Department of Surgery, General and Urgent Surgery Unit, Regional Hospital "U. Parini", Viale Ginevra, 3, 11100 Aosta, Italy.
Int J Surg. 2017 Apr;40:38-44. doi: 10.1016/j.ijsu.2017.02.016. Epub 2017 Feb 20.
Laparoscopic ventral hernia repair is widely used although its clinical indications are often debated. The aim of this study is to describe our surgical experience in order to establish the safety, efficacy, feasibility of laparoscopic ventral hernia repair and to identify the factors that influence the risk of recurrence in a group of patients treated with only one type of prosthetic mesh and by the same surgical team.
Between January 2007 and December 2016, 512 patients were admitted to the General and Urgent Surgery Unit, with diagnosis of ventral hernia. Of these, 244 were operated laparoscopically and 268 in a traditional open surgery. In 244 patients treated by laparoscopy we always used a composite mesh: 185 Parietex™ Composite mesh (Medtronic-Covidien, Minneapolis, USA), the remaining other with other types of prosthetic mesh. The type and size of surgical defects, features of surgical technique, length of hospital stay, rate of conversion, morbidity, mortality, and rate of recurrence at 5 years follow-up were retrospective analysed on the 185 patients who underwent surgery with Parietex™ Composite mesh.
We performed 185 laparoscopic ventral hernia repair with Parietex™ Composite mesh: 108 (58%) for incisional hernias and 77 (42%) for primary abdominal wall hernias. Mean age was 58 years (19-80). The mean size of abdominal defect was 5 cm (1,5-18), mean BMI was 30,4 kg/m (21-47), mean overlap of the mesh was 5 cm (3-6). The mean operative time was 54 min (30-180) and conversion rate was 3,2%. In 61 patients (33%) we performed a transversus abdominis plane block (T.A.P. block) to reduce postoperative pain. The mean length of hospital stay was 5 days (1-26) (2 days, mean value, in patient with preoperative T.A.P. block). The mortality rate was 0%; overall morbidity was 15,6%. At 5-year follow-up we observed 13 (7%) hernia recurrences. The features of patients with recurrence were as follows: mean age 50 years (19-74), mean ASA Score 3 (2-3), mean BMI 31 kg/m (21-44), mean size of hernial defect 7,5 cm (larger diameter), mean overlap 4,5 cm (3-6).
Laparoscopic repair of ventral hernia using composite mesh is an effective and safe procedure particularly suitable in the following cases: median and paramedian defects, diameter of defect between 5 and 15 cm, "swiss cheese" defects, obesity. In our experience the factors related to the patient and the surgical technique that may influence the onset of early or late recurrence as the follows: a defect size >5 cm (W2 of EHS Classification), an overlap of the mesh < 5 cm, a BMI of 30 kg/m or superior and the presence of significant comorbidities (ASA score: 3). Finally, we observed that the T.A.P. Block preoperative procedure can lead to reduced the clinical costs through a lower administration of analgesics used and a lower length of stay.
腹腔镜腹疝修补术被广泛应用，尽管其临床适应证仍存在争议。本研究旨在描述我们的手术经验，以确定在一组仅使用一种类型的补片并由同一手术团队治疗的患者中，腹腔镜腹疝修补术的安全性、有效性和可行性，并确定影响复发风险的因素。
2007 年 1 月至 2016 年 12 月，共有 512 例腹疝患者被收入普外科和急诊外科，其中 244 例采用腹腔镜治疗，268 例采用传统开放手术治疗。在 244 例采用腹腔镜治疗的患者中，我们始终使用复合补片：185 例使用 Parietex™复合补片（美敦力-科维迪安，明尼苏达州，美国），其余患者使用其他类型的补片。回顾性分析了 185 例接受 Parietex™复合补片治疗的患者的手术类型和大小、手术技术特点、住院时间、转化率、发病率、死亡率和 5 年随访时的复发率。
我们共进行了 185 例腹腔镜腹疝修补术，其中 108 例为切口疝，77 例为原发性腹壁疝。患者平均年龄为 58 岁（19-80 岁）。腹壁缺损的平均大小为 5cm（1-18cm），平均 BMI 为 30.4kg/m²（21-47kg/m²），补片重叠的平均大小为 5cm（3-6cm）。平均手术时间为 54 分钟（30-180 分钟），转化率为 3.2%。在 61 例（33%）患者中，我们行腹横肌平面阻滞（TAP 阻滞）以减轻术后疼痛。平均住院时间为 5 天（1-26 天）（术前行 TAP 阻滞的患者平均住院时间为 2 天）。死亡率为 0%；总发病率为 15.6%。在 5 年随访中，我们观察到 13 例（7%）疝复发。复发患者的特征如下：平均年龄 50 岁（19-74 岁），平均 ASA 评分为 3 分（2-3 分），平均 BMI 为 31kg/m²（21-44kg/m²），疝缺损的平均大小为 7.5cm（较大直径），补片重叠的平均大小为 4.5cm（3-6cm）。
使用复合补片的腹腔镜腹疝修补术是一种有效且安全的手术方法，特别适用于以下情况：正中或旁正中缺损、缺损直径 5-15cm、“奶酪孔”缺损、肥胖。根据我们的经验，与患者和手术技术相关的因素可能会影响早期或晚期复发的发生，包括：缺损大小＞5cm（EHS 分类的 W2）、补片重叠＜5cm、BMI 为 30kg/m²或更高以及存在显著合并症（ASA 评分：3 分）。最后，我们观察到术前 TAP 阻滞可以通过减少使用的镇痛药的剂量和降低住院时间来降低临床成本。
