Surgery for abdominal wall hernias is generally standardized and consists of two steps: adhesiolysis and repair of the hernia with intraperitoneal mesh.

The first skin incision is made at the greatest possible distance from the scars from previous laparotomies. This corresponds to a location on the right or left flank far lateral to the rectus muscle along the anterior axillary line. The dissection is deepened, incising the fascia and carefully splitting the muscles until the peritoneal cavity is accessed under direct vision. Before the first trocar is inserted under direct vision, two strong, nonresorbable sutures are passed through all the fascia and muscle layers of the abdominal wall and fixed with a tourniquet (Fig. 19.5). Then, after digital palpation of the peritoneal space and separation/loosening of nearby adhesions, a 10/11 trocar is introduced anterior to the large intestine. The fascial sutures are pulled taut with the tourniquets so that no gas is lost during surgery [14]. Another option is to use an optical trocar (Visiport™) to create the first trocar access.

The pneumoperitoneum is set at 12 mmHg, followed by the introduction of a 30° optic. Two additional 5 mm or smaller ports are introduced under visual control. It is important that the working trocars in the upper and lower abdomen are so placed that there is sufficient distance for placement of the mesh, with all four abdominal quadrants within reach.

If there are adhesions, exposure is achieved by pushing and pulling with atraumatic graspers. Grasping instruments should be used carefully as long as the structures in the adhesions are not well defined (Fig. 19.6). It is always possible that there are loops of intestine in or behind the fatty tissue of the omentum. Sometimes it is helpful when the surgeon uses the grasper with the dominant hand and presses against the abdominal wall with the non-dominant hand in the area of the adhesions. This can lessen the distance to the adhesions in the uplifted dome of the abdominal cavity. The intra-abdominal gas infiltrates into the fatty tissue and adhesions, forming a soap-like foam that makes it easier to loosen the adhesions.

Matted adhesions or bands are divided by sharp dissection with cold scissors. Under normal circumstances, energy-based devices are not used to divide adhesions, although they can be useful when the falciform ligament of the liver has to be severed or the urinary bladder must be separated from the anterior abdominal wall . The goal of the adhesiolysis is to expose 4–5 cm of anterior abdominal wall around the fascial defect. Care should be taken to avoid any unnecessary dissection of adhesions within the bowel loops. With obese patients and those with numerous scars from previous operations, it may not be possible to probe and detect all herniations prior to surgery. For this reason, adhesions should be lysed in the areas of all the scars so that any such undiagnosed hernias are not overlooked. It is not necessary to remove the hernia sac.

The fascial defect is determined by probing and pressing through the abdominal wall. The size of the mesh is determined by briefly releasing the pneumoperitoneum and using a pen to mark an area extending 4–5 cm all around the hernia and measuring it (Fig. 19.7). Then, the pneumoperitoneum is reestablished, and the entire team changes gloves. Only then is a preferably expanded polytetrafluoroethylene (ePTFE) light dual mesh placed on the table and tailored to fit the measurements. The mesh is marked on the side toward the fascia, with arrows indicating the cranial or caudal end. On the four corners and between them, eight nonresorbable sutures are placed in a U shape and knotted (Fig. 19.8). The sutures should be cut to a length of 10–15 cm so that it will be easier to grasp them later with the suture passer and pull them out. The sutures are then placed in the mesh, which is rolled up along the long edge. The optic trocar is removed, and the mesh, held with a grasper, is inserted through this incision into the abdominal cavity (Fig. 19.9).

At this point, the trocar is again inserted, the tourniquets are drawn tight, and the pneumoperitoneum is reestablished. The mesh can be unrolled and put into position with the fascial side facing up. First, the cranial sutures on the opposite side are pulled through with a suture passer or Endo Close™ (Covidien, 15 Hampshire Street, Mansfield, MA 02048 USA). To this end, a 2 mm incision is made with a pointed blade in the marked area. Both sutures of a pair come out through the same skin incision, but through separate fascial punctures, so that there is a tissue bridge of 0.5–1 cm between the two strands of the same suture pair. After both strands are drawn through separate punctures one after another, the mesh is drawn to the abdominal wall and fixed by pulling the threads. In the same way, the strands at the next site are drawn through the fascia through small skin incisions, taking care that the mesh is pulled taut. Only when the last sutures have been pulled through are they knotted, with the knots pushed in to the level of the fascia (Fig. 19.10).

The space between the transfascial sutures is fixed with spiral tacks. At this stage, the surgeon uses the non-dominant hand to press the tip of the tacking device as close as possible onto the abdominal wall to ensure secure fixation of the mesh on the fascia (Fig. 19.11). The mesh can also be fixed with absorbable tacks. There is as yet no convincing evidence for the argument that absorbable tacks cause fewer adhesions or nonabsorbable tacks cause significant adhesions or small bowel obstruction.

When fixation is completed, the abdominal cavity is again inspected for occult bleeding or intestinal wall lesions. Any blood is suctioned off. All the instruments are removed and the pneumoperitoneum is released. All incisions larger than 5 mm are closed with fascial sutures.