Tecnica chirurgica: selezione e

posizionamento della protesi

Paolo A. RiccioChirurgia Imola

Rationale for laparoscopic approach

• Avoiding dissection through previous operative sites within the abdominal wall and avoiding disruption of preexisting meshes

• Not uncommon discovery of multiple small fascia defects

Uranues 2008

Posizionamento della rete e incidenza di recidive (%)

• Underlay (intraperitoneale) 4.5 • Sublay (preperitoneale) 8• Onlay 14• Inlay 48

Rudmik, Hernia 2006

The current recommendations to ensure the success of this hernioplasty can be summarized as follows.

1 Complete dissection of the entire anterior abdominal wall to expose all hernia defects.

2 Careful measurement of the fascial defects3 Selection of a clinically proven prosthetic biomaterial4 A minimum of a 3 cm overlap of all fascial borders with a

larger area for obese patients or large recurrent hernias5 

Fixation of transfascial sutures and a metal fixation device

LeBlanc, World J Surg 2005

• 1,5 milioni di reti vengono impiantate ogni anno nel mondo per il trattamento chirurgico del laparocele

Weyhe, World J Surg 2007

Scelta della rete: evidenze dalla letteratura?

…nessuna evidenza!!

rete ideale prevenire aderenze buona integrazione nella

parete addominale basso rischio di infezioni resistenza alla tensione sufficiente elasticità biocompatibilità ( bassa

reazione infiammatoria e shrinkage)

manegevolezza

Stabilità della reteAdeguato

overlapIntegrazione

parietaleTecniche di

fissaggio

TrendsReti leggere, coated meshMacro + microporosità per una

migliore integrazione tissutale e prevenzione dello shrinkage

Maggiore elasticitàBarriera antiadesiva

The current recommendations to ensure the success of this hernioplasty can be summarized as follows.

1 Complete dissection of the entire anterior abdominal wall to expose all hernia defects.

2 Careful measurement of the fascial defects3 Selection of a clinically proven prosthetic biomaterial4 A minimum of a 3 cm overlap of all fascial borders with a

larger area for obese patients or large recurrent hernias5 

Fixation of transfascial sutures and a metal fixation device

LeBlanc, World J Surg 2005

Misurazione interna

Misurazione extracorporea

Le dimensioni dell’ernia sono calcolate attraverso il posizionamento di 4 aghi passati dall’esterno a delimitare i margini del difetto parietaleIl diametro è la distanza fra gli aghi in centimetri

Tecnica chirurgica• La rete viene

temporaneamente ancorata alla parete addominale da 4 punti cardinali (6 nei laparoceli > di 10 cm) per consentire una adeguata distensione e l’orientamento

Experience of laparoscopic incisional and ventral hernia repair

(2005 – 2012)

UO di ChirurgiaDir. Dott. S. Artuso

Patient Characteristics (222)Male/Female 84/138Age (y) 61.7 (15-88)Body mass index 28.8 (18-45)ASA classification 2.1 (1-3)Previous open hernia repair

24 (10.8%)

Max diameter size (cm) 8.4 (2-28)Operating time (min) 97.5 (25-240)Postoperative hospital stay (d)

4.8 (1-27)

Associated procedures 15 10 cholecistectomy 5 inguinal hernia

Type of defect (1)Laparoscopic Incisional Hernia Repair - LIHR (172)

Median laparotomies 145Lateral: 24

Left side 5Mc Burney 5Subcostal 10Lumbar hernia 4

Parastomal 3 Laparoscopic Ventral Hernia Repair - LVHR (50)

Umbilical hernia 29Epigastric hernia 21

Type of defect (3)Chevrel classification

Small (<= 5 cm) 45 (20.2%)Medium (6-9 cm) 69 (31.0%)Large (=> 10 cm) 71 (32.1%)

Type of defect (2)ABDOMINAL BORDER (42)

Subxiphoidal 8Suprapubic 24Subcostal 10

Type of defect (4)Swess-Cheese 37 (16.7%)

Type of ProsthesisSEPRAMESHVENTRALIGHT

40 (18.0%) 20 (9.0%)

DYNA-MESH 12 (5.4%)PARIETEX 5 (2.2%)COMPOSIX 33 (14.8%)PROCEED 110 (49.5%)PHISIOMESH 2 (0.9%)

Type of fixation (1)ABSORBABLE TACK 52 (23.5%)NON ABSORBABLE TACK 170 (76.5%)

Type of fixation (2) Use of Tissucol

OUTCOMESComplications 32 (14.4%)Recurrence 12 (5.4%)Conversion to open technique 8 (3.6%)

COMPLICATIONS (32)Prolonged seroma (> 8 wk) 12 (5.6%)Prolonged ileus 10 (4.7%)Prolonged pain (> 6 months) 5 (2.3%)Pulmunary Embolism 1 (0.6%)Myocardial Infarction 1 (0.6%)Pneumonia + wound infection 1 (0.6%)Wound infection 2 (0.9%)

RE-OPERATION (7)Intestinal injury 4 (1.8%)Postoperative bleeding 2 (0.9%)Trocar site erniation 1 (0.6%)

RECURRENCE 12 (5.4%)Time to recurrence (days): 537 (31-1517)

Treatment of recurrence:Laparoscopic repair 2

Open repair 5No repair 5

CONVERSION TO OPEN TECHNIQUE 8 (3.6%)Severity of adhesions 5 (2.2%)

Severity of adhesions and obesity 1 (0.5%)Complete prosthesis detachment 1 (0.5%)

Intestinal injury 1 (0.5%)