Technical aspects of performing laparoscopic hernioplasty in the treatment of large ventral hernias

Abstract

Laparoscopic hernioplasty is a promising treatment option for ventral hernias. The technique of intraperitoneal mesh placement (IPOM) is the most extensively studied and widely used for the closure of a defect during laparoscopic hernia repair. The large size of the defect and its diameter exceeding 10 cm are limiting factors in the selection of minimally invasive techniques for hernioplasty. The process of suturing the hernia prior to the placement of the mesh, as well as the technique used to fix it, show controversial results in terms of postoperative quality of life and the risk of recurrence.

Objective —  to study the technical aspects of performing laparoscopic prosthetic hernioplasty using the IРOM technique for the surgical treatment of patients with large primary ventral hernias (PVH) and postoperative incisional ventral hernias (IVH).

Materials and methods. The study included a total of 84 patients who were undergoing treatment at the clinical base of the Department of General Surgery No. 2 of Bogomolets National Medical University. There were 51 (60.7%) women and 33 (39.3%) men. The average age was 58.73±10.9 years. All patients were operated on for large ventral hernias. Of these, 52 (61.9%) patients had surgery for PVH (umbilical hernia, line alba hernia), while 32 (38.1%) — for IVH. In 56 (66.7) patients, the width of the hernia defect was > 10 cm, of which 24 (28.6%) patients had PVH. In these patients, 4 weeks before surgery, 100 units of botulinum toxin type A (BTA) were injected intramuscularly into the muscles of the anterior abdominal wall in accordance with the methodology developed in the clinic. All patients underwent laparoscopic prosthetic hernioplasty with IPOM under general combined anesthesia. Control examinations of patients were carried out 2 weeks, 1 month, 6 months, and 1 year after the operation.

Results. All patients underwent IPOM, while 38 (45.2%) patients underwent laparoscopic IPOM with suturing of the defect, 36 (42.9%) patients underwent IPOM with suturing the hernia defect before placing the mesh (IPOM+), and 10 (11.9%) patients underwent IPOM without suturing the defect. 32 (38.1%) patients were aged 65 years, including 10 patients who did not undergo suturing of the defect before the mesh placement. After the injection of BTA, the number of patients with a defect width of ≥10 cm decreased to 15 (17.8%). All of these patients had a defect smaller than 15 cm. The average duration of surgery for IPOM without hernia suturing was 60.00±11.30 min; for IPOM with laparoscopic suturing, it was 108.16±40.29 min; for IPOM+ with open suturing, it was152.08±40.64 min. The average length of stay in the hospital after surgery was higher in the group of patients who underwent hernioplasty using the IPOM+ technique compared to other techniques (p <0.001). In the early postoperative period, the complication rate was 13.1%; all cases were classified as minor (Grade I, II, IIIa) according to the Clavien–Dindo classification.

Conclusions. Laparoscopic hernioplasty using the IPOM is a safe and reliable method for large ventral hernia repair. Administering preoperative BTA injections enables the reduction of the defect and facilitates the execution of laparoscopic hernioplasty in patients with a primary hernia size of ≥10 cm.