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Laparoscopic treatment of subcostal incisional hernia

Authors

Abstract

One of the disadvantages of open nephrectomy is the appearance of symptomatic incisional hernias. In this video, we present the case of a patient with a subcostal incisional hernia occuring after an open nephrectomy repared laparoscopically.

Classification

tips and tricks

Keywords

laparoscopy, treatment of subcostal incisional hernia, eventration

Media type

Duration

08'25''

Publication

2008-10

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E-publication

WeBSurg.com, Oct 2008;8(10).
URL: http://www.websurg.com/doi-vd01en2412.htm

Laparoscopic treatment of subcostal incisional hernia

1. Clinical case presentation 00'18''

This video demonstrates the laparoscopic surgical treatment of an incisional hernia in a 60-year-old male patient with a previous surgical history of right nephrectomy operated on in 2003. This patient presents with an approximately 10cm symptomatic incisional hernia that will be managed laparoscopically through the placement of a 10 by 15cm mesh. The patient is placed in a supine position. A 10mm optical trocar is introduced at the umbilicus and two other 5mm trocars will be placed on the midline.

2. Hernia defect identification 00'50''

At this stage, the parietal defect can be observed and the mobilization of the defect is undertaken at its inferior border. In this case, the mobilization is started at the right parietocolic level and dissection is performed using monopolar scissors.

3. Hernia sac dissection 01'05''

Dissection is continued on the inferior limit of the incisional hernia. The right triangular ligament of the liver is divided, thereby allowing for a better view of the operative field. Here the amplitude of the defect can be observed very clearly and dissection of the peritoneum covering this defect is carried out commencing at its inferior border. During surgery, the defect is measured: it is a 7 by 8cm defect. Dissection of the peritoneum is continued with monopolar cautery in a cephalad direction at the level of the left border. Dissection has the objective of partially mobilizing the hernia sac without resecting it totally. Once this partial mobilization has been achieved, further freeing of the peritoneum is achieved at the free border of the hernia. This will allow for the posterior placement of the mesh. External compression is exerted and the limits of the dehiscence can be clearly identified.

4. Approximation of the hernia’s borders 03'30''

In order to reduce the size of the incisional hernia and reinforce the reconstruction, a suture is placed to approximate the edges of the defect. A non-absorbable running braided 0 suture is used. The running suture is started at the inferior limit of the hernia. Final traction is being exerted on the running suture using further external compression. Once the repair has been achieved, a slight mobilization is achieved at the level of the peritoneal flap.

5. Mesh placement and fixation 05'23''

Then, a 10 by 15cm dual layer mesh is placed. The protective anti-adhesive transparent film stays in contact with the abdominal cavity. Fixation of the mesh is started at its superior extremity. To do so, and with the help of a stapler, tackers are introduced through the 5mm trocar. The mesh is partially divided so that it fits the size of the hernial defect.

6. Peritoneal mesh covering 06'18''

The next step consists in covering the mesh using the peritoneal flaps that had been previously mobilized although it is not absolutely mandatory to do so because of the anti-adhesive characteristics of the mesh that has just been placed. As can be seen here, the mesh is being covered and sutured in place with the aid of tackers. Here is the final view of the intervention.

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