Introduction

Since the first report by Karl Leblanc [1] in 1993 laparoscopic ventral hernia repair has gained increased popularity among surgeons as well as patients over the conventional repair done through laparotomy with or without mesh. Among the benefits of the laparoscopic approach when compared to mesh open repair are the reduced postoperative pain, overall complication rate and hospital stay [2–4]. The use of mesh in open repair has become the rule since the superiority of the abdominal wall prosthetic reinforcement was demonstrated [5]. However, this means the use of long incisions, large subcutaneous flaps and prolonged drainage. While the advantages of laparoscopy over the open repair are still unclear, the risk of recurrence seems to be equivalent with rates of 9% or less for the most recent publications [6–9] when compared to large series of open repair with mesh [10]. However, so far there is no general agreement on whether the laparoscopic treatment should be used in very small or very large ventral hernias or as a primary method for repair. The use of an ePTFE patch has allowed a secure intraperitoneal placement of the mesh in contact with the visceral content. With the potential shorter hospital stay in mind we decided to use the laparoscopic approach patch from 1997 on as a deliberate approach with long-term assessment of safety and efficacy in the treatment of any type of ventral hernia.

Patients and methods

From March 1997 to March 2003, 155 laparoscopic ventral hernia repairs were attempted on 146 patients and only 3 patients had their operation done prior to January 1999. The 71 women and 75 men had a mean age of 57.4 years (25–88). One hundred and thirteen patients (73%) had an incisional hernia and 22% of the patients had a failure of a previous operation for ventral hernia. Preoperatively, the mean diameter of the defect measured clinically was 6.5 cm (1–25). The mean Body Mass Index was 28.5 with 15 (10%) of the patients with a BMI of 30 or over. Laparoscopy was selected as a deliberate approach for ventral hernia repair and only patients with a theoretical minimum 6-month follow-up available were included in this series. The technique used no routine gastric or bladder decompression (except for suprapubic hernias) and two ports were symmetrically positioned on each side of the abdomen (one 10 mm—usually in the left subcostal space—and three 5 mm). Only three ports were used for suprapubic hernias. Goretex Dualmesh Plus ePTFE mesh (WL Gore and Associates, Flagstaff, AZ, USA) was used with a size determined to allow a 3–5-cm overlap of the wall defect. According to the size of the mesh a variable number (4–8) of markers were drawn on the parietal side of the mesh as well as corresponding markers on the plastic drape covering the skin. Except for the first three patients the mesh was attached using a combination of Goretex CV2 sutures placed on each marker around the mesh and circumferential tack staples placement, the pneumoperitoneum being decreased to 8–10 mmHg during this stage. At the end of the procedure the sutures were tightened down and cut subcutaneously, the knots lying down on the aponeurotic fascia. All the patients presenting a ventral hernia seen during this period by the author were offered this type of repair. Since the largest Goretex mesh size is 24 cm by 36 cm, patients with hernias greater than 25 cm in diameter could not meet the requirements for a 5-cm mesh overlap of the wall defect and were offered an open repair with aponeurotic sutures and onlay polyester mesh (Welty procedure).

Results

In four patients the laparoscopy was converted to an open approach for peritoneal carcinomatosis, small-bowel and right-colon injuries and very severe adhesions (2.6% conversion rate). Two of these patients had an open mesh repair, the patient with a small-bowel injury had a suture repair and the right colon injury led to a right hemicolectomy and a delayed yet successful laparoscopic repair. The remaining 151 operations were completed laparoscopically in a mean 105.8 min (range 35–240) and 10 patients had a redo laparoscopic ventral hernia repair in this series (for recurrence, new hernia or delayed repair following injury). Additional procedures at the time of the hernia repair were performed in four patients (cholecystectomy and inguinal hernia repair). An average of four trocars were used (2–5). Table 1 shows the details of the implanted meshes, 69.5% of the patients received a 15 by 19 or a 18 by 24 cm mesh with a mean mesh surface of 341 cm2 (100–885). Patients usually resumed oral feeding by the following morning after the procedure, except in the case of ileus or small bowel obstruction. 82.8% of the patients had an eventful postoperative course. Complications are listed in Table 2 and the most frequent was fever and/or inflammatory reaction on the site of the hernia. Two patients died postoperatively (1.3%) both from pulmonary embolism, although this was not proven for one of the patients. Two patients had to be reoperated on during the hospital stay: one for an early intraabdominal bleeding and the other for a small bowel obstruction without explanation at reoperation. The length of stay was a mean 4.9 days ranging from the day of surgery to 56 days. Patients were followed-up regularly and were reviewed clinically for the last time during the summer of 2003 with a mean follow-up of 26.6 months (2–76). Six patients were lost to follow-up and 13 died during the follow-up period of unrelated causes. Among the survivors 71 had a control CT scan. Thirty-one patients (20.7%) complained of pain in the mesh fixation areas for more than 1 month postoperatively and 10 of these required local anesthetics injection to control this problem. One patient eventually had some tacks removed without significant improvement and was later reoperated on for recurrence. Twelve persisting seromas (8%) required needle aspiration. Eight patients developed a recurrence (5.4%) and six were reoperated on with open repair and Goretex mesh removal in one case. The five other patients had a redo laparoscopic repair adding another Dualmesh. Two patients presenting with a minor recurrence did not require or wish reoperation at this time. In addition to the recurrences two patients developed a new hernia distant from the initial repair and confirmed by a new laparoscopic repair with an additional Dualmesh. CT scan screening did not reveal any asymptomatic recurrent hernia. A total of four meshes were removed during the follow-up: one got infected, one was removed at the time of an open repair for recurrence and two were removed by other surgical teams during aorta femoral bypass and urostomy relocation without evidence of recurrence. One of these patients had no hernia repair after the mesh was removed when the aorta femoral bypass was performed and, as expected, had a hernia recurrence again treated laparoscopically. One patient has been reoperated elsewhere without removal of the mesh for a small bowel obstruction 1 year after the ventral hernia repair.

Table 1 Mesh size
Full size table
Table 2 Early complications
Full size table

Discussion

Most of the published series of laparoscopic ventral hernia repair use ePTFE graft [7–9, 11]. This material has demonstrated adequate fixation onto the peritoneal layer of the abdominal wall when compared to the material of reference such as polypropylene [12] with minimal adhesions with the intraperitoneal content [13, 14]. This has been attributed to the unique micro and macroporous structure of the Goretex Dualmesh on each side of the graft. Recent animal studies [15] have suggested that some composite grafts were also able to reduce adhesion formation when placed intraperitoneally. However back to 1997 ePTFE was the only product available for a secure intraperitoneal positioning. Most of the series that have been published in the literature have been using ePTFE grafts either mostly or exclusively [7, 9, 16–21] which makes comparison with our own series sensible. One of the most important features of the laparoscopic ventral hernia repair is the low rate of conversion compared to open repair. In the literature the rate of conversion to open ranges from 0% [22] to 10% [3] when excluding papers reporting a learning curve experience with a higher rate of conversion [23]. The largest series [7] reports a 3.6% conversion rate which is mainly due as in other papers including our own series to very severe adhesions or enteromy with major spillage. The size of the wall defect, for instance, does not seem to influence the rate of conversion to open repair [19]. The technique we have been using is derived from the one described by large American series advocating a prosthesis overlap of more than 3 cm in all directions [7] [24] or even 5 cm [16].

Although fatal complications are uncommon with a mortality rate close to 0% [7], several papers report unrecognized bowel injury during adhesions dissection that can lead to the patient’s death [4, 18]. One of the two deaths in our series has been documented as related to a pulmonary emboli, the other death is less clear. However no bowel dissection had been performed for this patient in whom the ventral hernia resulted from an open drainage of a necrotizing pancreatitis several months earlier. When learning curve studies are excluded the overall rate of complications ranges from 11.4% [17] to 28% [20]. Most of the series have complication rates of less than 20% [7, 9, 16] and most of the time complications are made of prolonged ileus, pain or minor infection at the trocar site and seromas/hematomas. Several studies have compared the rate of complication after laparoscopic and open repair [2–4, 25–28]. Except DeMaria who found no difference between the laparoscopic and open approach all the series including the meta-analysis [26] report significantly less complications with the laparoscopic approach. However, if complications are less frequent they can be more severe following a laparoscopic procedure with a rate of 2–4% bowel injury [26]. Seromas are to be considered hardly as complications unless they are persistent and require needle aspiration [7]. Susmallian [29] as well as others [18, 30] have emphasized the high frequency of postoperative seroma formation close to 100% of the cases most of the time unrecognized clinically. Even if mesh infection is rare after laparoscopic repair with ePTFE graft it can occur with a rate less than 2% [4, 7, 9, 16, 18, 19, 31]. In 2 instances this complication was more frequent in a series also using polypropylene mesh [27] or after percutaneous seroma drainage [2]. However no significant difference was found between open and laparoscopic repairs with respect to mesh infection [2–4]. Although comparative studies showed less postoperative narcotic requirements [3] after laparoscopic repair and intraabdominal placement of the mesh, the incidence of chronic postoperative pain ranges from 1.1% to 4.5% [4, 7, 16, 17, 32].There is no clear explanation for the development of chronic pain; some argue that transfascial sutures more than staples are responsible for chronic pain [7], although the series reporting chronic pain rates within the usual range up to 4.5% use staples only, sutures only or a combination of the two. In contrast LeBlanc [16] found a 2.5 times higher incidence of severe postoperative pain in an initial series not using transfascial series. There is no clear explanation for the higher rate of chronic pain in our series shared by another author [6], although an increased narcotic requirement has been demonstrated for larger hernias [20, 33]. However pain problems are usually controlled by repeated local and intrafascial injection of ropivacaine or other local analgesics [33, 34]. What has been unanimously aknowledged is a shorter hospital stay usually around 2 days after laparoscopic repair over the open approach most probably in relation to the absence of drainage but also because of the reduced postoperative pain [2–4, 25, 27, 28].

With the exception or very limited or learning curve series the recurrence rate ranges from 0% [19] to 17% [21] with mean follow-ups ranging from 18 [35] to 44 months [9]. Most of the series however report a recurrence rate comprised between 2 and 7% [3, 6, 7, 9, 16, 17, 31, 36] with mean follow-ups in the range 20–40 months. Despite the fact that in his series Rosen [21] observed recurrences throughout the long-term follow-up (range 4–65 months, mean 30 months) he also admitted that 9 out of those 17 recurrences occurred during the first postoperative year and that 65% were seen during the learning phase. Most of the recurrences seem to develop early after the laparoscopic repair [35]. After the problem of insufficient mesh overlap (less than 5 cm in all directions) was ruled out [9, 16, 35], the main factors that may explain failed laparoscopic repairs were identified as prior failed hernia repair and increased estimated blood loss/intraoperative complications as well as obesity [7, 21] . Although one typical mechanism of recurrence is detachment of the tacks [36] the role of fixation methods has not been identified as a factor for an increased rate of failures and several studies report recurrence rates of less than 4% using only staple fixation, although in a “double crown (row)” fashion [9, 31]. In his most recent report LeBlanc [16] observed a dramatic decrease of the recurrence rate from 9 to 4% with the use of a combination of transfascial sutures and tacks compared to tacks only. However, the series using only the staples was also the oldest one and the role of the learning curve could also be suspected. We favor the use of a combination of a single row of tacks around the edges of the mesh, primarily to avoid any incarceration of the small bowel between the mesh and the abdominal wall and 4–8 Goretex nonabsorbable sutures which secure the mesh onto the abdominal wall and are used as stay sutures to correctly position the mesh prior to stapling. No paper reports any superiority of the combination of tacks and sutures over tacks only, however an animal study reports a 2.5 times greater tensile strength of transabdominal sutures than of tacks [37]. All the series comparing laparoscopic and open repairs with mesh found at least as good results with respect to the long-term recurrence rate for the laparoscopic approach [4, 25, 27, 28]. Two papers found a significant improvement on the long term after laparoscopic repair [3, 28], however one of the papers [3] had a 30% rate of lost to follow-up patients in each group over a relatively short follow-up period (mean 20.8 months) making the comparison rather inconclusive. Future developments may allow for modification of the tack staples being used or even replacing them by glues to avoid complications such as tack herniation or adhesions related to staples [38].

Conclusions

Over the years the laparoscopic approach for ventral hernia repair has demonstrated its feasibility and reliability with a low rate of conversion to open and the ability to treat even the largest abdominal wall defects. Intraperitoneal mesh placement has been made possible with the use of ePTFE while avoiding the risk of bowel fistula and with a reduction in adhesion formation. The two advantages of the laparoscopic approach are clearly the reduced risk of postoperative complications and the shorter hospital stay in comparison to the more traditional open approach. However the potential risk of bowel injury during the hernia dissection should be considered as a specific pitfall of this procedure. The intraperitoneal placement of the ePTFE mesh gives as good results as the open approach with sublay or onlay polypropylene or polyester mesh on the long term but did not show any superiority in terms of recurrence rate. Improvements in mesh fixation techniques could reduce the risk of postoperative pain and make the laparoscopic approach with intraperitoneal ePTFE mesh an even more credible alternative to ventral hernia open repair.