Tag Archives: Herniorrhaphy

Article of interest: Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction

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Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012 Nov;204(5):709-16.

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Background: Several modifications of the classic retromuscular Stoppa technique to facilitate dissection beyond the lateral border of the rectus sheath recently were reported. We describe a novel technique of transversus abdominis muscle release (TAR) for posterior component separation during major abdominal wall reconstructions.

Methods: Retrospective review of consecutive patients undergoing TAR. Briefly, the retromuscular space is developed laterally to the edge of the rectus sheath. The posterior rectus sheath is incised 0.5-1 cm underlying medial to the linea semilunaris to expose the medial edge of the transversus abdominis muscle. The muscle then is divided, allowing entrance to the space anterior to the transversalis fascia. The posterior rectus fascia then is advanced medially. The mesh is placed as a sublay and the linea alba is restored ventral to the mesh.

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WARC Journal Club: Inguinal Hernia

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de Goede B, et al. Watchful Waiting Versus Surgery of Mildly Symptomatic or Asymptomatic Inguinal Hernia in Men Aged 50 Years and Older: A Randomized Controlled Trial. Ann Surg. 2018 Jan;267(1):42-49.

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RESULTS: Between January 2006 and August 2012, 528 patients were enrolled, of whom 496 met the inclusion criteria: 234 were assigned to elective repair and 262 to watchful waiting. The mean pain/discomfort score at 24 months was 0.35 [95% confidence interval (CI) 0.28-0.41)] in the elective repair group and 0.58 (95% CI 0.52-0.64) in the watchful waiting group. The difference of these means (MD) was -0.23 (95% CI -0.32 to -0.14). In the watchful waiting group, 93 patients (35·4%) eventually underwent elective surgery and 6 patients (2·3%) received emergent surgery for strangulation/incarceration. Postoperative complication rates and recurrence rates in these 99 operated individuals were comparable with individuals originally assigned to the elective repair group (8.1% vs 15.0%; P = 0.106, 7.1% vs 8.9%; P = 0.668, respectively).

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Article of interest: Long-term Results of a RCT of a Nonoperative Strategy (Watchful Waiting) for Men With Minimally Symptomatic Inguinal Hernias

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This week’s discussion included what are the best treatment options for asymptomatic and symptomatic inguinal hernias.

Fitzgibbons RJ Jr, Ramanan B, Arya S, et al. Long-term results of a randomized controlled trial of a nonoperative strategy (watchful waiting) for men with minimally symptomatic inguinal hernias. Ann Surg. 2013;258(3):508–515.

Results: Eighty-one of the 254 men (31.9%) crossed over to surgical repair before the end of the original study, December 31, 2004, with a median follow-up of 3.2 (range: 2-4.5) years. The patients have now been followed for an additional 7 years with a maximum follow-up of 11.5 years. The estimated cumulative CO rates using Kaplan-Meier analysis was 68%. Men older than 65 years crossed over at a considerably higher rate than younger men (79% vs 62%). The most common reason for CO was pain (54.1%). A total of 3 patients have required an emergency operation, but there has been no mortality.

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What is the impact of abdominal binder on seroma formation?

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One discussion this week included the impact of abdominal binder on seroma formation.

Reference: Christoffersen MW, Olsen BH, Rosenberg J, Bisgaard T. Randomized clinical trial on the postoperative use of an abdominal binder after laparoscopic umbilical and epigastric hernia repair. Hernia. 2015 Feb;19(1):147-153. doi:10.1007/s10029-014-1289-6

Summary: Application of an abdominal binder is often part of a standard postoperative regimen after ventral hernia repair to reduce pain and seroma formation. However, there is lack of evidence of the clinical effects.

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Surgeon’s choice: TEP or TAPP for recurrent inguinal hernia repair?

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One discussion involved the comparison of outcomes for TEP and TAPP for hernia repair.

Reference: Kockerling F, et al. TEP or TAPP for recurrent inguinal hernia repair-registered-based comparison of the outcome. Surgical Endoscopy. 2017 Oct;31(10):3872-3882. doi: 10.1007/s00464-017-5416-1

Summary: To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n = 1,464) or TEP technique (n = 782).

  • TAPP group: recurrent repair was performed for n=974/1,464 (66.5%) patients after suture and n=490/1,464 (33.5%) after mesh repair.
  • TEP group: recurrent repair was performed for n=554/782 (70.8%) patients following previous suture repair and for n=228/782 (29.2%) after mesh repair.

No significant differences were found between the recurrent operations in TEP vs TAPP technique with regard to the intraoperative complications, complication-related reoperations, re-recurrence rates, rates of pain at rest, pain on exertion, or chronic pain requiring treatment. Unfavorable results were identified only with regard to the higher seroma rates associated with TAPP; these responded to conservative treatment.

In summary, both TEP and TAPP can be recommended as effective techniques for treatment of recurrent inguinal hernia following previous open primary operation. The decision to use one or the other technique should be based solely on the surgeon’s expertise. The registry study presented here thus confirms the recommendations in the guidelines on laparo-endoscopic treatment of recurrent inguinal hernia following previous open primary operation.

 

What is the effect of abdominal insufflation on deep vein flow?

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One discussion this week involved the effect of abdominal insufflation on deep vein flow.

Reference: Yang C, Zhu L. Coagulation and deep vein flow changes following laparascopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study. Surgical Endoscopy. 2019 Feb 11. doi: 10.1007/s00464-019-06700-6.

Summary: The authors observed morphologic change of the iliac vein during TEP procedure. The iliac vein was almost completely collapsed, which not only impaired venous return from the lower extremities but also caused vein distention. The acute distention caused vessel wall damage due to mechanical disruption of the endothelial lining. Vessel wall damage is one of Virchow’s triad in the pathogenesis of thrombosis.

In this study, activated coagulation and impaired deep venous flow implied that the TEP procedure had a certain degree of potential risk for DVT during the early postoperative period.