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Surgical Technology International XXVIII contains peer-reviewed articles featuring the latest advances in surgical techniques and technologies.
April, 2016- ISSN:1090-3941
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Hernia Repair
Initial Experience with a New Macroporous Partially Absorbable Mesh: Introducing Ultrapro® Advanced™
Handojo Karen, MD, Resident, Meylemans Diederik, MD, Fellow, Department of Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium, Devroe Kurt, MD, Consultant, Vermeiren Koen, MD, Consultant, Aelvoet Chris, MD, Consultant, Tollens Tim, MD, Consultant, Head of Department, Department of Abdominal Surgery, Imelda Hospital, Bonheiden, Belgium
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Introduction: The Ultrapro® Advanced™ mesh (Ethicon, Sommerville, NJ) is a new mesh design, using the best characteristics from the previous platform, while adding new, advanced features. Our centre, Imelda Hospital, Bonheiden, Belgium, was chosen as one of the first clinical testing sites. The aim of this study was to present our preliminary data on complication rate and patient satisfaction.
Materials and Methods: From October 1, 2015 until January 31, 2016, we treated 57 patients, implementing 67 Ultrapro® Advanced™ meshes. One patient was excluded due to postoperative cerebral haemorrhage with aphasia. Only patients with more than one-month follow-up were included for further analysis, resulting in a population of 41 patients with 51 meshes. Of them, 35 were male and only 6 were female, with an average age of 61.4 years and an average BMI of 25.9. The indications were uni- and bilateral laparoscopic inguinal hernia repair (n = 23 and 10 respectively), open inguinal hernia repair (n = 3), and open incisional hernia repair (n = 5). Quality of life was measured preoperatively and at four weeks postoperatively, using the hernia specific Carolina Comfort Scale (CCS) questionnaire.
Results: The primary endpoint was complication rate. Only two patients (4.8%) mentioned a mild scrotal hematoma and two patients (4.8%) demonstrated a seroma. There were no superficial wound infections nor early recurrent hernias. Our secondary endpoint was quality of life, measured by the CCS questionnaire, which differentiates between a symptomatic and an asymptomatic group. A total of 13 patients were asymptomatic, whilst 28 patients reported some sort of discomfort, ranging from mild (n = 25) to moderate and/or daily symptoms (n = 3). No patients were disabled by their symptoms.
Conclusion: The Ultrapro® Advanced™ is a sequel of the classic Ultrapro® mesh with similar characteristics: it is a “lightweight�?, macroporous, partially absorbable mesh built out of thin filaments, while maintaining sufficient strength. Its improvement is due to incorporation of evidence-based characteristics such as an increased mesh elasticity. Furthermore, the surgical manipulation is improved thanks to the increased mesh memory. Our prospective cohort study shows good initial and short-term results after implementation of the Ultrapro® Advanced™. However, further prospective research is mandatory on the long-term outcomes.
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Articulating and Reloadable Fixation Devices for Hernia Repair
Alexandra M. Moore, MD, General Surgery Resident, Department of General Surgery, David Geffen School of Medicine at UCLA, University of California, Los Angeles, CA, David C. Chen, MD, Associate Professor of Clinical Surgery, Department of General Surgery, Lichtenstein Amid Clinic at UCLA, University of California, Los Angeles, CA
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There have been a variety of absorbable and permanent tacks, tack deployment systems, and fasteners developed for the fixation of mesh during laparoscopic ventral hernia repair. The manufacturer recommendation for all systems is for perpendicular deployment of these tacks into the tissue. Achieving this optimal angle with previously developed deployment systems is often challenging and can lead to tack failure, mesh migration, and recurrence, or may require the placement of additional ports. Additionally, current tack deployment systems lack the ability to reload, leading to increased cost when entire systems must be opened each time a reload is necessary. This article presents products designed to addresses both of these problems. These deployment instruments incorporate an articulating shaft or a hinge mechanism allowing for improved access to different parts of the abdominal cavity and delivering perpendicular placement of tacks with fewer port sites. Devices with the option of reloadable fixation decrease cost and reduce waste.
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A Complete Sutureless Hernia Repair for Primary Inguinal Hernia The Trabucco Repair: A Tribute to Ermanno Trabucco
Giampiero Campanelli, MD, Professor of Surgery, Insubria University, Varese/Como, Italy, Director , Center of Research and High Specialization for the Pathologies of Abdominal Wall and Surgical Treatment and Repair of Abdominal Hernia, Milan, Italy, President , European Hernia Society, Paris, France, Piero Giovanni Bruni, PHD, Researcher, Insubria University, Varese/Como, Italy, Consultant, Marta Cavalli, PHD, Researcher, University of Catania, Catania, Italy, Consultant , Andrea Morlacchi, MD, Resident , Insubria University, Varese/Como, Italy, Resident, Center of Research and High Specialization for the Pathologies of Abdominal Wall and Surgical Treatment and Repair of Abdominal Hernia, Istituto Clinico Sant’Ambrogio , Milan, Italy
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Since 1989, the authors have been using the Trabucco tension-free and sutureless technique for the repair of primary groin hernia with a pre-shaped mesh in more than 8,000 surgical procedures for complex and “simple�? abdominal and inguinal hernias; over 4,000 cases have been considered in this study. The great majority of these procedures were performed under local anaesthesia and with a complete and careful nerve sparing.
Compared to the Lichtenstein’s technique, which is currently the golden standard treatment worldwide, there are no significant differences in the observed recurrence rate (below 2%).
For the Law of Pascal, the pre-shaped prosthesis developed by Trabucco remains stretched uniformly in the inguinal canal, without the need to be secured with sutures and without forming dead space, which is a cause of infections, pain, and recurrence.
The main advantage of a tension-free and sutureless repair is given by the relevant reduction in postoperative chronic neuralgia, which is not an uncommon complication and, depending on its intensity, can also potentially jeopardize a patient’s work and social activities.
The identification and the sparing of the three nerves of the inguinal region is of crucial importance to reduce the rate of neuralgia in the short and long term. Furthermore, the use of a local anaesthesia imposes the surgeon to properly recognize those nerves and to respect them during the repair. It goes without saying that the complete exposition of the right anatomy of inguinal canal is mandatory.
The intentional section of one or more nerves, when it is not technically possible to achieve a satisfactory nerve sparing, or special tricks to create proper fenestrations (small window) on the edge of the prosthesis to prevent the scar tissue to involve the spared nerves, ensures a further reduction of the rate of neuralgia and excellent patient outcomes.
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Polyvinylidene Fluoride Mesh (PVDF, DynaMesh®-IPOM) in The Laparoscopic Treatment of Incisional Hernia: A Prospective Comparative Trial versus Gore® ePTFE DUALMESH® Plus
Alessandro Verbo, MD, Assistant Professor, Paolo Pafundi, MD, Alberto Manno, MD, Department of Emergency Medicine, Rocco Bacccaro, MD, Assistant Professor, Augusto Veneziani, MD, Assistant Professor, Rosa Colli, MD, Assistant Professor, Claudio Coco, MD, Associate Professor, Department of Surgical Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
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Background: Laparoscopic approach is now generally accepted for the treatment of incisional hernia. The ideal mesh is still to be found. The aim of this study is to compare the well-known Gore® DUALMESH® Plus (WL Gore & Associates, Flagstaff, AZ) to a new prosthesis, the DynaMesh®-IPOM (FEG Textiltechnik GmbH, Aachen, Germany), to clinically verify its potential benefits in the laparoscopic treatment of incisional hernia.
Materials and Methods: Comparing the results of the laparoscopic treatment of two groups of patients affected by incisional hernia using Gore® DUALMESH® Plus and DynaMesh®-IPOM.
Results: There were 45 females and 31 males, with age variable from 21 to 84 years of age. The two groups were well matched for age (median age 60 years for group A and 57.6 years for group B—p=0.44) and sex (28F and 17M group A and 13 F and 18 M group B—p=0.008), while median BMI resulted slightly higher in group B (26.12 group A and 29.74 group B—p=0.001). The median size of the defect was similar in the two groups (87.5 mm group A and 83.4 mm for group B—p=0.83), while the median operating time was slightly longer in group A (77 min group A and 67 min group B—p=0.44). No difference in the length of hospital stay was evidenced between the two groups (3.19 days for group A and 3 days for group B—p=0.74). Time to return to physical activity was similar between the two groups (13.46 days for group A and 12.7 days for group B—p=0.32). Minor complications occurred in 15 cases (19.7%): seromas (7 cases), prolonged ileus (6 cases), and hemoperitoneum (2 cases), without significant difference in the incidence of such complications in the two groups. Five recurrences (6.5% of cases) occurred. No differences in the recurrence rate was noted between the two groups (3 cases/7% for group A and 2 cases/6% for group B—p=00.7).
Conclusions: DynaMesh®-IPOM proved to be a safe and effective mesh for the laparoscopic repair of incisional hernia even when compared to DUALMESH® Plus.
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Stapled Mesh Reinforcement Technique (SMART) to Prevent Parastomal Hernias: Our Initial Experience and Review of the Literature
Simona Macina, MD, Resident, Francesca Mandolfino, MD, PhD, Specialist in General Surgery, Marco Frascio, MD, Professor of Surgery, Marco Casaccia, MD, Professor of Surgery, Cesare Stabilini, MD, PhD, Professor of Surgery, Rosario Fornaro, MD, Professor of Surgery, Tommaso Testa, MD, Consultant, Department of General Surgery, IRCCS San Martino Hospital, Genoa, Italy
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Parastomal hernia is one of the most common stoma related complication, with the correlated risk of incarceration, obstruction, and strangulation. The incidence is high (30–50%) and depends on the length of follow up. Different surgical options for repairing are defective with a 25–70% failure and recurrence rate. Prevention of parastomal hernia with mesh reinforcement seems to be effective. Three available trials are recruiting patients: Prism (with matrix porcine prothesis), Prevent (with preperitoneal polypropylene mesh), and the stapled polypropylene mesh stoma reinforcement technique (SMART). We performed the SMART procedure in six patients undergoing definitive colostomy. Our cases show that the procedure is rapid (duration range 15–20 minutes), cost effective (500 euro), and safe (in our experience, there are no post-surgical complications that are procedure-related). A long term follow-up and a higher number of patients will give us confirmation of the initial hopeful results.
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