Monthly publications : November 2016 | WebSurg, the online university of IRCAD

The incidence rate of parastomal hernias ranges from 10 to 50%, and repair of the symptomatic cases is usually challenging. The use of a prosthetic mesh demonstrated good results, reducing recurrences. The laparoscopic approach is feasible and has shown lower morbidity rates as compared to the conventional technique.
This is the case of a 64-year-old man, who underwent a parastomal hernia repair using Berger’s technique with a laparoscopic approach.

A Rossini, F Signorini, A Alcaraz, A Lopez Sivilat, S Reimondez, I Procikieviez, P Maldonado, L Obeide

Surgical intervention

Laparoscopic repair of parastomal hernia with DynaMesh®

The incidence rate of parastomal hernias ranges from 10 to 50%, and repair of the symptomatic cases is usually challenging. The use of a prosthetic mesh demonstrated good results, reducing recurrences. The laparoscopic approach is feasible and has shown lower morbidity rates as compared to the conventional technique.
This is the case of a 64-year-old man, who underwent a parastomal hernia repair using Berger’s technique with a laparoscopic approach.

LIVE INTERACTIVE SURGERY: Laparoscopic management of an incisional hernia in a multi-operated patient

In this video, Dr. Adrian Park demonstrates the laparoscopic management of an incisional hernia in a multi-operated patient. The operator indicates the main steps of the procedure with pros and cons of trocar placement in relation to hernia repair. Once adhesions have been taken down, the fascial closure is performed by means of an intracorporeal suturing. The tackers are used to secure the mesh, which is sufficiently large to cover the defect, and transmural sutures are used to anchor the mesh.

A Park, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: Laparoscopic management of an incisional hernia in a multi-operated patient

In this video, Dr. Adrian Park demonstrates the laparoscopic management of an incisional hernia in a multi-operated patient. The operator indicates the main steps of the procedure with pros and cons of trocar placement in relation to hernia repair. Once adhesions have been taken down, the fascial closure is performed by means of an intracorporeal suturing. The tackers are used to secure the mesh, which is sufficiently large to cover the defect, and transmural sutures are used to anchor the mesh.

LIVE INTERACTIVE SURGERY: Laparoscopic management of a bilateral inguinal hernia: TEP approach

In this video, Dr. Bernard Dallemagne briefly outlilnes the main steps of bilateral inguinal hernia repair by Totally extraperitoneal inguinal hernia repair or TEP repair. After the insertion of the trocars the anatomical landmarks are identified.The direct and indirect hernia contents are dissected and reduced ,lipoma is dissected .Finally the mesh are inserted and the defects are covered bilaterally and the abdominal cavity is desufflated to complete the procedure.

B Dallemagne, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: Laparoscopic management of a bilateral inguinal hernia: TEP approach

In this video, Dr. Bernard Dallemagne briefly outlilnes the main steps of bilateral inguinal hernia repair by Totally extraperitoneal inguinal hernia repair or TEP repair. After the insertion of the trocars the anatomical landmarks are identified.The direct and indirect hernia contents are dissected and reduced ,lipoma is dissected .Finally the mesh are inserted and the defects are covered bilaterally and the abdominal cavity is desufflated to complete the procedure.

LIVE INTERACTIVE SURGERY: Laparoscopic management of inguinal and Spiegelian hernia: TAPP approach

Spiegelian hernias are quite rare and account for 1 to 2% of all abdominal wall hernias. In this video, Dr. Joel Leroy demonstrates the key steps of the laparoscopic management of inguinal and Spiegelian hernia using a transabdominal preperitoneal (TAPP) approach. The operator briefly outlines the basic rules for port placement and dissection based on anatomical landmarks. In addition, he introduced the main points related to mesh fixation and closure in Spiegelian hernias.

J Leroy, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: Laparoscopic management of inguinal and Spiegelian hernia: TAPP approach

Spiegelian hernias are quite rare and account for 1 to 2% of all abdominal wall hernias. In this video, Dr. Joel Leroy demonstrates the key steps of the laparoscopic management of inguinal and Spiegelian hernia using a transabdominal preperitoneal (TAPP) approach. The operator briefly outlines the basic rules for port placement and dissection based on anatomical landmarks. In addition, he introduced the main points related to mesh fixation and closure in Spiegelian hernias.

Combining VATS and laparoscopic approach in the resection of ovarian carcinoma metastasis

This is the case of a 64-year-old woman with a history of hysterectomy and left adnexectomy. In 2012, a vaginal ultrasound revealed a right ovarian mass diagnosed as a right ovarian cancer. In December 2012, she underwent a right adnexectomy with pelvic, lumbo-aortic lymphadenectomy and omentectomy. Final pathological staging of the ovarian cystadenocarcinoma was pT3cpN1Mx (IIIC). She completed 6 cycles of adjuvant chemotherapy with carboplatin and paclitaxel. During the follow-up exam, the patient remained symptom-free and presented with a stable perihepatic lesion. In 2015, two new lesions were found on CT-scan: one in the anterior mediastinum (14mm) and another in the abdominal diaphragm in contact with a liver segment VIII (19mm). In addition, CA 125 raised from 19 to 50kU/L. PET-scan only evidenced these two new lesions (SUV= 10). Taking into account the patient’s excellent performance status, long disease-free survival, stability of lesions, with CT-scans performed with a 3-month interval, and the possibility of video-assisted surgery, it was decided to use VATS and laparoscopy to remove the lesions. Final pathological findings showed ovarian cystadenocarcinoma metastases in 2 lesions (R0). The third perihepatic lesion was a cyst. The patient was discharged on postoperative day 4.

F Cabral, JA Pereira, P Calvinho, P Amado, R Maio

Surgical intervention

Combining VATS and laparoscopic approach in the resection of ovarian carcinoma metastasis

This is the case of a 64-year-old woman with a history of hysterectomy and left adnexectomy. In 2012, a vaginal ultrasound revealed a right ovarian mass diagnosed as a right ovarian cancer. In December 2012, she underwent a right adnexectomy with pelvic, lumbo-aortic lymphadenectomy and omentectomy. Final pathological staging of the ovarian cystadenocarcinoma was pT3cpN1Mx (IIIC). She completed 6 cycles of adjuvant chemotherapy with carboplatin and paclitaxel. During the follow-up exam, the patient remained symptom-free and presented with a stable perihepatic lesion. In 2015, two new lesions were found on CT-scan: one in the anterior mediastinum (14mm) and another in the abdominal diaphragm in contact with a liver segment VIII (19mm). In addition, CA 125 raised from 19 to 50kU/L. PET-scan only evidenced these two new lesions (SUV= 10). Taking into account the patient’s excellent performance status, long disease-free survival, stability of lesions, with CT-scans performed with a 3-month interval, and the possibility of video-assisted surgery, it was decided to use VATS and laparoscopy to remove the lesions. Final pathological findings showed ovarian cystadenocarcinoma metastases in 2 lesions (R0). The third perihepatic lesion was a cyst. The patient was discharged on postoperative day 4.

Full laparoscopic repair of a post-traumatic diaphragmatic hernia with mesh insertion

This is the case of a 34-year-old man who suffered from a blunt trauma, 8 months before this surgery. He presented with oppressive chest pain, lasting for a week, increasing while exercising and decreasing when lying down. No history of chronic pathology or smoking was reported. He was admitted to hospital. CT-scan of the abdomen and thorax showed a left diaphragmatic hernia. A laparoscopic diaphragmatic hernioplasty was decided upon. The patient is placed in a right semi-lateral decubitus position, with a 45-degree tilt.
Three trocars were placed; two 5mm trocars in the left upper quadrant, in the anterior axillary line, and in the epigastrium, while a 12mm optical trocar is placed in the upper left quadrant, in the midclavicular line.
The left lung is collapsed. Laparoscopy revealed a left diaphragmatic defect, with a diaphragmatic hernia which contains the spleen, small bowel loops, and the omentum. The hernia contents are reduced into the abdominal cavity. The diaphragmatic defect is then sutured with non-absorbable material. A GORE® DUALMESH® biomaterial is placed over the previous defect and attached to the diaphragm with steel ENDO TACKERS™. A pleurostomy tube is placed and the lung is expanded. The patient outcome was uneventful and he was discharged 5 days after the procedure.

F Terrazas, J Lorenzo Silva, D Molina, A Gonzalez, H Bravo

Surgical intervention

Full laparoscopic repair of a post-traumatic diaphragmatic hernia with mesh insertion

This is the case of a 34-year-old man who suffered from a blunt trauma, 8 months before this surgery. He presented with oppressive chest pain, lasting for a week, increasing while exercising and decreasing when lying down. No history of chronic pathology or smoking was reported. He was admitted to hospital. CT-scan of the abdomen and thorax showed a left diaphragmatic hernia. A laparoscopic diaphragmatic hernioplasty was decided upon. The patient is placed in a right semi-lateral decubitus position, with a 45-degree tilt.
Three trocars were placed; two 5mm trocars in the left upper quadrant, in the anterior axillary line, and in the epigastrium, while a 12mm optical trocar is placed in the upper left quadrant, in the midclavicular line.
The left lung is collapsed. Laparoscopy revealed a left diaphragmatic defect, with a diaphragmatic hernia which contains the spleen, small bowel loops, and the omentum. The hernia contents are reduced into the abdominal cavity. The diaphragmatic defect is then sutured with non-absorbable material. A GORE® DUALMESH® biomaterial is placed over the previous defect and attached to the diaphragm with steel ENDO TACKERS™. A pleurostomy tube is placed and the lung is expanded. The patient outcome was uneventful and he was discharged 5 days after the procedure.

LIVE INTERACTIVE SURGERY: Laparoscopic management of a strangulated umbilical hernia: double-crown technique

In this video, Dr. Morales Conde outlines the main principles of strangulated umbilical hernia repair. After reduction of the contents of the hernia defect, adhesions are taken down and detached. The hernia defect is closed by means of a double loop suture and a piece of mesh which is sufficiently large to cover the hernia defect with a 5cm overlap of surrounding abdominal wall. The mesh is inserted and secured into position with two rows of tackers inserted concentrically.

S Morales-Conde, D Mutter, J Marescaux

Surgical intervention

LIVE INTERACTIVE SURGERY: Laparoscopic management of a strangulated umbilical hernia: double-crown technique

In this video, Dr. Morales Conde outlines the main principles of strangulated umbilical hernia repair. After reduction of the contents of the hernia defect, adhesions are taken down and detached. The hernia defect is closed by means of a double loop suture and a piece of mesh which is sufficiently large to cover the hernia defect with a 5cm overlap of surrounding abdominal wall. The mesh is inserted and secured into position with two rows of tackers inserted concentrically.

ICG angiography in AWR

In this lecture, Dr. Devinder Singh highlights complications related to ventral hernia repair. Skin perfusion zones in the abdominal wall can be healed using a device called SPY Elite. This device allows to perform ICG angiography which can be used in clinical and lab research. Dr. Singh also outlines the ICG safety profile as compared to other dyes available on the market. He describes the use of the SPY Elite device to accurately excise tissues in hernia repair. He also compares postoperative results in different cases with or without the use of the SPY Elite device and GI indications related to the use of this device.

D Singh

ICG angiography in AWR

In this lecture, Dr. Devinder Singh highlights complications related to ventral hernia repair. Skin perfusion zones in the abdominal wall can be healed using a device called SPY Elite. This device allows to perform ICG angiography which can be used in clinical and lab research. Dr. Singh also outlines the ICG safety profile as compared to other dyes available on the market. He describes the use of the SPY Elite device to accurately excise tissues in hernia repair. He also compares postoperative results in different cases with or without the use of the SPY Elite device and GI indications related to the use of this device.

Plastic surgery perspectives on abdominal wall reconstruction

In this lecture, Dr. Singh describes plastic surgery perspectives for abdominal wall reconstruction. He also compares the difference of approach for hernia repair between plastic surgeons and general surgeons. He also briefly describes the incision in different surgeries and their impact on skin perfusion zones with examples of different cases with postoperative complications. Dr. Singh also looks into microvascular surgery and abdominal wall free flap transplantation with regards to clinical outcomes. Finally, he provides a brief overview of tissue expanders used in different cases of abdominal wall repair.

D Singh

Plastic surgery perspectives on abdominal wall reconstruction

In this lecture, Dr. Singh describes plastic surgery perspectives for abdominal wall reconstruction. He also compares the difference of approach for hernia repair between plastic surgeons and general surgeons. He also briefly describes the incision in different surgeries and their impact on skin perfusion zones with examples of different cases with postoperative complications. Dr. Singh also looks into microvascular surgery and abdominal wall free flap transplantation with regards to clinical outcomes. Finally, he provides a brief overview of tissue expanders used in different cases of abdominal wall repair.

Mesh fixation: transfascial sutures, absorbable and non-absorbable peritoneal fixation, glues

In this video, Dr. Morales Conde highlights different techniques for mesh fixation in laparoscopic ventral hernia repair. Factors influencing pain, recurrence and adhesions are also demonstrated. Different techniques and materials to decrease pain and adhesions are outlined. The ideal laparoscopic ventral hernia repair can be achieved by decreasing mechanical fixation and increasing biological fixation to reduce pain and adhesions while preventing recurrence.

Mesh fixation: transfascial sutures, absorbable and non-absorbable peritoneal fixation, glues

In this video, Dr. Morales Conde highlights different techniques for mesh fixation in laparoscopic ventral hernia repair. Factors influencing pain, recurrence and adhesions are also demonstrated. Different techniques and materials to decrease pain and adhesions are outlined. The ideal laparoscopic ventral hernia repair can be achieved by decreasing mechanical fixation and increasing biological fixation to reduce pain and adhesions while preventing recurrence.

Biomaterials in hernia repair: key mesh properties for an optimized performance

In this lecture, Michel Therin provides a brief introduction of biomaterials along with key mesh properties for an optimized surgical hernia repair. He also describes potential clinical outcomes which can be influenced by mesh parameters. He concludes with the properties of the ideal mesh to prevent complications.

Biomaterials in hernia repair: key mesh properties for an optimized performance

In this lecture, Michel Therin provides a brief introduction of biomaterials along with key mesh properties for an optimized surgical hernia repair. He also describes potential clinical outcomes which can be influenced by mesh parameters. He concludes with the properties of the ideal mesh to prevent complications.

Seromas – Avoidance and management in inguinal and ventral hernia repair

In this lecture, Dr. Bruce Ramshaw briefly outlines the main aspects of inguinal seroma prevention. He also addresses the management of large scrotal seroma and postoperative treatments in different cases. He describes chronic seroma and its management to prevent recurrence. He puts forward AWR adaptations in order to eliminate abdominal wall drains, to minimize seromas/hematomas, and to prevent postoperative wound complications.

Seromas – Avoidance and management in inguinal and ventral hernia repair

In this lecture, Dr. Bruce Ramshaw briefly outlines the main aspects of inguinal seroma prevention. He also addresses the management of large scrotal seroma and postoperative treatments in different cases. He describes chronic seroma and its management to prevent recurrence. He puts forward AWR adaptations in order to eliminate abdominal wall drains, to minimize seromas/hematomas, and to prevent postoperative wound complications.

Inguinodynia: prevention and management

In this lecture, Dr. Bruce Ramshaw outlines the main risk factors which contribute to chronic pain in postoperative hernia repair along with means of prevention. The main topics addressed in the presentation include laparoscopic repair which might induce less pain, the choice of the mesh, the location and amount of fixation, and pain management. The technique used to decrease perioperative pain may be useful to prevent chronic pain. He also mentioned the non-operative and operative management of inguinodynia. Complications involved in management and prevention were also demonstrated.

Inguinodynia: prevention and management

In this lecture, Dr. Bruce Ramshaw outlines the main risk factors which contribute to chronic pain in postoperative hernia repair along with means of prevention. The main topics addressed in the presentation include laparoscopic repair which might induce less pain, the choice of the mesh, the location and amount of fixation, and pain management. The technique used to decrease perioperative pain may be useful to prevent chronic pain. He also mentioned the non-operative and operative management of inguinodynia. Complications involved in management and prevention were also demonstrated.

Inguinal hernia: is surgery always necessary?

In this lecture, Dr. Adrian Park demonstrates the main indications of hernia repair surgery and also outlines the pros and cons of a surgical intervention. He looks into the safety of watchful waiting in asymptomatic or minimally symptomatic inguinal hernias and into delaying surgical repair until symptoms increase. He also highlights the technical easiness and benefits of elective interventions versus emergent repairs.

A Park

Inguinal hernia: is surgery always necessary?

In this lecture, Dr. Adrian Park demonstrates the main indications of hernia repair surgery and also outlines the pros and cons of a surgical intervention. He looks into the safety of watchful waiting in asymptomatic or minimally symptomatic inguinal hernias and into delaying surgical repair until symptoms increase. He also highlights the technical easiness and benefits of elective interventions versus emergent repairs.

Laparoscopic repair of ventral hernia in complex locations

In this lecture, Dr. Morales Conde briefly outlines laparoscopic ventral hernia repair in complex locations (including lumbar, suprapubic, subcostal, subxiphoid, and parastomal hernias). He presents technical difficulties and complex anatomy in the lumbar area. The importance of appropriate identification of all nerves for mesh fixation is essential to prevent inguinodynia. The author also develops this identification issue based on the experience of surgeons, taking into account the indications and diagnostic imaging techniques and corresponding defect reconstructions based on anatomical landmarks in order to prevent recurrence and avoid complications.

Laparoscopic repair of ventral hernia in complex locations

In this lecture, Dr. Morales Conde briefly outlines laparoscopic ventral hernia repair in complex locations (including lumbar, suprapubic, subcostal, subxiphoid, and parastomal hernias). He presents technical difficulties and complex anatomy in the lumbar area. The importance of appropriate identification of all nerves for mesh fixation is essential to prevent inguinodynia. The author also develops this identification issue based on the experience of surgeons, taking into account the indications and diagnostic imaging techniques and corresponding defect reconstructions based on anatomical landmarks in order to prevent recurrence and avoid complications.

Focus On Complex Abdominal Wall Reconstruction (CAWR)

special focus dedicated to minimally invasive inguinal and ventral hernia and complex abdominal wall repair (CAWR) surgeries, including authoritative lectures and live surgical demonstrations on different techniques, approaches to hernia repair, prevention and management of inguinodynia, the use of different mesh materials, and postoperative care, all excerpted from the "Minimally Invasive Inguinal - Ventral & CAWR Surgery" IRCAD course, which was held on September 8-9, 2016

Focus On Complex Abdominal Wall Reconstruction (CAWR)

special focus dedicated to minimally invasive inguinal and ventral hernia and complex abdominal wall repair (CAWR) surgeries, including authoritative lectures and live surgical demonstrations on different techniques, approaches to hernia repair, prevention and management of inguinodynia, the use of different mesh materials, and postoperative care, all excerpted from the "Minimally Invasive Inguinal - Ventral & CAWR Surgery" IRCAD course, which was held on September 8-9, 2016