Incision

The patient is placed supine (face up) on the operating room table with a pillow placed under the knees and proximal things to slightly flex the hips and remove tension off the abdominal wall. If the hernia is lateral to the midline, the patient may have the side that the hernia is on elevated with pillows to facilitate exposure.

Generally, there is one 10 mm port used as the video port and 2 to 4 5 mm ports used to place the operating instruments. Generally the ports are placed in a configuration that fashions a triangle.

The Hasson cannula placement technique is used for both midline and lateral entries. The abdomen is insufflated to 15 mmHg and the camera is white-balanced and anti-fog solution is placed on the end of the camera.

The operating ports are placed under direct visualization after the skin is infused with a long-acting anesthetic and external palpation is performed to ascertain videoscopically that the entry point into the abdominal cavity is not in an area of dense adhesions.

A No. 11 blade is used to make stab wounds in the skin and the trochars are placed bluntly under direct visualization.

Indications

Incisional hernias greater than 2-3 cm in diameter

Spontaneous hernias (e.g., umbilical, epigastric, spigelian) greater than 2-3 cm in diameter.

Contraindications

Small hernias less than 2.5 cm (best repaired by primary tissue repair without mesh).

Extremely large hernias with loss of abdominal domain (i.e., bowel is essentially outside of the body).

Presence of extensive, dense intraabdominal adhesions such as seen in repeated abdominal surgeries or peritonitis or peritoneal dialysis.

Inability of patient to tolerate pneumoperitoneum (air placed into the peritoneal cavity to a pressure of 15 mmHg).

Surgical Details of Procedure

1. Selection of the appropriated two-sided mesh to be used to close the defect. Most commonly these meshes have a “bowel side” which is a non-adherent, polytetrafluoroethylene (PTFE) material and an “abdominal wall side” that is a polypropylene (Marlex) grid that allows for incorporation and ingrowth of the tissues of the underside of the abdominal wall.

2. The omentum to be dissected away from the hernia sac is grasped with endoscopic forceps and gentle traction is applied.

3. The border between the omentum and peritoneum is incised (cut) using laparoscopic scissors. Use of cautery to incise this tissue is discouraged because of the possibility of thermal injury to the bowel.

4. After each time a segment of tissue is cut, a sweeping motion is performed in the next area to be cut to better visualize the tissue plane.

5. The surgeon proceeds to “spread, cut, and sweep” until the entire junction between the omentum and the hernia sac is incised.

5. In addition to the sweeping motion, to better visualized the tissues, external finger pressure can be placed onto the hernia to “push the hernia into the belly.”

6. After the omentum is completely freed from the peritoneum at the edge of the hernia sac, it is reduced (placed back) into the peritoneal cavity from the hernia sac.

7. The peritoneum in the hernia sac is left intact.

8. The pressure in the abdomen is then lowered from 15 mmHg to 6-8 mmHg for correct sizing of the mesh to be placed. Keeping the intraabdominal pressure at 15 mmHg will result in too large of a mesh being placed with consequent “center sag” plaguing the repair.

9. The surgeon must carefully inspect the perimeter of the hernia sac to insure there is adequate free margins for securing the mesh. The minimum margin needed cirumferentially is 4 cm.

10. Most surgeons use an external marking system to mesh the needed size of mesh.

11. A long needle is placed externally in all four quadrants at the edge of the hernia defect and position is confirmed with the videoscope.

12. The skin sites of the needles are marked with indelible ink and a line on the abdominal wall is drawn to determine the perimeter of the defect and the required size and shape of the mesh.

13. A 4 cm margin is then drawn outside of the externally marked ink lines of the defect.

14. Four sutures are then placed in the dual-sided mesh with two sutures placed in opposite quadrants in a parallel manner (i.e., from the polypropylene side to the PTFE side and then from the PTFE side to the polypropylene side ) and two placed in opposite quadrants in a perpendicular manner (from the
polypropylene to the PTFE side).

15. Many surgeons orient the sutures so that the parallel sutures are placed in the 12 o’clock and 6 o’clock positions and the perpendicular sutures are placed in the 3 o’clock and 9 o’clock position.

16. Each suture is tied with the long tails left attached.

17. The dual mesh plug is then rolled tightly with the PTFE on the inside and the polypropylene side on the outside.

18. The rolled up mesh must then be passed into the abominal cavity. There are several ways to do this. One techinque is to remove the camera from the 10 mm video port which is usually in the left or right abdominal position.

19. A grasping forceps is then placed through the video port until it is seem on the outside of the patient.

20. The video port is then removed and the rolled mesh is placed in the grasper’s jaws and pulled into the abdominal cavity.

21. The video port is then replaced.

22. The mesh is then unrolled and the PTFE side is placed toward the bowel.

23. Either the 12 o’clock or 6 o’clock sutture is used to begin to secure the mesh to the underside of the abdominal wall.

24. A No. 11 scalpel is used to create a small skin wound at previously marked skin site of the desired suture.

25. A laparoscopic suturing needle is passed roughly perpendicularly through the abdominal wall and under direct visualization.

26. One of the loose ends of the suture is grasped and pulled out through the abdominal wall and secured with a hemostat

27. Using the same 3 mm skin incision, the laparoscopic suture needle is again passed roughly perpendicularly but is aimed about 1 cm away from the point where the first pass was intended.

28. The suture ends are then tied down firmly into the subcutaneous tissues.

29. Each of the other three previously placed sutures are brought up through the abdomen in a similal fashion.

30. Care must be taken to prevent the polypropylene edge of the mesh from rolling over so that it is exposed to bowel.

31. The mesh is inspected to insure that it lies flat against the inside of the abdominal wall and is slightly loose but not wrinkled.

32. The entire perimeter is now tacked to the inside abdominal wall using endoscopic tacks spaced 1 cm apart.

33. The tacks are placed after the surgeon places external pressure with the fingers pushing down on the outside abdominal wall to provide resistance to the tack applier.

34. Care must be taken so that no gap exists that would allow bowel or omentum to work its way under the edge of the mesh.

35. Most surgeons lavage the abominal cavity with the endoscopic suction irrigator and careful inspection is made for bleeding sites or the presence of bile or succus.

36. The ports are removed under direct visualization and the carbon dioxide in the abdomen is vented with close inspection of the mesh to insure that it is positioned properly on the underside of the abdomen.

37. The fascia opening of the 10 mm port is closed with a 2-0 absorbable suture and the skin is closed with 4-0 monocryl subcuticular stitches.

Lichtenstein Repair (aka tension-free repair or plug-and-patch repair)

Indications

Indirect inguinal hernia – this type of hernia occurs because of the weakness of the tissue in and around the inguinal canal. The tissue in this hernia projects through the internal inguinal ring that the spermatic cord and vessels traverse. By definition this hernia lies lateral to the inferior epigastric vessles. Contents of indirect inguinal hernias can include fat, bowel, peritoneum, and bladder. These hernias are extremely common and occur in 5% of men – they are the hernia that is most common in young men.

Direct inguinal hernia – these hernias are more common in older men. They are caused by a weakness in the anterior abdominal wall muscles and by definition protrude medial to the inferior epigastric vessels.

Incision

Parallel to inguinal ligament – this is the most common incision and is made approximately two finger breadths above the imaginary line running from the anterior iliac spine to the tubercle of the pubic bone. If there is a palpable bulge the over the external ring the incision is carried down to this area. The trend in hernia surgery is to make smaller incisions and most hernias can be repaired in non-obese patients through a 6-7 cm incision.

Surgical Details of Procedure

1. The incision is made through the skin with a No. 10 scalpel.

2. Dissection is carried through the subcutaneous tissue and through Scarpa’s fascia with Bovie cautery.

3. The fascia of the external oblique is appreciated and dissected free of the surrounding tissue.

4. A self-retaining retractor (e.g., Weitlander retractor) is placed to allow good visualization of the external oblique fascia.

5. A small incision is made in the center of the external oblique fascia along the lines of tissue.

6. The closed tips of a Metzenbaum scissors are placed through this small incision and pushed under the external oblique fascia both caudally (toward the feet) and cephalad (toward the head) to dissect away the ilioinguinal nerve that may be on the anterior surface of the cord.

7. The Metzenbaum scissors is then used to incise the external oblique fascia both cephalad and caudally.

8. The free edges of the fascia are grasped with hemostats and used to retract the fascia up into the wound to expose the cord.

9. Blunt dissection is then used (usually a gauze sponge over the surgeons forefinger or thumb) to dissect the cord and internal oblique muscle away from the underside of the external oblique fascia.

10. Most surgeons then make a diligent search for the ilioinguinal nerve which usually lies on the anterior part of the cord.

11. If located this is carefully dissected free from the cord with care taken to not directly grasp the nerve.

12. When the external oblique fascia is sufficiently dissected away from the cord the hemostat on the upper edge of the external oblique fascia is released and the nerve is put of the outside of the external oblique fascia and the hemostat is reapplied.

13. The self-retaining retractor is then moved to the inside of the cut edges of the fascia.

14. Using the tip of the forefinger that is placed on the pubic tubercle the cord is then bluntly dissected free of the floor of the inguinal canal. When mastering this maneuver surgical trainees are taught to “scrape your fingernail against the bone.”

15. A soft Penrose drain is then passed underneath the cord and any hernia contents.

16. An inspection is then made of the floor of the inguinal canal to ascertain if a direct hernia is present.

17. Regardless of whether a direct hernia is present, a diligent search must be made for an indirect hernia.

18. To locate an indirect hernia, the tissue layers of the cord must be carefully and meticulously dissected away from the spermatic vessels and spermatic cord.

19. This is done by blunt dissection of the cremasteric muscle fibers using a “stripping” technique that pulls the muscle fibers toward the internal ring.

20. Care must be taken not to injure the “cord structures” – the spermatic vessels and the vas deferens

21. When the hernia sac (a portion of the normally intraabominal peritoneum) is located in the cord tissues (it is a thin white filmy line) the edge is grasped with two fine-tipped hemostats.

22. A diligent search must be made for an accompanying cord lipoma (mass of intraperitoneal fat that has travelled with hernia through the internal ring).

23. If present the cord lipoma must be dissected free of the hernia sac down to the level of the internal ring.

24. The cord lipoma is usually transected with a bovie cautery after a stay suture of usually 2-0 Vicryl is placed at the base of the lipoma close to the internal ring.

25. After it is transected the lipoma remnant usually retracts into the abdomen.

26. The hernia sac is then opened so it can be inspected internally for presence of bowel or bladder wall.

27. This is done by retracting the hemostats placed on the edge of the sac and retracting up into the wound and making a small incision at the top edge with a Metzenbaum scissors.

28. The inside of the sac is then inspected for bowel or the side wall of the bladder.

29. If bowel is present it is manually reduced back into the abdominal cavity (i.e., pushed back into the abdomen with the surgeon’s finger)

30. If bladder is present it is more difficult to manually reduce. The level of intrusion is noted and care is taken to ligate the sac above the edge of the bladder.

31. The ligation of the hernia sac is performed by either twisting the cord and placing an absorbably suture at the cinch area or by placing a pursestring suture under direct visualization and then cinching this down onto the walls of the hernia sac.

32. The sac above the ligation is then resected (cut-off) and the hernia sac is allowed to retract into the abdomen.

33. If a direct hernia is present in the floor of the canal the surgeon may choose to close this with a mesh plug that resembles a badminton birdie.

34. The plug is moistened and then the edges are approximated with a hemostat and it is fitted gently into the defect so that the mouth of the plug springs open at the level of the fascial ring.

35. It is then secured in place using interrupted sutures (e.g., 2-0 or 3-0 Prolene sutures).

36. If there is an indirect hernia the surgeon will select the appropriately sized mesh patch.

37. The toe of the mesh is usually sutured in place first with a 2-0 or 3-0 Prolene suture placed into the fascia of the pubic tubercle and then through the edge of the mesh.

38. Interrupted sutures as above are then used to fasten the mesh (which is roughly fish-shaped with two tails fashioned from the one end due to the slit in the patch) circumferentially to the inguinal ligament and the conjoined tendon.

39. The tails of the mesh patch are wrapped around the cord with additional length given to the slit to ensure that the cord is not strangulated.

40. If a previously placed plug had been positioned in a direct hernia the mesh patch should completely cover the edges of the plug.

41. After the mesh patch has been secured circumferentially, the tip of the little finger is placed between the cord and the edge of the mesh to insure that the repair is not overly tight.

42. Many surgeons at this juncture ask the anesthesia team to valvsalva the patient (similar to pushing down when having a bowel movement) to insure that the plug and patch do not unduly move too much.

43. The wound is then irrigated with saline solution (many surgeons add an antibiotic such as kanamycing to the irrigation).

44. The hemostats are released and the nerve if it has been identified is gently restored to the anterior of the cord.

45. The edges of the external oblique are reapproximated using a running 3-0 Vicryl stitch.

46. The wound is then irrigated again and the subcutaneous tissue and Scarpa’s fascia is reapproximated using interrupted 3-0 Vicryl stitches.

47. The skin is closed using staples or a running subcuticular 4-0 absorbable suture such as Monocryl.

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