Abstract:

Laparoscopic ventral hernia repair (LVHR) remains a safe, reproducible, and popular method employed by surgeons to repair abdominal wall hernias. Patient selection, operative technique, instrumentation, and implant choice all remain surgeon dependent. Inherent in the technique is the option of using mesh. The decision of where to place the mesh and how to optimally fixate the mesh in the onlay, sublay, or intraabdominal positions also remain surgeon dependent and has been the subject of ongoing debates for the past two decades. In an ongoing effort to develop new methods for securing mesh to minimize pain without increased recurrence rates, novel mesh fasteners and mesh textiles have been developed. With increasing surgeon responsibility to improve value, surgeons should concentrate more on choosing the novel options that not only improve outcomes, but also reduce overall costs. This chapter reviews some of the emerging markets for these technologies.

Authors:

David J. Berler, MD, Resident, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, Thomas Cook, MD, Fellow, Our Lady of the Lake Physician Group, Minimally Invasive Surgery Institute, Baton Rouge, Louisiana, Karl LeBlanc, MD, Associate Medical Director, Our Lady of the Lake Physician Group, Baton Rouge, Louisiana, Brian P. Jacob, MD, Associate Professor, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York

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Abstract:

The use of the da Vinci robot for inguinal and ventral hernia repair has exponentially increased over the last five years. This increase is occurring in spite of historical cost analyses showing robotic surgery to be cost prohibitive for other general surgery procedures. Specific data regarding outcomes and cost analysis for hernia is lacking. The increase in robotic hernia repairs is likely related to intangible factors such as enhanced visualization, articulating instruments, and hospital resources. Further study of robotic hernia repair is needed prospectively as its use increases to delineate the true benefits.

Authors:

Nathaniel Stoikes MD, Assistant Professor, Section of Minimally Invasive Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, David Webb, MD, Assistant Professor, Section of Minimally Invasive Surgery, University of Tennessee Health Science Center, Memphis, Tennessee, Guy Voeller, MD, Professor, Section of Minimally Invasive Surgery, University of Tennessee Health Science Center, Memphis, Tennessee

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Abstract:

Patients who undergo laparoscopic ventral hernia repair can have significant post-operative pain and discomfort from both somatic pain due to mesh fixation and visceral pain due to CO2 insufflation pressure. In an attempt to improve outcomes, a Clinical Quality Improvement (CQI) project was implemented by a multi-disciplinary hernia team. CQI tools were applied for consecutive patients who underwent laparoscopic ventral hernia repair from June 2012 through September 2015 (39 months). Initiatives for improved patient outcomes during this period included the administration of a transversus abdominis plane (TAP) block and/or an intra-operative block with long-acting local anesthetic first, and then a low pressure pneumoperitoneum (LPP) system was implemented later in the project. One-hundred-twenty patients who underwent a laparoscopic ventral/incisional hernia repair were included in the analysis. Fifty-three patients had no block and had conventional insufflation at 15 mmHg (No Block-No LPP group). Outcomes for this group included a median time in the Post-Anesthesia Care Unit (PACU) of 126 minutes, a median length of stay of 4.0 days, a median use of opioid morphine equivalents (MEQ) in the PACU of 10.0, and a total use of opioid MEQ for the entire hospital stay of 100.0. Thirty-seven patients had blocks with a long-acting local anesthetic and conventional insufflation at 15 mmHg (Block only group). Outcomes for this group showed improvement for all outcomes, but none were statistically significant. Thirty patients had blocks with a long-acting local anesthetic and a low pressure pneumoperitoneum system with a standard pressure of 8 mmHg. Outcomes for this group included a median time in PACU of 83.6 minutes, a median length of stay of 1.5 days, a median amount of opioid use in the PACU of 5.0 MEQ, and a median use of opioid use for the entire hospital stay of 26.0 MEQ. All of these outcomes were statistically significant improvements compared with the No Block-No LPP and Block only groups. Implementation of a CQI program, including long-acting local anesthetic blocks and a low pressure pneumoperitoneum system as part of a multi-modal pain strategy for patients who underwent laparoscopic ventral hernia repair, was associated with decreased PACU time, decreased length of stay, and less opioid use in the PACU and for the entire hospital stay.

Authors:

Bruce Ramshaw, MD, Professor and Chair, Brandie Forman, BA, Hernia Clinician and Patient Care Manager, Eric Heidel, PHD, Assistant Professor, Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennessee, Jonathan Dean, MD, PGY5, Surgeon, Andrew Gamenthaler, MD, Surgeon, Michael Fabian, MD, Surgeon, Department of Surgery, Halifax Health, Daytona Beach, Florida

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Abstract:

Introduction: Minimally invasive laparoscopic and robotic techniques for ventral hernia repair have evolved to achieve the benefits and minimize the limitations of both the open Rives-Stoppa sublay mesh repair and laparoscopic intraperitoneal onlay mesh (IPOM) repair. By combining the principles of a retromuscular repair with the benefits of a minimally invasive approach, these techniques attempt to decrease recurrence, increase functionality, exclude mesh from the viscera, limit infection and wound complications, and minimize pain. The difficult ergonomics, challenging dissection, and extensive suturing make traditional laparoscopic sublay repair technically challenging and has led to increased robotic utilization to overcome these limitations. We describe a laparoscopic extraperitoneal sublay mesh repair technique using an endoscopic stapler to facilitate reapproximation of the linea alba and creation of the retromuscular space, and self-gripping mesh to position and fixate the prosthetic. Materials and Methods: Between January and June 2016, 10 patients with midline ventral and incisional hernias underwent laparoscopic extraperitoneal stapled sublay mesh repair with self-gripping mesh. Three of these cases included a laparoscopic posterior component separation with myofascial release of the transversus abdominis muscle to facilitate midline closure. Intraoperative and perioperative complications, early recurrence, pain, and narcotic usage were measured. Results: There were no significant intraoperative complications or conversions to open surgery. Patients were discharged at 1.2 days on average. Early postoperative complications included a hernia site seroma in one patient, which resolved without intervention. There were no early postoperative infections or recurrences. Compared with traditional laparoscopic IPOM repair, there was less acute postoperative pain and use of analgesics. Conclusions: Laparoscopic extraperitoneal stapled sublay mesh repair is a safe and effective method for the treatment of medium- to large-sized ventral and incisional hernias. This extraperitoneal stapled approach using self-gripping mesh facilitates a minimally invasive sublay repair and abdominal wall reconstruction using traditional laparoscopic tools.

Authors:

Alexandra M. Moore, MD, Resident, General Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California, Lisa N. Anderson, BS, Medical Student, Texas A&M Health Science Center, College of Medicine, Bryan, Texas, David C. Chen, MD, Associate Professor, Clinical Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California

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Abstract:

Single-port laparoscopic surgery is gaining increased attention because of its superiority in terms of cosmesis. A 1.5 cm vertical transumbilical incision is used for the single port, which is created by the glove method. We began applying single-port surgery to hernia repair in 2010, at which time we used the transabdominal preperitoneal (TAPP) approach. We began applying the totally extraperitoneal peritoneal (TEP) approach in 2013. Single-port TEP repair is now our standard procedure for inguinal hernia repair, and we consider it to be indicated for all cases of inguinal hernia unless the hernia has occurred during pregnancy, the patient is assigned to American Society of Anesthesiologists (ASA) class 3/4, or ascites due to liver cirrhosis is present. Provided herein is a step-by-step description of our single glove-port TEP hernia repair procedure, tips that facilitate the procedure, and a brief summary of the 102 cases in which we have performed TEP repair.

Authors:

Noriaki Kameyama, PhD, Chief Director, Department of Digestive Surgery, Tachikawa Hospital, Tokyo, Japan, Norihiro Kishida, PhD, Clinical Fellow, Department of Digestive Surgery, Tachikawa Hospital, Tokyo, Japan, Yuki Seo, PhD, Clinical Fellow, Department of Digestive Surgery, Tachikawa Hospital, Tokyo, Japan, Satoshi Tabuchi, MD, Clinical Fellow, Department of Digestive Surgery, Tachikawa Hospital, Tokyo, Japan, Toshiki Yamashita, MD, Senior Resident, Department of Digestive Surgery, Tachikawa Hospital, Tokyo, Japan

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