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Minimally Invasive Advances in AWR

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Presentation on theme: "Minimally Invasive Advances in AWR"— Presentation transcript:

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

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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

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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

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

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

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

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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

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 Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.
Is it effective? Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000. 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

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

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

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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, day follow-up Good outcomes

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

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

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


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