Laparoscopic Repair of Ventral Hernias
The theory behind laparoscopic ventral hernia repair is that because the problem is a defect in the fascia, an approach from inside the abdomen makes perfect sense. The role of this technique is still being defined. At present, it appears particularly appropriate for patients with relatively small defects who have not had previous mesh repair (hence no dense adhesions). It is considered relatively contraindicated in obese patients and is generally not considered appropriate for strangulated hernias.
SCORE™, the Surgical Council on Resident Education, classified laparoscopic repair of ventral hernia as an “ESSENTIAL COMMON” procedure.
STEPS IN PROCEDURE
Obtain laparoscopic access to the abdomen
Lyse any adhesions to anterior abdominal wall
Identify all fascial defects
Mark these on the anterior abdominal wall using a spinal needle to increase accuracy
Cut a dual mesh patch of sufficient size to provide overlap and cover all defects
Mark the patch so that you can identify the side to be placed next to the fascia and roll it up
Place horizontal mattress suture in each corner of the mesh
Pass mesh and sutures into abdomen
Unfurl the mesh and lay it flat upon the viscera
Take the suture corresponding to one of the far corners and pass it through the abdominal wall and tie it
Repeat this procedure with the other three sutures
Secure the spaces between the sutures using tacks
Close any trocar site greater than 5 mm diameter
HALLMARK ANATOMIC COMPLICATIONS
Visceral injury during entry or adhesiolysis
Missed defects or recurrence
Chronic pain due to sutures and tacks in peritoneum
LIST OF STRUCTURES
Linea alba
Rectus abdominis muscle
Inferior epigastric vessels
Initial Entry and Lysis of Adhesions (Fig. 49.1)
Technical and Anatomic Points
Choose an entry site remote from the defect and any old incision. This may require open entry with a Hasson cannula (see Chapter 46, Figure 46.3). Blind entry with a Veress needle in the left upper quadrant is an alternative in properly selected patients. This depends on the costal margin to provide resistance as the Veress needle is inserted and can only be used in patients in whom this area is free of old scars or probable adhesions from previous surgery in the region (e.g., splenectomy).
To perform blind left upper quadrant entry, select a point at the left costal border (Fig. 49.1A) well away from the hernia sac. Elevate the abdominal wall below the proposed insertion site with a towel clip and rely on counterpressure from the costal margin to elevate the cephalad portion. Make an incision and insert the Veress needle, checking for peritoneal entry in the usual fashion. Insert a laparoscope and explore the abdomen. An angled laparoscope facilitates inspection of the anterior abdominal wall.
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