Laparoscopic ventral hernia repair with composite mesh: Analysis of risk factors for recurrence in 185 patients with 5 years follow-up.

BACKGROUND: Laparoscopic ventral hernia repair is widely used although its clinical indications are often debated. The aim of this study is to describe our surgical experience in order to establish the safety, efficacy, feasibility of laparoscopic ventral hernia repair and to identify the factors that influence the risk of recurrence in a group of patients treated with only one type of prosthetic mesh and by the same surgical team. MATERIALS AND METHODS: Between January 2007 and December 2016, 512 patients were admitted to the General and Urgent Surgery Unit, with diagnosis of ventral hernia. Of these, 244 were operated laparoscopically and 268 in a traditional open surgery. In 244 patients treated by laparoscopy we always used a composite mesh: 185 Parietex™ Composite mesh (Medtronic-Covidien, Minneapolis, USA), the remaining other with other types of prosthetic mesh. The type and size of surgical defects, features of surgical technique, length of hospital stay, rate of conversion, morbidity, mortality, and rate of recurrence at 5 years follow-up were retrospective analysed on the 185 patients who underwent surgery with Parietex™ Composite mesh. RESULTS: We performed 185 laparoscopic ventral hernia repair with Parietex™ Composite mesh: 108 (58%) for incisional hernias and 77 (42%) for primary abdominal wall hernias. Mean age was 58 years (19-80). The mean size of abdominal defect was 5 cm (1,5-18), mean BMI was 30,4 kg/m2 (21-47), mean overlap of the mesh was 5 cm (3-6). The mean operative time was 54 min (30-180) and conversion rate was 3,2%. In 61 patients (33%) we performed a transversus abdominis plane block (T.A.P. block) to reduce postoperative pain. The mean length of hospital stay was 5 days (1-26) (2 days, mean value, in patient with preoperative T.A.P. block). The mortality rate was 0%; overall morbidity was 15,6%. At 5-year follow-up we observed 13 (7%) hernia recurrences. The features of patients with recurrence were as follows: mean age 50 years (19-74), mean ASA Score 3 (2-3), mean BMI 31 kg/m2 (21-44), mean size of hernial defect 7,5 cm (larger diameter), mean overlap 4,5 cm (3-6). CONCLUSIONS: Laparoscopic repair of ventral hernia using composite mesh is an effective and safe procedure particularly suitable in the following cases: median and paramedian defects, diameter of defect between 5 and 15 cm, "swiss cheese" defects, obesity. In our experience the factors related to the patient and the surgical technique that may influence the onset of early or late recurrence as the follows: a defect size >5 cm (W2 of EHS Classification), an overlap of the mesh < 5 cm, a BMI of 30 kg/m2 or superior and the presence of significant comorbidities (ASA score: 3). Finally, we observed that the T.A.P. Block preoperative procedure can lead to reduced the clinical costs through a lower administration of analgesics used and a lower length of stay.

International consensus conference on open abdomen in trauma.

BACKGROUND: A part of damage-control laparotomy is to leave the fascial edges and the skin open to avoid abdominal compartment syndrome and allow further explorations. This condition, known as open abdomen (OA), although effective, is associated with severe complications. Our aim was to develop evidence-based recommendations to define indications for OA, techniques for temporary abdominal closure, management of enteric fistulas, and methods of definitive wall closure. METHODS: The literature from 1990 to 2014 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-analyses] protocol. Seventy-six articles were reviewed by a panel of experts to assign grade of recommendations (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development, and Evaluation] system, and an international consensus conference was held. RESULTS: OA in trauma is indicated at the end of damage-control laparotomy, in the presence of visceral swelling, for a second look in vascular injuries or gross contamination, in the case of abdominal wall loss, and if medical treatment of abdominal compartment syndrome has failed (GoR B, LoE II). Negative-pressure wound therapy is the recommended temporary abdominal closure technique to drain peritoneal fluid, improve nursing, and prevent fascial retraction (GoR B, LoE I). Lack of OA closure within 8 days (GoR C, LoE II), bowel injuries, high-volume replacement, and use of polypropylene mesh over the bowel (GoR C, LoE I) are risk factors for frozen abdomen and fistula formation. Negative-pressure wound therapy allows to isolate the fistula and protect the surrounding tissues from spillage until granulation (GoR C, LoE II). Correction of fistula is performed after 6 months to 12 months. Definitive closure of OA has to be obtained early (GoR C, LoE I) with direct suture, traction devices, component separation with or without mesh. Biologic meshes are an option for wall reinforcement if bacterial contamination is present (GoR C, LoE II). CONCLUSION: OA and negative-pressure techniques improve the care of trauma patients, but closure must be achieved early to avoid complications.