In the News
More Overlap Means Fewer Hernia Recurrences: Size and Placement of Mesh Key to Success
Source: General Surgery News
When Karl LeBlanc, MD, MBA, FACS, a private practice general surgeon in Baton Rouge, La., performed the world’s first laparoscopic ventral hernia repair in 1991, he aimed for a mesh overlap of about 1 cm.
Twenty years later, he shakes his head at the notion of a 1-cm overlap. A growing body of evidence suggests that a larger mesh overlap, along with symmetrical placement of the mesh, result in far fewer hernia recurrences, Dr. LeBlanc said at the 15th Annual Hernia Repair Meeting.
“Increasingly, we’re looking at the more overlap, the better, when it comes to recurrence,” said Dr. LeBlanc, who has amassed one of the largest volumes of laparoscopic ventral and incisional hernia repairs in the world, with a total of more than 1,200 cases.
At the meeting, Dr. LeBlanc said that currently, he believes that an overlap of 5 cm or more is optimal. He extends the overlap to as much as 8 cm in patients who are obese, who have several prior recurrences or who have hernias unusually high or low in the abdominal cavity. “The algorithm I have in my head is the bigger the defect and the more comorbidities, the more overlap you need,” he said.
Over the past decade, it has become standard practice for surgeons to recommend a mesh overlap of at least 3 to 5 cm on all sides surrounding the defect. However, sparse robust data exist to back this up, so Dr. LeBlanc set out to evaluate this recommendation along with other technical factors that may affect the outcome of laparoscopic incisional and ventral hernia repairs.
He reviewed the PubMed and Cochrane Library scientific databases for the years 1992 to 2012, looking at all technical failures leading to hernia recurrence.
Overall, the review found little high-quality evidence that focused on technical reasons for repair failures. Of 111 articles that addressed technical issues in hernia repairs, the vast majority overlooked the question: Only 16 of them adequately assessed the effect of mesh overlap. In these studies, recurrence rates ranged from 9% to 14.3% when mesh overlapped by 2 to 3 cm. Recurrences dropped substantially to between 0% and 7% with mesh overlap of at least 3 to 5 cm. The studies included about 3,500 patients with an average of 25.5 months of follow-up and a mesh overlap of 2 to 5 cm.
In one of the largest reported series, an overlap of between 2 and 2.25 cm was associated with a recurrence rate of 9%. Recurrences dropped to 2% with an overlap of 4 cm or greater (JSLS 2008;12:51-57).
“What we’re seeing is that increasing the overlap of the fascial defect to between 3 and 6 cm results in decreasing the recurrence rate by at least half,” Dr. LeBlanc said.
Asymmetrical placement of the mesh was another contributing factor to recurrences, according to the literature review. Two studies linked failed repairs to inaccurate centering of the mesh or inadequate overlap on one side.
Experts noted that the quality of the published studies in hernia surgery is “notably weak,” with a lack of grade A evidence and little uniformity across the published studies.
MaciejSmietanski, MD, PhD, a hernia surgeon at the Medical University of Gdansk in Poland, said the report underscores a very important issue in hernia surgery, “that mesh overlap and the right positioning are the key factors for success.”
Dr. LeBlanc offered surgeons some technical tips to improve mesh placement in laparoscopic hernia repair. Surgeons must carefully measure both the defect and the mesh prior to surgery, and they should dissect any fat that could come in contact with the mesh.
Dr. LeBlanc also recommended that surgeons place a camera on both sides of the abdomen to assess both sides of the mesh. He said that he places sutures on two axes of the mesh prior to placement in order to help with mesh placement. “You put the mesh in, then pull one side of the suture up and then the other suture up so you know it’s centered superiorly and inferiorly,” Dr. LeBlanc said. He also said new mesh-positioning devices such as the Echo PS™ by Davol Inc., and AccuMesh™ Positioning System by Covidien, can help with accurate placement.
The conclusions of the review were similar to those in a retrospective study published last year in the Journal of Surgical Research (2012;177:e7-e13). Investigators from Baylor College of Medicine reviewed the outcomes of 201 patients who underwent laparoscopic ventral hernia repair between 2000 and 2010. They said potential solutions to the problem of mesh shift include increasing mesh overlap to 6 cm or greater, transcutaneous closure of central defect, securing transfascial sutures before tacking, placing operative side tacks first, and possible placement of contralateral ports to secure the mesh.
‘Watchful Waiting’ for Inguinal Hernia Safe, But Surgery Ultimately Likely
Source: General Surgery News
One of the ongoing debates in general surgery is whether to operate on men with asymptomatic or minimally symptomatic groin hernia, or wait.
A recent study—and one of the largest—of American men with these types of hernia demonstrated that waiting may be safe, but most patients will end up needing a repair within a decade, usually because of worsening pain. The older a man is, the more likely he is to undergo a hernia repair.
Elective hernia surgery offers value-for-money, improves quality of life for patients
Source: News Medical
New research suggesting that elective hernia surgery offers value-for-money and improved quality of life for patients has been published by the Journal of the Royal Society of Medicine. The new analysis is based on patients’ own assessments of their health-related quality of life together with costs reported by hospitals. The research also indicates that keyhole surgery may offer more health benefit and value for money than open surgery for hernia operations. Recently it has been suggested that the NHS could save money by reducing access to hernia repair surgery.
When Robotic Surgery Leaves Just a Scratch
SURGEONS once made incisions large enough to get to a gallbladder or other organs by using conventional tools they held in their own hands. Today, many sit at a computer console instead, guiding robotic arms that enter the patient’s body through small openings not much larger than keyholes.
Common hip disorder may raise risk for sports hernia
A common type of athletic hip disorder may increase the risk of a sports hernia, according to a new study.
Less invasive hernia procedure easier on patients: Study
Source — USNews.com
New research finds that a minimally invasive surgical procedure to treat hernias results in less chronic pain and a faster recovery when compared to a traditional approach.
The study “confirms what a lot of surgeons who do both procedures know already,” Brunt said. “There’s less pain and a bit of a faster recovery from the laparoscopic procedure.”
Laparoscopic hernia surgery surpassed traditional surgery in study
Source — The Washington Post
THE QUESTION When a hernia occurs in the groin, it can be repaired with traditional open surgery or minimally invasive laparoscopy. Might one option yield better results than the other?
Is Economy Class Air Travel Linked To Blood Clot Risk?
Source — Medical News Today
“Economy Class Syndrome” is a myth, your risk of developing a blood clot during a long-distance economy trip by plane is not higher than in first class, researchers report in an article published in Chest. The American College of Chest Physicians (ACCP) has issued new evidence-based guidelines which address some of the risk factors linked to DVT (deep vein thrombosis) – it says that there is no compelling evidence linking economy class air travel to the development of DVT.
Bilateral Hernias Should Be Repaired Simultaneously, Data Indicate
Source — General Surgery News
A large Swiss study has shown that bilateral total extraperitoneal (TEP) inguinal hernia repair has a risk profile comparable with that of unilateral hernia repair, a finding that suggests there is no value in delaying the second repair (Surg Endosc 2011 Nov 24 [Epub ahead of print]).
Hernia surgery now or later
Source — ABC-7
An estimated 5 million Americans have one. About 3% of our population will get one, the bulging medical condition known as a hernia.
“A hernia is essentially a defect or a hole in the abdominal wall that allows contents from inside the abdomen to push through the abdominal wall and usually present with a bulge or a mass in the tissue between the skin and the muscle,” says Dr. Darren Miter, a laparoscopic surgeon with Lee Memorial Health System.