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A minimally invasive component separation may lead to a dynamic abdominal wall after hernia repair, with reduced complications. We present early results of our patients undergoing this technique. Five patients were selected for open midline repairs; three with chronic infections, one with a prior midline skin graft, and one who desired a primary, tension-free repair. These three males and two females had a mean age of 50.8 +/- 21.1 years and body mass index of 30.9 +/- 6.2. The mean number of previous abdominal operations was 7 +/- 3.4 and previous attempted hernia repairs were 4 +/- 2.7. All patients had a midline laparotomy with lysis of adhesions. An endoscopic component separation was then performed bilaterally. Drains were left in the dissection bed. All patients had the midline closed; four received biologic mesh underlays. Mean operative time was 227 minutes +/- 49. Mean length of stay (LOS) was 9.2 days +/- 3.6. Early median follow-up was 6 months (range 0.25-9). Two patients required postop transfusions, and two patients had mild complications of the midline wound (hematoma, infection). To date, one recurrence was diagnosed by CT scan. Early evaluation of adopting the minimally invasive (MIS) component separation demonstrates minimal complications and good initial outcomes.

Background: Laparoscopic ventral hernia repair (LVHR) can be challenging in patients with large abdominal wall defects and loss of domain (LOD). When hernia contents are reduced, the pneumoperitoneum preferentially fills the sac, leaving no space for mesh manipulation. This study presents a modification for LVHR in LOD patients, as well as outcomes for a series of patients., Methods: Between September 2002 and August 2004, 10 patients with large ventral hernias and LOD underwent attempts at LVHR. The technique is modified by placing additional trocars to allow for fixation from above the mesh. Patient data were harvested from a prospective database and analyzed., Results: All hernias were recurrent in nature. Mean defect size was 626 cm(2), requiring 1 to 4 pieces of sutured Gore Dualmesh for a tension-free repair. Three patients' procedures were aborted after adhesiolysis, with concerns about missed enterotomies. All 3 underwent delayed mesh placement within the same hospitalization. Only 2 were successful. The third patient had significant bowel edema precluding mesh placement. Two patients were converted to open repairs (Rives-Stoppa and component separation). There were no mortalities, but there were 2 major complications: inferior vena cava thrombosis and transient abdominal compartment syndrome. In follow-up (7.7 months) there were 2 recurrences secondary to excision of infected mesh., Conclusion: It is possible to obtain a successful LVHR in patients with large defects and LOD. The technique is complex and is modified to allow for mesh fixation from above the mesh. Frequent change in patient positioning allows for visualization below the fascial defect.

Objective: The aim of this study was to evaluate our experience with LVHR in morbidly obese patients (BMI >40) and to compare their outcomes to those of patients with lower BMI., Methods: Data on adult (>18 years old) patients who underwent LVHR with mesh over the last 13 years performed by four experienced surgeons were collected retrospectively and from a previously collected database. Of the 1,071 patients, 901 had completed LVHR and were available for follow-up. One hundred and thirty-four patients (group A) met BMI criteria for morbid obesity (>or=40, mean 46), 767 patients had BMI < 40, mean 30 (group B). The follow-up time ranged from 1 to 91 months. The Wilcoxon rank sum test was used for nonparametric data analysis. Outcomes were stratified on the follow up time and analyzed using Cochran-Mantel-Haenszel methodology., Results: The groups did not differ in terms of ASA score, previous surgery and conversion rate (p=0.22, 0.32 and 0.23). Morbidly obese patients were younger (48.3 vs. 54; p<0.01) and were more often female (p=0.02), but this did not correlate with outcome. Group A also had longer operative time (154 vs. 119 min, p<0.01) and hospital stay (3.6 vs. 2.4 days, p=0.03). Mesh size was significantly larger in group A (449 vs. 349 cm(2), p=002). During mean follow-up time of 19 months hernia recurrence was 8.3% in group A and 2.9% in group B (p=0.003), with an odds ratio of 4.3 (95% CI 1.9-9.9). However, there was no significant difference in the rate of complications (19.7 vs. 15.3%; p=0.46)., Conclusions: LVHR in the morbidly obese population is both safe and feasible, although there is a higher, but still acceptable recurrence rate. Despite the increased risk for recurrence, LVHR in morbidly obese patients minimizes the potential wound and mesh complications that frequently occur for open mesh repair in this group of patients.

Background: The management of parastomal hernia is associated with high morbidity and recurrence rates (20-70%). This study investigated a novel laparoscopic approach and evaluated its outcomes., Methods: A consecutive multi-institutional series of patients undergoing parastomal hernia repair between 2001 and 2005 were analyzed retrospectively. Laparoscopy was used with modification of the open Sugarbaker technique. A nonslit expanded polytetrafluoroethylene (ePTFE) mesh was placed to provide 5-cm overlay coverage of the stoma and defect. Transfascial sutures secured the mesh, allowing the stoma to exit from the lateral edge. Five advanced laparoscopic surgeons performed all the procedures. The primary outcome measure was hernia recurrence., Results: A total of 25 patients with a mean age of 60 years and a body mass index of 29 kg/m2 underwent surgery. Six of these patients had undergone previous mesh stoma revisions. The mean size of the hernia defect was 64 cm2, and the mean size of the mesh was 365 cm2. There were no conversions to open surgery. The overall postoperative morbidity was 23%, and the mean hospital length of stay was 3.3 days. One patient died of pulmonary complications; one patient had a trocar-site infection; and one patient had a mesh infection requiring mesh removal. During a median follow-up period of 19 months (range, 2-38 months), 4% (1/25) of the patients experienced recurrence., Conclusion: On the basis of this large case series, the laparoscopic nonslit mesh technique for the repair of parastomal hernias seems to be a promising approach for the reduction of hernia recurrence in experienced hands.

Chronic infection of a prosthetic mesh implant is a severe complication of ventral hernia repair, and mesh explantation is usually required in these cases. Biologic mesh implants have a possible role in ventral hernia repair in this setting. Here we present a case of chronic mesh infection following ventral hernia repair and the use of a biologic mesh to repair the existing defect following explantation of the infected mesh. Analysis of the explant material demonstrated possible oxidative degradation of the original polypropylene. A review of the literature follows.

Background: New laparoscopic techniques introduced after residency have created a new teaching paradigm focused on animate courses and preceptor instruction. The aim of this study was to test the effectiveness of animate course instruction in teaching laparoscopic ventral hernia repair (LVHR), its success in relationship to the course participants' previous minimally invasive surgery experience, and the role of preceptors in adapting these techniques., Methods: Surgeons participating in a one-day LVHR course (lectures/animal laboratory) at the Carolinas Medical Center were surveyed concerning professional demographics, prior laparoscopic experience, and their performance of LVHR before and after the encounter. Standard statistics were used to determine significance (P<0.05)., Results: Of the 234 surgeons attending a LVHR course between 1999 and 2004, 171 (73%) answered the survey. Mean follow-up after the course was 427 days (range: 34-1202 d). Mean age was 45.9 years (range: 28-67 y). Mean time since residency was 14.4 years (range: 0.5-37 y), and 106 (62%) had learned at least basic laparoscopy in residency. One hundred twenty-six (73.7%) were in private practice. Since the course, 122 (71.3%) had performed a LVHR. They had performed a total of 2049 LVHRs (mean: 16.5; range: 1-102) compared with 1098 open herniorrhaphies (mean: 9; range: 1-23). There was no difference between those performing and not performing LVHR or the number executed with respect to practice type (P=0.67), age (P=0.47), years in practice (P=0.19), or laparoscopic experience in residency (P=0.42). Fifty-four (32%) surgeons had been precepted, and all have since performed LVHR. Surgeons with advanced laparoscopic experience were more likely to perform LVHR compared with those with only laparoscopic cholecystectomy experience (87% versus 33%, P=0.02). Indeed, of those with only laparoscopic cholecystectomy experience who performed LVHR, 80% were precepted. In the subset of surgeons who had not yet performed LVHR, 28 intended to start, 17 requested assistance, and 4 planned not to begin., Conclusions: A one-day course impacts surgeon practice patterns despite age or type of practice. Surgeons with advanced laparoscopic skills are more likely to perform LVHR. Most with limited experience will begin after working with a preceptor. Didactic instruction and a precepted experience may determine the future performance of advanced laparoscopy.

Background: One criticism of laparoscopic ventral hernia repair (LVH) is that the rectus muscles are not re-approximated to the midline, and the effect of LVH repair on the fascial edges is unclear. Progressive migration of the fascial edges toward the midline has been observed anecdotally, but objective evidence remains limited. The purpose of this study is to observe the effect of LVH repair on the rectus abdominus fascia., Methods: Patients undergoing LVH repair with defects > 10 cm in horizontal diameter were identified prospectively and enrolled. All were repaired laparoscopically with intraperitoneal placement of mesh (DualMesh, W.L. Gore and Associates) using a standard approach. Radio-opaque clips were placed at the fascial edges intraoperatively to mark the defect, and plain abdominal films were taken postoperatively (Time 1) to establish the initial distance between clips (measured in cm). A subsequent follow-up film was taken (Time 2), and the difference in clip distance per patient was recorded. Results were analyzed using a chi-squared test., Results: Twelve patients qualified for analysis and their results were compared. Mean fascial defect size was 15.1 cm (range 8.3-22.0). With respect to change in clip distance from Times 1 to 2, three events were observed: (1) Diminished (i.e. medialized), (2) Enlarged, or (3) No Change. Ten patients (83%) medialized, one patient enlarged, and one patient showed no change (chi2 (d.f. = 2) 9.17, p < 0.0023)., Conclusions: Medialization of the rectus abdominus fascia occurs in the majority of patients undergoing LVH repair. Causes for this phenomenon are unclear: however eliminating intrabdominal pressure with intraperitoneal mesh placement likely plays a role.

Contraction is a well-documented phenomenon occurring within two months of mesh implantation. Its etiology is unknown, but it is suggested to occur as a result of inadequate tissue ingrowth into the mesh and has been associated with hernia recurrence. In continuation of our previous studies, we compared tissue ingrowth characteristics of large patches of polyester (PE) and heavyweight polypropylene (PP) and their effect on mesh contraction. The materials used were eight PE and eight PP meshes measuring 10 x 10 cm2. After random assignment to the implantation sites, the meshes were fixed to the abdominal wall fascia of swine using interrupted polypropylene sutures. A necropsy was performed three months after surgery for evaluation of mesh contraction/shrinkage. Using a tensiometer, tissue ingrowth was assessed by measuring the force necessary to detach the mesh from the fascia. Histologic analysis included inflammatory and fibroblastic reactions, scored on a 0-4 point scale. One swine developed a severe wound infection that involved two PP meshes and was therefore excluded from the study. The mean area covered by the PE meshes (87 +/- 7 cm2) was significantly larger than the area covered by the PP meshes (67 +/- 14 cm2) (p = 0.006). Tissue ingrowth force of the PE meshes (194 +/- 37 N) had a trend toward being higher than that of the PP meshes (159 +/- 43 N), although it did not reach statistical significance. There was no difference in histologic inflammatory and fibroblastic reactions between mesh types. There was a significant correlation between tissue ingrowth force and mesh size (p = 0.03, 95% CI: 0.05-0.84). Our results confirm those from previous studies in that mesh materials undergo significant contraction after suture fixation to the fascia. PE resulted in less contraction than polypropylene. A strong integration of the mesh into the tissue helps prevent this phenomenon, which is evidenced by a significant correlation between tissue ingrowth force and mesh size.

When faced with large ventral hernias, surgeons frequently must choose between higher incidence of recurrence after primary repair and higher incidence of wound complications after repair with mesh. The aim of this study is to compare early outcomes between laparoscopic repair (LR) and components separation technique (CST), two evolving strategies for the management of large ventral hernias. We reviewed 42 consecutive patients who underwent CST and 45 consecutive patients who underwent LR of ventral hernia defects of at least 12 cm2. Demographics, hernia characteristics, and short-term outcomes were compared between groups. Patients in the LR group were younger (53 +/- 2 vs 68 +/- 2 years, P < 0.0001), had greater body mass index (34 +/- 2 vs 29 +/- 1 kg/m2, P = 0.02), and had larger hernia defects (318 +/- 49 vs 101 +/- 16 cm2, P < 0.0001) than patients in the CST group. The LR resulted in shorter length of hospital stay (4.9 +/- 0.9 vs 9.6 +/- 1.8 days, P < 0.0001), lower incidence of ileus (7% vs 48%, P < 0.0001), and lower incidence of wound complications (2% vs 33%, P < 0.001) than the CST. Both techniques resulted in similar operative times, transfusion requirements, and mortality. Recurrences occurred in 7 per cent of patients at mean follow-up of 16 months in the CST group and 0 per cent at mean follow-up of 9 months after LR. The LR may have a short-term advantage over the CST in terms of incidence of ileus, wound complications, and hospital stay. Because of their unique advantage over traditional hernia repairs, both techniques may play a significant role in the future treatment of large ventral hernias. Adequate training will be essential for the safe and effective implementation of these techniques within the surgical community.

Laparoscopic repair is a safe and effective method for treating ventral hernias. Although the risk of bowel injury is low, its management is controversial. When injury is suspected or repaired, the risk of infection might prohibit a repair with prosthetic mesh. The timing of safe mesh placement is unclear. We retrospectively reviewed 9 patients from our prospective laparoscopic ventral hernia database who were treated with a 2- to 6-day delay in mesh placement due to violation of the gastrointestinal tract or risk of unidentified or delayed injury. All 9 patients had large ventral hernias from previous laparotomies (average defect, 399.4 cm2) and presented for elective repair. Three of the patients were morbidly obese, and one was diabetic. The decision to delay mesh placement was made intraoperatively. Reasons for delay were colotomy with repair, extensive serosal tears, resection after enterotomy, and resection for chronic small bowel obstruction. All patients received broad-spectrum antibiotics while awaiting definitive repair. In 7 patients, mesh was successfully placed between postoperative days 2 and 6. Delayed mesh placement failed in 2 patients due to loss of domain with bowel edema. The average length of stay was 9 days (range, 6 to 15 days) and average follow-up was 136 days (range, 36 to 303 days). No early mesh infections or other major complications were reported. A short delay of 2 to 6 days with antibiotic coverage is a safe strategy for managing potential or recognized injury to the gastrointestinal tract during laparoscopic ventral hernia repair.

Background: New materials have been devised to prevent postoperative adhesions when placing a prosthesis in contact with abdominal contents., Methods: Eighty rats underwent laparotomy and denudation of the serosa of the cecum and peritoneal covering of the abdominal wall. Five treated mesh products (Parietex Composite, Parietene Composite, Bard Composix E/X, Sepramesh, and Gore-Tex Dual Mesh) and one untreated mesh product (untreated Parietene) were randomly placed between the cecum and abdominal wall. A group without mesh was used as control. The animals were sacrificed at 21 days following surgery and analyzed for the presence of adhesions., Results: The incidence of adhesion formation, mean adhesion area, maximum adhesion length, and strength of adhesion separation were similar between Parietex Composite, Parietene Composite, and Bard Composix E/X, and they were significantly less than with Sepramesh, untreated Parietene, and the control group. Gore-Tex Dual Mesh resulted in less adhesions, adhesion area, mean strength of separation, and work of separation than the untreated Parietene group and the control group. Sepramesh resulted in less strength and work of separation compared to the control group., Conclusions: The incidence of adhesions and work and strength of adhesion separation are reduced when using a treated mesh, compared to the untreated mesh and the control group without mesh. Parietex Composite, Parietene Composite, Bard Composix E/X, and Gore-Tex Dual Mesh were superior to Sepramesh, untreated Parietene, and the control group in the prevention of adhesion formation.

Objective: To evaluate the efficacy and safety of laparoscopic repair of ventral hernias., Summary Background Data: The recurrence rate after standard repair of ventral hernias may be as high as 12-52%, and the wide surgical dissection required often results in wound complications. Use of a laparoscopic approach may decrease rates of complications and recurrence after ventral hernia repair., Methods: Data on all patients who underwent laparoscopic ventral hernia repair (LVHR) performed by 4 surgeons using a standardized procedure between November 1993 and October 2002 were collected prospectively (85% of patients) or retrospectively., Results: LVHR was completed in 819 of the 850 patients (422 men; 428 women) in whom it was attempted. Thirty-four percent of completed LVHRs were for recurrent hernias. The patient mean body mass index was 32; the mean defect size was 118 cm2. Mesh, averaging 344 cm2, was used in all cases. Mean operating time was 120 min, mean estimated blood loss was 49 mL, and hospital stay averaged 2.3 days. There were 128 complications in 112 patients (13.2%). One patient died of a myocardial infarction. The most common complications were ileus (3%) and prolonged seroma (2.6%). During a mean follow-up time of 20.2 months (range, 1-94 months), the hernia recurrence rate was 4.7%. Recurrence was associated with large defects, obesity, previous open repairs, and perioperative complications., Conclusion: In this large series, LVHR had a low rate of conversion to open surgery, a short hospital stay, a moderate complication rate, and a low risk of recurrence.

Background: Recurrence rates after primary repair of ventral and incisional hernias range from 25% to 52%. Recurrence after open surgery is less likely if mesh is used, but the wide fascial dissection and required flap creation increase complication rates. Laparoscopic techniques offer an alternative., Study Design: To assess the safety and efficacy of laparoscopic ventral and incisional herniorrhaphy, we reviewed the records of all our patients who underwent such a procedure from November 1993 to August 1999. A laparoscopic approach was attempted in all patients considered to require a mesh repair. Patient demographic characteristics, operative details, and outcomes were recorded., Results: Of 415 patients scheduled to undergo laparoscopic ventral or incisional herniorrhaphy, conversion to an open procedure was necessary in 8. All the remaining 407 patients (205 men and 202 women; mean age 53.2 years; range 13 to 88 years) were included in the study. Mean fascial defect size was 100.1 cm2 (range 1 to 480 cm2). In 97% of patients, expanded polytetrafluoroethylene mesh was used. Mean operating time was 97 minutes (range 11 to 270 minutes). Mean estimated blood loss was 35 mL (range 10 to 150 mL). Average hospital stay was 1.8 days (range 0 to 17 days). There were 53 complications (13.0%), including cellulitis of a trocar site, infection requiring mesh removal, prolonged suture pain, persistent seroma, intestinal injury, hematoma or postoperative bleeding, prolonged ileus, urinary retention, respiratory distress, fever, intraabdominal abscess, and trocar site herniation. There were no deaths. During a mean followup time of 23 months (range 1 to 60 months), there were 14 hernia recurrences (3.4%), 6 in patients in whom only a stapling device (no sutures) had been used to secure the mesh to the abdominal wall., Conclusions: Laparoscopic repair was completed in 98.1% of patients in whom it was attempted. The complication rate was acceptable. A short hospital stay and minimal blood loss were documented. The recurrence rate was 3.4%. Laparoscopic ventral and incisional hernia repair appear to be safe and effective.

Introduction: Effective surgical therapy for ventral and incisional hernias is problematic. Recurrence rates following primary repair range as high as 25-49%, and breakdown following conventional treatment of recurrent hernias can exceed 50%. As an alternative, laparoscopic techniques offer the potential benefits of decreased pain and a shorter hospital stay. This study evaluates the efficacy of the laparoscopic approach for ventral herniorrhaphy., Methods: A retrospective review was performed for 100 consecutive patients with ventral hernias who underwent laparoscopic repair at our institutions between November 1995 and May 1998. All patients who presented during this period and were candidates for a mesh hernia repair were treated via an endoscopic approach., Results: One hundred patients underwent a laparoscopic ventral hernia repair. There were 48 men and 52 women. The patients were typically obese, with a mean body mass index (BMI) of 31 kg/m(2). Each had undergone an average of 2.5 (range; 0-8) previous laparotomies. Forty-nine repairs were performed for recurrent hernias. An average of two patients (range; 1-7) had previously failed open herniorhaphies; in 20 cases, intraabdominal polypropylene mesh was present. There were no conversions to open operation. The mean size of the defects was large at 87 cm(2) (range; 1-480). In all cases, the mesh (average, 287 cm(2)) was secured with transabdominal sutures and metal tacks or staples. Operative time and estimated blood loss averaged 88 min (range; 18-270) and 30 cc (range; 10-150). Length of stay averaged 1. 6 days (range; 0-4). There were 12 minor and (two) major complications: cellulitis of the trocar site (two), seroma lasting >4 weeks (three), postoperative ileus (two), suture site pain > 2 weeks (two), urinary retention (one), respiratory distress (one), serosal bowel injury (one), and skin breakdown (one) and bowel injury (one). Both of the latter complications required mesh removal. With an average follow-up of 22.5 months (range; 7-37), there have been (three) recurrences., Conclusion: The laparoscopic approach to the repair of both primary and recurrent ventral hernias offers a low conversion rate, a short hospital stay, and few complications. At 23 months of follow-up, the recurrence rate has been 3%. Laparoscopic repair should be considered a viable option for any ventral hernia.

The repair of large and/or recurrent ventral hernias is associated with significant complications and a recurrence rate that can be more than 50 per cent. Laparoscopic ventral herniorrhaphy, a recent development, has been shown to be safe and effective in the repair of ventral hernias. This study retrospectively reviews all ventral hernia repairs over a 3-year period, November 1995 through December 1998, at a community-based teaching hospital. The purpose of the study was to compare open and laparoscopic repairs. A total of 253 ventral hernia repairs were performed during this time, 174 open and 79 laparoscopic. The age, weight, and sex distribution was similar for each group. The hernias in the open group averaged 34.1 cm2 in size, and mesh used averaged 47.3 cm2. In the laparoscopic group, the hernia defect averaged 73.0 cm2, and the mesh size averaged 287.4 cm2. Operative time was longer in the open group, 82.0 versus 58.0 minutes. In the open group, there were 38 (21.8%) minor and 8 (4.6%) major complications, compared with 13 (16.5%) minor and 2 (2.5%) major complications in the laparoscopic group. Hospital stay was shorter for the laparoscopic group, 1.7 versus 2.8 days. At an average follow-up of 21 months (range, 2-40 months), there have been 36 recurrences in the open group (20.7%) compared with 2 recurrences in the laparoscopic group (2.5%). In this series, laparoscopic ventral herniorrhaphy compares favorably to open ventral herniorrhaphy with respect to wound complications, hospital stay, operative time, and recurrence rate.