Laparoscopic Repair of Incisional and Parastomal Hernias after Major Genitourinary or Abdominal Surgery

JOURNAL OF ENDOUROLOGY Volume 15, Number 2, March 2001 Mary Ann Liebert, Inc. Laparoscopic Repair of Incisional and Parastomal Hernias after Major Genitourinary or Abdominal Surgery PAUL M. KOZLOWSKI, M.D., 1 PETER C. WANG, M.D., 2 and HOWARD N. WINFIELD, M.D. 1 ABSTRACT Background and Purpose: Abdominal wall or parastomal hernias following major genitourinary or abdominal surgery are a significant surgical problem. Open surgical repair is difficult because of adhesion formation and poor definition of the hernia fascial edges. Laparoscopic intervention has allowed effective correction of these abdominal wall hernias. Patients and Methods: From November 1997 to June 2000, 14 male and 3 female patients underwent laparoscopic abdominal wall herniorrhaphy at our institution. Of these, 13 patients received incisional and 4 parastomal hernia repair. All hernia defects were repaired using a measured piece of Gore-Tex DualMesh. A retrospective review of each patient s history and operative characteristics was undertaken. Results: All repairs were successful. No patient required conversion to an open procedure, and there were no intraoperative complications. The average operative time was 4 (range 2.5 6.5) and 4.3 (range 3.75 5.5) hours in the incisional and parastomal group, respectively. The average hospital stay was 4.9 days (range 2 12) for the incisional group and 3.8 (range 3 4) days for the parastomal group. To date, two patients experienced a recurrence of incisional hernias, at 5 and 8 months postoperatively. No recurrences have developed in the parastomal hernia repairs at 2 to 33 months. Conclusion: Laparoscopic repair of abdominal wall incisional or parastomal hernias provides an excellent anatomic correction of such defects. Adhesions are lysed under magnified laparoscopic vision, and the true limits of the fascial defects are clearly identified. The DualMesh is easy to work with and has yielded excellent results. A comparison with open repair with respect to perioperative factors and long-term success is currently under way. INTRODUCTION ABDOMINAL WALL HERNIAS following major genitourinary or abdominal surgery are a significant surgical problem. It has been reported that as many as 26% of patients who undergo major abdominal surgery can develop an abdominal wall hernia. 1 3 Factors that may predispose a patient to the formation of such hernias include multiple abdominal operations, infection, obesity, poor nutritional status, and chronic medical problems, especially pulmonary, all of which interfere with normal healing. Traditionally, the repair of abdominal wall hernias has been approached via an open technique. A wide variety of methods have been developed, such as those described by Stoppa 4 and Wantz. 5 However, the recurrence rate after open incisional hernia repair has been reported to be as high as 54%. 6,7 Although the introduction of prosthetic material in incisional hernia repair has decreased the recurrence rates, the risk of wound infections and local wound complications may be increased. 8 13 Because of the high recurrence rates and subsequent attempts at correction followed by increasingly higher recurrence rates, an alternative to open surgery is needed. 14 With the advent of laparoscopic surgery, a new form of hernia repair became available to surgeons. The goal of the laparoscopic approach to abdominal hernia repair should be a decrease in recurrence rates and wound complications, while offering the patient the advantages of a minimally invasive procedure. The first laparoscopic incisional hernia repair was reported in 1993. 15 Since that time, studies comparing open and laparoscopic abdominal wall hernia repair have suggested that 1 Department of Urology, Stanford University, Stanford, California. 2 Department of Surgery, VA Health Care System, Palo Alto, California. 175

176 KOZLOWSKI ET AL. patients who undergo laparoscopic hernia repair experience the predicted advantages of less pain and shorter hospitalization, while the recurrence rate and infection complication are lower. 16,17 The purpose of this study was to review all patients who underwent incisional and parastomal hernia repair related to previous genitourinary and abdominal surgery at a single institution over a 2-year period. Patients PATIENTS AND METHODS We retrospectively reviewed the records of 14 male and 3 female patients ages 44 to 79 who underwent a laparoscopic incisional or parastomal hernia repair performed between November 1997 and June 2000 (Table 1). Patient age, sex, significant surgical and medical history, type of hernia repair, average operative time, surface area of mesh repair, time to return to full diet, hospital stay, complications, and recurrences were reviewed. Of the patients reviewed, 13 had incisional and 4 had parastomal hernia repairs. Defects of any size were included in this study. All repairs were performed laparoscopically, and no patient required open conversion. Surgical Technique TABLE 1. CHARACTERISTICS OF PATIENTS Patient Age Sex Hernia Type Previous Surgery Relevant Medical History a 1 44 M Incisional Ventral hernia repair None 2 48 M Incisional Cystoprostatectomy Renal Insuff. 3 51 F Incisional Splenectomy None 4 55 F Incisional Simple cystectomy w ileal loop None 5 57 F Incisional Nephrolithotomy, Open COPD 6 62 M Incisional AAA repair b CAD, HTN 7 64 M Incisional Exploratory laparotomy HTN 8 67 M Incisional AAA repair CAD, COPD, HTN 9 67 M Incisional Hiatal hernia HTN 10 68 M Incisional Collectomy CAD, HTN 11 75 M Incisional AAA repair COPD, C5 quad 12 78 M Incisional Cystoprostatectomy HTN, PVD 13 79 M Incisional Cystoprostatectomy HTN, COPD, DM 14 63 M Parastomal Cystoprostatectomy HTN, COPD, DM 15 68 M Parastomal Colectomy HTN, COPD, DM 16 76 M Parastomal Cystroprostatectomy DM, CAD 17 78 M Parastomal Cystroprostatectomy HTN, PVD a COPD 5 chronic obstructive pulmonary disease, CAD 5 coronary artery disease, HTN 5 hypertension, C-5 quad 5 C5 quadraplegia, PVD 5 peripheral vascular disease, DM 5 diabetes mellitus. b AAA 5 abdominal aortic aneurysm. 16F Foley catheter is placed in the bladder or stoma of the urinary diversion for a parastomal hernia repair. With the patient under general anesthesia, the Hasson cannula technique is used to obtain a pneumoperitoneum. The initial entry port is in a site farthest away from the hernia defect and original surgical incision, so as to minimize the risk of entry into an area of adhesions or bowel. In other words, if the hernia is in the right mid or lower abdomen, the Hasson cannula entry would be in the left upper quadrant. The working port size, number, and placement is dependent on the location, type, and size of the hernia. Generally, three or four ports (5 11 mm) are required. The basic objective is to space the ports in a triangular fan-shape configuration with the apex of the triangle directed to the hernia. All patients undergo preoperative CT scanning, with a loopogram performed in the case of parastomal hernias, to determine the contents of the hernia and define the extent of the fascial defect (Fig. 1). All patients received oral antibiotics and a full mechanical bowel preparation with Golytely and are typed and screened for blood products. Patients are routinely given one dose of broad-spectrum antibiotic on call to the operating room. An orogastric tube is placed for gastric decompression, and a FIG. 1. hernia. Preoperative CT scan demonstrating ileal parastomal

LAPAROSCOPIC INCISIONAL HERNIA REPAIR 177 FIG. 2. Laparoscopic view of ileal loop with mesenteric blood supply and parastomal fascial defect. Adhesiolysis is achieved with both blunt and sharp dissection. The hernia is emptied, and the fascial edges are freed of overlying tissue circumferentially beyond 3 cm. The mesentery supplying the ileal or colonic conduit is carefully identified and preserved with separation from surrounding herniated bowel in the case of parastomal hernia repairs (Fig. 2). The circumferential dimensions of the hernia defect are measured by percutaneously placing an 18-gauge spinal needle under laparoscopic guidance through the edge of the fascial defect. Once the size of the defect is determined, a piece of Gore-Tex DualMesh (W.L. Gortex) is cut 2 to 3 cm larger. Four quadrant stitches of 2-0 Gor-Tex are placed on the mesh, which is then inserted into the abdominal cavity through a 10/11-mm port site. The DualMesh has a smooth side, which diminishes adhesion formation, and a rough side, which causes more ingrowth of fibroblasts and collagen. The smooth side is oriented toward the bowel contents and the rough side toward the abdominal wall. The mesh is positioned and the quadrant stitches brought out percutaneously using the Carter Tomlinson (Inlet Medical, Eden Praire, MN) device. The ProTack (Autosuture Inc., Norwalk, CT) secures the Gore-Tex mesh to the fascia edge beyond the defect. Tacks are placed every 1.5 cm around the outer edge of the defect (Fig. 3). Final hemostasis is obtained, and the port sites are closed in the usual fashion. An abdominal wall binder is placed at the termination of the procedure, and the patient is encouraged to wear this binder as much FIG. 3. Laparoscopic view of position of Gore-Tex mesh in completed parastomal hernia repair. as possible over the ensuing 6 weeks. Strenuous or lifting activities are discouraged during this time. RESULTS All 17 patients tolerated the procedure well. The average operative time was 4 (range 2.5 6.5) hours for incisional repairs and 4.3 (range 3.75 5.5) hours for parastomal hernias. The average surface area of the DualMesh employed was 510 (range 285 884) cm 2 for incisional and 424 (range 196 720) cm 2 for parastomal hernias. It should be noted that the mesh was 2 to 3 cm circumferentially larger than the hernia defect. The other postoperative characteristics, hospital stay, complications, and success rate for the various types of hernia repairs are reflected in Table 2. No intraoperative complications occurred, and no patient required conversion to an open repair. Postoperative complications included prolonged ileus necessitating placement of a nasogastric tube for 2 or 3 days in three patients and postoperative angina in one patient. Most patients reported moderate discomfort in the areas where the mesh was secured with the tacks, but this generally resolved within 48 hours. Follow-up has ranged from 2 to 33 months. Patients have been followed with routine clinic visits and phone interviews. To our knowledge, there have been two recurrences to date in TABLE 2. RESULTS OF LAPAROSCOPIC REPAIR Av OR Av Av return Av hosp time surface to diet stay Hernia (h) area (cm 2 ) (days) (days) Success type No. (range) (range) (range) (range) Compl. (%) Incisional 13 4.0 510 3.2 4.9 4 a 85 (2.5 6.5) (285 884) (1 10) (2 12) Para-stomal 4 4.3 424 2.5 3.8 0 a 100 (3.75 5.5) (196 720) (1 3) (3 4) a Three patients with prolonged ileus; one patient with angina.

178 patients who underwent repair of incisional hernias. The first patient was a 57-year-old obese woman who had a history of a right nephrolithotomy through a flank incision. The mesh used in her repair was 15 3 19 cm (surface area 285 cm 2 ). The patient s recurrence was first noted on a return clinic visit 5 months after her laparoscopic repair. The patient has not undergone a repair of the recurrence to date. The second patient was a 68-year-old man who had previously undergone cardiac surgery, after which he developed an epigastric hernia in the lower 4 cm of the chest incision that extended into the abdomen. The patient had undergone a prior open repair, not involving prosthetic material, which had failed. The mesh used was 22 3 19 cm (surface area 418 cm 2 ). The recurrence was noted 8 months after the laparoscopic repair. To date, the patient has not undergone a repair for the recurrence. No recurrences have been seen in the parastomal group to date. DISCUSSION Recurrences after open incisional hernia repair have been associated with several causes, but infection and the size of the defect remain the most predominant. 18,19 The recurrence rate has been reported to be as high as 54%, with even higher rates for repeat open hernia repairs. 6,7 The addition of prosthetic materials such as Marlex mesh and polytetrafluoroethylene (PTFE) to open repairs has decreased these recurrence rates, but the results are still less than optimal. 8 13 With the advent of minimally invasive surgery in the early 1990s, laparoscopic intervention has been demonstrated to be a good alternative for the management of incisional hernias. Any new approaches to the repair of incisional or parastomal hernias should not only strive to reduce complications and recurrences but afford the patient a quicker and more comfortable recovery from surgery. The advantages of shorter hospitalization, faster recovery, and less postoperative pain have been observed in comparing laparoscopic and open inguinal hernia repair. 20 23 Furthermore, a study by Ramshaw and associates 16 has shown advantages of decreased wound complications and recurrence rates when comparing open and laparoscopic repair for large or recurrent ventral hernias. This retrospective study from a single medical center reviews the results of laparoscopic repair of incisional and parastomal hernias following major genitourinary or abdominal surgery. Our operative time and length of hospitalization are somewhat longer than in previously published studies. 16,17 However, it appears that the size of the hernia defect and measured mesh surface area were much larger than in the other series. In addition, our learning curve certainly affected the initial five cases. The most dangerous and time-consuming portion of the procedure is the lysis of bowel and omental adhesions from the abdominal wall and the reduction of the hernia contents. Adhesiolysis should be performed with judicious use of electrocautery or the Harmonic Shears (Ethicon Endosurgery, Cincinnati, OH), especially in proximity to the bowel. Careful inspection of the abdominal cavity for bleeding or bowel injury after placement of the mesh is mandatory. In the event of an enterotomy, the standard of care would be repair of the injury by laparoscopic means or laparotomy and removal of the mesh. Maintenance of the mesh (i.e., foreign body) in this situation would be discouraged. However, some authors have reported placing the mesh laparoscopically in the face of only an isolated smallbowel injury in a patient who has undergone a very thorough bowel preparation. 24 Mesh placement in the face of a largebowel injury is strictly contraindicated. Fortunately, no patient in our series sustained a bowel injury. The majority of complications reported in the literature are a result of infection or bowel injury. 16,17 In our group of patients, complications occurred only in the postoperative period and may be considered minor. In the 13 patients who underwent a laparoscopic repair of an incisional hernia, 2 (15%) have developed recurrences, at 5 and 8 months. Previously reported recurrence rates for incisional and ventral hernias after laparoscopic repair with prosthetic material have been 2% to 11%. 16,17 We believe that these two recurrences were attributable to the location of the hernias, as described in Results, thus making the securing of the mesh more difficult because of the adjacent diaphragm. In addition, it is also believed that because of our inexperience, an insufficient number of laparoscopic securing tacks were used in the area of the hernia, resulting in recurrence. No recurrences have been demonstrated to date in the four parastomal repairs. Of the currently available prosthetic materials, Gore-Tex mesh has been shown to cause a lesser foreign-body reaction, lower rate of adhesion formation, and decreased infection rate compared with other commonly used materials. 25,26 The smooth side of this material has a pore size of,3 mm, which diminishes tissue attachment, making this side optimally suited for contact with bowel. The rough side has a pore size of 22 mm that encourages fibroblast and collagen ingrowth and attachment to the mesh. This larger pore side is oriented for contact with the body wall so as to increase mesh adherence and support for the abdominal wall. All patients in our study group were repaired using Gore-Tex mesh. No patient in our group experienced mesh infection, bowel erosion, or fistula formation. Whereas conventional open hernia repairs require a large incision and wide dissection to define adequate facial edges, the laparoscopic approach facilitates the necessary adhesiolysis and definition of the hernia defect using minimally invasive access. Once the hernia sac has been cleared of the adherent bowel and omental adhesions, the DualMesh is positioned over the defect, maintaining a 2- to 3-cm circumferential margin. This laparoscopic technique has allowed us to clearly define and correct these troublesome abdominal hernias in patients who have already undergone major genitourinary or abdominal surgery. A contemporary comparison of this technique with a matched group of patients undergoing open surgical repair is ongoing. It is expected that our results will complement those in the literature showing that laparoscopic hernia repair is associated not only with a better postoperative course but with lower recurrence rates. CONCLUSION KOZLOWSKI ET AL. Laparoscopic incisional and parastomal herniorrhaphy in our hands proved to be a highly effective procedure. In this small series, all patients tolerated the procedure well with no intraoperative complications and only minor postoperative compli-

LAPAROSCOPIC INCISIONAL HERNIA REPAIR 179 cations. A comparison with open repair of similar types of hernias at our institution is currently under way. As with all laparoscopic techniques, proper training and surgical experience is essential before attempting these procedures. REFERENCES 1. Mudge M, Hughes LE. Incisional hernia: A 10-year prospective study of incidence and attitudes. Br J Surg 1985;72:70. 2. George CD, Ellis H. The results of incisional hernia repair in a 12- year review. Ann R Coll Surg 1986;68:185. 3. Iraelson LA. The surgeon as a risk factor for complications of midline incisions. Eur J Surg 1998;164:353. 4. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989;13:545. 5. Wantz G. Incisional hernioplasty with Mersilene. Surg Gynecol Obstet 1991;172:129. 6. Paul A, Korenkov M, Peters S, et al. Unacceptable results of the Mayo procedure for repair of abdominal incisional hernias. Eur J Surg 1998;164:361. 7. Luijendijk RW, Lemmen MH, Hop WC, et al. Incisional hernia recurrence following vest over pants or vertical Mayo repair of primary hernias of the midline. World J Surg 1997;21:62. 8. McLanahan D, King LT, Weems C, et al. Retrorectus prosthetic mesh repair of midline abdominal hernia. Am J Surg 1997;173:445. 9. Temudom T, Siadati M, Sarr M. Repair of complex giant recurrent ventral hernias by using tension free intraperitoneal prosthetic mesh (Stoppa technique): Lessons learned from our initial experience (fifty patients). Surgery 1996;120:738. 10. Koller R, Miholic J, Jakl RJ. Repair of incisional hernias with expanded polytetrafluoroethylene. Eur J Surg 1997;163:261. 11. Amid PK, Shulman AG, Lichtenstein L. A simple stapling technique for prosthetic repair of massive incisional hernias. Am Surgeon 1995;60:934. 12. Leber GE, Garb JL, Alexander AL, et al. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998;133:378. 13. White TJ, Santos MC, Thompson JS. Factors affecting wound complications in repair of ventral hernias. Am Surgeon 1998;64:276. 14. George CD, Ellis H. The results of incisional hernia repair: A twelve year review. Ann R Coll Surg Engl 1986;68:185. 15. Leblanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: Preliminary findings. Surg Laparosc Endosc 1992;3:39. 16. Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surgeon 1999;65:827. 17. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: A comparison study. Surgery 1998;124:816. 18. Hesselink VJ, Luijendijk RW, de Wilt JHW, et al. An evaluation of risk factors in incisional hernia recurrence. Gynecol Obstet 1993;176;228. 19. Bucknall TE, Cox PJ, Ellis H. Burst abdomen & incisional hernia: A prospective study of 1129 major laparotomies. Br Med J 1982; 284:931. 20. Wilson MS, Deans GT, Brough WA. Prospective trial comparing Lichenstein with laparoscopic tension-free mesh repair of inguinal hernia. Br J Surg 1995;82:274. 21. Liem MSL, van der Graaf Y, Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997;336:1541. 22. Stoker DL, Spiegelhalter DJ, Singh R, et al. Laparoscopic versus open inguinal hernia repair: Randomized prospective trial. Lancet 1994;343:1243. 23. Kozol R, Lange PM, Kosir M, et al. A prospective, randomized study of open vs laparoscopic inguinal hernia repair: An assessment of postoperative pain. Arch Surg 1997;132:292. 24. Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernias repairs: A personal series and review of the literature. J Soc Laparosc Surgeons 1999;3:293. 25. Bauer JJ, Salky BA, Gelernt IM, et al. Repair of large abdominal wall defects with expanded polytetrafluoroethylene (PTFE). Ann Surg 1987;206:765. 26. Law NW. A comparison of polypropylene mesh, expanded polytetrafluoro patch and polyglycolic acid mesh for the repair of experimental abdominal wall defects. Acta Chir Scand 1990;156:759. Address reprint requests to: Howard N. Winfield, M.D. Dept. of Urology, S-287 Stanford University School of Medicine 300 Pasteur Drive Stanford, CA 94305-5118 E-mail: hnw@stanford.edu