien, Wisconsin. She completed her general surgery internship and residency at St. Elizabeth’s Health Center in Youngstown, Ohio. Dr Grimm is an active member of the Society of Laparoendoscopic Surgeons.

John Thomas, MD, is with the Department of General Surgery at Stonewall Jackson Memorial Hospital in Westin, West Virginia. He completed his residency at Mount Carmel Health. Dr Thomas is an active member of the Society of Laparoendoscopic Surgeons.

References

1.     Wangensteen OH, Wangensteen SD, Klinger CF. Surgical infection and history. In: Simmons RL, Howard RJ, eds. Surgical Infectious Diseases. New York, NY: Appleton-Century-Crofts; 1982:1-10.

2.     Koch R. Die aetiologie der tuberculose. Berl Klin Wschr. 1882;9:221-230.

3.     Dorland’s Illustrated Medical Dictionary. 28th ed. Philadelphia, PA: WB Saunders Co; 1994:1341.

4.     Lister J. On a new method of treating compound fractures, abscesses, etc., with observations on the conditions of suppuration. Lancet. 1867;1:326-329, 357-359, 507-509, 2:95-96.

5.     Muscarella P, Steinberg SM. Postoperative wound infection. In: Cameron JL, ed. Current Surgical Therapy. 7th ed. St. Louis, MO: Mosby; 2001:1277-1282.

6.     Elek SD, Conen PE. The virulence of Staphylococcus pyogenes for man: a study of the problems of wound infection. Brit J Exp Path. 1957;38:573-586.

7.     Alexander JW, Kaplan JZ, Altemeier WA. Role of suture materials in the development of wound infection. Ann Surg. 1966;1965(2):192-199.

8.     Amid PK. Classification of biomaterials and their related complications in abdominal wall hernia repair. Hernia. 1997;1:15-21.

9.     Neel HB III. Implants of Gore-Tex. Comparisons with Teflon-coated polytetrafluoroethylene carbon and porous polyethylene implants. Arch Otolaryngol. 1983;109:427-433.

10.    Amid Pariz, et al. The goals of modern hernia surgery. How to achieve them: open or laparoscopic repair. Probl Gen Surg. 12;2:165-171.

11.    Deysine M. Pathophysiology, prevention and management of prosthetic infections in hernia surgery. Surg Clin North Am. 1998;78(6):1105-1115.

12.    Gilbert A, Felton LL. Infection in inguinal hernia repair considering biomaterials and antibiotics. Surg Gynecol Obstet. 1993;177:126-130.

13.    Patti JM. MSCRAMM-mediated adherence of microorganisms to host tissues. Annu Rev Microbiol. 1994;48:585-617.

14.    Bobyn JD, Wilson GJ, MacGregor DC, Pilliar RM, Weathersby GC. Effect of pore size on the peel strength of attachment of fibrous tissue to porous-surfaced implants. J Biolmed Mater Res. 1982;16:571-584.

15.    White RA. The effect of porosity and biomaterial on the healing and long-term mechanical properties of vascular prostheses. ASAIO. 1988;11:95-100.

16.    Fitzgibbons RJ Jr, Camps J, Cornet DA, et al. Laparoscopic inguinal herniorrhaphy: results of a multicenter trial. Ann Surg. 1995;221:13-130.

17.    Crist DW, Gadacz TR. Complications of laparoscopic surgery. Surg Clin North Am. 1993;73(2):265-289.

18.    Hume R, Bour J. Mesh migration following laparoscopic inguinal hernia repair. J Laparoendosc Surg. 1996;6(5):333-335.

19.    Kaufman Z, Engelberg M, Zager M. Fecal fistula:a late complication of Marlex mesh repair. Dis Col Rectum. 1981;24:543-44.

20.    Miller K, Junger W. Ileocutaneous fistula formation following laparoscopic polypropylene mesh hernia repair. Surg Endosc. 1997;11:772-773.

21.    Smith RS. The use of prosthetic materials in the repair of hernias. Surg Clin North Am. 1971;51(6):1387-1389.

22.    Schultz C, Baca I, Gotzen V. Laparoscopic inguinal hernia repair. Surg Endosc. 2001;15(6):582-584.

23.    Kapiris SA, Brough WA, Royston CM, O’Boyle C, Sedman PC. Laparoscopic transabdominal preperitonal (TAPP) hernia repair. A 7-year two-center experience in 3017 patients. Surg Endosc. 2001;15(9):972-975.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Laparoscopic Sleeve Gastrectomy

Laparoscopic Sleeve Gastrectomy: an Alternative for Recurrent Paraesophageal Hernia in Obese Patients. Cuenca-Abente F et al. 2006;10:86-89 • Cuenca-Abente et al describe their management of a case in which the work up of a morbidly obese, 70-year-old female revealed a recurrent large paraesophageal hernia. They report that a laparoscopic sleeve gastrectomy may be a useful alternative to fundoplication or gastropexy in the treatment of obese patients with complex paraesophageal hernias.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Hernias as a Source of Abdominal Pain

Hernias as a Source of Abdominal Pain: A Matter of Concern to General Surgeons, Gynecologists, and Urologists • Kavic MS 2005;9(3):249-251. Hernias may present in diverse and subtle ways. It is important that all surgeons who explore the abdominal and pelvic cavities be aware of the many possible presentations of hernias and the significance of that symptomatology.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Application of Doppler Technology

Application of Doppler Technology as an Aid in Identifying Vascular Structures During Laparoscopy • Neff M, Cantor B, Koren J, Geis WP, Curtiss S, Rosen S, Konigsberg S. 2004;8:259-261. A laparoscopic Doppler probe was found to provide useful information in identifying the cystic artery during laparoscopic cholecystectomy, to assess mesenteric blood vessels during laparoscopic colectomy, and to identify femoral vessels during laparoscopic preperitoneal hernia repair.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Hernias in Women: Uncommon or Unrecognized?

CHRONIC PELVIC PAIN

DEBORAH A. METZGER, PhD, MD

Considering the perceived rarity of hernias in women [1], the association between chronic pelvic pain and occult hernias is not generally considered when evaluating women with chronic pelvic pain [2]. However, based on a review of the literature and personal experience, nonpalpable, or occult hernias are a common source of chronic pelvic pain in women.

Most gynecologists and general surgeons are unaware of occult hernias and many do not believe that they exist; and therefore, they are controversial. However, Nyhus [3] described a spectrum of hernias differentiated by size, presence or absence of a sac, and the degree of deformity of anatomy. Type III hernias are more common in men, whereas Type I and II hernias (occult hernias) appear to be more common in women. Type I and II hernias, often referred to as occult inguinal hernias, have been reported to be associated with groin pain in men, women, and athletes [4].

Except for a mass in the groin, pain is the most common symptom of a hernia [5]. Pain is more common in the incipient stages of hernia, when the tissues are being stretched [6], and is by far the most common sole initial symptom caused by hernia. The pain is often sharp and may even be of the neuralgic type [7]. Symptoms may develop long before a palpable hernia develops. Thus, in women with chronic pelvic pain, it would be anticipated that the earlier, nonpalpable stages of hernias would predominate.

Because a variety of organ systems are involved in the spectrum of presentations of occult inguinal hernias, the diagnosis can be confusing. The primary symptom is groin pain that the patient may describe as “ovarian pain” (Figures 1 and 2). Other symptoms, such as pain with bowel movements, full bladder, or with intercourse, are related to exacerbation of the pain with increased intraabdominal pressure. Back pain, either uni- or bilateral, appears to be due to piriformis muscle spasm as this muscle is often quite tender on vaginal examination. Likewise, sciatica may be due to the stretch of the sciatic nerve as it passes over the tensed piriformis muscle. The exacerbation of groin pain with menses, which patients describe as different from cramps, is not readily explained, but commonly observed. Ilioinguinal, iliohypogastric, genitofemoral, obturator, and pudendal neuralgia symptoms may predominate, and the patient may complain of sharp, shooting pains up the vagina, around the hip and back, into the flank, down the thighs, and into the labia. These secondary problems make it more difficult to make the diagnosis of inguinal hernia especially since the patient may see a variety of specialists who may not connect all of the symptoms. Thus, the patient may have been diagnosed with lumbar disc problems, pelvic floor tension myalgia, sacroiliac instability, interstitial cystitis, endometriosis, abdominal wall trigger points, neuropathy, pudendal neuralgia, orthopedic problems of the hip, or psychosomatic problems.

Diagnosis of nonpalpable hernias in women relies almost exclusively on clinical examination. The small size of these hernias and the presence of incarcerated fat make it difficult to obtain useful information from ultrasound, computed tomography, magnetic resonance imaging, or herniography.

Examination of the abdomen in a supine position with the abdominal wall tensed may reveal tenderness over the course of the ilioinguinal or iliohypogastric nerves, or both. Abdominal examination in a standing position sometimes reveals a subtle bulge associated with the external inguinal canal. More often, however, there may be tenderness of the ring reproducing a component of the patient’s pain. The best predictor of an occult hernia is the vaginal examination. Often the pelvic floor muscles are tense and tender. Likewise, the ischial spines may be tender. Most telling is a reproduction of the patient’s pain by palpation of the internal inguinal area. The positive predictive value of this latter sign approaches 100% [8].

Oral medications that specifically target nerve pain, such as gabapentin, amitriptyline, and tramadol, are often helpful. Antiinflammatory medications, such as ibuprofen, naprosyn, and the cox-2 inhibitors, can be helpful. Narcotic medications in general are not particularly helpful for nerve-related pain. Topical medications, such as Lidoderm, 10% ketoprofen, 5% amitriptyline, 5% lidocaine, and/or 10% gabapentin, may reduce pain.

Myofascial release performed by a physical therapist trained in internal manual methods can sometimes be helpful in alleviating some of the muscle spasms. Nerve blocks may produce temporary relief, but the pain invariably returns.

Surgery is considered only when a patient has tried the medical treatments described above and still has a level of pain that interferes with her quality of life. Hernias are generally not visible at the time of laparoscopy and thus are usually missed by prior surgeons. To make the diagnosis, inguinal exploration of the affected side(s) is performed using a laparoscopic approach. A transverse incision is made in the peritoneum, and a careful exploration is performed to look for incarcerated fat or dilation of the indirect inguinal, direct inguinal, femoral, and obturator spaces. All 4 spaces are explored because it is common to find more than one type of hernia [8]. The incarcerated fat is removed, and a soft mesh is placed over the hernias. We do not use staples or tacs to hold the mesh in place because these fixation devices can cause pain and require additional surgery to remove them [9]. The peritoneum is then closed with an absorbable suture.

As with any type of laparoscopic surgery, risks are associated with hernia repair. Bleeding from vessels in the inguinal area, permanent damage to nerves, infection, adhesions, and continued pain are all potential risks. Postoperative pain is somewhat greater than with other types of laparoscopic procedures and should be treated with appropriate narcotics. Neuropathy may initially resolve and then reappear within 1 to 3 weeks following surgery and last 2 to 3 weeks before it spontaneously resolves. Some women require a series of nerve blocks to completely resolve the nerve pain. Overall, 80% to 85% of women obtain complete or significant pain relief from surgery for occult hernias [10].

The treatment of chronic pelvic pain has been limited by our ability to specifically diagnose and treat the cause(s) of pain. Because occult hernias are not generally apparent on laparoscopic evaluation, they should be considered in chronic pelvic pain patients with negative laparoscopy results or where the observed pathology is insufficient to explain the degree and type of pain.

Figure 1. Location of the ovarian point.

Figure 2. Patterns of pain in the presence of occult hernias. The pain can be unilateral or bilateral.

Address reprint requests: Deborah A. Metzger, PhD, MD, Harmony Women’s Health, 851 Fremont Ave, Ste 104, Los Altos, CA 94024, USA. Tel: 650 229 1010, Fax: 650 229 1011, E-mail: DrDebMetz@pol.net

Deborah A. Metzger, PhD, MD, is a gynecologic surgeon and reproductive endocrinologist whose major interest is the integrated treatment of women with chronic pelvic pain. After graduating from college (SUNY at Buffalo, 1973), she obtained a PhD in molecular endocrinology from Baylor College of Medicine in Houston, Texas (1979). She attended medical school at the University of Texas Medical School at Houston (1982) and completed her residency in Obstetrics and Gynecology (1986) and a fellowship in Reproductive Endocrinology and Infertility (1988) at Duke University in North Carolina. She has served on the medical school faculties of the University of Connecticut, Yale, and Stanford. Currently, she is Medical Director of Harmony Women’s Health in Los Altos, California.

She is recognized as one of the leading authorities in the treatment of endometriosis and chronic pelvic pain. In addition to her involvement in many professional societies, she is a founding member and past-President of the International Pelvic Pain Society. She has lectured extensively throughout the world, published widely in peer-reviewed journals and textbooks, and is one of the editors of Chronic Pelvic Pain: An Integrated Approach, the first book on the subject.

References

1.    Spangen L. Nonpalpable inguinal hernia in women. In: Hernia Fourth Edition. Nyhus LM, Condon RE, eds. Philadelphia: JB Lippincott Co; 1995:87-90.

2.    Kavic MS. Chronic pelvic pain, hernias and the general surgeon [editorial]. JSLS. 1999;3:89-90.

3.    Nyhus LM. Individualization of hernia repair: a new era. Surgery. 1993;114:1-2.

4.    Harris K, Davies K, Dumont S, Stephenson BM. A pain in the groin. Lancet. 1997;350:334.

5.    Roos H, Smedberg S. Symptomatic non-palpable inguinal hernias. Postgrad Gen Surg. 1992;4:131.

6.    Lichtenstein IL. Hernia repair without disability. St Louis, MO: CV Mosby; 1970.

7.    Ljungdahl I. Inguinal and femoral hernia. An investigation of 502 own operated cases. Acta Chir Scand. 1973;439:1-81.

8.    Metzger DA, Daoud I. Occult hernias in women with chronic pelvic pain. Plenary abstract presented at: International Congress of Gynecologic Endoscopy, American Association of Gynecologic Laparoscopists 26th Annual Meeting; September 24-28, 1997, Seattle, WA.

9.    Metzger DA. Groin pain in women. Presented at: 12th International Congress and Endo Expo, SLS Annual Meeting; September 22-25, 2003, Las Vegas, NV.

10.    Metzger DA, Daoud I. Occult hernias in women with chronic pelvic pain. Plenary abstract presented at: International Congress of Gynecologic Endoscopy, American Association of Gynecologic Laparoscopists Annual Meeting; November 14-16, 2000; Orlando, FL.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Groin Hernia Surgery in Evolution

MINIMALLY INVASIVE OPEN REPAIRS

PHILLIP  P. SHADDUCK, MD

INTRODUCTION

Groin hernias and their treatment remain a significant healthcare problem. They occur with an incidence of 1 in 350 to 500 men/year and have a lifetime prevalence in men of 6% to 27% [1-4]. Approximately 800000 inguinal/femoral hernia repairs are performed annually in the United States [1,4]. The socioeconomic impact of groin hernias on the US healthcare system is estimated to be several billion dollars annually. As one of the “most frequently performed operations in general surgery…even minor alterations in outcome and resource use have appreciable impact,” [5]. Fortunately, during the last 15 years, tremendous progress has been realized in herniorrhaphy techniques and outcomes. This article will review the historical background and summarize the latest techniques in this ongoing evolution.

EVOLUTION OF TECHNIQUES

Bassini made the critical observation that the successful treatment of hernias depends not on manipulation of the hernia sac but rather on repair of the underlying defect. Prior to Bassini’s observation in the 1880s, recurrence rates were essentially 100%. The repairs developed by Bassini, Halsted, and McVay addressed the myofascial defect and thereby reduced recurrence rates to 10% to 15%. These sutured repairs remained the mainstays of Shouldice’s multilayer repair reduced recurrence rates even further, to approximately 1% to 2%, and gained popularity by the 1980s. However, all of these sutured repairs resulted in tissue tension, postoperative pain, and temporary disability. Mesh techniques were developed to reduce tension, postoperative pain, disability, and recurrence rates. Though several mesh techniques were described through the mid to late 1900s (Cheatle, Nyhus, Condon, Stoppa, Rives, Wantz, and others), widespread acceptance of mesh repairs was not achieved until Lichtenstein’s “tension-free hernioplasty” in 1989. With the acceptance of open mesh repairs, and the laparoscopic cholecystectomy revolution at that same time, laparoscopic mesh repairs followed. By the early 1990s, the transabdominal preperitoneal placement (TAPP) and totally extraperitoneal placement (TEP) of mesh were being touted as minimally invasive techniques. Though the TAPP/TEP repairs did have the advantages of minimal pain and rapid postoperative recovery, they had the disadvantages of longer learning curves, higher operative costs, and rare but serious complications. Over the last decade, several investigators have endeavored to develop techniques that combine the best of both worlds–achieving the advantages of open mesh repairs (simplicity, safety, low recurrence, low cost) and of laparoscopic repairs (minimal pain and rapid recovery). Thus were born the “minimally invasive open repairs.”

THE “MINIMALLY INVASIVE OPEN REPAIRS”

The author considers the following to be “minimally invasive open repairs”: (1) the plug and patch repair (Rutkow, 1993); (2) the Prolene Hernia System (PHS) repair (Gilbert, 1999); and (3) the Kugel repair (Kugel, 1999). Taken together, these 3 new techniques already account for about 40% of hernia repairs performed in the United States (plug and patch >30%, Kugel 8% to 9%, PHS 1% to 2%). They approximate the Lichtenstein tension-free hernioplasty (approximately 40%) and exceed the laparoscopic repairs (approximately 10% to 15%) and sutured repairs (<10%) (Figure 1).

Several variations exist on the theme of a plug and patch repair. The best studied and most widely practiced technique is that developed by Dr Ira Rutkow [6,7]. This technique involves placement of a polypropylene plug through the hernia defect into the preperitoneal space, and then placement of a flat polypropylene patch on the inguinal floor, with little or no suture fixation (Figure 2).

The Prolene Hernia System (PHS) repair was developed by Dr Arthur Gilbert [8]. The PHS patch is also made of polypropylene and is described as a “3-in-1” device, incorporating an “underlay patch” that is positioned in the preperitoneal space, a “connector” that is placed thru the hernia defect, and an “onlay patch” that is placed on the inguinal floor, also with minimal fixation (Figure 3).

The Kugel technique was developed by Dr Robert Kugel [9]. The Kugel patch is a bilayer polypropylene patch with a self-retaining outer memory recoil ring. Through a 3-cm to 4-cm muscle splitting incision, the preperitoneal space is entered and a pocket developed, and the mesh is positioned in the preperitoneal space. This results in a repair that is anatomically very similar to the laparoscopic TAPP/TEP repairs (Figure 4).

All 3 of these techniques are accomplished in an ambulatory setting, with the patient under local or regional anesthesia, with operative times of about 30 minutes, minimal postoperative pain, and rapid recovery with little or no work restrictions. What are the results of these new techniques, and how do the results compare with those of other more established techniques?

RESULTS

A literature search of all published results for these minimally invasive, open repairs reveals about 20 randomized clinical trials (RCT) and prospective studies [10-30]. Most of these studies address the Rutkow plug and patch technique [10-24]; few published RCT and prospective studies exist for the Kugel and PHS repairs [25-27,29]. The available results from these publications are summarized and presented, in simplified form, alongside outcomes for more established mesh repairs (Lichtenstein and laparoscopic TAPP/TEP) (Table 1). Data from nonmesh, sutured repairs are not presented here. The interested reader is referred to the Cochrane metaanalysis for data demonstrating that open mesh techniques have fewer recurrences, allow quicker return to work, and cause less persistent pain than do nonmesh, sutured repairs. Each of the 5 mesh repairs presented in the table has advantages and disadvantages. The differences among the mesh techniques are, in many parameters, subtle. Based on available data, it appears that the minimally invasive open techniques have comparable perioperative and short-term results when compared with those of more established techniques and therefore merit additional study, particularly in randomized trials and prospective registries.

CONCLUSION

Groin hernias remain a significant healthcare problem. Herniorrhaphy is one of the most frequently performed general surgery operations. The cost of hernia treatment runs into the billions of dollars annually. In the last 2 decades, hernia repair techniques have undergone an evolution, almost revolution. The minimally invasive open repairs are the newest entries in this ongoing process. Though most would probably agree that we have not yet achieved an ideal hernia repair, it appears that we may be closer now than ever before.

Figure 1. Utilization of groin hernia repair techniques in the United States, 1970-2002. Adapted from Rutkow I. Surg Clin North Am. 1998;78:941.

Figures 2a, 2b, 2c. The plug and patch repair as described by Dr Rutkow [6,7]. The polypropylene mesh plugs and preformed onlay patch (Bard PerFix Plug, Davol, Cranston, RI, USA/Bard, Murray Hill, NJ, USA) are shown. The procedure is accomplished with the patient under epidural anesthesia, without routine antibiotics. A 4-cm to 6-cm oblique incision is made, and standard dissection is performed with cautery. No specific effort is made to identify or mobilize the nerves. For indirect hernias, the sac is mobilized high, not opened or ligated, and dropped back through the internal ring. The mesh plug is positioned into the internal ring, tapered end first, as shown here, and sutured to the crura with absorbable sutures. The onlay patch is then positioned in the inguinal canal as shown, with little or no suture fixation. For direct hernias, the sac is circumscribed circumferentially with electrocautery, invaginated, and then the mesh plug and onlay patch placed in a similar fashion.

Figure 3. The Prolene Polypropylene Hernia System (PHS) repair [8]. The “3-in-1” PHS prosthesis (Ethicon/Johnson & Johnson, Somerville, NJ, USA) incorporating the underlay patch, connector, and onlay patch. Standard incision and exposure are accomplished. For indirect hernias, high dissection of the sac is performed and the sac invaginated through the internal ring. The preperitoneal space is “actualized” with forefinger and sponge dissection. The onlay patch and connector are grasped with a sponge forceps, and the underlay patch is deployed into the preperitoneal space, inferior to the cord structures. The connector is positioned in the defect at the internal ring. The onlay patch is positioned along the inguinal floor, with overlap of the pubic tubercle and transverse aponeurotic arch. A slit is created in the onlay patch to accommodate the cord structures. The onlay patch is suture fixated to the pubic tubercle, the mid portion of transversus aponeurotic arch, and the mid portion of inguinal ligament.

Figures 4a, 4b. The Kugel repair [9]. The Kugel Hernia Patch (Davol, Cranston, RI, USA/Bard, Murray Hill, NJ, USA) is a bilayer polypropylene patch with a self-retaining outer “memory recoil ring.” Local, regional, or general anesthesia is used. A 3-cm to 4-cm transverse incision is made superior to the mid point between the pubic tubercle and anterior superior iliac spine. The external oblique is incised, the internal oblique and transversus abdominus split bluntly, and the transversalis fascia incised vertically. The preperitoneal space is entered and a pocket developed. For direct hernias, the hernia contents are reduced fully. For indirect hernias, the cord structures are delivered through the incision, and the indirect sac and/or “cord lipoma” mobilized high and invaginated into the preperitoneal space. Dissection can be blunt (by palpation), sharp, or both, under direct visualization (facilitated by headlight and 1” malleable retractor). An 8 x 12-cm (or 11 x 14-cm) Kugel patch is introduced into the preperitoneal pocket and positioned as shown, resulting in coverage of the pubis, Cooper’s ligament, rectus abdominus, transversus abdominus, and all direct inguinal/indirect inguinal/femoral defects and potential defects.

Address reprint requests to: Phillip Shadduck, MD, 4301 Ben Franklin Blvd, PO Box 15698, Durham, NC 27704, USA. Tel: 919 479 4400, Fax: 919 620 8212.

Dr Shadduck is Chief of General Surgery, Durham Regional Hospital; Attending Surgeon, Durham Veterans Administration Medical Center; and Assistant Consulting Professor of Surgery, Duke University Medical Center, Durham, NC. He received his undergraduate degree from the University of California, Riverside, and his medical degree from the University of California, Los Angeles. His surgical internship, residency, and research fellowship were completed at Duke University Medical Center.

References

1.    Rutkow IM. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin North Am. 1998;78:941-951.

2.    O’Riordan DC, Kingsnorth AN. Audit of patient outcomes after herniorrhaphy. Surg Clin North Am. 1998;78:1129-1139.

3.    Nilsson E, Haapanemi S. Hernia registers and specialization. Surg Clin North Am. 1998;78:1141-1155.

4.    Rutkow IM. Demographic and socioeconomic aspects of hernia repair in the United States in 2003. Surg Clin North Am. 2003;83:1045-1051, v-vi.

5.    Zib M, Gani J. Inguinal hernia repair: where to next? Aust N Z J Surg. 2002;72:573-579.

6.    Robbins AW, Rutkow IM. Mesh plug repair and groin hernia surgery. Surg Clin North Am. 1998;78:1007-1023.

7.    Robbins AW, Rutkow IM. The mesh-plug hernioplasty. Surg Clin North Am. 1993;73:501-512.

8.    Gilbert AI, Graham MF, Voigt WJ. A bilayer patch device for inguinal hernia repair. Hernia. 1999;3:161-166.

9.    Kugel R. Minimally invasive, nonlaparoscopic, preperitoneal, and sutureless, inguinal herniorrhaphy. Am J Surg. 1999;178:298-302.

10.    Pirski MI, Gacyk W, Witkowski P, Kostro J, Kot J. Mesh-plug operation for treating inguinal hernia. Randomized studies [in Polish]. Wiad Lek. 1997;50(suppl 1):391-395.

11.    Zieran J, Zieren HU, Jacobi CA, Wenger FA, Muller JM. Prospective randomized study comparing laparoscopic and open tension-free inguinal hernia repair with Shouldice’s operation. Am J Surg. 1998;175:330-333.

12.    Khoury J. A randomized prospective controlled trial of laparoscopic extraperitoneal hernia repair and mesh-plug hernioplasty: a study of 315 cases. J Lap Adv Surg Tech. 1998;8:367-372.

13.    Witkowski P, Pirski MI, Adamonis W, Smietanski M, Draczkowski T, Sledzinski Z. Mesh plug versus Bassini operation: a randomized prospective study. Hernia. 2000;4:305-310.

14.    Kingsnorth AN, Porter CS, Bennett DH, Walker AJ, Hyland ME, Sodergren S. Lichtenstein patch or Perfix plug-and-patch in inguinal hernia: prospective double-blind randomized controlled trial of short-term outcome. Surgery. 2000;127:276-283.

15.    Testini M, Miniello S, Piccinni G, et al. Trabucco versus Rutkow versus Lichtenstein techniques in the treatment of groin hernia. A controlled randomized clinical trial [in Italian]. Minerva Chir. 2002;57:371-376.

16.    Pavlidis TE, Atmatzidis KS, Lazaridis CN, Papaziogas BT, Makris JG, Papaziogas TB. Comparison between modern mesh and conventional non-mesh methods of inguinal hernia repair [in Italian]. Minerva Chir. 2002;57:7-12.

17.    Bringman S, Ramel S, Heikkinen TJ, Englund T, Westman B, Anderberg B. Tension-free inguinal hernia repair: TEP versus mesh-plug versus Lichtenstein: a prospective randomized controlled trial. Ann Surg. 2003;237:142-147.

18.    Zollinger RM, Konstantakos AK, Stellato TA, Hirschfield SS. Local anesthesia plus deep sedation for adult inguinal hernia repair in an ASU. Hernia. 1998;2(suppl):S12.

19.    Pelissier EP, Blum D, Damas JM, Marre P. The plug method in inguinal hernia: a prospective evaluation. Hernia. 1999;4:201-204.

20.    Fasih T, Mahapatra TK, Waddington RT. Early results of inguinal hernia repair by the “mesh plug” technique—first 200 cases. Ann R Coll Surg Engl. 2000;82:396-400.

21.    Bringman S, Ramel S, Nyberg B, Anderberg B. Introduction of herniorrhaphy with mesh plug and patch. Eur J Surg. 2000;166:310-312.

22.    Zdolsek JM, Enebog J, Wallon C, Kald A. A prospective evaluation of the PerFix Plug technique for groin hernia repair. Hernia. 2000;4:311-315.

23.    Zieran J, Hoksch B, Wenger FA, Opitz I, Muller JM. Inguinal hernia repair in the new millennium: plug and patch repair with local anesthesia. World J Surg. 2001;25:138-141.

24.    Millikan KW, Cummings B, Doolas A. The Millikan modified mesh-plug hernioplasty. Arch Surg. 2003;138:525-529.

25.    Kingsnorth AN, Wright D, Porter CS, Robertson G. Prolene Hernia System compared with Lichtenstein patch: a randomized double blind study of short-term and medium-term outcomes in primary inguinal hernia repair. Hernia. 2002;6:113-119.

26.    Zandi G, Vasquez G, Ortolani M, et al. Inguinal hernia repair. A comparison of the most important techniques. Minerva Chir. 2001;56:467-474.

27.    Fortelny R, Sporn S, Gero A. PHS—a double-leaved mesh in the open surgery of inguinal hernias [in German]. Zentralbl Chir. 2002;127:578-582.

28.    Murphy JW. A multicenter, 5-year safety data registry of the Prolene (polypropylene) hernia system (PHS)—an interim report. 5th annual meeting of the American Hernia Society; 2002 May 8-12; Tucson, AZ, USA.

29.    Fenoglio ME, Ham WE, Moore JT. Inguinal hernia repair: results using an open preperitoneal approach. Presented at: 5th annual meeting of the American Hernia Society; May 8-12, 2002; Tucson, AZ.

30.    Shadduck P. The learning curve for Kugel inguinal herniorrhaphy. Presented at: 5th annual meeting of the American Hernia Society; May 8-12, 2002; Tucson, AZ.

31.    Cheek CM, Black NA, Devlin HB, Kingsnorth AN, Taylor RS, Watkin DF. Groin hernia surgery: a systematic review. Ann R Coll Surg Engl. 1998;80(suppl 1):S1-S80.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

JOURNAL WATCH: JSLS Pneumomediastinum

Pneumomediastinum as a Complication of Preperitoneal Laparoscopic Hernioplasty • Madan AK, Likes M, Raafat A. JSLS(2003)7:73-75. Pneumomediastinum is a rare complication following laparoscopic preperitoneal hernioplasty and may be managed conservatively if it is an isolated finding.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source

Pelvic Floor Hernias: Tissue Repair or Replacement?

SYNTHETIC MESH AND XENOGENIC GRAFTS

JIM W. ROSS, MD, PhD

The recurrence of ventral abdominal or inguinal hernias has been reported to be 16% to 25% with “classical” hernia repairs, demonstrating that weakened in situ tissue used in these repairs has a poor long-term outcome. Today, these same hernia repairs have recurrences of less than 1% to 4% [1]. This dramatic improvement in successful long-term outcome is due to extensive use of tissue replacement and improvements in tissue substitution engineering. The most common tissue replacement sources include synthetic and biological materials. The use of synthetic mesh and xenogenic grafts in pelvic floor reconstructive surgery is extensive and will be reviewed here.

Synthetic Mesh. Synthetic mesh can be either a mono- or polyfilament weave (polyethylene, polypropylene, polytetrafluoroethylene). These materials have high-tensile strength, are long lasting, inert, nontoxic, and lack antigenicity. They can be engineered for mechanical mismatching to surrounding tissue, such that a stiff woven polypropylene mesh can promote intensive tissue ingrowth and develop intense scarification. This engineering design can be advantageous when high load-bearing is necessary. Polypropylene has been used extensively in general surgical repair of inguinal and abdominal wall hernias [2]. In gynecologic laparoscopy, it has been used for mesh-staple colposuspension [3,4] and for sacrocolpopexy [5].

A 5-year long-term success rate of 91% in 51 patients has been reported for laparoscopic sacrocolpopexies [6], which is comparable to that in studies utilizing an open abdominal approach [7-10]. Polypropylene mesh (Prolene, Ethicon, Inc., Sommerville, NJ) was used in this laparoscopic study [6]. Erosion has been reported with most synthetic materials, and 2 patients (4%) had vaginal erosion of the mesh, which is comparable to that in other reports (3% to 7%). One patient responded to trimming of the mesh and nightly estrogen vaginal cream. The second patient required trimming of the mesh and advancement of vaginal mucosa over the erosion site. The stiffness of polypropylene mesh plays a role in erosion, especially when attached to postmenopausal thinned out atrophic vaginal mucosa. We routinely amputate the proximal vaginal hernia sac down to the level of the ischial spines in severe prolapse. At this level, the endopelvic fascia (EPF) is more substantial for mesh attachment. Mesh stiffness can lead to increased rejection, fistula formation, encapsulated scar, erosion, pain, and nonfunctional end organs. One patient (work in progress) treated with a sacral colpoperniopexy had perineal and vaginal mesh erosion, which required removal of the mesh from the vaginal apex to the perineal body. Polypropylene with a softer weave is now available and should decrease erosion potential.

The newer multifilament polyesters now available are soft and their macroporosity results in less intense scarring and encapsulation. Polyesters have the same tensile strength as polypropylene and are much easier to work with laparoscopically because of their increased pliability. These polyesters appear to cut down on possible erosion and sinus tract formation, which are serious complications of sacral colpoperineopexies utilizing polypropylene [11]. Colpoperineopexy is the procedure of choice for descending perineum syndrome, frequently present with severe apical vault prolapse. In this repair, mesh is sutured to the perineal body, the posterior vaginal wall, and to the sacral promontory, effectively replacing the rectal vaginal septum and uterosacral ligaments. Attachment to the entire length of the posterior vaginal wall requires repair material that is soft, pliable, strong, and does not cause encapsulation. Intense scarification could lead to a nonfunctional vagina. We have a study in progress testing wide-weave polyesters with good early outcomes.

Xenogenic Grafts. The most common biological sources for tissue grafting are syngeneic, allogeneic, or xenogeneic in origin. Most recently, porcine dermis and small intestine submucosa (SIS) have been used extensively in pelvic floor reconstruction, especially posterior vaginal wall repair. Most studies utilize site-specific repairs, in conjunction with porcine dermal grafts, for a posterior vaginal wall defect [12,13]. We have an ongoing study of 57 women followed for greater than 6 months with Stage 2 or greater posterior vaginal wall defects (Pelvic Organ Prolapse Quantification System—POP-Q) [14]. Porcine dermis (n=33) or SIS (n=24) xenogeneic grafts were used for all repairs. These grafts were fixed to the uterosacral ligaments proximally, the rectovaginal septum arcus attachments laterally, and to the perineal body distally (Figures 1 and 2). No site-specific repairs utilize the patient’s own tissue. When an enterocele was present, the vaginal apex was opened via laparoscopy and the xenogeneic graft attached to the pubocervical fascia anteriorly and the uterosacral ligaments posterior-laterally. This technique results in a total replacement of the posterior EPF, reestablishment of the pericervical ring, and is not dependent on compromised in situ collagen tissue. The range of follow-up has been 6 to 33 months (mean, 17 months) with pelvic grading at 3 and 6 months and yearly. The average point A(p) was 0.25 and -.7 pre- and postoperatively (POP-Q). Surgical definition of cure was point A(p) -2.0 or less. At 1 year, 54 of 57 patients (95%) met the criteria for cure. Point A(p) in the 3 patients not meeting these criteria for cure was -1.0 in 2 and 0 in 1. All 3 patients were asymptomatic.

Both types of xenogeneic grafts were easy to use and suture in place. Porcine SIS implant sites were completely healed by 3 months and had a thinner pliable posterior wall, with the grafts being indiscernible. Porcine dermis healed more slowly and at 6 months, the posterior wall was still mildly indurated and thicker than the SIS implants. Differences in healing rate did not appear to be an important factor to patients. Neither early pliability nor increased thickness of the vaginal repair appeared to affect sexual function, as suggested by equal improvement in the sexual quality of life for patients with both grafts. Patients reported significant improvement in splinting, protrusion, evacuation, and dyspareunia in both groups. No grafts were rejected, and no significant complications occurred.

These xenogeneic grafts are being used just as successfully in anterior vaginal wall repair (Figures 3–5). They have been used in combination with both tension-free vaginal tape (TVT) and laparoscopic Burch colposuspension. In our clinic, we have found patients with severe paravaginal defects in which the arcus white line has been avulsed from the obturator internus muscle. Porcine SIS grafts have been used as a bridge to reapproximate the pubocervical fascia and arcus white line back to the lateral pelvic sidewall with excellent results.

We have used both types of xenogeneic grafts sutured to the distal end of polyester mesh strips (Parietex, Sofradim) for sacrocolpopexies. The end of the graft with porcine dermis or SIS is fixed distally to the perineal body or rectovaginal septum, and the polyester end is fixed to the promontory. The xenogeneic materials provide an excellent matrix for tissue ingrowth, and the polyester mesh has superior tensile strength. This “dual mesh” should decrease mesh erosion, because the polyester does not come in contact with the thinned out vaginal wall. The xenogeneic graft should result in a thicker, stronger vaginal wall with increased pliability. The ability to mix different materials for tissue replacement greatly increases our surgical options for reconstructive surgery.

Conclusion. Recurrent prolapse is a common complication in pelvic reconstructive surgery. Classical repairs are dependent on the use of weakened tissue with demonstrated abnormal collagen. This
issue has been compromised by pelvic floor muscle atrophy secondary to pelvic neuropathy. Currently, no treatment exists for pelvic neuromyopathy. The ability to use material that is stronger than in situ tissue or that has the potential to act as a scaffold for new tissue regeneration could be an alternative approach for pelvic reconstructive surgery. Synthetic mesh can be woven to have great tensile strength and be rapidly incorporated into surrounding tissue, making it ideal for areas of high stress. Biomaterials have multipotential for many types of repair. Xenogeneic grafts can be engineered for site-specific repairs that require both strength and function. Like all new technology, the use of these materials must be studied carefully before they are promoted for extensive use in patients. It is necessary to evaluate the long-term outcome of tissue replacement to determine which xenogeneic grafts and synthetic meshes will meet the unique requirements of pelvic floor reconstruction. The early studies for tissue replacement are encouraging.

Figure 1. Posterior vaginal wall dissection exposing rectovaginal septum and rectum.

Figure 2. Porcine dermal graft (inside the arrows) replacing the rectovaginal septum in posterior wall prolapse.

Figure 3. Anterior vaginal wall prolapse. Anchoring sutures have been placed through the arcus white from the ischial spines proximally to the pubic bone distally.

Figure 4. Porcine dermal graft (inside the arrows) replacing the rectovaginal septum in posterior wall prolapse.

Figure 5. Closure of the anterior vaginal wall defect.

Address reprint requests to: Jim W. Ross, MD, PhD, Director, Center for Female Continence, Clinical Professor, Dept Ob-Gyn, UCLA School of Medicine, 400 E Romie Ln, Salinas, CA 93901, USA. Tel: 831 757 3051, Fax: 831 757 3115, E-mail: jimross@redshift.com

Jim W. Ross, MD, PhD received his medical training at UCLA, where he also received his doctorate in Neuroendocrinology at the Brain Research Institute. He is the Director of the Center for Female Continence in Salinas, California and a Clinical Professor at UCLA. Dr Ross was a leader in the early development of laparoscopic pelvic reconstructive surgery, being the first to publish on laparoscopic repair of total pelvic prolapse. He has published on laparoscopic Burch colposuspension, paravaginal repair, and sacrocolpopexy. Dr Ross lectures in the United States and internationally and is on the editorial board of several laparoscopic organizations. His special interests include urinary and fecal incontinence, pelvic floor reconstructive surgery, and the neurophysiology of pelvic organ prolapse.

References

1.    Lepere M, Benchetrit S, Debaert M, et al. A multicentric comparison of transabdominal versus totally extraperitoneal laparoscopic hernia repair using PARIETEX meshes. JSLS. 2000;4:147-153.

2.    Liem MS, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med. 1997;336:1541-1547.

3.    Ou C, Presthus J, Beadle E. Laparoscopic bladder neck suspension using hernia mesh and surgical staples. J Laparoendosc Surg. 1993;3:563-566.

4.    Ross JW. Two techniques of laparoscopic Burch repair for stress incontinence: a prospective, randomized study. J Am Assoc Gynecol Laparosc. 1996;3:351-357.

5.    Ross J. Techniques of laparoscopic repair of total eversion after hysterectomy. J Am Assoc Gynecol Laparosc. 1997;4:173-183.

6.    Ross J. Complex laparoscopic pelvic reconstructive surgery. J Am Assoc Gynecol Laparosc. 2001;8:S60.

7.    Addison W, Timmons MC. Abdominal approach to vaginal eversion. Clin Obstet Gynecol. 1993;36:
995-1004.

8.    Brubaker L. Sacrocolpopexy and the anterior compartment: support and function. Am J Obstet Gynecol. 1995;173:1690-1696.

9.    Snyder T, Krantz KE. Abdominal-retroperitoneal sacral colpopexy for the correction of vaginal prolapse. Obstet Gynecol. 1991;77:944-949.

10.    Timmons M, Addison WA, Addison SB, Cavenar MG. Abdominal sacral colopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele. J Reprod Med. 1992;37:323-327.

11.    Cundiff G, Harris RL, Coates K, Low VHS, Bump RC, Addison WA. Abdominal sacral colpoperineopexy: a new approach for correction of posterior compartment defects and perineal descent associated with vaginal vault prolapse. Clin Obstet Gynaecol. 1997;177:1345-1355.

12.    Fischer A. Prolapse surgery using biomaterials. Eur Urology Suppl. 2002;1:29-32.

13.    Kohli N, Miklos JR. Dermal graft-augmented rectocele repair. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:146-149.

14.    Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:10-17.

www.Laparoscopy.org  The Laparoscopic Surgery Information Source