Laparoscopic Ventral and Incisional Hernia Repair

Abstract

Ventral and incisional hernia repair is one of the most frequently performed operations in daily surgical practice. Laparoscopic ventral and incisional hernia repair (LVIHR) is gaining increasing adoption in surgical practice. It has theoretical advantages but improvements in technique can still be made. The aim of this thesis is to study complications and techniques of LVIHR. Questions that we try to answer are: — What causes recurrence after LVIHR? — How can we treat chronic post-operative pain? — How should the mesh be fixated? — What are the clinical consequences of intra-abdominal mesh placement? In Chapter 2 all nine recurrences in a series of 505 LVIHRs were studied. We conclude that a risk factor for the development of recurrence in repair of an incisional hernia appears to be an incomplete coverage of the whole original incision by mesh. Chapter 3 describes a fatal case of intestinal ischemia after LVIHR. Intestinal ischemia therefore seems to be more related to laparoscopy in patients at risk for cardiovascular complications in general than to LVIHR specifically. In Chapter 4 we analyzed the effect of suture removal in 6 patients with persistent post-operative pain following LVIHR. We conclude that up to now there is no one single treatment option for chronic post-operative pain after LVIHR. In selected cases removal of transabdominal sutures can be beneficial. In Chapter 5 the results of a randomized study on mesh-fixation technique and pain and quality of life after LVIHR in 199 patients are presented. We conclude that there appear to be no significant differences in post-operative pain and quality of life between the three studied mesh-fixation techniques. In Chapter 6 a study investigating the impact of mesh-fixation technique on operative time in laparoscopic umbilical hernia repair in 138 patients is presented. We found a small but significant time advantage for the technique using only tacks. On the basis of these last two studies we cannot advise the use of one of the studied mesh-fixation techniques over the other. In Chapter 7 seventy-two reoperations after LVIHR are described. Three specific observations can be made: (1) no relaparoscopies had to be converted, (2) no inadvertent bowel lesions were encountered during adhesiolysis, and (3) SAOs were practically devoid of peri- and postoperative complications. We therefore conclude that the clinical consequences of intra-abdominal mesh placement during LVIHR seem insignificant. Final conclusions: What causes recurrence after LVIHR? An incomplete coverage of the whole original incision by mesh is a risk factor for developing a recurrence after incisional hernia repair. How can we treat chronic post-operative pain? There is no single treatment option for chronic pain after LVIHR. How should the mesh be fixated? Presently we cannot advise on what method of mesh fixation to use in LVIHR. What are the clinical consequences of intra-abdominal mesh placement? The clinical consequences of intra-abdominal mesh placement during LVIHR seem insignificant.