Laparoscopic Ventral Hernia Repair (VHR)
Has Definite Patient Benefits

Hernias are a very common problem in a surgical practice, and over the years many types of procedures have evolved to repair them. However, the majority of surgeons perform a conventional or modified Bassini repair, wherein the defect is closed by pulling the tissues of the abdominal wall together and stitching them. Although this method is still considered the "gold standard" for hernia repair, it has its downsides. Patients must avoid any straining or lifting for six to eight weeks, the recurrence rate ranges from 10% to 15%, and long-term numbness can be associated with the repair. Patients also frequently report uncomfortable pulling sensations across the stitch line that may last for several weeks.

While the majority of hernia repairs are done on the outside of the abdominal wall, this technique is at odds with physiology, as intra-abdominal pressure tends to push the repair out of the defect. A newer preperitoneal approach solves this problem by addressing teh repair between the layers of the abdominal wall. The advent of laparoscopic surgery has made ventral hernia repair an even more effective, promising choice. Benefits include:

• Natural pressure from the abdominal wall pushes the repair into the defect to strengthen the repair.
• The tension-free method alleviates any postsurgical pulling sensation.
• Less overall pain.
• A quick return to normal activities, usually within a week.

Treating the Hernia

The wall of the abdomen has natural areas of potential weakness, and hernias can develop at these or other areas due to a number of factors. Heavy strain on the abdominal wall, aging and injury can all contribute to a hernia occurrence, and people can develop one at any age.

Surgery is the only effective way to treat hernias, and surgeons are still "on the fence" about the best method. The traditional approach, done form the outside through an incision in the groin or the herniated area, is performed with great frequency and has a fair measure of success. The depth and width of the incision, which extends hrough the skin and subcutaneous fat to allow access to the level of the defect, cause some concern among patients due to the recovery time involved.

The approach preferred by Dr. Cloud and an increasing number of other skilled surgeons is the laparoscopic method using a specialized surgical mesh, Composix, for the repair. In this approach, a series of three to five small incisions allows for passage of several trocars. The laparoscope and a series of tools are passed inside through the trocars to repair the hernia from behind the abdominal wall. The Composix is then fixed over the hernia defect with the guidance of the laparoscope and held in place with small surgical staples.

The Compsoix prosthesis has two different surfaces. One surface is an ePTFE membrane that does not allow extensive tissue attachment. This side is exposed to the peritoneal cavity. The other surface has a polypropylene structure that allows tissue ingrowth and attachment to the abdominal wall.

The polypropylene acts like a plug to hold the sutures in place and eventually becomes incorporated by surriounding tissue. This strengthens the weakened area, and the natural bonding makes the area free of tension.

The laparoscopic operation is performed with general anesthesia, and the required incisions are less than an inch wide. This technique therefore allows many patients a shorter recovery time and less postoperative pain and discomfort. the quick bond created by the laparoscopic method likewise allows for almost immediate return to normal activity levels.
 

Contraindications and Complications

While certainly appealing for its effectiveness and lack of significant postsurgical recuperation, each case needs to be considered individually and carefully by a skilled surgeon. For example, the laparoscopic procedure is not recommended for patients who have bleeding problems, underlying medical conditions or previous abdominal surgery leading to dense scar tissue. The decision to perform an open procedure instead would be made based on patient safety in such instances.

Obese candidates, however, are often better candidates for laparoscopic surgery than traditional open surgery, because the tension within the abdomen allows for greater visualization.

The primary complications of laparoscopic surgery are bleeding and infection, but both remain uncommon in appropriate candidates for the procedure. A slight risk of injury to surrounding structures, such as the bladder, intestines, blood vessels and nerves, does exist, as it does with any surgery.

The Need for a Skilled Surgeon

The benefits of the laparoscopic method are very appealing to patients: a quicker return to work and normal activity, less pain after surgery and no scarring. However, this technique only offers such benefits in the hands of a skilled surgeon.

A study of the effectiveness of laparoscopic ventral hernia reair by the American College of Surgeons found the recurrence rate was 3.4% during a mean follow-up time of 23 months. that rate was not expected to change, since approximately 66% to 90% of ventral hernia recurrences develop within tow years after surgery.

In the series, most patients had good outcomes, even though they were typically obese, had large hernias and one-third had previously undergone an open hernia repair. The hospital stay averaged approximately two days, there were no deaths, and the complication rate was 13%.

This further supports the need for a skilled surgeon. Someone who can not only perform the surgery, but who also has the insight and expertise to determine the cnadidacy of each patient for laparoscopic ventral hernia repair.

The American College of Surgeons study thus concluded that the advantages of laparoscopic repair had to be weighed against the rare complications of the technique. Therefore, they supported a move toward laparoscopic ventral hernia surgery being performed by specialist surgeons only.

Dr. William G. Cloud is one such surgeon. A board-certified surgeoon with experience in cancer and abdominal surgery, he has particular expertise in advanced laparoscopic surgery and complex gastrointestinal procedures. He has performed numerous ventral hernia operations with much success and offers the laparoscopic method in his Morganton, NC, clinic.

Dr. Cloud is a referral source for many physicians confident in his skills and commitment to patient care, and he welcomes your hernia cases, as well. For more information, please call Dr. Cloud at 828.437.0847.