Minimally Invasive Advances in AWR

1. Minimally Invasive Advances in AWR • Tommy H Lee, MD • Creighton University • Omaha, NE

2. Nothing to Disclose

3. Overview • Laparoscopic ventral hernia repair • Laparoscopic component separation • Hybrid procedures • Which approach to use?

4. Incisional/Ventral Hernia:The Facts • A Frequent Complication of Laparotomy • 3% to 13% of All Laparotomies • 4 to 5 Million Laparotomies Annually in the US • = 400,000 To 500,000 Incisional Hernias • = 200,000 Repairs • The American Journal of Surgery, Vol 197, No 1, January 2009

5. “Traditional” Hernia Repair • Open • +/- Mesh • Onlay • Inlay • Underlay • Component Separation

6. Laparoscopic Repair • Wide overlap (3? 4? 5cm?) • +/- Transfascial sutures • +/- Primary closure of defect

7. Why Laparoscopic?Open vs. Laparoscopic • PRO • ↓ Operative Time • ↓ Risk of Serious Complications • ↓ Cost • Muscle Approximation → Better Functional Result • CON↑ Infection Rate? ↑ Recurrence Rate? Greater Post Operative Pain? Longer Time for Return to Usual Activities

9. Bisgaard et al (2009) • All patients aged 18 years or older who had elective surgery for incisional hernia in Denmark between 1 January 2005 and 31 December 2006 • 2896 Incisional hernia repairs • 1872 Open/1024 Laparoscopic • 2754 Primary /142 Recurrent

11. Bisgaard et al (2009) • Unsatisfactory results • Severe complication rate 3.5% • Mortality rate 0.4% • Reality of the disease?

12. 73 Laparoscopic vs 73 Open repairs

14. Itani et al (2010) • Laparoscopic - fewer complications, more serious

15. 8 RCTs, 536 patients • Hernia 23.2 to 141.2 cm2 • F/U 6 to 40.8 months British Journal of Surgery 2009; 96: 851–858

16. Forbes et al (2009) • Laparoscopic • No difference in recurrence • Fewer wound complications • Laparoscopic at least equivalent to open repair

17. Laparoscopic Ventral Hernia Technique • General anesthesia / Antibiotic prophylaxis • Table to table Prep • Insufflation needle - away from midline • Hasson • Initial 5 mm “Optical Trocar” • Three cannulae technique, all in the anterior axillary line

18. Technique • Lysis of adhesions • Size defect (avoid oversizing) • Intra-abdominal • Deflate abdomen • Primary closure of defect? • Place and secure mesh

19. Port Placement

20. Mesh

21. Fasteners • Absorbable • Slow-absorbing • No long-term foreign body • ?Adequate fixation • Non-absorbable • Protack

22. Fasteners • Depth of fixation limited!

23. Abdominal Wall Fixation

24. Abdominal Wall Sutures

25. Tricks of the Trade

26. Marking of the Prosthesis

29. Primarily close the defect

30. Securing the mesh

31. Laparoscopic Component Separation • Why laparoscopic? • Fewer wound complications • Seroma • Infection • Flap necrosis Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.

32. Laparoscopic Component Separation - Technique • http://www.sages.org/video/details.php?id=100888

33. Is it effective? • Laparoscopic component separation achieved 86% advancement compared to open

34. Rosen et al. • External oblique release

35. Is it effective? • Comparable amount of release • Tranversus abdominus and posterior sheath release compared to traditional ext. oblique + post. sheath release • p values not significant

36. Is it effective? • Large series lacking • 7 patients, average follow-up of 4.5 months • External oblique released laparoscopically • Posterior sheath released as necessary (open) • Alloderm underlay • 1 SSI, 1 hematoma, 1 resp failure

37. Is it effective? • Posterior sheath release followed by ext. oblique release • +/- mesh • 7 laparoscopic, 30 open, 1 year follow-up • Fewer complications in laparoscopic group • No ischemia, wound infection, dehiscence Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.

38. Is it effective? • 5 patients, less than 1 year follow-up • Laparoscopic ext oblique release • 4 had mesh underlay (biologic) • 2 mild wound complications • 1 recurrence (!) Am Surg. 75(7). 572-8.

39. Hybrid Procedure? • Combine elements: • Laparoscopic/Open lysis of adhesions • Laparoscopic intraperitonal mesh repair • Laparoscopic/Open component separation • Rives-Stoppa repair

41. Cox et al. • Open lysis of adhesions • Rives-Stoppa repair • Laparoscopic component separation to mobilize ant. sheath • Bridging mesh as needed • 6 patients, F/U 4-14 months • No recurrences • 1 recurrent EC fistula

42. Combined laparoscopic component separation and intraperitoneal mesh placement • 4 patients, 30-100 day follow-up • Good outcomes

43. Primary “shoelace” closure of defect • Better function? • Component separation (laparoscopic) as needed • No recurrences at 16.2 months • Surg Endosc. 2010 Nov 5

44. Moazzez et al. Surg Technol Int. 2010;20:185-91.

45. Moazzez et al (2010)

46. Moazzez et al (2010)

47. Moazzez et al (2010) • Fasica is closed

48. Guidelines... (Ventral Hernia Working Group - 2010) • Breuing et al, Surgery (2010), 148(3), pp 544-558.

49. Conclusion • Laparoscopic techniques are being developed • Approach needs to be tailored to particular needs of patient • No “universal” technique • Advantages/disadvantages to each