Christos Dimitriou, MD
World Laparoscopy Hospital
FMAS & DMAS, November 2016

Indications

Incisional hernias in the anterior abdominal wall are the most common type of ventral hernias; the other type being spontaneous hernias (i.e umbilical, epigastric and spigelian). An estimated 2-10% of all abdominal operations result in an incisional hernia. Fortunately, the development of new meshes such as the dual-sided mesh over the last years has allowed for a safe laparoscopic approach to the repair of such hernias. Although an expensive operation, the laparoscopic approach shortens the operating time and the hospitalization of the patient while the incisions cause less pain and there is a faster return to normal daily activities. Relative contraindications of this surgery include extremely large hernias with loss of abdominal domain or those associated with extensive, dense intra- abdominal adhesions.

Approach Considerations

The basic surgical principles of laparoscopic repair include the following: no tension technique, appropriate trocar placement and the use of mesh. The number of trocars used and their placement are related to the location and the size of the hernia, as well as the surgeon’s experience and choice. 

Preoperative Preparation

The patient must be free of skin infections and the respiratory function must be evaluated and optimized before the operation. If the hernia contains parts of the gastrointestinal tract such as bowel, appropriate imaging and endoscopy may be performed in order to avoid any intraoperative complications. The patient may be given a bowel preparation prior to surgery.

Anesthesia

General Anesthesia with endotracheal tube is required.

Operative Preparation

Perioperative antibiotics should be given according to the most recent national guidelines. The stomach must be decompressed with an orogastric tube, a Foley catheter must be placed and stockings are applied. The skin is prepared in a routine manner using antiseptics.

Position

The patient is placed in a supine position. A pillow might be placed under the knees as to relax the abdominal wall by producing mild flexion of the hips and knees. 

Instruments and Surgeon Position

All devices and instruments needed for the operation must be checked for proper function. The surgeon’s position must follow the principles of ergonomics in laparoscopic surgery i.e. suitable table height at 0.49 of surgeon’s height, alignment of surgeon, hernia and monitor, placement of monitor at a distance of 5 times its diagonal diameter and at a height no less than approximately 20cm from his/her visual axis.

 Incision and Exposure

The 10mm port of the laparoscopic telescope and the 5mm instrument ports are a function of the position of the hernia defect and the preference of the surgeon. The “Diamond-Baseball” principle of port placement should be followed for better ergonomics. Good exposure, traction, countertraction and good working angles between the instruments and the patient must never be compromised in an attempt to use fewer trocars. The ports need to be placed at a distance no less than 5cm with each other. One of the operating ports could be 10mm in size. 
The surgeon must decide where the entrance to the peritoneal cavity should be. A safe site for primary entrance would be Palmer’s point at ~3 cm below the left costal margin in the mid-clavicular line. Access to the peritoneal cavity is gained using either the closed or the open technique.

For the closed technique:

• Make an incision on the skin, no more than 3mm using a scalpel blade No. 11
• Lift the abdominal wall and insert the Veress needle through the incision at a 45o elevation angle but perpendicular  to the abdominal wall.
• After you hear the “double click” sound, do ascertainment tests (irrigation,aspiration and hanging drop tests) to check the correct placement of the needle

For the open technique:

• Make a transverse incision of 11mm according to the Langer lines
• Dissect the subcutaneous tissue and expose the sheath of the rectus abdominal muscle below
• Incise the sheath and dissect the external, internal and transverse abdominal muscles until you reach the peritoneum
• Grasp the peritoneum with two artery forceps
• Cut the peritoneum with caution as abdominal structures may lay underneath
• Insert the cannula using the blunt trocar into the peritoneal cavity
• Secure the port with lateral stay sutures 

When access is achieved,

• Connect the CO2  either to the Veress needle (for closed technique) or the port (for open technique)
• Begin inflating the intraperitoneal space according to the principles of insufflation
• Observe the rise of the intra-abdominal pressure and the total volume of gas as the abdomen and hernia distend

Regarding the first technique, after the intra abdominal pressure reaches 12-15mmHg,

• Take the needle out of the abdomen
• Enlarge the incision up to 11mm and
• By lifting the abdominal wall, slowly screw the cannula with the trocar into the peritoneal cavity

The camera is white-balanced and focused. The telescope is advanced down the port into the abdomen under direct vision and:

• All four quadrants of the abdomen are explored
• The hernia and its contents are evaluated
• Additional unrecognized hernia defects may be found
• Omental and other adhesions to the abdominal wall are visualized
• The 5mm instrument ports are placed after transillumination of the abdominal wall using the telescope, to show any regional  vessels within the abdominal musculature

Procedure

Adhesiolysis and reduction of the contents of the hernia sac.

In the typical incisional hernia, there are adhesions between the omentum and the hernia sac.
• Grasp the omentum near the abdominal wall with the forceps or the dissecting instrument
• Apply gentle traction
• Incise sharply the junction of the omentum with the peritoneum of the abdominal wall using laparoscopic scissors
• Reduce the sac into the abdominal cavity
• Any bleeding that might occur should be controlled

Alternatively,

• Invert the hernia sac externally using fingers
• Continue sharp cutting after visualizing the junction of the omentum with the peritoneal sac
Electrocautery should be minimal in order to avoid thermal injury of any structures involved in the hernia. If there is no clear plane between the intra-abdominal viscera and the abdominal wall, some surgeons resect abdominal wall tissue to preserve bowel integrity Existence of extensive dense adhesions, inability to reduce the hernia contents from the sac, or a bowel injury which is not easily repaired, requires conversion to an open laparotomy. Should the latter complication occurs, is regarded by many surgeons as a contraindication to the placement of mesh.

Mesh Placement

• Make a measurement of the perimeter of the defect and make sure there is clear zone for attachment of the mesh and for applying the sutures/clips
• Lower the intra-abdominal pressure to 6-8 mmHg and identify/mark the edges of the defect on the abdominal wall. If measurements are made with the abdomen fully inflated, the mesh will be too large
• Measure the defect’s size
• Choose the size of the mesh, and cut if necessary
• Place unabsorbable anchoring sutures at 5 to 6 cm intervals around the periphery of the mesh (usually four sutures at the
 corners at 3,6,9 and 12 o clock)
• Tie each suture in its midpoint and leave the long tails intact
• Mark the sites of the skin corresponding to the sutures
• Roll the mesh, or fold it in any other way you consider convenient
• Introduce the mesh to the abdominal cavity through the 10mm 
• Unfold and orient the mesh by making sure the right surfaces are facing towards the hernia and the abdomen
• Make a 1-2mm skin openings at the marked sites
• Pull the sutures through the abdominal wall muscles with a suture-passer instrument
• Secure the preattached sutures at the four quadrants setting the knot deeply
• Use an endoscopic stapling device such as a tacker to secure the exposed perimeter of the mesh
• Place the tacks 1 cm apart, applying external counterpressure with the hand while tacking 
Some surgeons, create a double-circle configuration with the outer line located close to the edge, to prevent the mesh from folding on itself.
Upon completion of the procedure:
• Lavage using the suction irrigation
• Inspect the abdomen for any bleeding sites
• Remove the operating ports under direct vision checking for bleeding sites
• Release the pneumoperitoneum
• Close the fascia of the 10mm trocar site with 00 delayed absorbable sutures
• Approximate the skin with subcuticular sutures
• Apply dry sterile dressings

Postoperative Care

• Remove the orogastric tube before the patient awakens
• Discontinue the Foley catheter when the patient is able to void
• Give Painkillers
• Advance diet as tolerated by the patient, starting with fluids within 1 day
• The use of an abdominal binder for 1 month is recommend by some surgeons

Complications

Intraoperatively, some patients might need repair of a bowel injury that may occur. Missed sites of bowel injury are associated with increased mortality. Postoperatively, some patients develop prolonged ileus which is usually managed conservatively. 
Hematomas may appear. Surgical-site infections are rare but if developed, they might require the removal of the mesh. Serum accumulation in the old hernia sac is common. Some patients may complain about pain at the fixation sites.

Bibliography - Internet Sources

1. Task Analysis of Laparoscopic procedures, World Laparoscopy Hospital Retrieved from:
    https://www.laparoscopyhospital.com/index.htm
2. Guidelines for laparoscopic ventral hernia repair, SAGES. Retrieved from:
 https://www.sages.org/publications/guidelines/guidelines-for-laparoscopic-ventral-hernia-repair/
3. Laparoscopic Ventral Hernia Repair, WebSurg. Mar 2014; 14(03) Retrieved from:
http://www.websurg.com/Laparoscopic_ventral_hernia_repair_(LVHR)-vd01en4221.htm 
4.Laparoscopic Incisional Hernia Repair Technique, Medscape. Retrieved from: http://emedicine.medscape.com/article/1892407-overview 
5. Robert M. Zollinger & E. Christopher Ellison (2011), Zollinger’s Atlas of Surgical Operations
6. Richard L. Whelan, James W. Freshman & Dennis L. Fowler (2006), The SAGES Manual: Perioperative Care In Minimally Invasive Surgery