This video demonstrates Suprapubic Incisional Hernia Repair by Mishra's Knot and Mobilization of the Urinary Bladder Performed by Dr. R.K. Mishra at World Laparoscopy Hospital. The suprapubic hernia is the term to describe ventral hernias located less than 4 cm above the pubic arch in the midline. Hernias with an upper margin above the arcuate line encounter technical difficulties, and the differences in repair methods forced us to define them as large suprapubic hernias. Laparoscopic repair of large suprapubic hernias can be considered the first option in treatment. The low recurrence rates reported in the literature and the lack of recurrence, as observed in our study, support this view.

Suprapubic incisional hernias occur in the lower abdominal region, often due to previous surgical procedures such as cesarean sections, hysterectomies, or pelvic surgeries. These hernias can cause discomfort, pain, and complications such as urinary disturbances. Surgical repair is essential to restore abdominal wall integrity and prevent recurrence. One effective technique for repair is the use of Mishra’s Knot for secure fixation combined with mobilization of the urinary bladder to create a tension-free repair.
 
Surgical Technique
 
1. Preoperative Preparation
- Detailed patient evaluation, including imaging (CT scan or ultrasound), to assess hernia size and location.
- Bladder catheterization to prevent intraoperative injury.
- Antibiotic prophylaxis to reduce infection risk.
 
2. Surgical Approach
- Incision and Exposure: A lower midline or previous incision is reopened to access the hernia sac. Adhesiolysis is performed to free the intestines and surrounding structures.
- Bladder Mobilization:
- The urinary bladder is carefully dissected and mobilized inferiorly to prevent tension during mesh placement.
- This step is crucial, as suprapubic hernias often involve bladder adherence to the hernia sac.
- Defect Closure with Mishra’s Knot:
- The hernia defect is approximated using Mishra’s Knot, a secure extracorporeal knot-tying technique that provides high tensile strength.
- This knot reduces tension at the suture line and minimizes the risk of recurrence.
 
3. Mesh Placement
- A non-absorbable polypropylene or composite mesh is placed in a sublay or onlay fashion to reinforce the repair.
- The mesh is fixed with Mishra’s Knot at multiple anchor points, ensuring stability.
- The bladder is repositioned to avoid contact with the mesh.
 
4. Wound Closure and Postoperative Care
- The layers of the abdominal wall are meticulously closed.
- A drain may be placed to prevent seroma or hematoma formation.
- Postoperative bladder function is monitored to detect any voiding dysfunction.
 
Advantages of This Technique
- Mishra’s Knot ensures a strong and secure repair with minimal suture-related complications.
- Bladder mobilization reduces tension, preventing recurrence and postoperative urinary retention.
- Lower recurrence rates compared to conventional suturing techniques.
- Minimally invasive approach possible with laparoscopic modifications.
 
Conclusion
Suprapubic incisional hernia repair using Mishra’s Knot and bladder mobilization is a highly effective technique. It ensures a secure, tension-free closure, reduces recurrence rates, and preserves urinary function. Surgeons should consider this approach for optimal patient outcomes in complex suprapubic hernias.