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.