|
RESULTS
The 407 patients in the data analysis were 205 men and 202
women, with a mean age of 53.2 years (range 13 to 88 years).
Most were obese, with a mean body-mass index of 32 (range 22
to 60). Eighty-nine percent of the patients had previously undergone
abdominal surgery. A total of 136 of the operations were performed
for recurrent hernias that had been treated with a conventional
open approach and the patients in this subgroup had undergone
an average of 1.9 previous repairs (range 1 to 7 repairs). Many
of the patients in whom open repairs had failed had intraabdominally
placed polypropylene mesh.
Most hernia defects were large; the mean size was 100.1cm2
(range 1 to 480cm2). Often, more than one hernia was found at
operation, even though preoperative abdominal examination had
revealed only a single defect. In nearly all cases, multiple
defects were covered with one large piece of mesh. In all but
14 patients, ePTFE mesh was used for the repair. The mean mesh
size was 287cm2 (range 24 to 924cm2). Mean operating time was
97 minutes (range 11 to 270 minutes), and estimated average blood
loss was 35mL (range 10 to 150mL). The mean postoperative hospital
stay was 1.8 days and ranged from a same-day discharge to 17
days.
There were no deaths. Fifty-three complications were recorded
(13.0% of patients; Table 1). The five patients with a trocar
site infection or cellulitis were treated successfully with oral
or intravenous antibiotics. In the four patients who had apparent
mesh infections, the mesh was removed after failure of intravenous
antibiotic therapy. Two of these patients previously had mesh
infections after open repair and had no apparent source of contamination
during the laparoscopic procedure. A third patient had a breakdown
of thin skin over the mesh, resulting in infection and mesh removal.
The fourth patient had a probable mesh infection that developed
several weeks postoperatively. Systemic antimicrobial therapy
produced some improvement but the patient's symptoms continued
and the mesh was resected. Cultures of specimens obtained intraoperatively
yielded negative results.
Table 1. Complications in 407 Patients Who Underwent Laparoscopic
Ventral or Incisional Hernia Repair
|
|
Complication |
n |
% |
|
|
Prolonged ileus |
9 |
2.21 |
|
Seroma >6wk |
8 |
1.97 |
|
Suture site pain >8wk |
8 |
1.97 |
|
Intestinal injury |
5 |
1.23* |
|
Cellulitis of trocar site |
5 |
1.23 |
|
Mesh infection |
4 |
0.98 |
|
Hematoma or postoperative bleeding |
3 |
0.74 |
|
Urinary retention |
3 |
0.74 |
|
Fever of unknown origin |
3 |
0.74 |
|
Respiratory distress |
2 |
0.49 |
|
Intraabdominal abscess |
1 |
0.25 |
|
Trocar site herniation |
1 |
0.25 |
|
Total |
53 |
13.0 |
|
* Six patients in our total experience had enterotomies,
but only five are listed here because the other patient required
conversion to an open repair and was not included in the data
analysis.
Five patients had known small-bowel enterotomies at the time
of operation. Minimal spillage was noted in all cases. In four
patients, the enterotomy was repaired and the herniorrhaphy was
completed laparoscopically. In the fifth patient, conversion
to an open procedure was necessary. None of these five patients
has had a recurrence or infectious complication. One additional
enterotomy was missed at the time of operation; the problem was
later suspected on the basis of results of a physical examination.
The patient underwent an operation in which a short segment of
small intestine and the mesh were resected.
In many patients, small, self-limited collections of fluid
developed over the mesh. Most resolved without intervention,
but eight patients (2%) had seromas that persisted for 6 to 10
weeks. One surgeon freely aspirated any palpable seroma during
office visits (this occurred in approximately one-third of his
patients) and subsequently reported that none of his patients
had a prolonged palpable fluid collection. No longterm complications
from any seromas were observed, regardless of whether they were
aspirated early or allowed to persist for a maximum of 10 weeks.
The eight patients with prolonged suture site pain (pain persisting
for longer than 8 weeks) described the discomfort as sharp or
burning at a single point with or without extension a short distance
across the abdomen along a dermatome pattern. Most had discomfort
with movement, but some had constant pain. Over the short term,
these patients took oral narcotics or nonsteroidal antiinflammatory
drugs. In most patients, the pain resolved with time or after
injection therapy involving repeated doses of Marcaine (Sanofi
Winthrop Pharmaceuticals, New York, NY) (in two patients).
Of the three patients with postoperative bleeding or hematoma,
one needed a transfusion but none required reoperation. The nine
patients with prolonged ileus had their hospital stay increased
for more than 24 hours. Of the three patients with a fever of
unknown origin, two underwent an exploratory laparoscopy during
the same hospitalization as the laparoscopic repair; results
were negative. All three patients recovered quickly, the cause
of the fever was never found, and these patients had no additional
problems. The two patients with respiratory distress required
observation in an ICU for at least 24 hours.
During a mean followup time of 23 months (range 1 to 60 months),
recurrent hernias developed in 14 patients (3.4%). Four occurred
in the patients who had a postoperative infection and subsequent
mesh removal. One was in the patient with the unsuspected bowel
injury at the time of operation, who subsequently underwent reoperation.
Six recurrences (43%) developed in patients in whom sutures were
not used at all or not used along sensitive areas of the abdominal
wall (ie, along the costal margin). One recurrence followed a
motor vehicle accident in which the patient was involved less
than 4 weeks after operation; the mesh tore from the lateral
margin of the repair. Six of the 14 recurrences were in nonmidline
ventral hernias.
Introduction
| Methods
| Results | Discussion
| References
| Commentary
JACS |
