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METHODS
Patients
Between November 1993 and August 1999, 415 consecutive patients
of 4 surgeons in 4 academic medical centers were scheduled to
undergo laparoscopic ventral or incisional hernia repair with
mesh. Factors involved in the surgeons' choosing a mesh repair
were a hernia >4cm, a recurrent hernia, or a hernia
in a morbidly obese patient. In 8 of the 415 patients, conversion
to open surgery was necessary because of an inability to reduce
incarcerated intestine (5 patients), loss of abdominal domain,
a need to resect strangulated intestine, or an enterotomy (1
patient each). For the remaining 407 patients, data were collected
prospectively (75% of patients) or retrospectively. The following
information was recorded for data analysis: patient age, gender,
body-mass index (weight in kg/height in m2), number of previous
abdominal operations, number of previous hernia repairs, size
of the fascial defect, type and size of the prosthetic mesh used,
operating time, and length of postoperative hospital stay. Followup
surveillance for complications and hernia recurrence was performed
by attending surgeons in the immediate postoperative period:
1 to 2 weeks, 3 months, and 6 months postoperatively, and yearly
thereafter.
Surgical technique
A similar operative technique was used by all surgeons in
the study. The method, which has previously been described,9,11,15
used an angled (30 or 45 degrees) 5-mm or 10-mm laparoscope.
Patients were given a prophylactic antibiotic agent, usually
a first-generation cephalosporin, before the procedure and every
2 hours during the operation. They were most commonly positioned
supine on the operating table, but some were placed in a lateral
or semilateral position, depending on the location of the hernia.
In many cases, a catheter was inserted to decompress the bladder.
Gastric decompression was accomplished by placement of an oral-gastric
tube.
Access to the abdomen was obtained
in an area away from the hernia by means of an open technique16
in approximately 75% of patients and a Veress needle in the remainder.
After exploration of the abdomen, additional trocars were placed,
as needed, under direct visualization. Adhesiolysis was performed
to free the anterior abdominal wall, and the margins of the hernia
defect were delineated and circumferentially cleared to a distance
of at least 4cm. The hernia sac contents were reduced, but the
peritoneal sac itself was left in situ. Dissecting within the
preperitoneal plane in an attempt to develop an intact layer
to separate the mesh from the abdominal contents is extremely
difficult in patients who have had a previous laparotomy. This
is especially true in those with only a thin layer of subcutaneous
fat and skin overlying the hernia. A preperitoneal dissection
was not performed in these patients.
In 97% of patients, expanded polytetrafluoroethylene (ePTFE)
mesh (Gore-Tex DualMesh Biomaterial, WL Gore, Flagstaff, AZ)
was used. The mesh was tailored to overlap all hernia margins
by 3cm to 4cm and was introduced through a 10-mm trocar site.
After the mesh was positioned intracorporeally, nonabsorbable
sutures were placed through the full thickness of the abdominal
wall circumferentially at 4-cm or 5-cm intervals by using a laparoscopic
suture passer (Gore Suture Passer Instrument, WL Gore). The sutures
were tied down and the knots buried in the subcutaneous tissues.
The circumference of the mesh was then stapled to the posterior
fascia at intervals of no more than 1cm; 5-mm spiral staples
were used. Early in the series, tacks alone were used to secure
the mesh but this practice was subsequently discontinued. No
drains were inserted.
Introduction
| Methods | Results
| Discussion
| References
| Commentary
JACS |
