Laparoscopic repair of wound defects in the elderly: our experience of 5 years

Background Laparoscopic approach for wound defects is a procedure that aims to reduce surgical aggressiveness against the abdominal wall by using minimal incisions and dedicated instruments. Methods We report our experience about clinical outcome of elderly patients undergoing laparoscopic repair for incisional hernias (Group I) and primary inguinal hernias (Group II) from June 2007 to September 2012. We analyzed preoperative and postoperative data for the laparoscopic approach in the elderly. Results and discussion In our experience there was no significant difference in laparoscopic procedure between normalweight and overweight patients. Conclusions Laparoscopic repair for primary inguinal hernias and incisional ventral hernias with transabdominal placement of composite mesh in the elderly achieves excellent results with lower morbidity in comparison with open surgical approaches.


Background
Laparoscopic approach of wound defects is a procedure that aims to reduce surgical aggressiveness against the abdominal wall by using minimal incisions and dedicated instruments. The procedure also aims to decrease total hospital stay and morbility [1][2][3].
We report our experience about clinical outcome of elderly patients undergoing laparoscopic repair for incisional hernias (Group I) and primary inguinal hernias (Group II). Aim of this study is to assess the safety of laparoscopic wound defects repair in elderly patients; moreover the study wants to test our technique efficacy after 5 years of experience.
Wound defects diagnosis based on objective and clinical aspects, physical examination and radiologic findings like US and CT. For this study we also considered: hernia defect size, recurrence rate and operative time. All procedure-related complications were evaluated. 42% of the patients were normalweight with a mean BMI of 25 kg/ m2, 41% 25 > BMI > 30 (overweight), 17% BMI > 30 (obesity).

Results and discussion
There were no significant differences in laparoscopic procedure between normalweight and overweight elderly patients [1][2][3]. There were no conversions to open procedure. Mean operative time was 116 minutes (range: 50 -325). We analyzed preoperative and postoperative data not finding any significant difficulty difference in the laparoscopic approach in the elderly [10][11][12][13]. In primary inguinal hernias, in 37,5% of cases we used not absorbable polypropylene mesh, in 42,5% tridimensional polyester-collagen composite mesh and in 20% lightweight multifilament partly absorbable mesh.
Meshes were fixed in 82.5% of cases with absorbable fixation device, in 5% with not absorbable device and in 12.5% with fibrin glue.
In ventral hernias we used in all cases a polyester double-face mesh and fixed with absorbable devices. There was no difference as far as concerns the elderly quality of life between different meshes or fixation methods.
All procedures were performed by an expert surgeon or by a resident with an expert surgeon; there was no significant difference in intraoperative complications and operation time depending on the first operator.

Conclusion
Laparoscopic repair of primary inguinal hernias and incisional ventral hernias with transabdominal placement of composite mesh in the elderly achieves excellent results with lower morbidity in comparison with open surgical approaches. In our experience, adequate fixation of the mesh, mesh extension to cover the entire defect and standardization of the placement space between the sutures are crucial to the success [10][11][12].
Despite the retrospective analysis of our sample, the study showed that elderly patients can be operated with laparoscopic approach with the same advantages that would be obtained if operated with open technique [13,14]. The resident with an expert surgeon can obtain the same results of an expert surgeon as far as concerns outcomes and morbidity.
We consider surgery approach more difficult in the elderly in some cases [15] but we also considered laparoscopic approach is, in general, a safe and feasible technique in acute pathology [16] and a safe approach also in the elderly [17,18]. In our experience, laparoscopic repaire of wound defects is a good standard technique also in the elderly.

Competing interests
The authors declare that they have no competing interests.
Authors' contributions AGF: conception and design, interpretration of data, given final approval of the version to be published. VM: critical revision, interpretation of data, given final approval of the version to be published. SE: conception and design, interpretration of data, given final approval of the version to be published. AF: acquisition of data, drafting the manuscript, given final approval of the version to be published. SC: acquisition of data, drafting the manuscript, given the final approval of the version to be published. EG: acquisition of data, drafting the manuscript, given the final approval of the version to be published. AS: critical revision, interpretation of data, given final approval of the version to be published. MS: acquisition of data, drafting the manuscript, given final approval of the version to be published.

Declarations
Funding for this article came from personal funds. This article has been published as part of BMC Surgery Volume 13 Supplement 2, 2013: Proceedings from the 26th National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://www.biomedcentral.com/bmcsurg/supplements/13/ S2 Published: 8 October 2013