Aims Ventral hernias are a frequent pathology in general surgery.Its association with rectus abdominis diastasis and groin hernias is not uncommon.Currently, the minimally invasive approach of these pathologies is becoming more frequent.We present the usefulness of the e-TEP-approach to treat different types of hernias and diastasis at the same surgical-procedure. Methods Video-case presentation. Results 73-year-old-man,surgical-histories:umbilical-hernioplasty with onlay-mesh and lap-sigmoidectomy. Physical-examination:midline ventral-hernia(M2–3W2:8cm),diastasis(6cm) and right groin hernia. CT-scan: midline ventral-hernia with small-bowel into the hernial-sac and small defect(15mm) in the right flank(L2).We decided to perform a laparoscopic-extraperitoneal-technique(eTEP). We use 4 ports(2×12mm, 2×5mm).The surgery begins dissecting the left and right retromuscular space using a dissector balloon.We continue with the supraumbilical cross-over transecting the left posterior-sheath and then the right posterior-sheath and complete the dissection of the other retromuscular space.The dissection continues down to the pubis, dissecting the right groin space.We continue with the right-TAR,at this area we observe the lateral defect and continue the dissection on the preperitoneal-space.After that we continue with the closure of the posterior-sheath using 2–0 V-lock and the anterior-sheath using Monomax-loop-1.We placed a 3D-PVDF-mesh for right groin-hernia and 30×40cm-PVDF-mesh fixed with glue and left a drainage.The patient had a satisfactory evolution and was discharged in 2°POD. Conclusions The enhanced view totally-extraperitoneal approach (eTEP) is an effective and safe option in cases of ventral hernias associate with groin hernias and rectus abdominis diastasis,as in the case presented.Posterior component separation-techniques(TAR) allow us to achieve a correct and tension-free closure of the abdominal wall and place a wide mesh covering all hernial-defects.
Aim Current studies show the correct closure of the abdominal wall must be carried out with a technique of giving many points and separated from each other with very little distance (small-bites technique) and with a suture of slow absorption.We conducted a review of our experience in abdominal wall closure in which we used a 3–0 polydioxanone (PDS®II)-suture using small-bites technique. Methods Retrospective study analyzing our database of patients in whom laparotomy and abdominal wall closure were performed using small-bites with PDS 3–0 suture, needle 26mm-½C, during November-2018 to October-2020.Emergency and elective laparotomies were analyzed. Results 164 patients were analyzed(men:59.8%,age:73(IQR:61–78years)).LOS:6(IQR:5–10days). Pathological history: diabetes mellitus (28%), arterial hypertension (62.2%), dyslipidemia(67.1%), smoking (45.1%), alcohol consumption(19.5%), cardiovascular disease(19, 5%).BMI:27.45±4.2kg/m2(Range:18.31–38.29).Overweight:70.7%. Obesity:28%. Laparotomy location: midline(47.6%), pfannenstiel(30.5%), transverse or subcostal(22%). Laparotomy was performed as an auxiliary to laparoscopy in 35.4%. Emergency surgery:40.2%. Neoplasms:56.1%. Associated with hernia repair:17.1%. Associated with surgical reoperations:9.8%. Complications: no evisceration, SSI(11%),no eventration until current follow-up (17.5±4.3months). Overweight patients and those who underwent emergency surgery had a higher incidence of SSI (13.6% vs. 4.2% p=0.07; 18.2% vs. 6.1% p=0.015).The location of the laparotomy, the association with hernia repair, reoperations, and neoplasms were not associated with a higher incidence of SSI (p>0.05). Conclusions The closure of the abdominal wall using small-bites technique with slow resorption suture (PDS®II 3–0) with a small needle, provides a safe and effective closure, both in midline and transverse laparotomies, in emergency surgery and in patients with associated neoplasms, without increasing the number of complications and with no evidence of evisceration or eventrations.
Aim Large or complex incisional hernias require more than just mesh placement.There are techniques such as component separation, retromuscular techniques (Rives-Stoppa, transversus abdominis muscle release-TAR), which help to repair the hernia and physiologically rebuild the abdominal wall.However, this type of technique can present a higher incidence rate of complications, such as hematomas, seromas, SSI, skin necrosis.We present our initial experience in complex abdominal wall reconstruction using the retromuscular sublay technique (RST). Methods Retrospective study analyzing our database of patients with complex incisional hernia undergoing abdominal wall surgery using the RST, during November-2018 to October-2020.In addition, we conducted a comparative analysis with patients undergoing hernia repair using the onlay-technique. Results 44 patients underwent RST (male:56.8%, age:66(IQR: 52–73years)). Hospital stay:4(IQR: 2–6days).Pathological history: diabetes mellitus (4.5%), arterial hypertension(20.5%), dyslipidemia(36.4%), smoking(34.1%), alcohol consumption(27.3%), cardiovascular disease(9.1%).ASA-classification:I(9.1%), II(59.1%), III(31.8%). BMI: 29.3±2kg/m2. Hernia location: midline(95.5%), others(4.5%). Preoperative botulinum toxin (PBT): 20.45%. Preoperative progressive pneumoperitoneum (PPP): 9.1%. Type of surgery performed: Rives-Stoppa(68.2%), TAR(31.8%). Postoperative complications: global(13.6%), Clavien-Dindo≥III:0%, clinical seroma(13.6%) and ultrasound-seroma(22.7%), SSI(0%). Hernia recurrence:0%. In the bivariate analysis of patients undergoing hernia repair using the RST compared to patients undergoing onlay repair, we observed that the RST presented lower incidence of global complications, both clinical and ultrasound seromas, surgical site infections and recurrences (13.6% vs 39.1% p=0.004; 13.6% vs 33.3% p=0.019; 22.7% vs 39.1% p=0.07; 0% vs 14.5% p=0.008; 0% vs 5.8% p=0.1; respectively). Conclusions In our enviroment, the management of complex incisional hernias using RST and the use of PBT and PPP is effective and safe, with a lower incidence of complications and recurrences.
Aims Ventral hernias are a common pathology in general surgery and its association with rectus abdominis diastasis and inguinal hernias is frequent.The surgical technique for the repair of this type of hernias is ideally a retromuscular technique associated or not with a posterior separation of components (transversus abdominis muscle release-TAR).We present the utility of the e-TEP-approach to treat different types of hernias associated with rectus abdominis diastasis in the same surgical procedure. Methods 71-year-old-man,surgical-histories:open right-hernioplasty and laparoscopic-radical prostatectomy.Physical examination:midline ventral-hernia (M3W2:6cm),left-inguinal-hernia and diastasis(5cm).We decided to perform a laparoscopic-eTEP-approach. Results We use 5ports(3×12mm,2×5mm).1°step is to dissect the left retromuscular-space using a dissector balloon,and continuous with the supraumbilical cross-over transecting the left posterior-sheath and then the right posterior-sheath completing the dissection of the other retromuscular-space.The dissection continues down to the pubis dissecting the midline hernial-sac and then dissecting the left-inguinal-space.Due to the tension to close the posterior-sheath,we decided to perform a right-TAR.We begin the right-TAR up-to-down using the monopolar-electrocautery, at this area we observe adhesion due to the ports of the previous surgery.Next, we continue with the closure of the posterior and anterior-sheaths using 2–0 V-lock suture.We placed a 3D-PVDF-mesh for the left-inguinal-hernia and another 30×30cm polypropylene-mesh in the retromuscular-preperitoneal space.The patient presented a satisfactory evolution,was discharged 1°POD. Conclusions The minimally invasive e-TEP approach is an effective and good option in cases of ventral-hernias associate with inguinal-hernias and diastasis without increasing the incidence of postoperative complications and with better postoperative recovery,less postoperative pain, shorter LOS,lower rates of recurrence and lower healthcare costs.
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