Laparoscopic Incisional Hernia Repair

Chapter 54 Laparoscopic Incisional Hernia Repair



Parag Bhanot, MD



INTRODUCTION


Incisional hernia formation after laparotomy is a complication that occurs in approximately 20% of patients.1 Several open hernia repair methods have been developed, but they are associated with significant recurrence rates and wound-related complications secondary to extensive tissue dissection.2,3 The application of minimally invasive surgery techniques has led to the development of laparoscopic methods for repairing incisional hernias. Several comparative studies now demonstrate the high rate of success and low associated morbidity compared with those of the open approach.4–7


Since they were first reported in the literature in 1992, the number of laparoscopic ventral hernia repairs (LVHR) performed has significantly grown as excellent outcomes have been published. Although complications have been reported to occur less frequently when compared with those of the open approach, they continue to remain an issue, especially in less experienced hands. Heniford and coworkers8 reported an overall complication rate of 13.2% in a series of 850 patients.



INDICATIONS



• Hernia defect 4 cm or greater

• Recurrent hernia

• Multiple hernias

• Morbidly obese individuals


CONTRAINDICATIONS



Absolute



• Surgeon inexperience

• Inability to tolerate general anesthesia

• Inability to tolerate laparotomy

• Advanced cardiopulmonary disease

• Uncorrectable coagulopathy

• Portal hypertension with abdominal wall varices


Relative



• Active wound infection

• Loss of abdominal domain

• Severe abdominal adhesions


OPERATIVE STEPS


Although the technical aspects of LVHR vary, the operation involves a series of well-defined steps.


Step 1 Patient preparation and positioning

Step 2 Abdominal access

Step 3 Trocar placement

Step 4 Lysis of adhesions

Step 5 Reduction of hernia contents

Step 6 Evaluation of fascial defect

Step 7 Mesh selection and preparation

Step 8 Mesh fixation

Step 9 Trocar removal and fascial closure


OPERATIVE PROCEDURE



Abdominal Access and Trocar Placement



Trocar Insertion Injuries


An open or closed technique may be used for access to the peritoneal cavity. A number of complications can occur while gaining access to the peritoneal cavity because a significant number of these patients may have had multiple abdominal procedures. The total number of trocars placed is dependent on several factors, including the extent of adhesions and the size and location of the hernias. Trocars should be placed at least 5 cm away from the fascial defect to allow mesh placement with appropriate fascial overlap (Fig. 54-1).


image

Figure 54-1 A, Although the mesh has been sized to provide appropriate overlap to cover the fascial defect, its fixation is compromised as the edge of the mesh overlaps with one of the 5-mm trocars. B, The trocars are placed at an appropriate distance from the fascial defect to allow circumferential fixation of the mesh.


Complications of trocar insertion are discussed in Section I, Chapter 7, Laparoscopic Surgery.



Lysis of Adhesions



Intestinal Injury


Adhesiolysis can be the most difficult and technically challenging portion of the operation. This is especially evident in patients with multiple previous surgeries and/or previously placed mesh. Soper and associates9 reported their results of 121 consecutive patients that showed an enterotomy rate of 11.4% in patients with prior hernia repairs compared with 0% in patients undergoing a first-time repair.9



• Consequence



An enterotomy can jeopardize the remainder of the operation by affecting the ability to proceed with mesh placement. This is dependent on the degree of contamination and the portion of the bowel injured. An unrecognized bowel injury can have catastrophic consequences with resultant intra-abdominal sepsis.

Grade 3/4/5 complication


• Repair



The decision on the approach used to repair the bowel injury is based on surgeon experience and degree of contamination. Conversion to an entirely open procedure should not be considered a failure. Alternatively, a smaller incision can be used to allow repair of the enterotomy followed by continuation of the laparoscopic approach. With increasing surgeon experience, a laparoscopic repair of the enterotomy may be performed.


• Prevention



A complete visualization of all of the adhesions is critical to ascertain whether or not bowel is adherent to the abdominal wall (Fig. 54-2A). This usually requires changing the camera port to the contralateral side. A plane allowing for a safe dissection should be developed between the abdominal wall and the adhesions. A majority of the dissection should be performed without the use of energy sources such as ultrasonic shears, especially adjacent to the bowel wall, to prevent thermal injury (see Fig. 54-2B and C). If dense adhesions are present, dividing the hernia sac or adjacent fascia may aid the adhesiolysis (see Fig. 54-2D). The surgeon should avoid grasping the bowel directly and instead use the surrounding adhesions to provide countertraction.

image

Figure 54-2 A, In addition to the omental adhesions to the anterior abdominal wall, which can be taken down with blunt dissection, a loop of small bowel is also clearly seen inside the fascial defect. This should be carefully cleared off of the peritoneum with sharp dissection to prevent serosal injury. B, The majority of the adhesiolysis can be performed with sharp dissection without use of energy sources. An avascular plane is developed between the peritoneum and the adhesions. C, As the adhesions are taken down close to the proximity of small bowel, it is critical to visualize the tips of the scissors, as depicted in this photograph, in which a potential for injury is evident. The use of ultrasonic shears would most definitely cause a thermal injury to the bowel wall. D, When there are a number of adhesions or dense adhesions, it is safer to divide the hernia sac from the edge and reduce the contents with the peritoneum attached to the adhesions. Normally, this is unnecessary and the hernia sac is left in situ.



Hemorrhage


Minimal bleeding can result from a number of sources. However, significant bleeding is rare and usually recognized intraoperatively. Major sources are raw surfaces of the abdominal wall after extensive adhesiolysis, injury to abdominal wall vessels such as the inferior epigastric vessels, or from large-caliber vessels found within the adhesions.



• Consequence



Significant postoperative bleeding is very rare, with a reported incidence of less than 2% of patients requiring a blood transfusion.

Grade 1 complication


• Repair



Abdominal wall bleeding can be controlled with direct pressure and/or placement of sutures to ligate the vessel. Larger-caliber vessels present in mature adhesions or omentum are controlled with ultrasonic shears or clips.


• Prevention



The development of an avascular plane between the adhesions and the peritoneum will prevent violation of the dissection into the abdominal wall muscles. Transillumination of the abdominal wall to visualize the vessels before trocar placement and placement of fixation sutures should be employed when possible. This may not be possible when operating on an obese individual. All adhesions should be examined for the presence of large-caliber vessels before lysing (Fig. 54-3).

image

Figure 54-3 Adjacent to the portion of bowel involved within the adhesion, there is also a large-caliber vessel separate from the mesentery. This vessel needs to be ligated before it is separated for the abdominal wall to prevent hemorrhage that would obscure dissection planes.

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Jun 21, 2017 | Posted by in GENERAL SURGERY | Comments Off on Laparoscopic Incisional Hernia Repair

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