Incisional and 11
Ventral Hernia
Repair Including
Component
Separation
Ventral and incisional hernias centered around the umbilicus and on or close to the |
Indications |
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midline are good indications for the laparoscopic approach. Lateral hernias close to bony |
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structures (ribs, pubis, iliac crest) or following incisions on the flank are difficult and |
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require special techniques (Fig. 11.1). |
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Positioning |
Technique |
The patient should be in the supine position on the operating room table with both arms |
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tucked. This will give the surgeon and assistant/camera holder sufficient room to stand |
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on the same side. If the hernia being repaired is in the lower abdomen, a Foley catheter |
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should be placed to prevent bladder injury. The operating room table should be capable |
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of rotating in different directions to help with exposure of the hernia and to use gravity |
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to assist in manipulating the bowel away from the operative field. |
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N. Katkhouda, Advanced Laparoscopic Surgery,
DOI: 10.1007/978-3-540-74843-4_11, © Springer-Verlag Berlin Heidelberg 2011
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Chapter 11 Incisional and Ventral Hernia Repair Including Component Separation |
Good indications
Difficult indications
Fig. 11.1 Indications for laparoscopic ventral hernia repair. Orange color on the middle indicates sites of good indication for laparoscopic ventral or incisional hernia repairs. Yellow color on the periphery indicates sites of less favorable indications for laparoscopic ventral and incisional hernia repairs
Pneumoperitoneum
Pneumoperitoneum can be achieved with either the Hasson technique or by using the Veress needle. This can be done in the midline if it is not close to the hernia, but if the hernia is in the midline, Palmers point in front of 11th rib on the left side is a safe place. If there are any doubts about Veress needle placement, the Hasson technique should be used.
Port Placement
Usually, three ports placed in a triangulated fashion suffice for a ventral hernia repair. The ports should be placed on the opposite side of the hernia. For example, if the hernia is from an open appendectomy, the ports should be placed on the left side of the patient. For midline hernias, the ports can be placed on either side, but it is safer to place them on the opposite side of a previous surgical site to decrease the risk of getting into
Technique |
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D A
C S
B
VH CA
Fig. 11.2 Trocar placement for laparoscopic incisional hernia repair. Dotted line indicates incisional or ventral hernia. C camera; B left hand of surgeron; A right hand of surgeon; D additional 5 mm trocar for tacker. S surgeon; CA camera assistant
adhesions (Fig. 11.2). For example, if a midline hernia is from an open left hemicolectomy, it is better to place the ports on the right side of the abdomen. One port should be at least 10 mm in order to introduce the mesh into the abdominal cavity. The additional trocars for the introduction of the tacker are 5 mm.
Adhesiolysis
The first step is to reduce the hernia contents and free up the abdominal wall from adhesions. Adhesiolysis should be done with either sharp dissection with scissors or with the harmonic scalpel (Fig. 11.3). Using cautery with scissors can be very dangerous, as it can result in an unnoticed bowel injury and should be done very carefully.After the adhesions are taken down, the contents of the hernia should be reduced into the abdominal cavity by traction from inside the abdominal cavity and with the help of the assistant from outside the abdominal cavity to push them into the abdomen. If the hernia sac contains only omentum, it can be amputated, reduced, and then removed from the abdominal cavity.
The hernia can be excised and removed. This will decrease the risk of seroma, but if it is very close to skin, it may result in devascularization of the skin or a puncture hole in the skin.
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Chapter 11 Incisional and Ventral Hernia Repair Including Component Separation |
Fig. 11.3 Adhesiolysis using the harmonic shears
Measurement of the Hernia Defect
The hernia defect can be measured from the inside or the outside of the abdomen (Fig. 11.4). The measurement from inside is more precise and is performed using a paper ruler introduced into the abdominal cavity, or using a suture stretched across the hernia defect with two graspers and measured outside.
A thin long spinal needle is used to measure the defect from the outside of the abdominal cavity. The needle is pushed through the skin to exit superiorly, inferiorly, and on the right and left side of the hernia, right 5 cm away from the edge of the fascial defect so as to mark the defect and the 5 cm overlap (Fig. 11.5). These four points are marked and drawn on the skin to measure the defect. It is important to remember that as the inside girth of abdominal cavity is shorter than the outside girth, this technique tends to overestimate the hernia defect size and should be considered when the transfascial sutures are passed through the abdominal wall. Deflating the abdomen at this point decreases the difference between the inside and outside girth (larger diameter), making the measurement from the outside more precise.
Placement of Mesh
Bilayer mesh, with one side made of materials that do not adhere to the bowel and the other side made of materials that facilitate tissue ingrowth in contact with fascia and muscles, should always be used for ventral hernia repair. It is very important to make sure that the side of the mesh that touches on the bowel side stays on the correct side.
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6 cm.
5cm.
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5 |
cm |
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6 cm. |
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3
Mesh
Draped abdomen
6 cm. |
Internal view
Fig. 11.4 Measurement of the hernia defect (6 cm in this example) with a 5-cm overlap. 1, 2, 3, 4 indicate the periphery of the mesh and the site of introduction of the suture passer
Markings
Hernia defect
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3-5 cm. |
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overlap |
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Fig. 11.5 Technique using the 20 gauge or spinal needle to mark the hernia defect and 5 cm overlap
174 Chapter 11 Incisional and Ventral Hernia Repair Including Component Separation
A minimum of 3–5 cm of overlap on each edge is necessary to decrease the risk of recurrence. For example, if the hernia defect is 5 × 5 cm, the mesh should be between 11 × 11 and 15 × 15 cm. The mesh is rolled and introduced through the 10 mm port. Adding a 5-mm port on the other side of the abdomen can help with pulling the mesh inside and later the port can also be used to place tacks (Fig. 11.2). The following are two techniques that can be used to fix the mesh to the abdominal wall:
1. Double Crown technique: In this technique, the mesh is fixed to the abdominal wall with two rows of tacks. The first row is placed right at the fascial defect and the second row is placed at the edge of mesh approximately 6–10 mm from the edge. We now use the absorbable tacks that will dissolve in less than 6 months (Fig. 11.6).
2. Transfacial sutures: In this technique, four nonabsorbable sutures are placed at each corner of the mesh (Fig. 11.7). These sutures are tied twice and then cut long enough to be passed through the abdominal wall. The length of overlap is added to each side of the hernia mark on the skin and a new marking that corresponds to the mesh size is drawn on the skin. The exit site of these sutures is then marked on the skin.After the mesh is introduced into the abdominal cavity, these four sutures are passed through the abdominal wall. The suture passer is introduced through the abdominal wall through a stab wound (Fig. 11.8). The mesh should be flat, but not under too much tension. The transfascial sutures are then tied (Fig. 11.9). The dimple in the skin can be fixed easily by pulling the skin away from the abdominal wall. Tacks are then placed at the edge of the mesh as needed to decrease the risk of bowel herniation between the mesh and the abdominal wall. The addition of a 5-mm port on the opposite side, if not previously placed, will help in placing tacks on the side that is close to the ports.
At the end, Tisseel can be sprayed on the tacks and the edge of the mesh, which may help in decreasing adhesion of the bowel to the tacks; spraying Tisseel between the mesh and the fascia may also help reduce the risk of seroma formation (Fig. 11.10).
Fig. 11.6 “Double crown” fixation technique using absorbable tacks
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Fig. 11.7 Transfascial sutures for fixation of mesh
Fig. 11.8 Passage of the suture passer for transfascial fixation of the mesh
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Chapter 11 Incisional and Ventral Hernia Repair Including Component Separation |
Fig. 11.9 Completion of the “suture and tack” technique
Fig. 11.10 Optional application of fibrin glue on the tacks to reduce the risk of small bowel
adhesions