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JOURNAL WATCH: SURG ENDOSC

A Lifelike Patient Simulator for Teaching Robotic Colorectal Surgery: How to Acquire Skills for Robotic Rectal Dissection. Marecik SJ et al. 2008;22:1876-1881 • The authors report on the creation and use of a cost-effective, portable, and reusable model for training in robotic rectal dissection. Various components were included or added to the device depending on the procedure being simulted, but the basis of the tool is a plastic model of the human pelvic skeleton mounted onto a sturdy laminate-covered base using an adjustable bracket to alter the pelvic angle. The authors concluded that the trainer provided an accurate simulation of true robotic rectal dissection.

JOURNAL WATCH: J Minimally Invasive Gynecol

The Efficacy of Viewing an Educational Video as a Method for the Acquisition of Basic Laparoscopic Suturing Skills. Akl MN et al. 2008;15(4):410–413 • The twelve participants in this prospective observational study were evaluated performing 5 tasks after watching a 6 minute basic principles video: needle intro through trocar, needle loading and positioning, running continous suture, intra- and extracorporeal knot tying. The authors concluded that an educational video appears to be an effective method.

Virtual Reality and Computer-Enhanced Training Devices Equally Improve Laparoscopic Surgical Skill in Novices

PICK FROM JSLS, JOURNAL OF THE SOCIETY OF LAPAROENDOSCOPIC SURGEONS

PRATHIMA KANUMURI, MD, SABHA GANAI, MD, EYAD M. WOHAIBI, MD, RONALD W. BUSH, BS, DANIEL R. GROW, MD, NEAL E. SEYMOUR, MD

INTRODUCTION

The advent of simulation training of minimally invasive surgical skills has created significant opportunities for ongoing development of innovative training methods. Several recent investigations have shown that the use of computer-driven simulation training devices results in transfer of skills into the operating room environment [1-4], and mandatory application of simulation methods has been forwarded as a means of improving surgical results and patient safety [5]. A growing number of laparoscopic simulation training platforms and generally limited institutional resources have created difficulties for educators faced with the prospect of introducing these training methods into their programs [6]. Ideally, the decision to procure a specific device ought to be based on the anticipated effectiveness in the specific application for which it will be used.

A wide variety of laparoscopic simulators is now available, and they can be broadly classified into videoscopic and computer-driven laparoscopic simulation platforms, which are further divided into virtual reality (VR) and computer-enhanced videoscopic (CE) trainers. These trainers primarily differ in their user interface and ability to provide reliable performance measurements. Videoscopic trainers allow manipulation of actual physical objects and require manual data collection. In contrast, VR trainers utilize a virtual environment and provide computer automated performance metrics. CE trainers attempt to bridge the gap between videoscopic and VR systems, their user interface is similar to the former, but they provide computer-generated performance metrics like VR trainers do [7]. Despite these fundamental differences, their intended purpose is the same: To provide assessment and training in specific skills based on sophisticated performance measurement capabilities that would not be available without the use of desktop computing. Effective performance measurement is the basis for establishment of performance objectives and for proficiency-based training, which is emerging as the educational model of choice in skills training [8].

In the present study, we examined training effectiveness of examples of the 2 classifications of computer-driven laparoscopic skills trainers using proficiency-based training models with the specific aims of (1) demonstrating that novice surgical trainees can acquire complex laparoscopic skills using fundamentally different simulation systems and (2) to demonstrate that the use of performance objectives established by a homogeneous group of more advanced trainees will result in similar levels of
skills improvement with the 2 systems.

METHODS

Study participants were 16 Tufts University School of Medicine third-year medical students on their General Surgery and Obstetrics and Gynecology clerkships at Baystate Medical Center. The study was exempted from full review by our Institutional Review Board, and informed consent was not required for enrollment. The general study design called for students to undergo a pretraining assessment in laparoscopic intracorporeal suturing and knot tying. Participants were then randomized to train to perform this task using either a VR (n=8) or CE (n=8) simulator. At the end of the 4-week clerkship, a posttraining assessment identical to the pretraining assessment was conducted, and students had to complete an end of study survey   characterizing qualitative aspects of their training experience.

Pre- and Posttraining Assessments

The pre- and posttraining assessments consisted of performance of a laparoscopic suturing and intracorporeal knot tying task in a live anesthetized porcine model (25kg to 30kg, Yorkshire pig sedated with intramuscular ketamine 100mg/kg and xylazine 10mg/kg and maintained under general anesthesia using endotracheal isoflurane) under a specific protocol approved by the Institutional Animal Care and Use Committee. Immediately before both assessments, all participants received standardized didactic instruction explaining task performance as described in the SAGES Fundamentals of Laparoscopic Surgery (FLS) course, and viewed the FLS video demonstration of a suturing and knot tying sequence. This was followed by a brief quiz to assess their understanding of the task and associated errors. In the operating room, each student was given 5 minutes (min) to perform the task, which was video-recorded for subsequent analysis. The specific task consisted of approximation of 2 loops of small intestine using standard instrumentation and laparoscopic port placement. This was accomplished with 2-0 silk suture and SH needle (Ethicon) with an initial surgeon’s knot and then 2 subsequent square throws. The animal was euthanized after the assessments were completed. Although general instructions were provided, no mentoring or feedback was given during student performance of any task.

Simulation Training

VR simulation training was conducted using MIST-Suture software (SimSurgery, AS, Oslo, Norway). “Interrupted Suture” task was run on a MIST-VR simulator (Mentice AB, Göteborg, Sweden) with an Immersion Virtual Laparoscopic Interface (Immersion Medical, Gaithersburg, MD) (Figure 1). Performance metrics consisted of a composite score for time and errors.

CE training was accomplished using a ProMIS simulator (Haptica Ltd., Dublin, Ireland) (Figure 2), and a custom model of 2 adjacent 1-inch Penrose drains that permitted the intracorporeal suturing and knot tying task to be performed with the same technique and instrumentation used for the operating room assessments. This simulator consists of a torso model containing optical motion sensors to detect instrument movement characteristics. Performance metrics consisted of time, instrument path length, and smoothness of motion.

To facilitate distributed learning of the task, students were scheduled for 8 one-hour mentored training sessions over the 4-week rotation, but were permitted to have additional training under the same conditions. VR and CE training was mentored by either the full-time skills lab training technician or a surgeon researcher, both of whom were experts in performing the task. The training objectives for each system were based on the performance scores of 2 fourth- and 2 fifth-year general surgery residents. For the purposes of this study, proficiency was defined as achievement of performance scores within one standard deviation (SD) of the predefined objectives on 3 consecutive task iterations.

End-of-Study Survey

After the posttraining assessment, students completed a survey soliciting demographic information and prior laparoscopic experience (description of specific activities during cases). Qualitative impressions of the importance of simulation training, the importance of haptic cues in simulators, and the educational value of the specific training system used, were surveyed with responses given on a 3-point scale of “very effective,” “effective,” or “not effective.”

Video Analysis

The pre- and posttraining assessment videos were reviewed by 2 independent surgeon raters, blinded to student identity and training status, using a performance assessment tool previously validated at our institution [9]. For the purposes of this analysis, the task was divided into 2 phases. In the “Suturing Phase,” the needle was brought to a functional position, driven through the 2 loops of bowel, and then secured after the suture was pulled through the tissue to the appropriate length to permit knot tying. The “Knot-tying Phase” was defined as the performance of a surgeon’s knot and then 2 successive square simple throws to complete a square knot. Video rating consisted of quantifying discreet events during each phase that pertained to efficiency, expert-defined correct behaviors, and specific errors to produce a summative performance score.

Statistical Analysis

Data are expressed as means with 95% confidence intervals (CI). Comparisons between groups were conducted by Mann Whitney U test and comparisons within groups before and after training by Wilcoxon matched pairs test. Comparisons of achievement of proficiency, task completion rates, and questionnaire data were by Fisher’s exact test. The Mann Whitney U test was performed using Epi Info software (Version 3.3.2, Centers for Disease Control, Atlanta, GA), and Wilcoxon matched pairs test and Fisher exact test were performed using GraphPad Instat software (San Diego, CA). Statistical significance was taken at a P<0.05.

RESULTS

The average age of the participants was 26±1 years, and the sex distribution was 63% (n=10) male and 37% (n=6) female. The participants had minimal prior laparoscopic experience, ranging from no experience to holding the camera.

Training Sessions

Performance curves for the VR and the CE-trained groups had a classic appearance of early, rapid improvement, followed by a more gradual pattern of incremental improvement (Figure 3). There were no significant differences in the proportion of students who reached proficiency [VR 75% (n=6); CE 88% (n=7)] and in percentage compliance for scheduled training sessions (VR 73%; CE 67%) (Table 1). The sum of total recorded task time was comparable between groups [VR 115 min (range, 61 to 169); CE 111 min (85-136); P>0.05]. However, the total number of iterations completed by the VR-trained students was significantly lower compared with that of CE-trained students [VR 17 (8-26); CE 38 (30-45); P<0.05], because the time taken to complete one iteration on the VR trainer was longer than that on the CE trainer (VR 9±2 min; CE 3±1 min). Time taken to reach the predefined proficiency level was significantly shorter in the VR group compared with that in the CE group [VR 43 min (range, 28 to 59); CE 75 min (range, 45 to 104); P<0.05).

Pre- versus Posttraining Assessment Performance

The interrater reliability for video analysis of pre- and posttraining performance was 0.88. The overall task completion rate was significantly higher posttraining for both the VR-trained and CE-trained groups (P<0.01) (Table 2). The time to task completion decreased on the posttraining assessment (P<0.01) for both the VR (P<0.05) and CE (P<0.01) groups. It must be noted that time to task completion did not represent a true value, reflecting completion of the task in all students because the longest possible figure for task time capped at the 300 second limit. This resulted in a larger effect on the pretraining assessment, where 13 of 16 students did not complete the task. Despite this limitation, the decrease in mean time after training was highly significant. Suturing phase time and video analysis score were also compared because all students completed this phase on both pre- and posttraining assessments. A significant improvement was demonstrated for both measures in the VR-trained group but not in the CE-trained group. Comparison of pre- and posttraining total video analysis scores was not feasible due to the very low task completion rate on pretraining assessment (3 of 16 participants). No significant differences were noted between groups on the pretraining assessment with the exception of the suturing phase score, which was higher in the CE group. The 2 groups did not differ in their posttraining assessment time or total video analysis score.

End-of-Study Survey

Survey responses indicated that students had minimal exposure to laparoscopic surgery, ranging from no experience to watching cases and holding the camera. Students generally felt that haptic feedback was important during training on simulators, and that the use of the 2 platforms was effective in increasing their skill levels, without any significant differences in the frequency of “effective” and “very effective” responses between the 2 groups (Table 3). However, all students in the CE group felt that their system simulated reality effectively, compared with only 38% in the VR group, a difference that was statistically significant.

DISCUSSION

Based on results from previous studies [1-4], we assumed that laparoscopic skills in novices would improve with objectives-based training and did not include an untrained control arm in the study design. This reflects our belief that properly implemented training on simulator systems with demonstrated face and construct validity will result in skills transfer to an OR setting and that examination of performance relative to totally untrained individuals does not have to be pursued in every circumstance. The repeated measures model utilizing each subject as his or her own control was selected instead, permitting us to address the study aim with an appropriate number of subjects. Medical students with minimal prior laparoscopic experience achieved a training benefit within the framework of a 4-week clerkship. Survey results indicate that over the course of their rotations, activities during laparoscopic teaching cases contributed minimally to the observed improvement in skills.

Although there were no significant differences in either the magnitude of skills improvement achieved with training on the VR system versus the CE system, or in the absolute levels of measured skills at the end of training, the study may not have been sufficiently statistically powered to detect small differences in the magnitude of skills transfer. Despite this, the skills transfer effects of simulation training to operative performance, can be described as comparable. Although pretraining skills were otherwise homogeneous in the 2 groups, a slightly higher CE-trained group pretraining suture phase scoring was observed. This is likely due to a sampling phenomenon with a fairly small experimental group size. The proficiency targets proved to be achievable for the majority of students, and the fact that 3 students did not achieve these objectives did not hinder demonstration of skills transfer. Because training was conducted on platforms that used different performance metrics (time and error composite scores on the VR trainer, and time, path length, and smoothness on the CE trainer), it is difficult to compare some of the training results. Students in the VR training group took less time to reach the designated proficiency targets compared with the CE training group. However, we cannot conclude that the VR system facilitates faster learning because we did not stop training on either system when the proficiency targets were reached, and some students did additional task iterations after achieving proficiency levels. In addition, as stated above, 3 of the students did not achieve proficiency levels. Performance objectives were based on historical performance of PGY 4 and 5 residents, with objectives for VR established 1 year before CE objectives. It is possible that uneven skill levels between disparate groups of residents may have confounded the simulator performance data on which the objectives were based, and also contributed to the differing times to achieve proficiency targets.

The inability to make comparisons of total video analysis scores pre- and posttraining due to the low task completion rate on the pretraining assessment was a limitation in our study. Although we have given the results of the suturing phase score, this value is limited as it represents only a portion of the task that is arguably less difficult than knot tying. The low task completion rate was probably because the task is a fairly difficult one for novices and task performance time was limited to 5 minutes. Time was capped based on the expectation that all students would be able to complete the task in the posttraining assessment after sufficient training. We felt that it was important not to allow the initial assessment to constitute a training opportunity by allowing essentially unlimited time to complete the task. Though a truncated task completion time may seem problematic, we successfully demonstrated a significant improvement in task completion rate and task completion time during the posttraining assessment.

Several prior studies have compared the effectiveness of videoscopic and VR trainers. These have made recommendations that both systems are effective in improving skills [10], that there may be training value to concurrent use of both system types [11], or that VR training has an advantage [12,13]. The application of performance objectives in our study allowed us, to a great extent, to ensure that desired performance benchmarks on the 2 system types were comparable. Under these circumstances, although a minority of participants (comparable proportions on the 2 systems) did not achieve these objectives, we have demonstrated that comparable levels of performance improvement can be achieved with trainers that are fundamentally different in the experience provided to users.

Although performance results were similar, we have found in our experience that VR trainers offer some practical advantages over videoscopic and CE trainers. These pertain to automated performance metrics that can be easily retrieved and examined, but more importantly, are obtained under very standardized conditions. During self-directed practice, even with the performance measures available with a sophisticated system such as ProMIS (CE trainer), it is impossible to comment on what actually occurred during training unless video recordings are examined. Because VR tasks are, for the most part, rules-based, performance measures reflect achievement of steps specifically defined in the simulator software. Although this facilitates standardization, software-dependent tasks can be less free-form compared with videoscopic and CE trainers, and such constraints can be viewed as a disadvantage.

Both VR and CE training devices are roughly equivalent in price ($35,000 to $50,000), and the number of facilitator hours for training on the respective systems was also approximately the same (despite the small difference in “time to reach proficiency” between the systems). Hence, there does not appear to be an advantage that would steer a program director to one or the other of these systems. However, it is important to note that VR trainers may prove to be more cost-effective when compared with videoscopic trainers (computer-enhanced, or not) due to considerations that enter the usage picture that might influence the quality of the training experience during self-directed practice. These include automation in the course of uniform task setup, consistent qualitative performance metrics, and mentoring cues in more advanced systems. These features allow more effective self-directed practice in VR, and might necessitate the use of a facilitator with all associated costs to achieve a similar effect on a videoscopic (or CE) trainer. Our study was not designed to analyze the cost-benefit ratio of individual systems, but we believe it is an important question that ought to be addressed in our future work.

The absence of haptic feedback features on the VR system we used permitted some information to be gleaned on the value of these characteristics in this type of training. The presence of “haptic cues,” defined as “sense of touch” or tactile characteristics associated with interactions between physical objects, may have contributed to the higher perceived level of realism associated with the CE trainer. The end-of-study survey results for the 2 systems were comparable, except that CE trainees were more likely to feel that their system simulated reality effectively compared with VR trainees. Because subjects performed pre- and posttests with real laparoscopic instruments in live porcine models, they were able to compare their simulation training experience with “reality,” despite the fact that laparoscopic surgical exposure was limited. Our results are supported by other studies comparing videoscopic trainers and nonhaptic VR trainers [12,14,15]. We hypothesize that this is due to both realism and familiarity issues that do not necessarily result in a degraded training experience. Although the ability to appreciate tactile features of objects with which a surgeon interacts may be perceived as an essential component of learning, there is no compelling evidence to show that it is necessary for the types of skills acquisition we have studied. Despite a clear perception among the participants, irrespective of the training platform used, that haptic features are important in a simulator, the performance results of our study do not substantiate this belief. Because VR trainers at an approximate price point less than $80,000 do not feature haptic user interfaces, this finding is an important one, irrespective of any preconceived beliefs. Considerable development efforts are required to achieve believable force feedback interactions, and newer generation high-fidelity VR simulators that offer this feature are quite expensive [6]. It may be that this higher level of fidelity will be shown to be important for full procedural simulations, but for basic manipulative skills training, the haptic component of fidelity appears to be dispensable. The newest full haptic VR trainers may offer force feedback interactions of sufficiently high quality to permit a comparison of training effectiveness with nonhaptic VR systems to be made using identical software platforms. This would remove the variable of fundamentally different operating environments from the comparison.

CONCLUSION

Based on this study’s data, we conclude that novice surgical trainees can acquire complex laparoscopic skills using fundamentally different simulation systems provided that training is objectives based and ample opportunities are given to achieve these objectives. However, it is not possible to recommend one simulator type over another. Given the devices that are currently available, it is our belief that expected performance outcomes are more tightly linked to the quality of training and to the clinical assessment methodology, than to the specific features of the simulator. Although the assumption that haptic feedback is important for simulator fidelity may be supportable, it appears that use of a VR system with a nonhaptic user interface permits very similar training results to that achieved with a CE system that allows interaction with real physical objects. Based on our use of these 2 systems, we feel that either can be used in a formative training program with the expectation of a good training effect. The results of future use in routine training activities should provide additional opportunities to confirm the achievement of training goals with virtual reality and hybrid, computer-enhanced training platforms.

Figure 1.  MIST-VR simulator (Mentice AB, Göteborg, Sweden) with Immersion Virtual Laparoscopic Interface (Immersion Medical, Gaithersburg, MD) (A). This device was set up to run MIST-Suture software (SimSurgery, AS, Oslo, Norway) on the “Interrupted Suture” task (B).

Figure 2.  The ProMIS computer-enhanced simulator (Haptica Ltd., Dublin, Ireland) (A). This device was set up for users to approximate 2 segments of Penrose drain with an interrupted suture (B).

Figure 3.  Performance curves for trainees on both virtual reality and computer-enhanced devices had a classic appearance of early, rapid improvement, followed by a more gradual pattern of incremental improvement. Virtual reality device: MIST-VR (A); Computer-enhanced device: ProMIS (B, C, D).

Reprinted from JSLS, Journal of the Society of Laparoendoscopic Surgeons. 2008;12(3):219–226.

Baystate Medical Center, Department of Surgery, Tufts University School of Medicine, Springfield, Massachusetts, USA (Drs Kanumuri, Ganai, Wohaibi, Seymour, Mr Bush).

Baystate Medical Center, Department of Obstetrics and Gynecology, Tufts University School of Medicine, Springfield, Massachusetts, USA (Dr Grow).

Correspondence: Neal E. Seymour, MD, Associate Professor of Surgery, Tufts University School of Medicine, Vice Chairman, Department of Surgery, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA. Telephone: 413 794 4025, Fax: 413 794 1764, E-mail: neal.seymour@bhs.org

References

1. Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Ann Surg. 2002;236:458-463.

2. Grantcharov TP, Kristiansen VB, Bendix J, et al. Randomized clinical trial of virtual reality simulation for laparoscopic skills training. Br J Surg. 2004;91:146-150.

3. Hyltander A, Liljegren E, Rhodin PH, Lonroth H. The transfer of basic skills learned in a laparoscopic simulator to the operating room. Surg Endosc. 2002;16:1324-1328.

4. Ganai S, Donroe JA, St Louis MR, et al. Virtual-reality training improves angled telescope skills in novice laparoscopists. Am J Surg. 2007;193:260-265.

5. Schijven MP, Jakimowicz JJ, Broeders IA, Tseng LN. The Eindhoven laparoscopic cholecystectomy training course--improving operating room performance using virtual reality training: results from the first E.A.E.S. accredited virtual reality training curriculum. Surg Endosc. 2005;19:1220-1226.

6. Schijven M, Jakimowicz J. Virtual reality surgical laparoscopic simulators. Surg Endosc. 2003;17:1943-1950.

7. Stylopoulos N, Cotin S, Maithel SK, et al. Computer-enhanced laparoscopic training system (CELTS): bridging the gap. Surg Endosc. 2004;18:782-789.

8. Gallagher AG, Ritter EM, Champion H, et al. Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training. Ann Surg. 2005;241:364-372.

9. Thompson RE, Earle DB, Kuhn JN, et al. Use of a new performance assessment tool for a complex laparoscopic task. Surg Endosc. 2006;20(suppl 1):S342.

10. Munz Y, Kumar BD, Moorthy K, et al. Laparoscopic virtual reality and box trainers: is one superior to the other? Surg Endosc. 2004;18:485-494.

11. Madan AK, Frantzides CT. Prospective randomized controlled trial of laparoscopic trainers for basic laparoscopic skills acquisition. Surg Endosc. 2007;21:209-213.

12. Hamilton EC, Scott DJ, Fleming JB, et al. Comparison of video trainer and virtual reality training systems on acquisition of laparoscopic skills. Surg Endosc. 2002;16:406-411.

13. Youngblood PL, Srivastava S, Curet M, et al. Comparison of training on two laparoscopic simulators and assessment of skills transfer to surgical performance. J Am Coll Surg. 2005;200:546-551.

14. Madan AK, Frantzides CT, Tebbit C, Quiros RM. Participants' opinions of laparoscopic training devices after a basic laparoscopic training course. Am J Surg. 2005;189:758-761.

15. Botden SM, Buzink SN, Schijven MP, Jakimowicz JJ. Augmented versus virtual reality laparoscopic simulation: what is the difference?: a comparison of the ProMIS Augmented Reality Laparoscopic Simulator versus LapSim Virtual Reality Laparoscopic Simulator. World J Surg. 2007;31:764-772.

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.

JOURNAL WATCH: SURG ENDOSC

Natural-orifice Transgastric Endoscopic Peritoneoscopy in Humans: Initial Clinical Trial. Hazey JW et al. 2008;22:16-20 • To investigate the feasibility and develop needed techniques and technology for NOTES, the authors conducted a study performing transoral transgastric diagnostic peritoneoscopy. Ten patients underwent diagnostic laparoscopic evalution of a pancreatic mass, and the findings were recorded by anatomical abdominal quadrant. A second surgeon, blinded to the initial results then performed transgatric peritoneoscopy. Diagnostic findings between the two methods were compared, and the authors concluded that transgastric diagnostic peritoneoscopy is safe and feasible.

JOURNAL WATCH: OUTPATIENT SURGERY MAGAZINE

A Better Way to Predict Operative Risk. Ahmad I. October 2007:98-100 • The author points out that the ASA Physical Status Classification System is being used in ways it was never intended including determining patient operative risk. In this anesthesia alert, Milad presents a simple scale based on clinical data as well as personal clinical experience. The scale comes from quantifying three categories of information from the patient’s chart and was applied to 5604 patients throughout 2006. Results of the study indicated that the scale is accurate.

JOURNAL WATCH: OBG MANAGEMENT

Major Vascular Injury During Laparoscopy: Pearls to Cope. Milad M. April 2008:62-68 • This surgical techniques article presents a case of “Trocar Insertion, Then a Bleed” in a 29-year-old nulliparous patient undergoing diagnostic laparoscopy. Milad notes that gynecologic laparoscopy has a rate of major complication similar to that of laparotomy and a higher rate of major vascular injury. How to avert and handle this type of injury is further discussed with Milad detailing (including diagrams) the following 5 pearls:

(1) Pay attention to subtlety, starting at the preop visit; consider the patients height, weight, BMI, and surgical history.

(2) Don’t undervalue that ounce of prevention: select an entry technique wisely, tips to facilitate entry, no single trocar is fail-safe.

(3) Don’t be the king or queen of denial. A major vascular injury should immediately be suspected when a retroperitoneal hematoma or brisk bleeding is visualized.

(4) No man is an island. Get help when you need it.

(5) Identify, secure, and control the site of injury: laparoscopy is usually not an option, a vertical skin incision is best, control the bleeding, repair the laceration.

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.

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PAUL ALAN WETTER, MD

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