3/21/2011. Advances in laparoscopic ventral hernia repair. Laparoscopic approach well-suited for simple hernias:

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1 Advances in laparoscopic ventral hernia repair Topics Technique of laparoscopic ventral hernia repair Patient selection Is laparoscopic any better than open? Recent advances (or, should we say, advances?) 2nd generation mesh Absorbable tack fixation Jonathan Carter, MD Assistant Professor of Surgery, UCSF Nothing to disclose Laparoscopic components separation Patient selection Laparoscopic approach well-suited for simple hernias: no contamination (entry to GI, biliary, GU tracts) no fistulas or stomas to deal with no infected prosthetic mesh or other active intraabdominal infections not much loss of abdominal domain no attenuated skin bridge over hernia sac abdomen not hostile 1

2 Results of laparoscopic ventral hernia repair Results of laparoscopic ventral hernia repair Retrospective, multicenter review of 850 lap ventral hernia repairs. All hernias were at least 4cm diameter eptfe underlay technique used with fascial overlap at least 4cm Fascial fixation every 3-6 cm ProTack every 1-1.5cm Mean follow-up of 20 months (range 1-96 months) Results of laparoscopic ventral hernia repair Results of laparoscopic ventral hernia repair Prospective trials: laparoscopic versus open 2

3 Laparoscopic versus open repair: data from prospective trials Laparoscopic versus open repair: data from prospective trials 170 patients prospectively randomized open vs. laparoscopic Outcome measures: recurrence LOS complication rate return-to-work Laparoscopic technique: Parietex mesh, double crown of Protacks, no fascial fixation Open technique: Rives-Stoppa repair with polypropylene Median follow-up was 24 months. Method of follow-up and dropout rate not reported. Laparoscopic versus open repair: meta-analysis Laparoscopic versus open repair: meta-analysis 3

4 Laparoscopic versus open repair: meta-analysis If we artificially produce tissues of the density and toughness of fascia and tendon, the secret of the radical cure of hernia would be discovered - Theodor Billroth to his pupil Czerny, 1878 LOS Complications The ideal mesh would be sided: vigorous tissue ingrowth on parietal side, no adhesions on visceral side minimal or no shrinkage easy to handle and implant. stretchy. cheap stays soft (maintains compliance). No chronic inflammatory response resistant to infection Composite Mesh Parietal Layer Visceral Layer Proceed polypropylene oxidized regenerated cellulose DualMesh macroporous eptfe microporous eptfe Parietex polyester weave collagen film Sepramesh polypropylene Na-hyaluronate / carboxymethylcellulose no degradation over time Composix E/X heavyweight polypropylene microporous eptfe 4

5 Head-to-head trial in rabbits Mesh implanted as underlay Harvested at 120 days.the future? Head-to-head in rats, harvested at 7 and 30 days. ADHESIONS TISSUE INGROWTH large-pore polypropylene Winners: Parietex and Sepramesh day 0 in rabbit day 90 5

6 Does permanent tack fixation contribute to chronic pain? Does transabdominal fascial fixation contribute to chronic pain? Surgical Endoscopy 2009 Prospectively randomized lap ventral hernia patients to 1. ProTacks every 5mm along perimeter + Vicryl transfascial every 5cm 2. ProTacks every 5mm along perimeter + Mersilene transfascial every 5cm 3. ProTacks only, double crown technique Mesh was DualMesh, 3cm fascial overlap Primary end point = pain on VAS at 2 weeks, 6 weeks, 3 months Secondary end point = quality of life score on SF-36 Randomized ~200 patients, ~60 completed follow-up in each group Surgical Endoscopy 2009 Surgical Endoscopy 2009 PAIN SCORES (VAS, range 0-100) QoL (by SF-36) Also, no correlation between pain and the number of tacks used 6

7 SorbaFix AbsorbaTack Does permanent tack fixation cause adhesions? Advances: laparoscopic components separation Surgical Endoscopy 2009 Can medialization of the rectus muscles (even under tension) improve outcomes? 7

8 Advances: laparoscopic components separation Advances: laparoscopic components separation But no data yet to support improvement in outcomes of conventional laparoscopic hernia repair. Hernia 2007 And some are now advocating primary sutured repair under tension without components separation Conclusions Advantages of laparoscopic ventral hernia repair: Recurrence rate same or better 5-fold reduction in wound complications / mesh infections 2-day reduction in length of stay Disadvantages of laparoscopic hernia repair: More seromas Twice the risk of inadvertent enterotomy Best mesh on market today is Parietex or Sepramesh Don t let concerns about chronic pain affect your decision to use or not use transfascial fixation. It doesn t matter. Absorbable suture doesn t help either. Absorbable tacks might reduce visceral adhesions (but data is weak) Many experts are starting to advocate for medialization of the rectus in all cases, and are developing minimallty-invasive techniques to do it. Time will tell whether this can reduce the recurrence rates even more. 8