Indikationen zur laparoskopischen Versorgung großer Narbenhernien

Abstract

Hernia surgeons and patients have learned to appreciate the advantages of minimally invasive laparoscopic procedures. After overcoming the early learning curve phase, smaller wound surface areas, shorter operation times and briefer hospital stays have become routine. Severe surgery-related complications are rare. Patients with poor risk profiles (e.g. age >70 years, BMI >30 and nicotine consumption) profit especially from these advantages. This positive picture is clouded, however, by the need for an intraperitoneal mesh and specifically by the unchanged recurrence rate. The latter is not significantly lowered even by laparoscopic intraperitoneal on-lay mesh (laparoscopic IPOM) procedures. The current literature shows that irrespective of surgical technique, e.g. retromuscular mesh or laparoscopic IPOM, the risk profile and size of the hernia defect are independent factors that determine the prognosis for recurrence. While a cure of incisional hernia is no longer the only goal, the new indication scenario has two main goals: (a) for young patients at low risk or in patients for whom functional and morphological reconstruction of the abdominal wall are of primary importance, an open retromuscular mesh procedure is indicated (despite the higher morbidity) and (b) for older patients and chiefly for patients with a complex risk profile for whom treatment of the ventral hernia symptoms is paramount, laparoscopic procedures are indicated (due to the lower morbidity). This algorithm assumes that the treating surgeons have the requisite expertise and is discussed using the examples of four complex case reports.

The Treatment of Incisional Hernia

“…Incisional hernia repair involves the use of a synthetic mesh and can be performed by conventional (open) surgery or minimally-invasive (laparoscopic) surgery (17,18). Currently used surgical techniques as well as the …”

Continuous Laparoscopic Closure of the Linea Alba with Barbed Sutures Combined with Laparoscopic Mesh Implantation (IPOM Plus Repair) As a New Technique for Treatment of Abdominal Hernias

“…The treatment of severe abdominal wall hernias is a challenge, both conventionally and laparoscopically. The size of the hernia gap, in particular with the classical IPOM as bridging method, has a great influence on the shear forces to the mesh and, therefore, on possible bulging phenomenon and the forces acting on the fixation points ( 1 ). In an abdominal wall model, it could be proved that the mesh overlap should be proportional to the size of the hernia defect ( 2 ).…”

“…As a consequence, in addition to functional morphological aspects of the abdominal wall reconstruction, the closure of the linea alba has the advantage that a sufficient overlap with a mesh is again possible. In addition to the well-known advantages of laparoscopic care (lower wound infection and seroma rate, shorter hospital stay) compared to retromuscular hernia repair (Rives–Stoppa-sublay-technique), this method, which was one of the first described by Chelala, does not lead to the destruction of intact muscle compartments or of the segmental nerve innervation ( 1 , 4 , 5 ). In cases with very large hernia defects, however, the technique reaches its limits.…”

Laparoscopic intraperitoneal onlay mesh with fascial repair (IPOM plus) for ventral and incisional hernia

“…The advantages of IPOM plus over open retro muscular hernia repair like Rives-Stoppa technique: first method does not disturb muscle compartments or the segmental nerve innervations, provides additional benefit as a complete exploration of the abdominal cavity, the possibility to add another procedure if needed, an easier adhesiolysis due to the magnification of the view, and a lower postoperative abdominal pain because no wide dissection is performed [4].…”