Complications resolution of laparoscopic techniques, clinical cases
Bowel perforation and mesh infection after laparoscopy
Operations for diastasis recti performed by laparoscopic techniques, although advertised as"minimally invasive," involve the placement of a mesh, of necessity in direct contact with the viscera (meshintraperitoneal).
The mesh (and its means of fixation called Tacker) being in contact with the viscera, can give rise to even medium- or long-term complications ranging from adhesion syndrome to intestinal perforation.
The intestine in direct contact with a prosthetic foreign body (intraperitoneal mesh and fixation media) may adhere to it, suffering from the limitation in its movements (adhesion syndrome) or worse may slowly injure itself (decubitus or perforation) even over a long time.
The problem is not the net per se is but is the "where this net is housed," that is, in direct contact with the viscera.
An intestinal microperforation can become a continuous source of bacteria contaminating the mesh itself and the abdominal cavity imposing surgical resolution as we see in this clinical case and depicted in the diagram.
That is why we are opposed to laparoscopic methods and prefer to operate mainly by robotic.
In fact, in R-Tapp robotic surgery, there is no contact between the mesh and the intestine eliminating the risk of these complications at the root.
Diastasis recurrence, pain and adhesions after laparoscopic technique
This case of recurrence following laparoscopic technique started from an initially small diastasis of 2.7 cm (at the minimum limits of operability), which later recurred to 3.6 cm becoming larger than at the beginning.
The patient thus started from a very modest diastasis and had no particular risk factors being normal weight and without comorbidities.
Thus, in this case the recurrence is due, without special excuse, to primitive suture failure.
This may have an explanation in the fact that the suture in these surgeries is posterior (posterior plication) then posteriorly unbalanced (introflective or extraflective) with some asymmetry and probably less tensile strength than a central suture.
Such a suture includes not only the necessary muscle-aponeurotic tissues but also peritoneal tissue and pre-peritoneal fat, which are interposed in the suture rhyme probably interfering with healing and limiting the tightness of the reconstructed midline.
The pain the patient describes is due to the mesh fixation media called Tackers that penetrate the abdominal wall and can result in focal tensile points (not necessarily under stress) and irritation of nerve endings.
Intestinal channeling disorders are brought about by adhesion syndrome, which easily occurs due to the intraperitoneal mesh, which inevitably comes into contact with the intestines.
On this patient, we decided to maintain a conservative attitude for now.
Reintervention after a laparoscopic technique poses a number of nontrivial issues.
As we saw in the previous case (where immediate provision had to be made because of the perforation), these reinterventions are difficult to approach endoabdominally , having the mesh in contact with the bowel.
An investigative lysis of adhesions is often necessary just to gain access to the reconstruction, which must be demolished and then restored with another technique.
Sometimes it is even necessary to divide the reintervention into two stages by separating the demolition part from the reconstructive part to allow time for the tissues to recover.
The reinterventions of these clinical cases therefore are therefore not risk-free, and sometimes (in non-urgent cases) it is not easy to decide whether it is convenient to surgically correct or to maintain a conservative stance, where the patient will unfortunately live with the various complaints and a larger recurrent distasis than the initial one.
Therefore, as we always say it is good to carefully evaluate the surgical technique that is proposed to us, "a reconstruction for diastasis recti must succeed well and on the first surgery," transitions from one reconstruction to another, on the other hand, are risky and difficult.