Laparoscopic Access to the Difficult Abdomen in Patients with Large Abdominal Wall Defects

Fig. 18.1

Patient with large abdominal wall defect after iterative surgery

In the open entry technique, a small, 2–2.5 cm incision is made through the entire thickness of the abdominal wall and the peritoneum is entered either under direct vision or bluntly with the surgeon’s index finger. Care must be taken when incising the fascia because the peritoneum might be absent and the intestines might be directly adherent to the fascia. In general, open entry is time consuming and carbon dioxide may leak out around the trocar.

Open entry, as described, can be created quickly and safely, even in a difficult abdomen. This technique avoids the limitations of most open techniques and eliminates the complications associated with blind insertion of a Veress needle or trocar [8].

Patient Selection

Patients even with large abdominal wall defects can be treated safely laparoscopically. The size of the defect, patient habitus (obesity), and expected intestinal adhesions both to the abdominal wall and/or to the hernia sac are no longer contraindications. The limitations of laparoscopic incisional hernia repair arise when defects are close to the chest, ribs and pelvic bones or in both flanks close to the lumbar area. Hernia imaging and localization using computed tomography may aid in planning the operation. Comorbidities such as diabetes, immunosuppression , and/or obesity may increase postsurgical complication and recurrence rates.

Surgical Technique

The patient should be placed supine on the operating table properly fixed so that the table may be tilted as desired. A Foley catheter and a gastric tube should be inserted routinely. With the above described open access technique the abdomen can be entered at any point sufficiently distant from the defect, but not beyond the anterior axillary lines. Dissection then proceeds as follows: the fascia is incised, the muscles are separated carefully, and the pre-peritoneal area is entered under direct visualization. Now the peritoneum is opened, preferably sharply. Depending on the length of the opening one or two strong non-absorbable sutures are passed through all the layers of the abdominal wall and peritoneum, and fixed using the suture (Rummel) tourniquet technique (Fig. 18.2a, b). Next, after finger palpation of the peritoneal area and loosening/separation of all adhesions within reach, a 10/11 mm trocar is put in place and the suture tourniquets are tightened. This maneuver prevents loss of gas and ensures full mobility of the inserted trocar. During surgery, all necessary material such as a mesh or circular stapler anvil can easily be introduced or removed. After the completion of surgery, the fascia is closed using the same suture and further sutures can be added as necessary.

Fig. 18.2

(a) After separation of the abdominal wall layers under visual control sutures are placed through all layers. (b) Fixation of the first trocar with two suture tourniquets (Rummel) narrowing the fascia and preventing gas loss

After the first trocar has been inserted safely, the pneumoperitoneum is adjusted to 12–14 mmHg, and the abdomen is entered preferably with a 30° optic. If necessary, further adhesions can be lysed with the blunt tip of the first trocar while the optical device is still in the trocar and the surgeon can see what he/she is doing. Once enough space has been created, further trocars, preferably two 5 mm ports, are inserted under direct visualization. The maintenance of an appropriate distance and triangulation between the trocars are important to allow ease of working in all quadrants (Fig. 18.3).