Outcomes of laparoscopic ventral hernia repair with routine defect closure using “shoelacing” technique

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Abstract
Laparoscopic approach has become standard for many ventral hernia repairs. The benefits of minimal access include reduced wound complications, faster functional recovery, and improved cosmesis, among others. However, “bridging” of hernia defects during traditional laparoscopic ventral hernia repair (LVHR) often leads to seromas or bulging and, importantly, does not restore a functional abdominal wall. We have modified our approach to LVHR to routinely utilize transabdominal defect closure (“shoelacing” technique) prior to mesh placement. Herein, we aim to analyze outcomes of LVHR with shoelacing. Consecutive patients undergoing LVHR with shoelacing were reviewed retrospectively. Main outcome measures included patient demographics, previous surgical history, intraoperative time, mesh type and size, postoperative complications, length of hospitalization, and hernia recurrence. Forty-seven consecutive patients underwent LVHR with defect closure. Average body mass index (BMI) was 32 kg/m2 (range 22–50 kg/m2). Eighteen (38%) patients had an average of 1.5 previous repairs (range 1–3). Mean defect size was 82 cm2 (range 16–300 cm2), requiring a median of 4 (range 2–7) transabdominal stitches for shoelacing. Two patients required endoscopic component separation to facilitate defect closure. Mean mesh size used was 279 cm2 (range 120–600 cm2). Mean operative time was 134 min (range 40–280 min). There were no intraoperative complications. Average length of hospitalization was 2.9 days (range 1–10 days). There were two major postoperative complications [one pulmonary embolism (PE), one stroke]; however, there was no wound-related morbidity or significant seromas. At mean follow-up of 16.2 months, there have been no recurrences. LVHR with defect closure confers a strong advantage in hernia repair, shifting the paradigm towards more physiologic abdominal wall reconstruction. In this series, we found our approach to be safe and comparable to historic controls. While providing reliable hernia repair, the addition of defect closure in our patients essentially eliminated postoperative seroma. We advocate routine use of the shoelace technique during laparoscopic ventral hernia repair.