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)
• Onlay
• Inlay
8
14
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
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
Misurazione
extracorporea
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
Age (y)
Body mass index
ASA classification
Previous open hernia
repair
Max diameter size (cm)
Operating time (min)
Postoperative hospital
stay (d)
Associated procedures
84/138
61.7 (15-88)
28.8 (18-45)
2.1 (1-3)
24 (10.8%)
8.4 (2-28)
97.5 (25-240)
4.8 (1-27)
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
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
NON ABSORBABLE TACK
52 (23.5%)
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)
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 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%)