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The aim of the study was to introduce a new surgical treatment for anterior cutaneous nerve entrapment syndrome, a frequently unrecognised disorder in the general population responsible for chronic abdominal wall pain with limited treatment options to date. We hypothesised that intraperitoneal onlay mesh reinforcement could dissipate excessive increases in intra-abdominal pressure and prevent entrapment of the neurovascular bundle. Retrospective cohort analysis was performed between September 2002 and March 2014. All consecutive patients diagnosed with anterior cutaneous nerve entrapment syndrome refractory to conservative treatment (n= 30) underwent laparoscopic intraperitoneal onlay mesh reinforcement of the painful area in the abdominal wall. Planned follow-up took place at 2, 6 and 12 weeks after surgery and at time of analysis (March 2015). Primary outcome was patients’ satisfaction after treatment at short and long term (last follow-up) using a verbal rating score as measurement (1 = I am very satisfied; I never experience pain, 2 = I am satisfied; I occasionally experience some pain, 3 = I have improved but experience pain on a regular basis, 4 = I have had no result on this treatment, 5 = my pain is worse after treatment). Scores 1 and 2 were classified as success, and scores 4 and 5 as failure of the treatment. Thirty patients underwent laparoscopic intraperitoneal onlay mesh reinforcement. None were lost to follow-up (mean 54 ± 44 months, range 12–122, median 38). Short- and long-term success rates were 90 and 71 %, respectfully. Intraperitoneal onlay mesh reinforcement of the abdominal wall seems to be a promising option for the treatment of intractable anterior cutaneous nerve entrapment syndrome.

Interpretation of the outcome after laparoscopic repair (LR) of ventral hernias presented in the literature often is based on pooled data of primary ventral hernias (PVH) and incisional ventral hernias (IVH). This prospective cohort study was performed to investigate whether this pooling of data is justified. The data of 1,088 consecutive patients who underwent LR of PVH or IVH were prospectively collected and reviewed for baseline characteristics, operative findings, and postoperative complications classified as Clavien grade 3 or higher. The PVH group consisted of 662 patients, and the IVH group comprised 426 patients. The mean Association of American Anesthesiologists classification was higher in IVH group (1.92 vs 1.68; P≤ 0.001), as was rate of conversion to open surgery (7 vs 0.5 %; P< 0.001). The IVH group required more adhesiolysis (76 vs 0.9 %; P< 0.001), a longer procedure (73 vs 42 min; P< 0.001), and a longer hospital stay (4.53 vs 2.43 days; P< 0.001). The recurrence rate was higher in the IVH group (5.81 vs 1.37 %; P< 0.001), as was total complication rate (18.69 vs 4.55 %; P< 0.001). This study showed significant differences in baseline characteristics and operative findings between patients undergoing PVH repair and those undergoing IVH repair. Continued pooling of data on LR of IVH and PVH combined, commonly found in the current literature, seems incorrect.

Abstract: Background: The main source of postoperative pain after laparoscopic repair of ventral hernia is thought to be fixation of implanted mesh. This study aimed to analyze whether a relation exists between the number of tacks used for fixation and postoperative pain. Methods: To reduce the number of prognostic variables, only patients with primary umbilical hernia who underwent laparoscopic repair with double-crown mesh fixation were enrolled in this study. Two groups differing only in the manner of tacking were compared. Group 1 (n = 40), collected from previous studies, showed no specific efforts to minimize the number of tacks. Group 2 was a cohort of 40 new patients who underwent double-crown fixation using the minimal number of tacks considered to provide adequate mesh fixation. To eliminate systematic and random errors, the study analyzed only for postoperative pain. The severity of the patients’ pain was assessed preoperatively and then 2, 6, and 12 weeks postoperatively using a visual analog scale (VAS) ranging from 0 to 100. Results: The mean number of tacks used differed significantly between the two groups: group 1 (45.4 ± 9.6) vs group 2 (20.4 ± 1.4) (p = 0.001). Postoperative pain differed significantly only at the 3-month postoperative assessment: group 1 VAS (5.78) vs group 2 VAS (1.80) (p = 0.002). Conclusions: Although postoperative pain differed significantly at the 3-month follow-up assessment, both VAS scores were so low that from a clinical point of view, this difference seems irrelevant. Fewer tacks do not create less pain, nor do more tacks create more pain. This absence of a correlation between the number of tacks used and postoperative pain may indicate that pain after laparoscopic repair of at least small ventral hernias possibly is generated according to some “threshold” principle rather than according to a cumulative effect created by more points of fixation.

Abstract: Background: Persistent, activity-limiting pain after laparoscopic ventral or incisional hernia repair (LVIHR) appears to be related to fixation of the implanted mesh. A randomized study comparing commonly used fixation techniques with respect to postoperative pain and quality of life has not previously been reported. Methods: A total of 199 patients undergoing non-urgent LVIHR in our unit between August 2005 and July 2008 were randomly assigned to one of three mesh-fixation groups: absorbable sutures (AS) with tacks; double crown (DC), which involved two circles of tacks and no sutures; and nonabsorbable sutures (NS) with tacks. All operations were performed by one of two experienced surgeons, who used a standardized technique and the same type of mesh and mesh-fixation materials. The severity of the patients’ pain was assessed preoperatively and at 2 weeks, 6 weeks and 3 months postoperatively by using a visual analogue scale (VAS). Quality of life (QoL) was evaluated by administering a standard health survey before and 3 months after surgery. Results in the three groups were compared. Results: The AS, DC, and NS mesh-fixation groups had similar patient demographic, hernia and operative characteristics. There were no significant differences among the groups in VAS scores at any assessment time or in the change in VAS score from preoperative to postoperative evaluations. The QoL survey data showed a significant difference among groups for only two of the eight health areas analyzed. Conclusion: In this trial, the three mesh-fixation methods were associated with similar postoperative pain and QoL findings. These results suggest that none of the techniques can be considered to have a pain-reduction advantage over the others. Development of new methods for securing the mesh may be required to decrease the rate or severity of pain after LVIHR.

Abstract: Background: All hernia recurrences in a series of 505 patients who underwent laparoscopic repair of a ventral hernia (n = 291) or incisional hernia (n = 214) were analyzed to identify factors responsible for the recurrence. Methods: In all laparoscopic repairs, an expanded polytetrafluoroethylene prosthesis overlapping the hernia margins by ≥3 cm was fixed with a double ring of tacks alone (n = 206) or with tacks as well as sutures (n = 299). During the mean follow-up time of 31.3 ± 18.4 months, nine patients (1.8%) had a recurrence, eight of which were repaired laparoscopically. Operative reports and videotapes of all initial repairs and repairs of recurrences were analyzed. Results: All recurrences followed an incisional hernia repair (p < 0.001). Five recurrences developed after mesh fixation with both tacks and sutures and four after mesh fixation with tacks alone (p = 1.0). All recurrences were at the site of the apparently sufficient original incision scar: in eight patients, the recurrent hernia was attached to the mesh; in one, it developed in another part of the scar. All initial repairs had been performed without technical errors. Upon repair of the recurrences, a new, larger mesh was placed over the entire incision, not just the hernia. There were no re-recurrences during follow-up (mean 19.8 ± 10.3 months). Conclusions: Recurrence after incisional hernia repair appears to be due primarily to disregard for the principle that the whole incision—not just the hernia—must be repaired. Our experience supports the idea that the entire incision has a potential for hernia development. Insufficient coverage of the incision scar is a risk factor for recurrence after laparoscopic repair of ventral and incisional hernia.