Risks of subsequent abdominal operations after laparoscopic ventral hernia repair

Puraj P Patel, DO, Michael W Love, MD, Jeremy A Warren, MD, William S Cobb, MD, Joesph A Ewing, MS, Alfredo M Carbonell, DO. Greenville Health System

Laparoscopic ventral hernia repair (LVHR) is well accepted, however, the rate of patients requiring future abdominal operations is not well understood.   This study identifies the common characteristics of LVHR patients undergoing reoperation and its attendant sequelae.

A review of a prospectively maintained database at a hernia referral center identified patients who underwent LVHR between 2005 and 2014.  Furthermore, a retrospective review identified LVHR patients who underwent subsequent abdominal operations.   Outcomes of those reoperations were collected.  Data are presented as a mean with ranges.

A total of 757 patients underwent LVHR, with 24 conversions to open repair.  Of the remaining 733 patients, age was 56.5 years, BMI 33.9 kg/m2, hernia size 115cm2 (range 1-660 cm2), mesh size 411cm2 (range 17.7-1360 cm2), operative time 143 minutes, and length of stay 3.6 days.  Mesh used was ePTFE (57%), barrier polyester (35%), and barrier polypropylene (8%).  After a mean follow up of 19.4 months, overall recurrence rate was 8.46%. Subsequent abdominal operations were performed in 17% (125 patients); 21% of these patients required greater than two subsequent operations.  Mean time from index hernia repair to reoperation was 5.5 years.  The most common indication for reoperation was recurrent hernia (36 patients, 28.8%), followed by hepatopancreaticobiliary (19 patients, 15.2%), infected mesh removal (19 patients, 15.2%), bowel obstruction (18 patients, 14.4%), gynecologic (10 patients, 8%), colorectal (8 patients, 6.4%), bariatric (5 patients, 4%), trauma (1 patient, 0.8%), and other (9 patients, 7.2%).  Overall, 2.5% developed a mesh infection (n=19; ePTFE 15, polyester 2, polypropylene 2); all of whom required mesh removal.  Only 53% underwent a subsequent hernia repair.  Fifteen percent of patients who developed mesh infections, had a subsequent abdominal operation between their index hernia repair and development of the mesh infection.  At the time of reoperation for bowel obstruction, the incidence of enterotomy or unplanned bowel resection (EBR), as a direct result of mesh-bowel adhesions was 27% (n=5: polyester 3, ePTFE 2).  No other indication for reoperation resulted in EBR.

In a large consecutive series of LVHR, the rate of abdominal reoperation was 17%, and appears to increase with time.  A reoperation for bowel obstruction carries an increased risk of EBR as a direct result of mesh-bowel adhesions.  Surgeons should strongly consider, and discuss with patients the potential morbidity of future abdominal surgery prior to offering an intraperitoneal mesh hernia repair.

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