Short-Term Outcomes Post Laparoscopic Abdominal Wall Reconstruction: A Novel Approach and Prospective Multi-Institutional Case Series Study

Hamid R Zahiri, DO1, Olmos I Holmatova, MD1, Heidi Miller, MD2, Adrian E Park, MD, FACS1, Yuri W Novitsky, MD, FACS2, Igor Belyansky, MD, FACS1. 1Anne Arundel Medical Center, 2University Hospital Case Medical Center

Background: Rives and Stoppa technique involves placement of mesh between the rectus muscle and the posterior rectus fascia, often referred to as a retrorectus repair.  As direct evolution of this surgical approach, Transversus Abdominis Release has been one of the recently described surgical approaches that adds to a growing armamentarium of AWR techniques and has been widely embraced by hernia surgeons.  We present a series of patients that underwent a novel minimally invasive TAR and Rives Stoppa approaches to address complex hernia defects, completed entirely laparoscopically at two hernia centers. 

Methods: Eleven patients underwent laparoscopic AWR for complex hernias in August and September of 2015 at two institutions: Anne Arundel Medical Center and University Hospital Case Medical Center.  Operative approach consisted of lysis of adhesions (as necessary), bilateral posterior rectus sheath release, closure of the posterior fascial layer, closure of the anterior abdominal wall defect and large mesh implantation.  When appropriate bilateral transversus abdominis release was performed to achieve anterior defect closure.  

Short-term (30-day) outcomes were analyzed, including wound and non-wound related complications, as well as, preoperative and postoperative quality of life (QOL) using Carolinas Comfort Scale (CCS).       

Results: Six males and Five females with mean age and BMI of 64.2 and 30.7, respectively, underwent a mean OR time of 354.7 minutes.  There were 6 TAR and 5 Rives Stoppa procedures. Average mesh area used was 837.5 cm2.  Mean EBL and LOS were 100.0 cc and 5.7 days, respectively.   No subcutaneous flaps were raised avoiding the need for subcutaneous drains.  There were no perioperative complications.  All of the subfascial drains were removed prior to patient discharge. On initial follow-up visit at four weeks, there was no evidence of wound complications, bulging or hernia recurrences. 

QOL assessment with CCS in the first 30 days showed 50% of patients had improvements in pain and mobility after surgery compared to their baseline (prior to surgery).   One patient had increased pain, although, this was not significant (≥2 on scale)

Conclusion: Laparoscopic TAR and Rives Stoppa repairs are novel surgical approaches to complex abdominal wall defects.  These interventions have the potential to reduce early perioperative pain, facilitate recovery and decrease length of hospital stay for patients.  Their place in the field of AWR is yet to be determined.  Further work will focus on patient selection as well as reporting long-term outcomes.

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