FINES DEL REGISTRO INMOBILIARIO

EVIDENCE REPORT

METHODS (SEARCH STRATEGY)

The indications for laparoscopic treatment of incisional hernia located near the abdominal borders and para-stomal hernias have been investigated according to a specific research building covering the last 4 years from former consensus conference. We worked on these different search engines: PUBMED central,

EMBASE and Cochrane. Further autonomous investigation of literature over the last year was also carried out. 77 articles were examined with the given research building extending it up to June 2013. Out of these 33 were considered off topic and 16 refer to traditional “open” anterior surgical approaches. 6 more articles were not taken into account for the full text evaluation because not in English language. The remaining 22 articles were full text examined. 14 articles concerning this topic published before

1/1/2009 were also considered when poor proofs on surgical indications have been taken out in the last 4 years.

RESULTS

Incisional hernias located near the abdominal border are commonly indicated those kind of defect arising close to bony structures delimiting the abdominal wall. Among them we have both median (M1 and M5) and lateral defects (L1 and L4) according to EHS classification[155]. To date the research of literature found only an article approaching this specific topic with a retrospective evaluation of results of LR for the whole

aforementioned sites[144]. The article confirmed that mesh fixation by tacks on the edge of defects is feasible especially in suprapubic site, whereas few intracorporeal stitches are required in subxiphoidal space and transparietal stitches are sometimes necessary in subcostal regions to obtain good postoperative course

and recurrence rate. More frequently the authors take into account the single types of hernia or postoperative results are analyzed together with those derived from LR of more common incisional hernias out of large series. Former experience of consensus conference failed to find significant influences on PO course according to the site of hernia and no contraindication was found for the LR among surgical groups with greater experience at least[80].

• Lumbar incisional hernias

Previous surgery usually produces abdominal wall musculature denervation causing disruption of normal anatomy and large bulging defects that occupy most of the lumbar region[156]. Authors seem to consider laparoscopic surgery as the best approach to locate precisely and evaluate the characteristics of the defect and its contents[157]. Patients usually are placed in a lateral position and the mobilization of the colon is often necessary to obtain an adequate posterior parietal margin. The largest series of 35 LR in 13 years showed significant better results in terms of early PO course and less incidence of recurrence when compared to open repair. LR should be indicated as procedure of choice except for large hernia because of higher incidence of recurrence than open repair[158]. LR of lumbar defect is usually performed by a combination of both trans- abdominal stitches and metallic tacks and is always described as technically challenging and should be performed by experienced laparoscopic surgeons[157-158]. Recurrence after LR seems to be significantly higher for subcostal than lumbar defects[159] and in some case of complex incisional hernia the use of a double mesh technique may be advisable[160]. A “double mesh” technique has also been previously described in case

of marked parietal atrophy in a retrospective series of 11 patients in 10 years. The combined use of two running suture with non-absorbable monofilament material should restore the normal anatomy, thereby improving muscular function of the area, at the cost of the repair not being“tension-free”[161].

• Sub-xiphoid and subcostal incisional hernias

Desciptions of LR for these kind of hernias in the last 4 years bring some recommendations in terms of low PO morbidity and recurrence rate of 5%[162]. Few isolated cases of LR by means of suture alone for small defect size are also described[163]. A review of 113 patients treated for subxiphoid incisional hernia after median sternotomy over a period of 20 years published before 2009 remain the main source of data on this specific topic [164]. Only 21 cases of LR have been described by three different authors with a recurrence rate ranging from 10% to 33% among the larger retrospective series[165,166]and may be more likely related to a learning curve of the technique[180]. Avoidance of both tacks and sutures placing in the cephalad most portion of the mesh is thought to contribute to higher recurrence rates in respect of LR for other heria sites. An important technical point concerning the LR is the need to dissect the falciform ligament up to the hepatic veins providing a good cranial overlap ensuring generous retroxiphoid overlap beyond the edge of the hernia defect[180]. Endoscopic tackers can be used around the edges to fix the prosthesis avoiding the placing beyond the costal chondral margin[164,180]. In other series the placement of additional full-thickness or intraperitoneal abdominal wall stitches allow additional strength to mesh fixation[144,180]. LR seems to be as effective as open approach although long term comparative studies should be advocated.

The presence of a colostomy is more frequently associated with the development of parastomal hernias meanwhile no other significant patient-related or postoperative risk factors seem to have significant relationship with the incidence of parastomal hernias[167].The majority of the literature about treatment of parastomal hernia consists of retrospective studies and case series with only small

numbers of patients. A total of 12 studies for 338 LR with meshes were included in a systematic review comparing with 13 studies for 283 “open” prosthetic repair. LR had no significant advantage over open repair in terms of morbidity, mortality and recurrence rate[168]. Both the Sugarbaker[181,182] and the keyhole[183,184] techniques are currently used with a slight prevalence of the latter. The use of a mesh with a slit is related to significant higher mean recurrence rate (34.6% vs 11.6%)[168- 170,179,184] while the risk of mesh infection and overall postoperative morbidity did not differ significantly between surgical techniques although there are insufficient data available to compare these approaches on other aspects of postoperative course. A recent multicentric cohort study on 61 modified Sugarbaker technique stated that this is safe and feasible in experienced hands with an overall morbidity of 19 % and recurrence rate of 6.6 % after a mean follow-up of 26 months[170]. In addition Sugarbaker LR has been found in recent series to be technically less demanding and associated with decreased surgical time so that should be proposed as a good alternative to open prosthetic repair[171]. One theoretical concern with this technique would be that lateralizing the bowel could lead to severe bowel obstructing angulation even though there has not been a reported occurrence in previous series[168]. A combination of both technique has been recently described as“sandwich repair” reporting lower recurrence rate (2%) over a median follow up of 20 months[172]. e-PTFE are the most frequently used prosthetic materials for LR in both techniques. Sporadic reports with the use in a keyhole fashion of composite meshes attached with intracorporeal sutures to the bowel serosa are also available[173] besides rigorous long-term follow-up are expected to validate their placing. The using of an inert mesh material which does not adhere to abdominal

structures, such as polyvinylidene fluoride (PVDF) was used in the sandwich technique in 47 patients with a promising low incidence of post-operative mesh-related infections[172] when compared to 3.6% prosthetic infection with the use of ePTFE patch [168]. Primary LR with transabdominal suture on either side of the lateralized bowel along with modified sugarbaker mesh placement was found to be effective in lowering recurrence rate [169] and should be performed in selected small parastomal hernias or in some large ones to ensure adequate approximation of the edges prior to mesh deployment [174].

• Suprapubic incisional hernias

Since the first description laparoscopic approach in 2001 [175] experience with LR of such hernias is limited with poor long-term mean follow-up ranging from 2.6 months [176] to 4.8 years[177] in the 4 larger series available in the dedicated literature. Apart from the distinct advantages of laparoscopy, authors agree that LR of such hernias allows complete assessment of both the hernial defect and previous scar with reduced chance of potentially “missed” defects [176,177]. Comparative studies with open techniques were not found and only one article was published on this specific topic since 1/1/2009; to date this is the largest series of LR for such incisional hernias providing a retrospective study of 72 patients over a period of 10 years[178]. All the authors debating on LR underline the importance of pre-peritoneal surgical dissection by developing of a peritoneal flap for direct visualization of the pubic bone,Cooper’s ligaments, and the inferior epigastric and iliac vessels to obtain adequate mesh overlap in an area with limited space [76,176-178]. Urinary catheter is mandatory and a distended bladder could also be useful in some cases to enable identification of the surgical field and to demonstrate any occurrence of eventual operative injury[176]. Most of the authors advocate the elevation of the peritoneum flap with the bladder at the end of procedure to cover Cooper’s ligaments and the inferior mesh edge, especially in case

of PP based prosthesis, allowing the bladder to resume anatomic position[175-178]. The meshes are most frequently fixated to the periostium of the posterior pubis and Cooper’s ligaments bilaterally[186] which are believed to represent the strongest tissues of the pelvis, holding sutures as well as helical tacking devices to allow enough inferior fixation of the mesh [76]; further fixation of the meshes is usually performed in a double crown fashion avoiding damage of neurovascular structures. The inferior margin of the mesh should extend below the pubic arch by 2 cm at least to enable secure fixation to Cooper’s ligaments bilaterally[76,176,177]. The inherent difficulties associated with LR of such hernias, including lack of adequate overlap, are associated with relatively high recurrence rate[49]that is extimated to be around 6 % on average[76,176,177]; there is some evidence among the larger series to support the additional use of transabdominal (TA) sutures to reduce incidence of recurrence rate[176,178]. Different ways of combining TA and tacks are described by the main authors without any significant difference in terms of outcomes to support the use of a specific technique: TA sutures followed by circumferential tacks every 1 cm and additional TA sutures every 3 cm[176], spiral tacks every 1 cm and TA sutures every 4–5 cm[178] or intracorporeal PP sutures[76] every 4–5 cm were alternatively proposed to circumferentially fix the mesh to the abdominal wall. TA sutures passing through the periosteum of the pubis using a suture passer to fix the inferior margin of the mesh[178] may cause pain and may lead to the risk of osteitis pubis[177]. A retrospective study on 17 patients undergoing LR in 17 years reported the usefulness of intracorporeal polypropylene sutures in a running fashion to completely suture the hernial defect, thus restoring the abdominal domain preventing the postoperative “bulge” in the anterior abdominal wall, potentially reducing the size of the mesh require to reinforce de repair[76]. Overall complications rate after LR is reported to be between 16.6 and 38%; morbidity has been specifically investigated in a review of 47 patients in 4 years and the occurrence of complications was found to be related to larger defect size, history of previous hernia repair, greater number of previous surgeries, and higher BMI, although these correlations were not statistically

significant[176].