minimally invasive advances in awr tommy h lee, md creighton university omaha, ne

Minimally Invasive Minimally Invasive Advances in AWRAdvances in AWRTommy H Lee, MDTommy H Lee, MD

Creighton UniversityCreighton University

Omaha, NEOmaha, NE

Nothing to DiscloseNothing to Disclose

OverviewOverview

Laparoscopic ventral hernia repairLaparoscopic ventral hernia repair

Laparoscopic component separationLaparoscopic component separation

Hybrid proceduresHybrid procedures

Which approach to use?Which approach to use?

Incisional/Ventral Incisional/Ventral Hernia:Hernia:The FactsThe Facts

A Frequent Complication of LaparotomyA Frequent Complication of Laparotomy

3% to 13% of All Laparotomies3% to 13% of All Laparotomies

4 to 5 Million Laparotomies Annually in the US4 to 5 Million Laparotomies Annually in the US

= 400,000 To 500,000 Incisional Hernias= 400,000 To 500,000 Incisional Hernias

= 200,000 Repairs= 200,000 Repairs

• The American Journal of Surgery, Vol 197, No The American Journal of Surgery, Vol 197, No 1, January 20091, January 2009

““Traditional” Hernia Traditional” Hernia RepairRepair

OpenOpen

+/- Mesh+/- Mesh

OnlayOnlay

InlayInlay

UnderlayUnderlay

Component SeparationComponent Separation

Laparoscopic RepairLaparoscopic Repair

Wide overlap (3? 4? 5cm?)Wide overlap (3? 4? 5cm?)

+/- Transfascial sutures+/- Transfascial sutures

+/- Primary closure of defect+/- Primary closure of defect

Why Laparoscopic?Why Laparoscopic?Open vs. LaparoscopicOpen vs. Laparoscopic

PROPRO

↓ ↓ Operative TimeOperative Time

↓ ↓ Risk of Serious Risk of Serious Complications Complications

↓ ↓ CostCost

Muscle Muscle Approximation → Approximation → Better Functional Better Functional ResultResult

CONCON↑ Infection ↑ Infection Rate? ↑ Recurrence Rate? ↑ Recurrence Rate? Greater Post Rate? Greater Post Operative Pain? Operative Pain? Longer Time for Longer Time for Return to Usual Return to Usual ActivitiesActivities

Bisgaard et al (2009)Bisgaard et al (2009)

All patients aged 18 years or older who had All patients aged 18 years or older who had elective surgery for incisional hernia in elective surgery for incisional hernia in Denmark between 1 January 2005 and 31 Denmark between 1 January 2005 and 31 December 2006 December 2006

2896 Incisional hernia repairs2896 Incisional hernia repairs

1872 Open/1024 Laparoscopic1872 Open/1024 Laparoscopic

2754 Primary /142 Recurrent2754 Primary /142 Recurrent

Bisgaard et al (2009)Bisgaard et al (2009)

Unsatisfactory resultsUnsatisfactory results

Severe complication rate 3.5%Severe complication rate 3.5%

Mortality rate 0.4%Mortality rate 0.4%

Reality of the disease?Reality of the disease?

•73 Laparoscopic vs 73 Open repairs73 Laparoscopic vs 73 Open repairs

Itani et al (2010)Itani et al (2010)

Laparoscopic - fewer complications, more Laparoscopic - fewer complications, more seriousserious

8 RCTs, 536 patients8 RCTs, 536 patients

Hernia 23.2 to 141.2 cmHernia 23.2 to 141.2 cm22

F/U 6 to 40.8 monthsF/U 6 to 40.8 months

British Journal of Surgery 2009; 96: 851–858British Journal of Surgery 2009; 96: 851–858

Forbes et al (2009)Forbes et al (2009)

LaparoscopicLaparoscopic

No difference in recurrenceNo difference in recurrence

Fewer wound complicationsFewer wound complications

Laparoscopic at least equivalent to open repairLaparoscopic at least equivalent to open repair

Laparoscopic Ventral Laparoscopic Ventral Hernia TechniqueHernia Technique

General anesthesia / Antibiotic prophylaxisGeneral anesthesia / Antibiotic prophylaxis

Table to table PrepTable to table Prep

Insufflation needle - away from midlineInsufflation needle - away from midline

HassonHasson

Initial 5 mm “Optical Trocar”Initial 5 mm “Optical Trocar”

Three cannulae technique, all in the anterior Three cannulae technique, all in the anterior axillary lineaxillary line

TechniqueTechnique

Lysis of adhesionsLysis of adhesions

Size defect (avoid oversizing)Size defect (avoid oversizing)

Intra-abdominalIntra-abdominal

Deflate abdomenDeflate abdomen

Primary closure of defect?Primary closure of defect?

Place and secure meshPlace and secure mesh

Port PlacementPort Placement

MeshMesh

FastenersFasteners

AbsorbableAbsorbable

Slow-absorbingSlow-absorbing

No long-term foreign bodyNo long-term foreign body

?Adequate fixation?Adequate fixation

Non-absorbableNon-absorbable

ProtackProtack

FastenersFasteners

Depth of fixation limited!Depth of fixation limited!

Abdominal Wall FixationAbdominal Wall Fixation

Abdominal Wall SuturesAbdominal Wall Sutures

Tricks of the TradeTricks of the Trade

Marking of the Marking of the ProsthesisProsthesis

Primarily close the Primarily close the defectdefect

Securing the meshSecuring the mesh

Laparoscopic Laparoscopic Component SeparationComponent Separation

Why laparoscopic?Why laparoscopic?

Fewer wound complicationsFewer wound complications

SeromaSeroma

InfectionInfection

Flap necrosisFlap necrosis

Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.

Laparoscopic Laparoscopic Component Separation - Component Separation - TechniqueTechnique

http://www.sages.org/video/details.php?id=100888

Is it effective?Is it effective?

Laparoscopic component Laparoscopic component separation achieved 86% separation achieved 86% advancement compared advancement compared to opento open

Rosen et al.Rosen et al.

External oblique releaseExternal oblique release

Is it effective?Is it effective?

Comparable amount of releaseComparable amount of release

Tranversus abdominus and posterior sheath release compared to Tranversus abdominus and posterior sheath release compared to traditional ext. oblique + post. sheath releasetraditional ext. oblique + post. sheath release

p values not significantp values not significant

Is it effective?Is it effective?Large series lackingLarge series lacking

7 patients, average follow-up of 4.5 months7 patients, average follow-up of 4.5 months

External oblique released laparoscopicallyExternal oblique released laparoscopically

Posterior sheath released as necessary (open)Posterior sheath released as necessary (open)

Alloderm underlayAlloderm underlay

1 SSI, 1 hematoma, 1 resp failure1 SSI, 1 hematoma, 1 resp failure

Is it effective?Is it effective?

Posterior sheath release followed by ext. oblique releasePosterior sheath release followed by ext. oblique release

+/- mesh+/- mesh

7 laparoscopic, 30 open, 1 year follow-up7 laparoscopic, 30 open, 1 year follow-up

Fewer complications in laparoscopic groupFewer complications in laparoscopic group

No ischemia, wound infection, dehiscenceNo ischemia, wound infection, dehiscence

Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.Lowe et al. Plast. Reconstr. Surg. 105: 720, 2000.

Is it effective?Is it effective?

5 patients, less than 1 year follow-up5 patients, less than 1 year follow-up

Laparoscopic ext oblique releaseLaparoscopic ext oblique release

4 had mesh underlay (biologic)4 had mesh underlay (biologic)

2 mild wound complications2 mild wound complications

1 recurrence (!)1 recurrence (!)

Am Surg. 75(7). 572-8.Am Surg. 75(7). 572-8.

Hybrid Procedure?Hybrid Procedure?

Combine elements:Combine elements:

Laparoscopic/Open lysis of adhesionsLaparoscopic/Open lysis of adhesions

Laparoscopic intraperitonal mesh repairLaparoscopic intraperitonal mesh repair

Laparoscopic/Open component separationLaparoscopic/Open component separation

Rives-Stoppa repairRives-Stoppa repair

Cox et al.Cox et al.

Open lysis of adhesionsOpen lysis of adhesions

Rives-Stoppa repairRives-Stoppa repair

Laparoscopic component separation to mobilize ant. Laparoscopic component separation to mobilize ant. sheathsheath

Bridging mesh as neededBridging mesh as needed

6 patients, F/U 4-14 months6 patients, F/U 4-14 months

No recurrencesNo recurrences

1 recurrent EC fistula1 recurrent EC fistula

Combined laparoscopic component separation Combined laparoscopic component separation and intraperitoneal mesh placementand intraperitoneal mesh placement

4 patients, 30-100 day follow-up4 patients, 30-100 day follow-up

Good outcomesGood outcomes

Primary “shoelace” closure Primary “shoelace” closure of defectof defect

Better function?Better function?

Component separation Component separation (laparoscopic) as needed(laparoscopic) as needed

No recurrences at 16.2 No recurrences at 16.2 monthsmonths

Surg Endosc. 2010 Surg Endosc. 2010 Nov 5Nov 5

Moazzez et al. Surg Technol Int. 2010;20:185-Moazzez et al. Surg Technol Int. 2010;20:185-91.91.

Moazzez et al (2010)Moazzez et al (2010)

Moazzez et al (2010)Moazzez et al (2010)

Moazzez et al (2010)Moazzez et al (2010)

Fasica is closedFasica is closed

Guidelines... (Ventral Guidelines... (Ventral Hernia Working Group - Hernia Working Group - 2010)2010)

Breuing et al, Surgery (2010), 148(3), pp 544-558. Breuing et al, Surgery (2010), 148(3), pp 544-558.

ConclusionConclusion

Laparoscopic techniques are being developedLaparoscopic techniques are being developed

Approach needs to be tailored to particular Approach needs to be tailored to particular needs of patientneeds of patient

No “universal” techniqueNo “universal” technique

Advantages/disadvantages to eachAdvantages/disadvantages to each