Tecnica chirurgica: selezione e posizionamento della protesi

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1 Tecnica chirurgica: selezione e posizionamento della protesi
Paolo A. Riccio Chirurgia Imola

2 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

3 Posizionamento della rete e incidenza di recidive (%)
Underlay (intraperitoneale) 4.5 Sublay (preperitoneale) Onlay Inlay Rudmik, Hernia 2006

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5 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

6 1,5 milioni di reti vengono impiantate ogni anno nel mondo per il trattamento chirurgico del laparocele Weyhe, World J Surg 2007

7 Scelta della rete: evidenze dalla letteratura?
…nessuna evidenza!!

8 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

9 Stabilità della rete Adeguato overlap Integrazione parietale
Tecniche di fissaggio

10 Trends Reti leggere, coated mesh
Macro + microporosità per una migliore integrazione tissutale e prevenzione dello shrinkage Maggiore elasticità Barriera antiadesiva

11 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

12 Misurazione interna

13 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

14 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

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19 Experience of laparoscopic incisional and ventral hernia repair
(2005 – 2012) UO di Chirurgia Dir. Dott. S. Artuso

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21 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 cholecistectomy 5 inguinal hernia

22 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

23 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%)

24 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%)

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

26 Type of fixation (2) Use of Tissucol

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

28 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

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

30 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%)