By Christina Frangou
Orlando, Fla.—When Karl LeBlanc, MD, MBA, FACS, a private practice general surgeon in Baton Rouge, La., performed the world’s first laparoscopic ventral hernia repair in 1991, he aimed for a mesh overlap of about 1 cm.
Twenty years later, he shakes his head at the notion of a 1-cm overlap. A growing body of evidence suggests that a larger mesh overlap, along with symmetrical placement of the mesh, result in far fewer hernia recurrences, Dr. LeBlanc said at the 15th Annual Hernia Repair Meeting.
“Increasingly, we’re looking at the more overlap, the better, when it comes to recurrence,” said Dr. LeBlanc, who has amassed one of the largest volumes of laparoscopic ventral and incisional hernia repairs in the world, with a total of more than 1,200 cases.
At the meeting, Dr. LeBlanc said that currently, he believes that an overlap of 5 cm or more is optimal. He extends the overlap to as much as 8 cm in patients who are obese, who have several prior recurrences or who have hernias unusually high or low in the abdominal cavity. “The algorithm I have in my head is the bigger the defect and the more comorbidities, the more overlap you need,” he said.
Over the past decade, it has become standard practice for surgeons to recommend a mesh overlap of at least 3 to 5 cm on all sides surrounding the defect. However, sparse robust data exist to back this up, so Dr. LeBlanc set out to evaluate this recommendation along with other technical factors that may affect the outcome of laparoscopic incisional and ventral hernia repairs.
He reviewed the PubMed and Cochrane Library scientific databases for the years 1992 to 2012, looking at all technical failures leading to hernia recurrence.
Overall, the review found little high-quality evidence that focused on technical reasons for repair failures. Of 111 articles that addressed technical issues in hernia repairs, the vast majority overlooked the question: Only 16 of them adequately assessed the effect of mesh overlap. In these studies, recurrence rates ranged from 9% to 14.3% when mesh overlapped by 2 to 3 cm. Recurrences dropped substantially to between 0% and 7% with mesh overlap of at least 3 to 5 cm. The studies included about 3,500 patients with an average of 25.5 months of follow-up and a mesh overlap of 2 to 5 cm.
In one of the largest reported series, an overlap of between 2 and 2.25 cm was associated with a recurrence rate of 9%. Recurrences dropped to 2% with an overlap of 4 cm or greater (JSLS 2008;12:51-57).
“What we’re seeing is that increasing the overlap of the fascial defect to between 3 and 6 cm results in decreasing the recurrence rate by at least half,” Dr. LeBlanc said.
Asymmetrical placement of the mesh was another contributing factor to recurrences, according to the literature review. Two studies linked failed repairs to inaccurate centering of the mesh or inadequate overlap on one side.
Experts noted that the quality of the published studies in hernia surgery is “notably weak,” with a lack of grade A evidence and little uniformity across the published studies.
Maciej Smietanski, MD, PhD, a hernia surgeon at the Medical University of Gdansk in Poland, said the report underscores a very important issue in hernia surgery, “that mesh overlap and the right positioning are the key factors for success.”
Dr. LeBlanc offered surgeons some technical tips to improve mesh placement in laparoscopic hernia repair. Surgeons must carefully measure both the defect and the mesh prior to surgery, and they should dissect any fat that could come in contact with the mesh.
Dr. LeBlanc also recommended that surgeons place a camera on both sides of the abdomen to assess both sides of the mesh. He said that he places sutures on two axes of the mesh prior to placement in order to help with mesh placement. “You put the mesh in, then pull one side of the suture up and then the other suture up so you know it’s centered superiorly and inferiorly,” Dr. LeBlanc said. He also said new mesh-positioning devices such as the Echo PS™ by Davol Inc., and AccuMesh™ Positioning System by Covidien, can help with accurate placement.
The conclusions of the review were similar to those in a retrospective study published last year in the Journal of Surgical Research (2012;177:e7-e13). Investigators from Baylor College of Medicine reviewed the outcomes of 201 patients who underwent laparoscopic ventral hernia repair between 2000 and 2010. They said potential solutions to the problem of mesh shift include increasing mesh overlap to 6 cm or greater, transcutaneous closure of central defect, securing transfascial sutures before tacking, placing operative side tacks first, and possible placement of contralateral ports to secure the mesh.
Dr. LeBlanc is a speaker/consultant for Covidien, Davol Inc., and W.L.Gore & Associates. He also has received a research grant from Cousin Biotech Inc.,/Medline and is a shareholder in Via Surgical Ltd.