Laparoscopic approach for recurrent incisional hernia

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Laparoscopic approach for recurrent incisional hernia

Authors

M Simone, J Marescaux

Media type

Surgical video

Duration

07'00''

Publication

2005-10

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E-publication

WeBSurg.com, Oct 2005;5(10).
URL: http://www.websurg.com/doi-vd01en1672.htm

Laparoscopic approach for recurrent incisional hernia

1. Case description 00'00''

This is the case of a female patient 48 years old who presents with chronic abdominal pain in the left iliac fossa. In this area exists an incisional scar from a remote Pfannenstiel incision as well as a mesh repair of an incisional hernia of this incision performed 2 years ago.

2. Incisional scar 00'13''

On physical exam, it is noted that the repair has a recurrent hernia in the area of the patient’s pain. There is no evidence of incarceration of the hernia sac contents and the patient is offered an elective laparoscopic repair of this hernia. The patient is placed in a right lateral decubitus position. The surgeon and assistant are oriented above the patient similar to a laparoscopic inguinal hernia repair with the surgeon opposite the site of the hernia and the assistant on the left side of the patient operating the camera. On the initial review of the left lower quadrant we identified the hernia defect. We utilize a total of 3 ports for this procedure. The first is a 12mm port that is placed in the umbilical region to be utilized for the video laparoscope, and the 2 operative ports will then be placed in the left and right flank of the patient as you see being utilized at this time. We begin the dissection with the opening of the peritoneum by monopolar cautery. Note that the bowel is out of harm’s way. The positioning of the patient as well as the right lateral tilt and Trendelenburg table orientation also aids in the exposure.

3. Old mesh removal 01'30''

We begin to open the peritoneum a few centimetres away from the defect of the abdominal wall and use gentle traction to separate it from the preperitoneal fat. The mesh comes into view and is obscuring the full view of the defect. We therefore elect to resect some of it to aid in the visualization of our repair. The round ligament will soon come into view as well. This round ligament will impair our proper coverage of the mesh over the defect so we will also dissect this out of the way as well. The mesh was placed posterior to the fascia in a previous repair and therefore has an intimate relationship.

4. Round ligament 02'19''

We resect the mesh and the associated peritoneum however since we will have a large surface area free of peritoneum and we don’t anticipate difficulty in re-approximation of the peritoneum at the end of the procedure despite having to resect this peritoneum. As the hernia defect is adjacent to the inguinal region, we will utilize this anatomy in planning our placement of the mesh. We therefore identify the pubic bone medially, the epigastric vessels anteriorly and avoid the inferior danger zone when we will place our tacks for the mesh. Currently we are dissecting free the preperitoneal fat from the peritoneum as well as the round ligament. We utilize this stapling device to ligate the ligament and then we cut it with the scissors once again obtaining a clear area for the mesh to be placed. Once the round ligament is ligated we can see that we have an open area here as well as the incisional hernia.

5. Incisional hernia 03'29''

We complete some additional dissection of the peritoneum more anteriorly to create a good 5cm circumference about the defect that maintain proper mesh placement.

6. New mesh placement 03'44''

The Endoroll mesh is then placed into the patient which is a polypropylene mesh. This mesh is then oriented appropriately as stated before to maintain at least 5cm circumferentially from the edge of the defect. As we believe this was part of the reason for the recurrence of the previous posterior placement hernia repair. After we note the mesh to be in the appropriate position we utilize a tacking device to approximate the mesh to the pubic bone as well as to the anterior abdominal wall. Alternatively we can also utilize a stapling device for the same task.

7. Reperitonization 04'37''

An important tenet in the placement of a preperitoneal mesh is that of maintaining the mesh out of the intra-abdominal cavity. Good dissection under the peritoneum away from the anterior abdominal wall allows this larger piece of mesh to be maintained anterior to the peritoneum and thereby avoiding minimal risk of the mesh coming in contact with the intra-abdominal contents. Utilizing the tacking device, we place our hand exterior to aid in the placement of the tacks. The peritoneum is then re-approximated with the tacking device and after we note the peritoneum re-approximation. And after noting appropriate needle instrument and sponge counts we remove our trocars under direct visualization and approximate the 12mm port site fascial incision with absorbable sutures. We remove the mesh through the port site prior to the completion.