Incisional Hernia + Mesh+Lap TEP/TAPP

Question 1

Classification of Incisional hernia

Answer 1

The recurrence rate after laparoscopic repair of a recurrent hernia ranges between
9% and 12%, which is an improvement when
compared with recurrence rates of 20% after conventional repair with prosthetic material

Question 2

Material of Mesh

Answer 2

• Material used for mesh manufacturing can be classified into two classes: synthetic and biologic.
• Synthetic meshes can be either permanent or degradable, while all biologic meshes are degradable.
• Permanent mesh is currently made of either:
• polypropylene
• polyethylene terephthalate polyester,
• expanded polytetrafluoroethylene.
  Permanent mesh is durable and of relatively low cost
• Degradable synthetic mesh, including Vicryl mesh, is eventually eliminated and loses structural support, but it does offer the advantage of lower mesh infection rates.
• Degradable mesh is associated with high recurrence rates, but it can be used for temporary abdominal wall closure in contaminated or infected fields.
• Pore size and mesh weight are also important aspects of mesh design.
  Such heavy- weight meshes induce a significant inflammatory reaction and ensure exaggerated fibrotic response, leading to mesh contraction and excessive hardening of the mesh and surrounding tissues which can lead to chronic pain symptoms

Question 3

Newer type of Mesh
( Synthetic Biomaterial mesh)

Answer 3

• Newer synthetic biomaterial meshes, including Gore BioA or Phasix, degrade over a longer period of time and may reduce recurrence rates, but long-term effectiveness is unknown.
• Biologic meshes are decellularized, collagen-rich porcine, bovine, or human tissue.
• These meshes are designed to allow host cellular ingrowth, promoting incorporation and eventual replacement of the mesh with host tissue.
• Biologic meshes are a high cost alternative to synthetic degradable mesh and can be used in infected fields. However, their efficacy in preventing recurrence is unclear.
  - Biologic meshes are expensive and studies suggest that there is a high risk of recurrent IH when they are used (>50% after 3 years)

Question 4

Open mesh repair of incisional hernias

Answer 4

• The open retrorectus (e.g. Rives–Stoppa repair) has become the gold standard repair technique for large midline hernias.
• It should be noted that mesh shrinkage occurs in all synthetic prosthesis (polypropylene 3.6%–25.4%, expanded polytetrafluorethylene 4%–51%, polyester 6.1%–33.6%), therefore many authors advise to aim for a 5 cm overlap of mesh and native abdominal wall when repairing large incisional hernias.

However, this may be unachievable when performing a sublay approach away from the midline, and the linea semilunaris may limit the lateral extent of the mesh placement when utilizing a retro-muscular technique

Question 5

Management of Complex incisional hernia

Answer 5

• Where there is a very large defect, or where there has been significant contamination, it may not be possible to close the abdominal wall primarily and obtain adequate opposition of the tissues.
• In such circumstances, bridging the defect with a mesh (synthetic or biologic) often results in poor outcomes.
• Consequently, there may be a need to employ a component separation technique (CST) or transversus abdominis release (TAR).
• Transversus abdominis is divided to gain access to the retro-muscular space and a mesh can then be placed in the extraperitoneal plane.
• Such techniques allow the closure of defects >30 cm in diameter.
• In extreme circumstances, tissue expanders (placed between external oblique and transversus abdominis muscles) and autodermal grafts may be employed as a substitute for fascia to bridge remaining defects.

Question 6

What is the recurrence rate with CST + mesh ?

Answer 6

When mesh is added to component separation, recurrence rates may be as low as 4% to 10% depending on follow up period. (Schwartz)

Question 7

Types of Femoral hernia repair

Answer 7

The diagram shows three types of approaches:

1.	Infrainguinal Approach: Also known as Lockwood’s approach, this is performed below the inguinal ligament.
2.	Transinguinal Approach: Known as Lotheissen’s approach, it involves an incision through the inguinal canal.
3.	High Approach: Also known as McEvedy’s approach, this is performed with a higher incision, above the inguinal ligament.

Question 8

How mesh works

Answer 8

• Encourages Tissue Integration: Over time, the body’s tissues grow into the mesh, creating a more natural and robust repair. This is known as mesh incorporation, where the mesh becomes integrated with the abdominal wall tissue, providing strength and stability.

Question 9

Differences between lap TAPP and TEP

Answer 9

Pros & Cons Summary

TEP – Pros:
* 🚫 No peritoneal entry → less risk of bowel injury & adhesions
* 🛌 Less post-op pain
* ✅ Good for primary, unilateral hernias

TEP – Cons:
* ⛰️ Steeper learning curve
* 👁️ Limited exposure
* 💨 Risk of emphysema

⸻

TAPP – Pros:
* 👁️ Better anatomical view
* ♻️ Suitable for bilateral or recurrent hernias
* 🛤️ Easier learning curve

TAPP – Cons:
* ⚠️ Risk of bowel injury, adhesions
* 😣 Possibly more post-op pain
* ✅ Need to close peritoneum