In open surgery, the size of the incision may be a concern, while in laparoscopic technique the cost of the mesh may be a concern - how does one balance this option?
2 or less than 2cms defect open repair with an incision in the umbilical crease gives good cosmetic result.Recurrence is a possibility without a mesh .Larger than 2cm defect Lap mesh repair is a better option.Simple,takes more or less same time,pain is more or less same,recurrence is less,early return to work but it comes with a cost .
Yes i do agree for small defects/hernia an open technique would be a more attractive option-but do you place a mesh through a 2cm or less incision by using the open technique do you just do an anatomical suture repair.
In those cases "size" and "previous history" does matter. Laparoscopic approach should be a consider for larger hernias (in my opinion exceeding 4 cm) and recurrence hernias. We should also consider patient size, too. In obese patients the benefit of laparoscopic repair is even bigger in smaller hernias.
Is there any evidence available for the open repair of umbilical hernias using mini-incision with or without mesh.
My teacher in surgery often said "umbilical hernia surgery is preparatory to incisional surgery". I usually avoid to perform direct repair of umbilical hernia. In smaller, i prefer direct access, and implant of a stamp size mesh. In larger i think that the best technique is single port laparoscopic repair
The mesh may need to extend a few cm beyond the edges of the defect
Any hernial defect more than 2 cm needs mesh for repair. In my opinion, these cases can be done via laparoscopy. Meshless repairs are best treated via open method
I feel both procedures are good but in developing countries where cost in important i would recommend open surgery for umbilical and small paraumbilical hernia.
I have been doing open repair for over 15 years mostly under local anaesthesia. Never regretted it to date. In children suture repair, in adults always a mesh repair . It is logical if we use tension free repair in inguinal hernia then why should it be tension repair in umbilical hernia. I would do laparoscopic repair only for defects more than 4cm because of unnecessary expense and there is not much else to gain.
Raj
In small defects an anterior properitoneal repair using polypropylene mesh is a safe and cheap technique. In defects larger of 4 centimeters laparoscopic way represents the gold standard. Some prosthetic devices are indicated when the peritoneum layer is not well definite, but I have had some cases of prosthetic infection using two of this devices, furthermore they are very expensive.
I feel hernias over 4 cm are best repairs laparoscopically. 2-4 open and if necessary one can use Ventral patch mesh which I believe are available to 6.5 cm and are designed to be used intraperitoneally. As I do a lot of these under local anaesthesia in high risk cases, I have found them to be a valuable prosthesis. Expensive but way less than laparoscopic approach and also can be used under Local anaesthesia .
yes very true i agree with Dr R. Bhutiani ,Dr KHALID GONDAL and Dr Giorgio Vasquez. . However i would like to know if there are any published reports on technique and advantages of open umbilical hernia repair or gold standard repair for umbilical hernia.Because the textbooks mention mayo's repair as effective-but these incur larger insicions and laparoscopic surgery incur higher costs---so is there something inbetween ---small insicion and low cost ???
Thank you dear dr snoop, I feel umbilical and small paraumbilical hernia have usually defect around 1cm ,and open technique can be used with 3cm to 4cm incision and with low cost.in our public sector hospital on an average 2 to 3 cases are done weekly and finances are an issue .we feel comfortable with open technique .
International guidelines stated that ventral defects (primitive or postincisional) measuring less than 2-3 cm should not be treated by the laparoscopic route (defects comparable to those of the trocars). Therefore, the open repair is mandatory in such cases. However, a piece of mesh could reduce the incidence of recurrences in any case, and an attempt of positioning some piece of reinforcement should be carried out even under local anaesthesia (plug, disk etc). If the hernia is larger, a metanalysis from the Cochrane reported excellent result (superior in the short-medium period) for the laparoscopic repair as compared to the open repair. Laparoscopic umbilical repair is also be considered such as an excellent indication during the learning curve. Lastly, the presence of concomitant surgery should be taken into consideration (i.e: lap chole, colon surgery, etc).
I do agree with LB, any ventral hernia defect 2cm or less are ideally treated by o.pen repair(sages guidelines).Lap is good with wide coverage of the defect for defects above 2cm.Open crease incision gives good cosmetic result but covering with onlay
small piece of mesh will not serve the purpose.
I do agree with Dr Prasanna Reddy and Dr Lapo Bencini.however if a mesh is to be placed what would be the ideal overlap required for open umbilical hernia repair.
In open repair at least 2cm to 3cm to prevent the recurrence when the mesh shrinks.In lap repair my personal preference is wider coverage as I donot close the defect.
As mesh shrinkage is common and migt go up to 30% an overlap of 4 cm is necessary to avoid recurrence.
For small size hernias,I think that anterior properitoneal repair using polypropylene mesh is a safe technique with reasonably cosmetic effects and a low cost. If the size of the defect is larger than 5-6 centimeters laparoscopic approach seems better at least for cosmetic considerations. The problem arises from the high costs of the prosthetic dual layer materials that are necessary for intraperitoneal repair. So, I think that is correct for our patients to present both options and to let them to choose regarding the cost of surgery, the cosmetic effect and the time for returning to normal activity.
I do agree with you. Smaller hernias below 4 can should be repaired by conventional open mesh repair. This follows international guidelines. From my personal experiences and publish data lap approach does give even more benefit to obese patients as it it associated with lower incidence of infection. Also I prefer defect closure as it is reducing risk of seroma formation and giving better cosmetic effect.
Two italian consensus conference confirms the superiority of laparoscopic approach vs laparotomic approach in terms of incidence of wound infenction and shorter hospital stay also for large hernias (more than 10cm). Same incidence of recurrences.
In my practice I tend to repair significant majority of Umbilical hernias under LA and open with a mesh placed extraperitoneally. If however the peritoneum gets opened or has to be opened to reduce any adherent contents, then I use a Ventral patch intraperitoneal mesh but placed from out side. I have been lucky in that I have had one wound infection in over 15 years. Frankly I have not seen any true Umbilical hernia over 5-6 cm for the last 10 years or so. I am wondering if the large herniae are either port site herniae or even ventral herniae being considered as Paraumbilical hernia. May be the large true Umbilical hernia are not that common in UK.
Recently Dr. S Baydo presented this cosmetic option similar to Culdolaparoscopy.
Colpotomy entrance in Culdolaparoscopy
10th International Congress & Endo Expo. December 2001
JSLS. 2001,5;326
New York, NY
I agree smaller hernias primary repair. Mostly open repairs. I feel that by the time you have tacked a mesh into the abdominal wall that lap repairs are more painful than open
I prefer open mesh repair in most cases. Laparoscopic hernia repairs are perfect for bigger or reccurent hernias. Age, complications must be taken into account, too. In children only natural tissues repairs with good results.
SAGES guide lines suggest 2 to 3 cms defects open anatomical repair,larger than that Lap is preferable with with wide coverage of mesh 3 to 5 cms beyond the defect.
I agree that small hernias pain, cost and overall risk of surgery all favour open repair
Open done as a day case majority can be under local anaesthesia even in patients with comorbidities ones scar under the belly button which too fades away to almost invisible.
Many of patients in iraq present with large multi locular paraumbilical hernia with crowded adherent contain . Is it easy to manage by minimal invasive techniques or by LA ?
There is no best for all, we have to deal with the skin, that stay after repair, as well the opportunity of abdominoplasty.
Azzawi Hadi,
Looking at the picture and the pot-belly protuberant abdomen, I personally feel that an open surgical procedure of panniculectomy with abdominoplasty should be better than laparoscopic attempt. There is a misuse of technology in bigger centres under the guise of scientific advancement but they actually promote industry than science. There are lot of other personal issues that are better not discussed here. Lot of vested commercial interests may be involved. Western industrialists use such gullible sources in developping and under-developped nations.
Agree with you. People in West have forgotten,” just because you can do it does not mean you should do it”
Putting the mesh sublay is the most important issue, whether laparoscopy or open. Personally I prefer open for paraumbilcal hernia
Reliable repair e-MILOS, but a skin problem with large umbilical hernias
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