Technique |
177 |
Difficult Ventral or Incisional Hernias
Incisional or ventral hernias close to bony structures (the xyphoid process, ribs, pubis, pelvis) or following flank incisions for nephrectomy or spine surgery are very difficult to fix. (Fig. 11.1).
For the hernia around the xyphoid process or the ribs, one has to take down the falciform ligament and place the mesh above the liver. The anchoring of the mesh should use tacks or intracoporeal sutures, without use of a suture passer.
For suprapubic hernias, the inferior border of the mesh should be fixed with tacks to the pubic bone and to Cooper’s ligament.
Finally, hernias of the flank can possibly be more challenging, as they do not present as hernias but rather as eventrations due to muscular nerve atrophy. The author prefers an open approach for larger hernias.
Pain Following Laparoscopic Ventral or Incisional Hernia Repair
The disposition of the intercostal nerves shows that some minor injury to the nerves is unavoidable, especially with the suture and tack repair (Fig. 11.11). The sutures will sometimes entrap a nerve, resulting in chronic pain. The patient should be forewarned about the occurrence of postoperative pain during the preoperative clinic visit. Local injections are used, and sometimes removal of the responsible suture with the inherent neuroma is the last resort.
Rectus abdominis
External oblique
Internal oblique
Transverse abdominis
Fig. 11.11 Disposition of the intercostal nerves as they innervate the muscles of the abdominal wall; this may explain postsurgical chronic pain issues
178 |
Chapter 11 Incisional and Ventral Hernia Repair Including Component Separation |
Laparoscopic |
The goal is to divide laparoscopically the fascia of the external oblique laterally to the |
Component |
rectus sheath. This will separate the components of the large muscles of the abdomen |
Separation |
and reduce the size of the midline defect and consequently, the size of the mesh to be |
|
used. It will also reduce the tension on the closure of the defect. |
|
Three trocars are placed, one 10 mm under the costal margin, another 10 mm in the |
|
flank, and a final 5 mm trocar in the right lower quadrant (Fig. 11.12). The Hasson tech- |
|
nique is used for the right upper quadrant port (A); the aponeurosis of the external oblique |
|
is identified and opened, and a balloon dissector is inflated beneath the external oblique |
|
and above the internal oblique to create a working space(Fig. 11.13).A 10-mm trocar (B) in |
|
the flank is inserted into the space to allow for an electrical scissor to divide the fascia of |
|
the external oblique laparoscopically, just lateral to the rectus sheath going downwards |
|
towards the right lower quadrant (Fig. 11.14). In order to divide the upper part of the exter- |
|
nal oblique fascia,a 5-mm trocar is inserted (C).The camera is moved from the right upper |
|
quadrant trocar to the middle 10 mm trocar, and a scissor is introduced into the 5 mm |
|
trocar to complete the division. The same maneuver is performed on the opposite side. |
|
After the component separation is finished, it is possible to perform an incisional |
|
hernia repair using a smaller mesh, as the component separation allows the edges of the |
|
fascial defect to be brought closer together; alternatively, a full laparoscopic incisional |
|
hernia repair with a sublay mesh can be performed. |
|
The main advantage of the laparoscopic component separation technique is to |
|
avoid the risk of devascularizing the skin, which can occur with the open method. |
Fig. 11.12 Trocar placement for laparoscopic component separation. A initial introduction site for the balloon dissector, and the Hasson trocar for the camera; B trocar port for the electrical scissors; C additional 5 mm port for the scissor to finish up the division of the cephalad portion of the external oblique fascia
Laparoscopic Component Separation |
179 |
Fig. 11.13 Introduction of the balloon dissection in the space beneath the fascia of the exter-
nal oblique and above the internal oblique
External oblique |
fascia divided |
Transv |
abdomi |
nternal obliqu |
Fig. 11.14 Division of the external oblique fascia with electrical scissors, until the subcutaneous fat is visible. This will achieve a separation of the components and a subsequent release of the tension on the closure of the defect
180 |
Chapter 11 Incisional and Ventral Hernia Repair Including Component Separation |
Selected
Further
Reading
Alvarez C (2004) Open mesh versus laparoscopic mesh hernia repair. N Engl J Med 351(14):1463–1465
Bingener J, Buck L, Richards M, Michalek J, Schwesinger W, Sirinek K (2007) Long-term outcomes in laparoscopic vs open ventral hernia repair. Arch Surg 142(6):562–567 Fujita F, Lahmann B, Otsuka K, Lyass S, Hiatt JR, Phillips EH (2004) Quantification of
pain and satisfaction following laparoscopic and open hernia repair. Arch Surg 139(6):596–600
Kennealey PT, Johnson CS, Tector AJ 3rd, Selzer DJ (2009) Laparoscopic incisional hernia repair after solid-organ transplantation. Arch Surg 144(3):228–233
Malas M, Katkhouda N (2002) Herniation through the falciform ligament following laparoscopic surgery. Surg Laparosc Endosc 12:115–116
Novitsky YW, Cobb WS, Kercher KW, Matthews BD, Sing RF, Heniford BT (2006) Laparoscopic ventral hernia repair in obese patients: a new standard of care. Arch Surg 141(1):57–61
Ponsky TA, Nam A, Orkin BA, Lin PP (2006) Open, intraperitoneal, ventral hernia repair: lessons learned from laparoscopy. Arch Surg 141(3):304–306