Tecnica chirurgica: selezione e posizionamento della protesi Paolo A. Riccio Chirurgia 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 defects 3 Selection of a clinically proven prosthetic biomaterial 4 A minimum of a 3 cm overlap of all fascial borders with a larger area for obese patients or large recurrent hernias 5  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 rete Adeguato overlap Integrazione parietale Tecniche di fissaggio

Trends Reti leggere, coated mesh Macro + microporosità per una migliore integrazione tissutale e prevenzione dello shrinkage Maggiore elasticità Barriera 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 defects 3 Selection of a clinically proven prosthetic biomaterial 4 A minimum of a 3 cm overlap of all fascial borders with a larger area for obese patients or large recurrent hernias 5  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 parietale Il 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 Chirurgia Dir. Dott. S. Artuso

Patient Characteristics (222) Male/Female 84/138 Age (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 145 Lateral: 24 Left side 5 Mc Burney 5 Subcostal 10 Lumbar hernia 4 Parastomal 3 Laparoscopic Ventral Hernia Repair - LVHR (50) Umbilical hernia 29 Epigastric hernia 21

Chevrel classification Type of defect (2) ABDOMINAL BORDER (42) Subxiphoidal 8 Suprapubic 24 Subcostal 10 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 (4) Swess-Cheese 37 (16.7%)

Type of Prosthesis SEPRAMESH VENTRALIGHT 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

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

COMPLICATIONS (32) RE-OPERATION (7) 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 Pneumonia + wound infection Wound infection 2 (0.9%) RE-OPERATION (7) Intestinal injury 4 (1.8%) Postoperative bleeding Trocar site erniation

RECURRENCE 12 (5.4%) Time to recurrence (days): 537 (31-1517) Treatment of recurrence: Laparoscopic repair 2 Open repair 5 No 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%)