Intraperitoneal Onlay Mesh Repair: Clinical Implications

Laparoscopic repair of ventral abdominal wall hernias is growing in popularity. This technique is at least as safe and effective in general when compared to open repair of ventral abdominal wall hernias.

The aim of this thesis was to investigate clinical outcome after intraperitoneal onlay mesh repair, for ventral abdominal wall hernia, or reinforcement, for anterior cutaneous entrapment syndrome, in order to improve preoperative counselling of patients and to further advance surgical technique. To accomplish this aim, five different questions were formulated that until now have been insufficiently answered in the literature.

Is pooling of data – as was customary before publication of this study - of primary with incisional ventral hernia justified? In chapter 2important differences are demonstrated in all aspects of laparoscopic repair from patient characteristics to complexity and risks of procedure to intra- and postoperative complications to late outcome. Surgeons in their “learning curve” of acquiring skills for performance of laparoscopic repair must be aware of these differences. Using pooled data evidently leads to inexact preoperative counselling of patients. We argue that the practice of pooling these two entities together should come to an end.

What are the main complications after intraperitoneal onlay mesh repair? In chapter 2we summarise the main complications after intraperitoneal onlay mesh repair. Inchapter 3we concluded that a persistent posterior seroma seems to be a relatively frequent complication after laparoscopic repair of usually larger ventral hernias with ePTFE meshes. An initial wait-and-see policy seems justified. A subset of symptomatic patients may require laparoscopic excision of the thick neoperitoneum that provides a good outcome. In chapter 4we argue that laparoscopic repair of primary and incisional hernia in fertile women, who intend to have further pregnancies, is an acceptable therapeutical option that causes no significant problems during pregnancy or delivery.

How do the number and type of tacks influence postoperative pain perception? In chapter 5 we investigated the relationship between postoperative pain and the number of tacks used for fixation of a mesh. Fewer tacks do not necessarily create less pain for the patient; nor do more tacks create more pain. In chapter 6we investigated the relationship between postoperative pain and the type of tacks (nonabsorbable versus absorbable) used for fixation of a mesh. Absorbable tacks seem to cause less early postoperative pain at 6 and 12 weeks when compared to nonabsorbable titanium tacks. At follow up chronic pain was not different between both groups. Given the very low VAS scores in both groups, the clinical significance of these finding remains questionable.

Is a two-port procedure for laparoscopic ventral hernia repair feasible? In chapter 7we described step for step a 2-port procedure (How-I-Do-It).

Is laparoscopic intraperitoneal onlay mesh reinforcement a treatment option for intractable anterior cutaneous entrapment syndrome? In chapter 8we investigated whether intraperitoneal onlay mesh reinforcement could alleviate pain at the trigger point. Short- and long-term success rates of 90% and 71%, respectively. Prospective studies are required to validate this new treatment concept.