Safety and feasibility of concomitant ventral hernia repair and total laparoscopic hysterectomy: A single-centre experience of over 1000 cases.

Laparoscopic hysterectomy was first performed in the year 1989 and since then has gradually emerged to be the procedure of choice compared to the open approach. Although vaginal hysterectomies can also be performed with fairly similar outcomes, laparoscopy has its advantages, that it can be performed even in cases where vaginal hysterectomy cannot be performed.[ 1 ] In 1992, laparoscopic ventral hernia repair was first reported, and since its inception, it has been widely practiced worldwide with various different procedures being introduced.[ 2 ] These include intraperitoneal onlay meshplasty (IPOM) to enhanced totally extraperitoneal (eTEP) repairs. IPOM, introduced by Karl Leblanc in 1993, is easily reproducible and can be performed for almost all ventral hernias.[ 3 4 ] Concomitant surgery combining hernia repair with hysterectomy combines the advantages of getting both surgeries done in a single setting; however, this is considered controversial by many due to the placement of a mesh in a clean-contaminated environment. There are several instances in the literature where it has proven to be safe to combine a hernia repair with a clean-contaminated surgery such as total laparoscopic hysterectomy (TLH), cholecystectomy and bariatric surgery.[ 5 6 7 8 9 10 11 ] In this article, we studied retrospectively the safety of placing a mesh (IPOM) along with a TLH from a single-centre experience with over 1000 cases in 15 years.

A total of 1058 patients who satisfied our inclusion and exclusion criteria were analysed. The types of hernias are classified in detail as mentioned in Table 1 . Defects were closed in all the cases with nonabsorbable sutures (1-loop polyamide or 1 PBT) intracorporeally. A composite mesh (Proceed or Parietex) was used in all the cases. The mesh was fixed with transfascial and interrupted intracorporeal sutures in all cases. Mesh fixation devices were used whenever the mesh size exceeded 20 cm. The mean age of the patients was 48.23 years, with a SD of 2.19. The mean BMI was 33.21 kg/m 2 , with an SD of 1.83. The mean defect size was 5.8 cm, with an SD of 1.65. The mean operating time was 231 min, with an SD of 10.15. The mean duration of hospital stay was 3.2 days, with an SD of 0.84 [ Table 2 ]. There were no cases of 30-day readmission or mortality. Fifty-two patients (4.9%) had seromas in the post-operative period. Of those, only 18 (1.7%) warranted aspiration, which did not resolve spontaneously. We had only one case (0.094%) of mesh infection, which presented with abdominal pain and persistent low-grade fever after evaluation and underwent mesh explanation. There was no open conversion [ Table 3 ]. Classification of hernias Demographic, pre-operative, intraoperative and post-operative characteristics BMI: Body mass index, SD: Standard deviation Post-operative complications Two patients experienced recurrence (0.189%), one of whom underwent open repair after 24 months and the other of whom underwent eTEP repair 32 months after the initial surgery. Both patients were followed up at least 1 year after the second procedure.

Meshes can be safely placed in a clean-contaminated environment alongside TLH. This has the advantage of combining two surgeries in one Setting, hence avoiding additional surgeries. However, this requires proper surgical expertise in both the fields of laparoscopic surgery. There are no conflicts of interest.

In comparison with men, women are 3%–5% more susceptible to develop ventral hernias during their lifetime mostly due to obesity and multiparity.[ 16 17 ] Incisional hernias are found to be more common in females than in males for similar reasons.[ 18 ] Any hernias, if not operated, early can lead to an array of complications, such as obstruction, incarceration and even strangulation. In a study conducted on 5 years watchful waiting as an alternative to surgery, there was a 16% probability of the patients with umbilical hernia requiring surgery and a 4% chance of requiring emergency surgery.[ 19 20 ] There were instances in the literature where cases of spontaneous rupture of the hernia leading to evisceration have been reported, although this has been very rare.[ 21 22 ] Performing an anatomical repair for hernias where TLH is planned is a safer option but just involves approximating the defect without mesh placement, which is not sufficient in most cases. They can lead to the recurrence of hernias in the future, as shown in a study conducted by Shah et al ., in which the recurrence rate was approximately 22.22% if only anatomical repair was performed over a follow-up period of 2.5 years.[ 23 ] In addition, extensive research was conducted by Katzen et al . where they concluded that the long-term recurrence rate after anatomical repair for small umbilical hernias (<1 cm) is 7.5%.[ 24 ] Concomitant surgery is not a new concept in the field of minimally invasive surgery; however, controversy remains in regard to combining mesh repair with clean-contaminated surgery, such as TLH.[ 5 ] There are many reports justifying the safety of this approach including a few of our studies where we established the safety of concomitant hernia repair along with clean-contaminated procedures such as TLH, cholecystectomy and bariatric surgeries including gastric bypass.[ 9 10 11 ] Staged procedures where only TLH was performed in the first sitting with subsequent hernia repair later, although considered safe, have their disadvantages, which include exposing the patient to anaesthesia multiple times, increasing the duration of hospital stay and its associated cost. There is always the possibility of hernia-related complications such as obstruction or strangulation, which can occur in the interval period and can increase morbidity.[ 9 ] Other options, such as performing just an anatomical repair in combination with TLH as discussed previously, are also safe but have high chances of recurrence, leading to additional surgical procedures.[ 9 23 24 ] The third option is to initially perform IPOM, followed by TLH at a later time. However, the indication for TLH remains and performing any surgery after a mesh placement presents additional challenges. Therefore, performing TLH and IPOM repair simultaneously mitigates all the potential complications previously mentioned. The primary reason for any surgeon to hesitate to place a mesh in a clean-contaminated environment is the risk of mesh infection. Many hypotheses exist concerning the safety of keeping the mesh in a cleanly contaminated field. A study conducted by Cozacov et al . revealed that peritoneal cultures after clean-contaminated surgeries were negative for lap sleeve gastrectomy and approximately 15% positive for lap Roux-en-Y gastric bypass (RYGB).[ 25 ] However, many studies, including our study on combining clean-contaminated surgeries such as bariatric procedures (including RYGB) with IPOM Plus, have shown no evidence of mesh infections.[ 10 26 27 ] Dunn et al . have highlighted the importance of these protective mechanisms in animal studies.[ 28 ] The role of peritoneal cultures can be partially attributed to the immune response of the peritoneum, which involves three primary cell systems: macrophages, lymphocytes and mesothelial cells. Macrophages, typically found in concentrations of about 5 × 10 5 –10 6 /mL in the peritoneum, are regarded as the first line of defence against microorganisms in this area.[ 29 ] In addition, mesothelial cells play a role in recruiting leukocytes, thereby aiding the immune response by producing cytokines and chemokines such as interleukin-1α and interleukin-1β.[ 30 ] Another mechanism for clearing bacteria from the peritoneal cavity is diaphragmatic lymphatic absorption.[ 28 ] All the mechanisms described above are the possible hypotheses which could explain the absence of increased mesh infection even when placed in a clean-contaminant environment. The duration of hospital stay was relatively short in our series (3.2 days) compared with a few other studies in the literature (3.46 and 4 days).[ 31 32 ] The incidence of post-operative complications such as seroma was approximately 4.9% in our series, whereas in other published reports, it was 28.9% and 25%, respectively.[ 31 33 ] This could possibly due to the mandatory sac excision and approximation of the defects in our cases. In our series, only one patient had mesh infection (0.094%), which was negligible. We had reported nil mesh infection in our previous reports of these concomitant repairs alongside bariatric surgery.[ 10 11 ] Pring et al . and Bower et al . reported rates of 3.33% and 2%, respectively.[ 34 35 ] Recurrence rates were also much lower in our series (0.189%), whereas rates of 12.5% and 8% were reported by Itani et al . and Bencini et al ., respectively.[ 32 36 ] It is important to note that with our technique of IPOM, we had reported a recurrence rate of 0.55% in 2007.[ 14 ] A review of the literature concerning the organisms involved revealed that, in many studies, the mesh infections were caused mainly by Staphylococcus and Streptococcus species and not by enteric pathogens.[ 37 38 39 ] This explains the importance of proper painting and draping techniques, sterilisation of the surgical instruments with ideal sterilising techniques and changing the trocars, instruments and gloves of the entire operating team between procedures. The collaboration between surgeons and gynaecologists is vital in managing hernias in patients planned for hysterectomy. When we work together, we combine our expertise to address both the hernia and the gynaecological condition simultaneously, minimising patient recovery time and reducing the need for multiple surgeries. This integrated approach enhances patient care by providing comprehensive treatment, optimising surgical outcomes and ensuring a quicker return to normal activities. In addition, such collaboration fosters a multidisciplinary environment of mutual respect and continuous learning, ultimately benefiting patients’ well-being. It is also important that a proper selection of cases followed by a meticulous surgical technique is mandatory. There should always be a low threshold to place a mesh in case of inadvertent contamination of the surgical field.

After approval from the institutional ethical committee, data of all the patients who underwent concomitant TLH with ventral hernia repair were collected retrospectively from our hospital database and medical records department. Females with more than 40 years of age who were planned for TLH for gynaecological conditions such as myomas (major), abnormal uterine bleeding, uterovaginal (UV) prolapse with symptomatic hernias or asymptomatic hernias diagnosed incidentally Patients deemed fit for laparoscopic surgery under general anaesthesia. Females with more than 40 years of age who were planned for TLH for gynaecological conditions such as myomas (major), abnormal uterine bleeding, uterovaginal (UV) prolapse with symptomatic hernias or asymptomatic hernias diagnosed incidentally Patients deemed fit for laparoscopic surgery under general anaesthesia. Pelvic Inflammatory disease/chronic tubo-ovarian abscess Severe pelvic endometriosis Suspicious of malignancies. Complicated hernias - obstruction and strangulation Patients not fit for general anaesthesia. Pelvic Inflammatory disease/chronic tubo-ovarian abscess Severe pelvic endometriosis Suspicious of malignancies. Complicated hernias - obstruction and strangulation Patients not fit for general anaesthesia. Between January 2006 and January 2021, 1273 cases were reviewed, and 1058 cases satisfied our inclusion and exclusion criteria. Amongst the 215 cases excluded, 110 cases underwent only anatomical repair of hernias. Meshes were not placed due to incidences of endometriotic changes or suspicions of malignancies. Hundred and five patients had hernia-related complications such as obstruction and strangulation where mesh was not placed and hence excluded [ Figure 1 ]. The major indications for these hysterectomies were either myomas (major), abnormal uterine bleeding or UV prolapse. Demographic, pre-operative, intraoperative and post-operative data of each patient were collected, which included age, body mass index (BMI), previous abdominal surgeries, European Hernia Society classification of hernias, duration of surgery, length of hospital stay, intra- and post-operative complications and long-term recurrences. Data analysis Post-operative complications, both immediate and late, were documented. The immediate post-operative complications included seroma, haematoma or surgical site infections, whereas the late post-operative complications included mesh infection and recurrence. Out of the 1058 cases, 782 patients had a minimum follow-up period of 2 years, either through telephone conversations or direct hospital visits, and 155 patients had at least 1 year of follow-up, while 121 patients were lost to follow-up within the 1 st year, as shown in Figure 2 . The median follow-up duration for all patients was 2.8 years. Categorical variables are presented as counts and percentages. Continuous variables are presented as the means and standard deviations (SDs). Follow-up data The hernia repair is similar to our technique published by us in 2007 where we suture close all midline defects (which is popularly referred to as the IPOM plus in recent years[ 12 13 ]) and suture fixation of the mesh where we had reported a recurrence are of 0.55%.[ 14 ] Under general anaesthesia, the patient would be placed in the Trendelenburg position with both legs split into a modified lithotomy position. With the use of the Veress needle insufflation technique, pneumoperitoneum will be created. The contents of the hernia will be reduced initially, and hysterectomy subsequently performed. A 5-mm working port is placed in the right iliac fossa which may be converted to a 12-mm port if a morcellator is to be used. Once laparoscopic hysterectomy is completed, the specimen will be retrieved through a morcellator or vaginum. The vaginal vault will be closed using 1-polyglactin suture in a continuous fashion. A thorough wash will be given and the fluids completely suctioned out. After the hysterectomy, patient’s legs will be brought together, and the patient will be re-draped with fresh set of drape sheets. The standard positions of ports for umbilical and infraumbilical hernias are 10 mm for the camera at the epigastrium and right and left hypochondrial 5-mm working ports. In patients with epigastric hernias, the ports will be placed in the left lateral abdominal wall. With a new set of trocars and instruments, laparoscopic IPOM plus will be performed. The hernial sac will be excised completely to reduce any seromas postoperatively. Defects will be closed using 1-loop polyamide suture or barbed 1- polybutester (1-PBT) sutures intracorporeally in continuous fashion. A composite mesh with at least 5 cm coverage all around the defect will be placed against the anterior abdominal wall and is fixed transfacially and intracorporeally using 1-0 polyamide sutures. The omentum would be splayed all over the bowel loops and pneumodeflated. Mesh fixation devices may be used for large meshes.[ 9 14 15 ]