title: Transabdominal midline reconstruction by minimally invasive surgery: technique and results.
abstract: BACKGROUND
  The introduction of the minimally invasive approach changed the way abdominal surgery was carried out. Open suture and mesh reinforcement in ventral hernia repair used to be the surgeon's choice of procedure. Although the laparoscopic approach, with defect bridging and mesh fixation, has been described since 1993, the procedure remains largely unchanged. Evidence shows that defect closure and retro-muscular mesh positioning have the best outcomes and are the best surgical practice. We therefore aimed to develop and demonstrate a procedure which combined the good results of open surgery using the Rives-Stoppa principles, particularly in terms of recurrence, with all the benefits of minimally invasive surgery.
  
  
  METHODS
  Between October 2012 and February 2014, 15 post-bariatric surgery patients underwent laparoscopic midline incisional hernia repair. The peritoneal cavity was accessed through a 5-mm optical view cannula at the superior left quadrant. A suprapubic and two right and left lower quadrant cannulas were inserted for inferior access and dissection. The defect adhesions were released. The whole midline was closed with an endoscopic linear stapler, including the defect, from the lower abdomen, 4 cm below the umbilicus, until the epigastric region, including posterior sheath mechanical suturing and cutting in the same movement. A retrorectus space was created in which a retro-muscular mesh was deployed. Fixation was done using a hernia stapler against the posterior sheath from the peritoneal cavity to the abdominal wall muscles. Selection was based on xifo-umbilical incisional midline hernias post open bariatric surgery. Pregnant women, cancer patients, or patients with clinical contraindications were excluded.
  
  
  RESULTS
  The patients mean age was 51.2 years (range 39-67). Four patients were men and eleven women. Two had well-compensated fibromyalgia, four had diabetes, and five had hypertension. The mean BMI was 29.5 kg/m2 (range 23-31.6). Surgery was performed successfully in all cases through four ports; the number of incisional hernias was 3 ± 2, with a mean maximum width of 3.75 cm (range 2.1-9) and maximum length of 14 cm (7.5-20.5). The mean surgical time was 114.3 min (range 85-170), and the median hospital stay was 1.4 days. No intra-operative or immediate post-operative complication or death occurred. One patient had a seroma treated conservatively 1 week after surgery and another had a retro-muscular infection treated with percutaneous drainage. CT-Scans made before and after the procedure, showed total closure of the defect. QOL questionnaire showed satisfaction, acceptance, and no complaints.
  
  
  CONCLUSIONS
  Although the study involved a small number of patients, it has proved the technique to be feasible, easy to perform, and have the combined benefits of laparoscopic and open surgery. The results, shown by CT-scan, peri-operative, and QOL findings, were good.
authors.affiliation: Department of Digestive Surgery, Hospital das Clínicas, GAstroenterology Department, University of Sao Paulo, Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255, 05403-000, São Paulo, Brazil. thiagocosta2002@yahoo.com.br.
authors.forename: T N
authors.initials: TN
authors.lastname: Costa
authors.affiliation: Department of Digestive Surgery, Hospital das Clínicas, GAstroenterology Department, University of Sao Paulo, Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255, 05403-000, São Paulo, Brazil.
authors.forename: R Z
authors.initials: RZ
authors.lastname: Abdalla
authors.affiliation: Department of Digestive Surgery, Hospital das Clínicas, GAstroenterology Department, University of Sao Paulo, Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255, 05403-000, São Paulo, Brazil.
authors.forename: M A
authors.initials: MA
authors.lastname: Santo
authors.affiliation: Department of Digestive Surgery, Hospital das Clínicas, GAstroenterology Department, University of Sao Paulo, Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255, 05403-000, São Paulo, Brazil.
authors.forename: R R F M
authors.initials: RR
authors.lastname: Tavares
authors.affiliation: Department of Digestive Surgery, Hospital das Clínicas, GAstroenterology Department, University of Sao Paulo, Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255, 05403-000, São Paulo, Brazil.
authors.forename: B M Z
authors.initials: BM
authors.lastname: Abdalla
authors.affiliation: Department of Digestive Surgery, Hospital das Clínicas, GAstroenterology Department, University of Sao Paulo, Medical School, Av. Dr. Enéas de Carvalho Aguiar, 255, 05403-000, São Paulo, Brazil.
authors.forename: I
authors.initials: I
authors.lastname: Cecconello
mesh_terms: D034861:Abdominal Wall / Q000601:surgery; D058107:Abdominal Wound Closure Techniques; D000328:Adult; D000368:Aged; D050110:Bariatric Surgery / Q000009:adverse effects*; D005260:Female; D006555:Hernia, Ventral / Q000601:surgery*; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D000069290:Incisional Hernia / Q000601:surgery*; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D019651:Plastic Surgery Procedures / Q000379:methods; D017568:Rectus Abdominis / Q000601:surgery; D013526:Surgical Mesh
keywords: Abdominal wall reconstruction; Incisional hernia; Midline; Minimally invasive surgery; Obesity; Ventral hernia