12_1_7-2 figure 2.jpg
12_1_7-2 figure 1.jpg

Early Experience of Laparoscopic Ventral Hernia Repair in Kenya

Ndungu BM1, Mburu JK1, Ondede K2

  1. School of Medicine, University of Nairobi

  2. Department of Surgery, Kenyatta National Hospital

Correspondence to: Dr. Bernard M Ndungu, P.O. Box 2058-00202 KNH, Nairobi, Kenya. Email: bmndungu@ yahoo.com

Abstract

Background: Laparoscopic ventral hernia repair (LVHR) is gaining popularity amongst minimal access surgeons with numerous advantages over conventional open repair. We present the first local series of LVHR and analyse morbidity profile of the patients. Methods: Records of all patients who had LVHR were analysed in relation to hernia characteristics, operative, early and intermediate outcomes. Results: Twenty-seven patients (23 females, 4 males) had LVHR. Of these, four were primary hernias while rest were incisional. The age range was 16 to 76years. The mean size of the defect was 75 cm2. A composite mesh was used in all the patients except one patient who had a pure prolene mesh. The mean operative time and hospital stay were 130 minutes and 3 days respectively. There were two conversions and no other major complication.With a follow-up period of 3-36 months, there was one recurrence at the fourth months.

Conclusion:Our initial experience with this modality shows that LVHR is a feasible option with great potential in both treatment success and reduction of surgical morbidity.

 

Key Words: Laparoscopy, Laparoscopic ventral hernia repair, Ventral hernia

Introduction

Ventral hernias are fascial defects of the anterolateral abdominal wall through which intermittent or continuous protrusion of abdominal tissue or organs may occur. More than 80% of ventral hernias in adults are incisional hernias. They occur after 10-26% of abdominal procedures (1,2). Many repair methods have been described for these hernias. Traditional primary repair entails a laparotomy with suture approximation of strong fascial tissue on each side of the defect. However, recurrence rates after this procedure range from 41% to 52% during long-term follow-up (2–4). Herniorrhaphies in which large prosthetic meshes are implanted have lower failure rates (12–24%), but the required dissection of wide areas of soft tissue contributes to an increased incidence of wound infections and wound-related complications (12% or higher) (3,5,6). The interest in less morbid herniorrhaphies and the appeal of minimally invasive surgery encouraged development of laparoscopic methods for repairing ventral hernias. The technique is based on the same physical and surgical Pascal’s principle as the open underlay procedure (7,8,9). Since the first report of laparoscopic ventral hernia repair (LVHR) in 1993(10), the operation has grown in popularity with the belief that it may offer shorter hospital stay, improved patient outcomes, and fewer complications than traditional open procedures. There have been several well-received series that have reported comparatively lower infection and recurrence rates in the laparoscopic approach to ventral hernia repair (4-6). We report our initial experience with laparoscopic ventral hernia repair and analyse the perioperative events and morbidity profile to improve future outcomes.

 

Methods

Twenty seven patients had LVHR completed between December 2008 and December 2013. Two patients had the attempted LVHR converted to open mesh repair. The patient’s age, sex, hernia type and co-existing medical problems were recorded. The hernia defect size, prosthetic material used in the repair, method of fixation of the prosthesis, operative time, length of postoperative hospital stay, peri-operative and post-operative complications were recorded.

 

The same operative technique was used on all patients. Surgery was performed with patients in the supine position under general anaesthesia. Pre-operative prophylactic antibiotics were given in all cases. All patients were catheterised to decompress the urinary bladder. Gastric decompression was achieved by placement of a naso-gastric tube. Access to the abdomen was accomplished at the Palmer’s point by means a Verres needle. Pneumoperitoneum was induced to a preset pressure of 12 to 14 mm Hg depending on the size of the patient. Two additional ports (5 and 10mm) were made along the mid-axillary line, far away from the hernia. Adhesiolysis was done using non-energised sharp and blunt dissection with minimal use of diathermy to avoid inadvertent thermal injury to the bowel. The hernia contents were reduced but the peritoneal sac was left in-situ. The margins of the hernia defect were delineated and measured on the surface of the abdominal wall (Figure 1). The area of the hernia was approximated by taking its longest dimension as its diameter. A composite mesh (Proceed- Ethicon; or Omyra- Braun) was used in 26 patients while one patient had a pure polypylene mesh. The mesh was tailored externally on the abdominal wall to covers the hernial defect by a margin of at least 3 cm and introduced into the abdominal cavity via the 10mm port (Figure 2). After the mesh was positioned