Omentum overlay in laparoscopic prosthetic treatment of postincisionl

and umbilical hernias

Abstract

Objective: To analyze different factors that affect laparoscopic treatment of small eventrations and
umbilical hernias using prosthetic mesh with omentum overlay.

Material and Methodology:

41 cases were selected in which we used this laparoscopic prosthetic technique. The study duration
was 5 years between 2011 and 2016.Data were collected from case reports and discharge sheets and
were analyzed by the analytic program SPSS version 20.
Laparoscopic pro epiploic mounted mesh approach with great omentum lining was applied to 28
cases with the diagnosis of umbilical hernia and 13 cases of postoperative incisional hernias.
 The studied parameters included were: parietal defect dimensions, localization (for incisional
hernias), the average length of surgical intervention, intraoperative accidents/complications, average
length of hospitalization social reintegration, the rate of recurrence.
Cases of acute complicated phase (incarceration, strangulation) were excluded.

Results:
Among the patients, in which this surgical technique was used, 28 had umbilical hernias and 13 had
post incisional hernias. The average time of surgery was 1 hour and 5 minutes, 6 postoperative
complications remitted under conservative treatment, with a mean hospitalization of .3 days. No
intraoperative complications occurred.

Conclusions:
Proepiploic laparoscopic treatment using omentum is a reliable alternative to a more expensive and
difficult procedure involving Dual Mesh.

Keywords: hernia, mesh, omentum overlay, laparoscopy

Introduction:
Abdominal wall defects treatment has been an ongoing concern, with numerous
methods of
repair.
Umbilical hernias represent approximately 6% of all abdominal hernias.
Postoperative incisional hernia has a relatively low incidence under local favorable
evolution (1-3%), its incidence increased significantly to 25-50% in postoperative
evolutions complicated with wound infection.
The therapy for this two types of parietal defects has known numerous ways of
surgical repair both in tissular or prosthetic approach. Surgical treatment in "open
surgery" of umbilical and incisional hernias acquired in the last decade’s minimally
invasive surgery, more frequently laparoscopic variant of it.
Material and methods:
Laparoscopic pro epiploic mounted mesh approach with great omentum lining was
applied to 21
cases with the diagnosis of umbilical hernia and 15 cases of postoperative incisional
hernias.
Acute complicated phase (incarceration, strangulation) cases were excluded.
The parameters analyzed were: parietal defect dimensions, localization (for
incisional hernias), the average length of surgical intervention, intraoperative
accidents/complications, the average length of hospitalization, socio-professional
reintegration, the rate of recurrence.
Preoperative therapy with antibiotics was reserved only for cases with comorbidities
(patients with ascites, chronic bronchitis etc). 5000 units of subcutaneous heparin
assure deep venous thrombosis prophylaxis in the day before surgery, and by
sequential leg compression before surgery. An orogastric tube and Foley catheter
were placed after general endotracheal anesthesia is induced.
The pneumoperitoneum is achieved with a Veress needle insertion, mostly inserted
in the left
upper quadrant 3 cm inferior to the left costal margin in the midclavicular line
(Palmer’s point).
Alternative sites include right hypochondrium and the right or left iliac fossae
depending on the
parietal defect placement.(4,5)
A 10 mm port is placed percutaneously at a point along the anterior axillary line
away from the
edge of the abdominal defect. Using a 30º laparoscope placed through the 10 mm
port. One or
two (more often two) additional 5 mm ports are placed under direct vision, avoiding
proximity
with anterior superior iliac spine, for a better mobility of the instruments.
Laparoscopic examination of the abdomen was performed, any abnormalities were
noted, inspection of abdominal wall for additional hernias, the great omentum’s
dimensions and quality. Under conditions of low dimensions or poor quality of great
omentum, DualMesh prosthesis was
considered a better choice.
For large, complex hernias a fourth trocar can be placed on the opposite side of the
abdomen.
Typical instruments for laparoscopic surgery are used, adding EndoClose forceps,
Reverdin’s needle, and LigaSure sealing instrument for a better hemostasis control.
In the absence of any contraindications, the incarcerated content is reduced. No
attempt is made to remove the hernia sac.
An appropriate size mesh is chosen or tailored to adequately close the defect, with an
overlap of
2-4 cm circumferentially. Nylon 8 or resorbable wires were used at mesh extremities.
The mesh
is then rolled and inserted through 1 cm port into the abdominal cavity .The mesh is
unrolled in
the abdominal cavity .Using EndoClose forceps and Reverdin’s needle the sutures
are pulled transabdominal through small skin incisions .The sutures are pulled tight
and the mesh is raised to the abdominal wall .The anchoring sutures are tied in
subcutaneous tissue, further skin traction placing them on the abdominal muscles
aponeurosis.
The posterior face of the mesh is tackled with omentum, and depending on
hemostasis quality a drainage tube can be placed in Douglas.
Results:
The study was focused on the group that received minimally invasive surgical
treatment in
laparoscopic approach.
Laparoscopic approach using proepiploic mesh accounted overall for the two
diseases was
38.88% of all surgical treatment methods. Depending on the size of abdominal wall
defect distribution for umbilical hernia was: 5 cases under 2 cm, 12 cases with sizes
between 2-4 cm, 7 cases with sizes between 4-6 cm, 4 cases with parietal defects
ranging between 6-8 cm. Parietal defects dimensions for post-incisional hernias
were: 9 cases with sizes under 5 cm, 4 cases with sizes between 5-7 cm, more
frequently their location being 69.23 % in the upper abdomen, 30.76% in the lower
abdomen.
The average duration of surgical intervention was one hour and five minutes. Post
incisional hernias treatment required a longer duration of surgery an average of 1
hour and 12 minutes compared with average time for umbilical hernias 58 minutes,
due to both, aderential syndrome adhesiolysis and additional hemostasis, in three
situations preferring Douglas drainage.
No intraoperative complications occurred. In immediate postoperative period, four
cases of seroma and two cases with the algic syndrome were remitted under
conservative treatment. None
of the cases were considered necessary for conversion to open surgery. The average
hospitalization stay was 3.3, days.
Follow-up surveillance for complications recurrence and socio-professional
reintegration was performed at two weeks, two months and six months after
discharge. Remarking a quicker social
reintegration, a much higher aesthetic benefit compared to open surgery. Four cases
could not be followed-up at six months. No data was available to suggest cases of
recurrence using this technique.

Discussions:
All ventral hernias can be repaired by laparoscopy as the standard procedure.
Although various factors do place limits on laparoscopic repairs, such as the size of
the defect and the location where it has occurred. Emergency cases must be analyzed
case-by-case to assess whether a laparoscopic operation should be performed. (6,7).
This procedure involves laparoscopic intraperitoneal fitting of prosthetic mesh.
The technique summarizes the advantages of laparoscopic tissular and prosthetic
repair of the abdominal wall. The laparoscopic approach has a significant
contribution in preventing recurrence risk by avoiding postoperative over sizing of
the parietal defect, risk often encountered in open surgery, because the tension in the
suture is proportional to the size of the incision. Another advantage is represented by
the internal abdominal wall placement of the mesh without a significant incision
through parietal muscles, procedure that increases abdominal parietal resistance.
Mainly the disadvantages of this type of intervention are that it is addressed to
early lesions (small and medium dimensions) increased cost of instruments, longer
operative time, the requirement of general anesthesia , pregnancy, etc.
The margin that overlaps the parietal defect in our study were between 2 and 4 cm,
considering these values sufficient for the addressed defects, as well as a
consideration due the necessity of a complete mesh coating with omentum
(8,9,10,11,) The mounting mode of the prosthesis and their nature is still a subject
controversy. Ideal mesh in laparoscopy should be as inert as possible in contact with
visceral peritoneum.
Frequently used prostheses were polypropylene or polyester macro porous, with
opinions that
this type of prosthesis predisposes to intestinal fistulas. In our experience omentum
overlapping
prevent evolution to such complications, by preventing adhesions between mesh and
abdominal
viscera, with results comparable with Dual Mesh prosthesis (11,12,13,14) Dual Mesh
prosthesis
represent standard choice in surgical treatment of umbilical and post-incisional
hernias, but are more difficult to access due to a higher acquisition cost, being also
harder to handle during surgery (14).
Limitations of the method lie in the impossibility of a correct mesh fitting in large
abdominal defects, in the necessity of a sufficient size and quality of omentum,
situations in which we prefer Dual Mesh .(16,17)
We consider that this modality of umbilical and post-incisional hernias treatment
resembling with a Dual Mesh approach, with additional benefits from a classic
surgical approach, but lack of a bigger study group and that we don’t have
significantly statistic group with Dual Mesh prosthesis for comparison, as well we’ve
used this technique only for small and medium defects make us to be reserved to
final conclusions.(18,19,20,21,22)

Conclusions:
The minimally invasive laparoscopic treatment of umbilical hernias and post-
incisional hernias, using intraabdominal mesh overlay with great omentum, is a
feasible alternative to a more expensive and difficult Dual mesh procedure.
Minimizing the risk of complications occurred due to mesh – abdominal viscera
contact, by omentum overlay is a technique, which gave satisfactory results every
time it was used.
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