Recurrent incisional hernia: laparoscopic management with a collagen-coated double layer mesh

Laparoscopic incisional hernia repair using a mesh is an effective method and is associated with lower complication rates. The use of meshes has become essential for the repair of all hernias since the recurrence rates are consistently lower when meshes are used. In order to prevent recurrence, the principle of the overlapping of the defect must be respected. In this video, the case of a 60-year-old patient with a recurrent incisional hernia is presented. The operation is performed using 3 ports. One port is a 10mm one for the camera and we use two 5mm ports for the instruments.

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Recurrent incisional hernia: laparoscopic management with a collagen-coated double layer mesh

Authors

D Mutter, J Marescaux

Abstract

Laparoscopic incisional hernia repair using a mesh is an effective method and is associated with lower complication rates.
The use of meshes has become essential for the repair of all hernias since the recurrence rates are consistently lower when meshes are used. In order to prevent recurrence, the principle of the overlapping of the defect must be respected. In this video, the case of a 60-year-old patient with a recurrent incisional hernia is presented. The operation is performed using 3 ports. One port is a 10mm one for the camera and we use two 5mm ports for the instruments.

Classification

new techniques

Keywords

Recurrent incisional hernia, laparoscopic management, collagen-coated dual mesh

Media type

Surgical video

Duration

09'18''

Publication

2009-06

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E-publication

WeBSurg.com, Jun 2009;9(06).
URL: http://www.websurg.com/doi-vd01en2578.htm

Recurrent incisional hernia: laparoscopic management with a collagen-coated double layer mesh

1. Introduction 00'21''

We report the case of a 69-year-old patient presenting with a recurrent incisional hernia. Clinically, the defect appears to be about 5cm in size. We usually perform this operation using 3 ports. One port is a 10mm one for the camera and we use two 5mm ports for the instruments.

2. Freeing of adhesions 00'55''

Dissection starts always by the freeing of the previous adhesions. There is a debate whether there is a need or not to open and to remove the peritoneum from the defect. In such a case when the defect is located very high in the abdomen, we prefer to lower the peritoneum in order to avoid the placement of the mesh above the round ligament. As you can see, we started the procedure by opening the peritoneum and lowering the whole peritoneum around the defect. We do not resect systematically the sac. Today, there is no demonstration about the potential benefit of the sac resection. There is no difference in the frequency of the postoperative seroma. The main objective of this freeing is to see whether the patient has multiple perforations or whether this patient has only a single defect in the peritoneum.

3. Dissection of the defect\'s edges 02'08''

The edges of the defect are progressively dissected, then very clearly identified. This is very much a key point of the procedure in order to exactly assess the size of the defect and to ideally place the mesh. In this patient, part of the sac is lowered and dissected and part of the sac is left in the abdomen. One of the risks of the dissection of the sac, if the patient is not fatty, is to have the skin attracted into the abdomen leading to a skin injury. In this case, we prefer to cut the attachments and to leave part of the sac in place. The main risk at this stage is to have a small bowel injury during the manipulation. So a very clear view of the operative field must be kept at all times. The objective is to obtain a place to put the mesh, a place that is much bigger than the size of the defect. The usually admitted rule is to have the mesh overlap the defect over about 5cm on all of its size.

4. Identification of defect position and introduction of needles transparietally 03'26''

We identify very clearly the position of the defect and the size of the requested mesh. We place needles transparietally. These needles are used as landmarks. Here as you can see, the landmarks allow us to draw on the skin the position and the ideal size of the mesh.

5. Mesh insertion 03'48''

Here we use a collagen-protected mesh of about 15 by 15cm. This mesh is rolled onto itself and is placed in the abdomen. The drawing we have on the skin has a second major importance. It will be used to fix very clearly the 4 edges of the mesh. Here you can see that the mesh was inserted after being rolled into a swab.

6. Mesh fixation 04'20''

The stitches on the edges will be taken using a Berci needle. The 2 parts of the stitches are taken separately outside in order to allow a fixation with a very slight tension laterally. The Berci needle is inserted directly under direct vision. This needle is inserted after a very small incision, which will not be closed at the end of the procedure due to its very little size. We try to avoid placing too much tension on this in order to let the mesh in contact to the bowel at this level. In fact, the tension on the mesh will not allow to very clearly see the Berci needle outside. Here the Berci needle grasps the second edges of the mesh. The distant edges are placed first and the edges close to the camera are fixed secondly. Fixation of the mesh at its 4 edges really represents a key point of the ideal fixation of the mesh. It is the only way to be sure that the mesh well overlaps the defect over more than 5cm. Here a little grasper is placed on the stitches in order to avoid too much tension. When the 4 stitches are fixed, it is possible to suture them with the knot placed through the skin. At this stage, we are sure that this mesh overlaps the defect over 5cm. Then we place a double crown suture using clips fixing the mesh all around the defect.

7. Fixation of protacks 06'56''

Protacks are used, non-absorbable ones that safely fix the mesh all around the defect. The mesh is placed without tension. We perform a tension-free repair without suture of the defect of the parietal wall. After having placed the tackers all around the mesh, a crown of tackers is placed just around the defect. This is controlled by hand counter-pressure placed around the defect. This technique allows a very safe and clear positioning of the mesh and a very nice overlapping of the mesh over the defect. Here we can see very clearly the tackers around the defect and the overlap of the mesh. Remaining tackers are used here. The round ligament in this patient is placed over the mesh. Some peritoneum in excess is removed. In fact, in such a patient, we use a collagen-coated mesh that can stay in contact to the small bowel and it is useless to preserve too much peritoneum. Here we just fix again the round ligament in its correct position thanks to several tackers. Removing the round ligament would induce a risk of postoperative bleeding, that is why we prefer to completely recreate the normal anatomical situation. In case of re-operation, this would also simplify the surgical procedure. No drain is used. The patient can be discharged the day after the surgical procedure.