Hybrid surgery in hernias: Our experience

Introduction:

Hybrid surgery is a procedure in which laparoscopic and open surgical steps are used for a better outcome to the patient. The aim of this study is to identify the factors that necessitated hybrid surgery in cases of hernia.

Materials and Methods:

It is a retrospective narrative study of 69 patients with hernia, who underwent hybrid surgery. Deciding factors and outcomes were analysed. Results: Of the 69 cases, 32 were open surgery followed by laparoscopy (OL)/open surgery followed by laparoscopy and then by open surgery again (OLO) and 37 were laparoscopy followed by open surgery (LO)/laparoscopy followed by open surgery and then by laparoscopy once more (LOL). Incorporating laparoscopic steps during open surgery helped in combining multiple surgeries, intra-abdominal adhesiolysis, etc., without enlarging the incision. Open surgical steps incorporated during laparoscopy, helped in reduction of irreducible hernia, darning of defects from outside, etc., Ventral hernia with apron and need for combining other surgeries had an association with OLO (P < 0.001). Inguinal hernia or ventral hernia without apron, irreducibility and need for omentectomy had an association with LO/LOL (P < 0.001). Factors having statistically significant association with sandwich repair were large defect size, multiple previous open surgeries, presence of precipitating factors and recurrent hernias.

Conclusion: Hybrid surgery offers definite benefits in select cases of hernias. Case-to-case planning is needed preoperatively and should be based on the difficulties anticipated. It will help the surgeon perform a safe procedure.

Keywords:

Hernia repair, hybrid, laparoscopy, laparoscopy followed by open surgery and then by laparoscopy once more, open surgery followed by laparoscopy and then by open surgery again

Introduction

Hernia is a very common disease which can be managed successfully with open surgery or laparoscopy. In a subgroup of patients, both open and laparoscopic surgical steps are combined for a desirable outcome.^[1] Such procedures are grouped under the umbrella term, ‘hybrid surgery’, for example, simultaneous laparoscopic cholecystectomy and open ventral hernia repair. A hybrid surgery where both laparoscopic and open surgical steps are applied for hernia repair alone is called a hybrid hernia repair.^[1] Hybrid surgery is not an on-table decision or laparoscopy converted to open because of difficulty or a complication. It is a pre-operative decision. In this article, we aim to bring to light our experience in this procedure.

Materials and Methods

It is a retrospective narrative study conducted amongst 69 patients with hernia, who underwent hybrid surgeries by our team during 2009–2019, at two centres. It accounted for 4.7% of the total hernia surgeries performed by us during the specified time period. The procedure was open first or lap first:^[1],[2] open surgery followed by laparoscopy (OL)/open surgery followed by laparoscopy and then by open surgery again (OLO) or laparoscopy followed by open surgery (LO)/laparoscopy followed by open surgery and then by laparoscopy once more (LOL). The rationales for doing hybrid surgery were analysed and grouped. Outcomes were assessed.

Definitions

Sandwich repair

The abdominal wall was augmented on the outer and inner aspect, with mesh on both sides or with mesh on one side and a fascial flap on the other.^[3]

Open-favoured adhesions

In case of adhesions, where open surgery is better and safer than laparoscopy, perform adhesiolysis completely.

Lap-favoured adhesions

In case of adhesions, where laparoscopy is preferable over open surgery due to ease of access, perform visualisation and adhesiolysis. More details are provided in [Table 1].

Table 1: Open-favoured adhesions and lap-favoured adhesions

Defect pattern (open-favoured or lap-favoured defects)

Just like adhesions, defects also are lap favoured or open favoured. The factors that decide defect pattern are (a) size of the defect, (b) number of defects and (c) nature of the surrounding muscles (muscle loss, papery thin muscles and divarication). In laparoscopy, a larger mesh can be kept. However, huge defects (ventral defects >8 cm^[1] and inguinal defects >4 cm) that need plication and darning are better closed through an open incision.^[4] In incisional hernia following renal transplant, some parts of the defect were better covered with a laparoscopically placed large mesh, while a portion over transplanted kidney was better covered with an open onlay mesh. In cases of bilateral inguinal hernia with a small umbilical defect <1 cm, inguinal defects can be better dealt with laparoscopically, while primary closure of the umbilicus, which is used as the primary trocar site, can be done by open technique.

Inclusion and exclusion criteria

All cases of hernias operated by our team using hybrid technique in the specified time period in the two centres were included. Hernia repairs with open technique alone or laparoscopy alone were excluded from the study.

Operative technique

Open surgery followed by laparoscopy

In some cases, there was difficulty in placing the initial trocar. It was due to multiple surgeries in the past resulting in intra-abdominal adhesions or because of obstructed hernia with abdominal distension. We opted for open technique first as trocar placement can be safer under vision. Cases with huge skin apron, badly scarred skin or presence of multiple healed sinuses also needed a skin incision initially. In such cases, although there was no difficulty in laparoscopic trocar placement, the position of trocars can be based on the skin loss and the hernial defect. Trocars placed under the skin flap had better cosmesis, and it did not leave any scar on the exposable area of the abdomen.

A skin incision was made preserving sufficient healthy skin to get a cover and, at the same time, to get a good cosmesis. Sac was opened, adhesiolysis was performed and contents were reduced. Once the peritoneal cavity was reached, the primary trocar was placed under vision or under hand guidance. Hernial defect was temporarily approximated with multiple Allis forceps or a 1-0 polypropylene suture. Then, laparoscopic working ports were placed and laparoscopic surgery was performed.

Laparoscopy helped in combining other surgeries like lysing lap-favoured adhesions, getting a better defect cover with a larger mesh, sandwich mesh repair, placing of mesh laparoscopically in cases where open mesh placement was not possible because of lengthy divarication, with papery thin muscles and very less subcutaneous fat, bridging the gap due to loss of muscle when a large abdominal wall mass was excised or in cases of healed sinuses, scar, colostomy reversal, etc., and reducing the length of incision for open surgery.

After laparoscopic steps are completed, some cases required final open steps. An onlay mesh placement for sandwich repair or darning from outside was performed. Some cases had an apron and required dermolipectomy and creation of neoumbilicus. The skin incisions were then closed. These come under OLO [Figure 1].

Figure 1: Presentation of open surgery followed by laparoscopy and open surgery again at last

Laparoscopy followed by open surgery

Initially, laparoscopic ports were placed. Dissection of hernia was done as much laparoscopically possible. After that, skin over the hernia was incised [Figure 2].

Figure 2: Presentation of laparoscopy followed by open

The following steps were better done with open method, tackling of irreducibility and open-favoured adhesions, augmentation of defect closure with suturing or darning of the defect, division of cord structures, sandwich mesh repair, sublay mesh repair or transversus abdominis release, excision and removal of contents/tissues, like devascularised omentum, closure of defect in which the defect pattern favoured open method of repair and excision of the large redundant sac or scar to attain better cosmesis. In some cases, a laparoscopic mesh placement was done after the open procedure. Those cases were grouped under LOL [Figure 3]. Open mesh placement was onlay, sublay, preperitoneal or Lichtenstein’s with polypropylene meshes or partially absorbable meshes. Laparoscopic mesh placement was preperitoneal or intraperitoneal onlay mesh (IPOM) placement, performed using dual meshes or polypropylene meshes.

Figure 3: Presentation of laparoscopy followed by open surgery and again laparoscopy at last

Statistical analysis

Descriptive statistics were used to assess the baseline characteristics of the data. Qualitative variables such as gender, type of surgery, precipitating factors, recurrent hernias and apron were presented as frequency and percentages. Quantitative variables such as age and defect size were presented in mean and standard deviation. For the association of qualitative variables, either Chi-squared test or Fisher’s exact test (if cell values are <5 or zero) was used. Continuous variables were compared using Mann–Whitney U-test. A value of P < 0.05 was considered statistically significant. All data were entered in Microsoft Excel and analysed using SPSS version 20 (IBM SPSS Statistics, Software version 10.0, USA, 2020).

Results

Amongst 69 patients with hernia who underwent hybrid surgeries, 42 (61%) cases were ventral hernia repairs, 22 (32%) were inguinal hernia repairs and 5 (7%) were combined ventral and inguinal hernia repairs. The age ranged from 4 to 85 years, with an average of 48.30 ± 15.77 years. There were 34 males and 35 females. M: F was 3:11 for ventral hernia and 21:1 for inguinal hernia (P < 0.001). Sixty-eight (98.55%) patients complained of abdominal swelling. Sagging of the abdomen or apron was complained of by 29 (42.03%) patients. Pain was complained by 21 (30.43%) patients. Ulceration of skin was seen in one case.

The body mass index varied from 16 to 42 kg/m² and the average body mass index was 26.53 ± 5.23 kg/m². Out of the 69 cases, 2 (2.90%) were underweight, 28 (40.58%) were normal weight and 26 (37.68%) were pre-obese. Thirteen cases (18.84%) were obese (obesity class I – 9 cases, obesity class II – 2 cases and obesity class III – 2 cases). Other precipitating factors were lower urinary tract symptoms (LUTS) in 9 (13.0%) cases, respiratory illness in 6 (8.69%) cases and constipation in 1 case. LUTS were more with inguinal hernia (P = 0.001). Chronic respiratory illness also was more with inguinal hernia, and obesity was more with ventral hernia, but these were not significant (P = 0.237 and P = 0.114, respectively). Precipitating factors were absent in 43 (62.32%) cases.

Thirty-two patients had a history of previous abdominal surgeries. Thirty cases had undergone open surgeries, of which 12 had 1 open surgery, 15 had 2 open surgeries and 3 had 3 or more abdominal surgeries. Six cases had undergone laparoscopic surgeries, of which five had one laparoscopic surgery and one patient had two laparoscopic surgeries. Four patients had both open and laparoscopic surgeries. Thirteen (18.84%) cases were recurrent hernias: 1 lap recurrence and 12 open recurrences. Of these 12 open recurrences, 9 were first recurrence, 2 were second recurrence and 1 was third recurrence.

Twenty-five (36.23%) patients had other surgeries combined along with hernia repair. Such cases included nine cholecystectomies, nine tubal ligations, three sleeve gastrectomies, two appendectomies, two total laparoscopic hysterectomies, two ovarian cystectomies, one excision of appendices epiploicae and one orchidectomy for undescended testis.

Of the 69 cases, 32 (46.38%) were OL/OLO and 37 (53.62%) were LO/LOL. Of OL/OLO, all 32 cases were OLO. Of LO/LOL, 8 cases were LO and 29 were LOL.

The defect size varied from 1 to 13 cm (mean: 4.47 ± 3.20 cm) for ventral defects and 0.5–8 cm (mean: 3.88 ± 1.88 cm) for inguinal defects. Defect size and need for darning for defect closure were associated with both types of hybrid surgeries (defect size: ventral: P = 0.024, inguinal: P = 0.022 and darning: P = 0.013). Defect size was an important factor in deciding sandwich repair also. In ventral hernia, the average defect size was 9.60 ± 2.30 cm in the sandwich group while 3.93 ± 2.72 cm in the non-sandwich group which is found to be significant (P = 0.003). In inguinal hernia, the average defect size was 4.83 ± 0.753 cm in the sandwich group while 3.71 ± 1.90 cm in the non-sandwich group (P = 0.167). Ten (14.5%) cases had sandwich repair. Types of sandwich repair performed were open onlay + laparoscopic IPOM in three cases, open onlay + laparoscopic preperitoneal repair in one case, open onlay + open sublay in one case and open fascial flap + open sublay in one case for ventral hernias, open Lichtenstein’s repair + laparoscopic preperitoneal repair in two cases and open Lichtenstein’s repair + open preperitoneal repair in two cases for inguinal hernias. The frequency and correlation of factors necessitating hybrid surgery are given in [Table 2] and [Table 3], respectively.

Table 2: Frequency table of factors deciding hybrid surgery

Table 3: Factors deciding hybrid surgery, correlation with type of surgery and sandwich

The duration of post-operative hospital stay varied from 1 to 7 days, with an average of 2.66 ± 1.19 days. Two patients had extended hospital stay due to immediate post-operative complications. One had severe cough followed by haematoma scrotum, necessitating exploration. The other had paralytic ileus for 2 days, which was managed conservatively. At the time of 1-month follow-up, two patients were found to have seroma and one patient had delayed wound healing. No complications were observed at the follow-up assessment at 1 year. The follow-up varied from 1 to 10 years, with an average of 5.21 ± 3.16 years.

Discussion

Laparoscopic surgery has definite advantages over open surgeries. Literature describes lesser morbidity (in terms of sepsis and pain) and mortality and shorter hospital stay with laparoscopy. It also has a lesser chance of seroma and wound-related issues and lesser mesh-related issues. Patients are more satisfied because of earlier return to work. A larger mesh can be placed.^{[1],[4],[5],[6]} In select cases, open surgery surpassed laparoscopy, when associated with large defects, unsightly scars or aprons and massive adhesions.^[1],[4] Some cases needed open surgical steps along with laparoscopic steps. These cases accounted for 4.7% of total hernia cases operated by us. Other studies show the incidence around 10%.^[1]

In open-first technique (OL/OLO), the open surgery was performed initially for one of these reasons; apron: in cases of ventral hernia with a large apron, we raised the flap and placed the trocars. This avoided scars in the umbilical and supraumbilical regions.^[7] Association of apron and OLO was found to be statistically significant, dense adhesions expected at the site of laparoscopic entry: in patients with history of enterocutaneous fistulas, three or more laparotomies, post-operative wound site infections and mesh rejection; dense adhesions need to be expected.^[1],[7],[8] Incision was made over the hernia to reduce the contents, and trocars were placed under direct vision. This group comprised 16 (23.19%) cases in this study and badly scarred skin or presence of multiple healed sinuses.^[7],[8] In four cases, we opted for excision of the scar first, as trocar placement could be planned based on the skin loss and the hernial defect. In cases of obstructed hernias, abdominal distension may make the primary trocar placement unsafe. Incision needs to be made over the hernia and contents to be reduced after ensuring bowel vascularity. Trocars are placed under direct vision. We did not have such cases in this series. Combining laparoscopy helped in combining other surgeries, adhesiolysis (lap-favoured adhesions) and mesh sandwich repair and reducing the length of incision of open surgery. Adhesiolysis and reduction of open incision, when laparoscopy is combined with open surgery, is discussed in other studies.^[7],[9] These are in addition to the already known advantages of laparoscopy.

In lap-first technique (LO/LOL), we noticed that combination of open method was helpful in tackling open-favoured adhesions. Laparoscopic mesh was augmented by the following open methods: defect closure from outside, darning, fascial flap, component separation or sandwich mesh. Examination of contents, removal of contents or tissues which were excised and excision of redundant sac were also better carried out in an open manner. During hernia repair, the following procedures were also done when necessitated: omentectomy, fat excision, orchidectomy for undescended testis, subcutaneous peritoneal cyst excision and prolene sinus excision. Adhesiolysis and augmentation of repair were reported in other studies also.^[7],[8]

Ventral hernia with an apron and a need for combining other surgeries was significantly associated with OLO. Ventral hernia without an apron, but having irreducibility, need for omentectomy and need for darning for defect closure, was significantly associated with LO. Inguinal hernia with irreducibility and need for omentectomy was significantly associated with LOL. Large defects needed darning from outside for defect closure by hybrid method. Factors such as large redundant sac, obesity, multiple previous abdominal surgeries, recurrent hernias and presence of multiple precipitating factors were also noticed in hybrid surgery, but the association was not statistically significant (P > 0.05).

Sandwich mesh repair was done in cases where higher chance of recurrence was expected. These included cases with large defects (ventral defects >8 cm and inguinal defects >4 cm), multiple previous open surgeries, presence of precipitating factors and recurrent hernias. It is in accordance with the general recommendations based on the literature review.^[3]

Two features of the defect need to be assessed: defect size and defect pattern. Defect size as a criterion for decision-making for ventral hernia is discussed in the literature^[10],[11] and in our study. Another important factor which we felt worth considering was the pattern of the defect importantly observed in nine cases.

There are various studies comparing laparoscopy and hybrid surgery. Post operative seroma, protrusion of mesh, complex adhesiolysis and pain scores were lesser in the hybrid group.^{[2],[7],[11],[12]} Hybrid repair also reduces recurrence rates.^[13] In our study, although comparison with laparoscopy alone or open alone was not available, outcomes were good and no major untoward incident was noted.

Practical difficulties

The most commonly encountered difficulty was lack of space either due to gas leak or restriction following darning in abdominoplasty. When laparoscopy was done after making an open incision, air leak happened. Allis forceps were applied, approximating the defect to reduce this problem. In some cases, we need to switch between laparoscopy and open surgery multiple times. Hence, wall closure was deferred till the completion of all other steps. For the same reason, mesh placement was done towards the end of the procedure. In cases of abdominoplasty, when plication was done initially, we had difficulty in mesh placement due to crumbled fascia. If plication was done after the laparoscopic placement of mesh, it led to crumbling of mesh. In both the methods, difficulties need to be anticipated and procedure to be done with a case-to-case assessment.

Conclusion

Hybrid surgery offers definite benefits in select cases of hernias. Hybrid surgery was performed in patients having ventral hernias with apron, lax abdomen, irreducibility, large defect or when there was a need to combine other surgeries. Inguinal hernias with irreducibility or large defects were tackled with hybrid surgeries to have better results. Case-to-case planning is needed preoperatively and should be based on the difficulties anticipated. It will help the surgeon in performing an excellent procedure and give a better outcome to the patient.

Acknowledgements

We are thankful to Mr. Subin Thomas for language editing and grammar corrections, Ms. Anithadevi T S for the data analysis and Mr. Dipin Prakash and Mr. Maneesh for data entry.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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