Laparoscopic repair of strangulated incisional hernia

This video presents a case of strangulated incisional hernia in the McBurney's position. The surgeon frees omental adhesions before reducing the hernial contents, which included a dusky small bowel. No resection was necessary. The hernial sac is then dissected and delivered into the peritoneal cavity. The defect in the abdominal wall is small and is closed primarily with interrupted sutures. The area is then covered with a vicryl mesh, which is anchored to the abdominal wall. The peritoneum is used to cover over the mesh.

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Laparoscopic repair of strangulated incisional hernia

Authors

M Simone, J Marescaux

Abstract

This video presents a case of strangulated incisional hernia in the McBurney's position. The surgeon frees omental adhesions before reducing the hernial contents, which included a dusky small bowel. No resection was necessary. The hernial sac is then dissected and delivered into the peritoneal cavity. The defect in the abdominal wall is small and is closed primarily with interrupted sutures. The area is then covered with a vicryl mesh, which is anchored to the abdominal wall. The peritoneum is used to cover over the mesh.

Classification

complex cases

Keywords

strangulated incisional hernia, right iliac fossa, laparoscopic repair, vicryl mesh

Media type

Surgical video

Duration

05'00''

Publication

2005-02

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E-publication

WeBSurg.com, Feb 2005;5(02).
URL: http://www.websurg.com/doi-vd01en1544.htm

Laparoscopic repair of strangulated incisional hernia

1. Case presentation 00'08''

This video will demonstrate laparoscopic repair of a strangulated incisional hernia. The patient was admitted as an emergency with acute abdominal pain and intestinal obstruction. There was no flatus passed for the preceding 2 days. The patient has had 3 previous operations including a cholecystectomy, appendicectomy, and prostatectomy for cancer. Clinical examination revealed an irreducible hernia in the right iliac fossa at McBurney’s point.

2. Hernia reduction and sac dissection 00'37''

A decision was made to take a laparoscopic approach. Following division of the omental adhesions, we can see the hernia here from the laparoscopic view. This is reduced using a double pressure technique using external compression together with traction internally. The segment of bowel seems viable. The hernial sac is then reduced by grasping the peritoneum from the inside. We start the repair of the defect by opening the peritoneum above the hernial sac in order to avoid the deep inguinal ring. The dissection is continued using traction and sharp dissection in order to separate the peritoneum from the abdominal wall. This is done until the hernial sac is completely free. The sac is almost completely reduced now. The hole in the abdominal wall is clearly visible. Now enough space needs to be created preperitoneally in order to accommodate the prosthetic mesh. We make a thorough check for hemostasis in order to avoid any hematoma around the mesh.

3. Dissection of spermatic cord 02'54''

Here we see the vas deferens and the genital vessels going into the deep inguinal ring medially. These structures are isolated by careful dissection. The anatomy is demonstrated clearly here with the cord structures going into the deep inguinal ring. As you can see, the defect is situated superolaterally from the deep ring.

4. Hernia repair 03'48''

Once we are certain that the inguinal elements are away, we continue with the repair of the defect. Two non-absorbable interrupted sutures are inserted to close the defect. We then measure the area in order to fashion a suitably shaped mesh. A resorbable Vicryl mesh is used due to the possible contamination from the bowel strangulation increasing the risk of infection with a non-resorbable mesh. Once the mesh is lying comfortably, the peritoneum is brought back over it. This is then tacked to its original position using the staple gun device. Once this has been achieved, the strangulated portion of bowel is again inspected for viability. It looks intact and well-vascularized. This is the end of the operation.