POLSKI PRZEGLĄD CHIRURGICZNY 2014, 86, 7, 350–352
10.2478/pjs-2014-0062
SURGICAL TREATMENT A N D T E CH N I C A L I M P R O V E M E N T S
Umbilical hernia repair with Proceed Ventral Patch Sajad Ahmad Salati, Azzam Al Kadi Qassim College of Medicine, KSA Umbilical hernia is one the commonest surgical lesions and there is a variety of methods available for its repair. Proceed Ventral Patch is a recent and novel innovation in hernia management and we present a successful management of umbilical hernia in a 45 years old obese patient with this technique. Key words: ventral hernia, umbilical hernia, mesh, ventral patch
Umbilical hernia repair is the one of the commonest general surgical operations. Globally a wide range of techniques is used depending on available equipment, skills of the surgical staff and health status of the patient. Ventral patch is a recent addition to this surgical armamentarium. This report presents the successful use of this latest technique for management of an umbilical hernia in a 45 years old female. Case report A 45 years old female reported with a history of swelling in the umbilical area of two years duration. The swelling would disappear when the patient lies down and appear only, when patient is erect. The patient would only feel mild ache (Visual analogue scale for pain score: 3-4/10). There was no other past medical or surgical history of significance. She had history of four full term normal deliveries. On examination, the patient was obese (weight: 86 kg, BMI: 34.1) and there was a wide shallow umbilicus (fig 1A) with reducible hernia about 3.5 x 2.5 cm. Baseline laboratory parameters including complete blood count, blood sugar and coagulation profile were within normal limits. The patient was counselled and various options of hernia repair were explained includ-
ing Proceed TM Ventral Patch ( EthiconJohnson & Johnson). Proceed TM Ventral Patch was selected and patient was operated upon under general anaesthesia. The hernia sac was dissected (fig. 1B) and the contents were reduced and the redundant portion of the sac excised. The hernia defect was found to be about 1.5 cm in size. The defect was closed after fixing the ventral patch (4.3 x 4.3 cm) in the pre-peritoneal space (fig. 1C-E). There were no postoperative complications and there were no features suggestive of hernia recurrence at 18 months of follow up. The patient was satisfied with the outcome. Discussion Umbilical hernia is one of the commonest surgical disorders with a prevalence of about 2% in adult population (1). The disease is reported to be about 5 times more common in females and multiparity and obesity are considered to be important etiological factors (2). There are numerous methods of hernia repair ranging from simple suture repair to complex laparoscopic hernioplasty. Each method has its merits and demerits. While suture herniorrhaphy is associated with high recurrence rates, the laparoscopic techniques Unauthenticated Download Date | 12/29/16 2:36 PM
Umbilical hernia repair with Proceed Ventral Patch
351
Fig. 1. (A) wide, shallow umbilicus with reduced hernia, (B) hernia after dissection, (C) Proceed Ventral Patch, (D) Ventral Patch after placement under the hernia defect, (E) Ventral Patch after fixation, (F) repair after excision of redundant flanges and approximation of hernia defect margins
need sophisticated setup. Open mesh repair is the middle pathway and currently more than 200 meshes are available in market and the current literature supports the hypothesis that patient characteristics need to be carefully matched to choice of prosthetic if the goal of minimization of complications, readmissions, and the number of postoperative office visits is to be achieved (3). Ventral patch is a recent innovation in the field of ventral hernia repair. This Ventral Patch by design is sterile, light weight, selfexpanding, partially absorbable, flexible laminate mesh prosthesis. It is a large pore monofilament mesh comprised of multiple layers of absorbable and non-absorbable materials, laminated together with an absorbable polydioxanone polymer. The patch has a central disc and two flanges with threads (fig. 1C). The central disc is negotiated through hernia defect and fixed in intra/extra-peritoneal plane with the help of flanges. After fixation, the excess portion of flanges is excised and hernia defect approximated. Only a few series have been published on this subject of use of ventral patch for hernia management. Ambe P et al presented a single center experience of fifty-seven patients with small and medium size ventral hernias treated with ventral patches in the period between
May 2009 and December 2010 and found hernia repair with this technique to be safe and effective (4). The hernia treated by Ambe et al. (4) included thirty-six umbilical, eight epigastric, seven incisional and six recurrent umbilical hernias. The mean duration of surgery was remarkably low i.e., only 30.7 minutes and there was only one hernia recurrence. Bontinck et al in 2013 recommended using the ventral patch only for primary ventral hernias smaller than 2 cm after finding that the hernia defect size was the most important factor determining the outcome of hernia repairs with ventral patch (5). To conclude, ventral patch promises to be an effective means of management of ventral hernia of smaller sizes without demerits of aggressiveness of laparoscopic hernioplasty or frequent recurrences of simpler methods like suture herniorrhaphy. This conclusion has also been stressed by Tollens et al. in his study (6).
Acknowledgement The authors express gratitude to the patient for allowing the use of case history and images for academic purposes including publication in medical journals. Unauthenticated Download Date | 12/29/16 2:36 PM
352
S. A. Salati, A. Al Kadi
references 1. Velasco M, Garcia-Urena MA, Hidalgo M et al.: Current concepts on adult umbilical hernia. Hernia 1999; 3(4): 233-39. 2. Dabbas N, Adams K, Pearson K, Royle GT: Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011 January; 2(1): 5. Published online 2011 January 19. doi: 10.1258/shorts.2010.010071 3. Le D, Deveney CW, Reaven NL et al.: Mesh choice in ventral hernia repair: so many choices, so little time. Am J Surg 2013; 205(5): 602-07 discussion 607. doi: 10.1016/j.amjsurg.2013.01.026. 4. Ambe P, Meyer A, Kohler L: Repair of small and medium size ventral hernias with a Proceed Ventral
Patch: a single center retrospective analysis. Surg Today 2013; 43(4): 381-85. doi: 10.1007/s00595-0120245-2. 5. Bontinck J, Kyle-Leinhase I, Pletinckx P et al.: Single centre observational study to evaluate the safety and efficacy of the Proceed Ventral Patch to repair small ventral hernias. Hernia 2013 Jul 24 (Epub ahead of print). DOI: 10.1007/s10029-0131140-5. 6. Tollens T, Struyve D, Aelvoet C, Vanrijkel JP: Introducing the Proceed Ventral Patch as a new device in surgical management of umbilical and small ventral hernias: preliminary results. Surg Technol Int 2010; 19: 99-103.
Received: 18.02.2014 r. Adress correspondence: Qassim College of Medicine, Arabia Saudyjska e-mail: [email protected]
Unauthenticated Download Date | 12/29/16 2:36 PM
10.2478/pjs-2014-0062
SURGICAL TREATMENT A N D T E CH N I C A L I M P R O V E M E N T S
Umbilical hernia repair with Proceed Ventral Patch Sajad Ahmad Salati, Azzam Al Kadi Qassim College of Medicine, KSA Umbilical hernia is one the commonest surgical lesions and there is a variety of methods available for its repair. Proceed Ventral Patch is a recent and novel innovation in hernia management and we present a successful management of umbilical hernia in a 45 years old obese patient with this technique. Key words: ventral hernia, umbilical hernia, mesh, ventral patch
Umbilical hernia repair is the one of the commonest general surgical operations. Globally a wide range of techniques is used depending on available equipment, skills of the surgical staff and health status of the patient. Ventral patch is a recent addition to this surgical armamentarium. This report presents the successful use of this latest technique for management of an umbilical hernia in a 45 years old female. Case report A 45 years old female reported with a history of swelling in the umbilical area of two years duration. The swelling would disappear when the patient lies down and appear only, when patient is erect. The patient would only feel mild ache (Visual analogue scale for pain score: 3-4/10). There was no other past medical or surgical history of significance. She had history of four full term normal deliveries. On examination, the patient was obese (weight: 86 kg, BMI: 34.1) and there was a wide shallow umbilicus (fig 1A) with reducible hernia about 3.5 x 2.5 cm. Baseline laboratory parameters including complete blood count, blood sugar and coagulation profile were within normal limits. The patient was counselled and various options of hernia repair were explained includ-
ing Proceed TM Ventral Patch ( EthiconJohnson & Johnson). Proceed TM Ventral Patch was selected and patient was operated upon under general anaesthesia. The hernia sac was dissected (fig. 1B) and the contents were reduced and the redundant portion of the sac excised. The hernia defect was found to be about 1.5 cm in size. The defect was closed after fixing the ventral patch (4.3 x 4.3 cm) in the pre-peritoneal space (fig. 1C-E). There were no postoperative complications and there were no features suggestive of hernia recurrence at 18 months of follow up. The patient was satisfied with the outcome. Discussion Umbilical hernia is one of the commonest surgical disorders with a prevalence of about 2% in adult population (1). The disease is reported to be about 5 times more common in females and multiparity and obesity are considered to be important etiological factors (2). There are numerous methods of hernia repair ranging from simple suture repair to complex laparoscopic hernioplasty. Each method has its merits and demerits. While suture herniorrhaphy is associated with high recurrence rates, the laparoscopic techniques Unauthenticated Download Date | 12/29/16 2:36 PM
Umbilical hernia repair with Proceed Ventral Patch
351
Fig. 1. (A) wide, shallow umbilicus with reduced hernia, (B) hernia after dissection, (C) Proceed Ventral Patch, (D) Ventral Patch after placement under the hernia defect, (E) Ventral Patch after fixation, (F) repair after excision of redundant flanges and approximation of hernia defect margins
need sophisticated setup. Open mesh repair is the middle pathway and currently more than 200 meshes are available in market and the current literature supports the hypothesis that patient characteristics need to be carefully matched to choice of prosthetic if the goal of minimization of complications, readmissions, and the number of postoperative office visits is to be achieved (3). Ventral patch is a recent innovation in the field of ventral hernia repair. This Ventral Patch by design is sterile, light weight, selfexpanding, partially absorbable, flexible laminate mesh prosthesis. It is a large pore monofilament mesh comprised of multiple layers of absorbable and non-absorbable materials, laminated together with an absorbable polydioxanone polymer. The patch has a central disc and two flanges with threads (fig. 1C). The central disc is negotiated through hernia defect and fixed in intra/extra-peritoneal plane with the help of flanges. After fixation, the excess portion of flanges is excised and hernia defect approximated. Only a few series have been published on this subject of use of ventral patch for hernia management. Ambe P et al presented a single center experience of fifty-seven patients with small and medium size ventral hernias treated with ventral patches in the period between
May 2009 and December 2010 and found hernia repair with this technique to be safe and effective (4). The hernia treated by Ambe et al. (4) included thirty-six umbilical, eight epigastric, seven incisional and six recurrent umbilical hernias. The mean duration of surgery was remarkably low i.e., only 30.7 minutes and there was only one hernia recurrence. Bontinck et al in 2013 recommended using the ventral patch only for primary ventral hernias smaller than 2 cm after finding that the hernia defect size was the most important factor determining the outcome of hernia repairs with ventral patch (5). To conclude, ventral patch promises to be an effective means of management of ventral hernia of smaller sizes without demerits of aggressiveness of laparoscopic hernioplasty or frequent recurrences of simpler methods like suture herniorrhaphy. This conclusion has also been stressed by Tollens et al. in his study (6).
Acknowledgement The authors express gratitude to the patient for allowing the use of case history and images for academic purposes including publication in medical journals. Unauthenticated Download Date | 12/29/16 2:36 PM
352
S. A. Salati, A. Al Kadi
references 1. Velasco M, Garcia-Urena MA, Hidalgo M et al.: Current concepts on adult umbilical hernia. Hernia 1999; 3(4): 233-39. 2. Dabbas N, Adams K, Pearson K, Royle GT: Frequency of abdominal wall hernias: is classical teaching out of date? JRSM Short Rep. 2011 January; 2(1): 5. Published online 2011 January 19. doi: 10.1258/shorts.2010.010071 3. Le D, Deveney CW, Reaven NL et al.: Mesh choice in ventral hernia repair: so many choices, so little time. Am J Surg 2013; 205(5): 602-07 discussion 607. doi: 10.1016/j.amjsurg.2013.01.026. 4. Ambe P, Meyer A, Kohler L: Repair of small and medium size ventral hernias with a Proceed Ventral
Patch: a single center retrospective analysis. Surg Today 2013; 43(4): 381-85. doi: 10.1007/s00595-0120245-2. 5. Bontinck J, Kyle-Leinhase I, Pletinckx P et al.: Single centre observational study to evaluate the safety and efficacy of the Proceed Ventral Patch to repair small ventral hernias. Hernia 2013 Jul 24 (Epub ahead of print). DOI: 10.1007/s10029-0131140-5. 6. Tollens T, Struyve D, Aelvoet C, Vanrijkel JP: Introducing the Proceed Ventral Patch as a new device in surgical management of umbilical and small ventral hernias: preliminary results. Surg Technol Int 2010; 19: 99-103.
Received: 18.02.2014 r. Adress correspondence: Qassim College of Medicine, Arabia Saudyjska e-mail: [email protected]
Unauthenticated Download Date | 12/29/16 2:36 PM
