Laparoscopic techniques

As part of the patient’s medical history, the endourologist should be cognizant of both the patient’s surgical history and the presence of abdominal wall hernia. If there is a plan to repair the hernia, the surgeon should have a working knowledge of the types of mesh prosthetics currently in use and be familiar with potential complications of mesh implantation. There are currently both biologic and synthetic meshes available for use in repair of abdominal wall defects (Tables 113.1–113.3).

Technical principles

Every hernia of the abdominal wall has one common denominator: a musculofascial defect through which abdominal contents or preperitoneal structures can herniate. The repair of the musculofascial defect has evolved over the last century in an attempt to decrease postoperative discomfort, provide earlier return to activity, and decrease the rate of recurrence. The repair of inguinal, incisional/ventral, and parastomal hernias all require the defect either be closed primarily, bridged with a prosthetic, or most commonly, a combination of primary closure with prosthetic reinforcement.

Surgical literature has clearly shown that the use of mesh implants decrease the overall rate of recurrence [2, 3]. In addition, especially in dealing with midline defects, it is preferred to restore continuity of the musculature by direct suture or with some form of myofascial release, facilitating midline closure. It is clear that most forms of direct closure will place tension across the wound even with fascial release procedures. For this reason, it is proper to reinforce the closure with some form of prosthetic “buttress.”

Prosthetics used in hernia repair have evolved rapidly over the last 20 years. The use of polypropylene mesh for abdominal wall closure was first reported in 1962, and for many years was the only viable option in hernia repair [4]. The material elicits a strong inflammatory reaction in the surrounding tissues, with scar plate formation.

It soon became apparent that although mesh implants decreased overall hernia recurrence rates, the use of plain, heavyweight polypropylene created potential problems. If polypropylene is placed in an intra‐abdominal location, it can cause severe inflammatory reaction in adjacent organs, leading to dense impenetrable adhesions with potential erosion and fistula formation. In addition, the use of mesh or foreign material in any form can exacerbate wound infection and can necessitate removal with potential catastrophic results. Often this requires multiple surgical procedures for resolution.

With consideration of these findings, prosthetic research and development has evolved with the following principles:

• Tensile strength must be maintained to avoid prosthetic rupture.
  
• An adhesive barrier should be placed for potential use in any intra‐abdominal location adjacent to viscera.
  
• Implants should be designed for easy deployment using either open or laparoscopic techniques.
  
• Potential resistance to infection should be considered.
  
• Using prosthetic material which contracts over time can be a source of abdominal pain and lead to recurrent herniation.

The technical aspects of mesh placement have also been studied carefully with reference to the rate of recurrence and complications.

• Mesh can be placed intraperitoneally, preperitoneally (retromuscular), or as an onlay over the muscular closure (Figure 113.1).
  
• It is imperative to overlap the defect by at least 4–6 cm in all directions.
  
• Depending on location, the mesh must be fixed to the abdominal wall with sutures, staples, fibrin glues, or the use of self‐fixating mesh.
  
• Inlay techniques that do not overlap the repair, but merely bridge the defect should be avoided.

Laparoscopic repair of incisional/ventral abdominal wall hernias

Incisional hernia

Incisional hernias can develop in any region of the abdominal wall where previous fascial closure has been performed. The incidence of the midline hernia has been reported to be 11–23% after midline laparotomy [5]. Causes of incisional hernia are most often a combination of technical and patient‐related factors. Wound infection, obesity, smoking, and malnutrition are the most common related factors in incisional hernia occurrence. Correct technique in fascial closure is imperative. It is important for the laparoscopic surgeon to note that incisional hernia can develop in port sites, most commonly when 10 mm or larger ports are used. It is not clear from the literature that fascial closure of 10 mm or larger port sites decreases the incidence of hernia, but generally, most surgeons advocate fascial closure both in the midline and laterally, especially below the semilunar line.

Preop consideration

As stated previously, there are two aspects to consider when performing a laparoscopic urologic procedure in patients with concurrent ventral hernia. Is the hernia within the surgical field of the proposed urologic procedure? Will it present a hazard secondary to adhesions and the presence of incarcerated structures? This can be defined with preoperative contrast computed tomographic (CT) scans if necessary. At our institution, general surgery is often consulted preoperatively and simultaneous repair of the hernia is often completed at the time of the urologic procedure. In fact, smaller ventral hernia sites have been used to extract the operative specimen followed by open repair of the hernia.

Laparoscopic repair

Laparoscopic repair of incisional hernia should be performed selectively based on the size of the defect and its location. In a general sense, the larger the defect the more difficult it is to restore muscular continuity and provide a symmetrical appearance of the abdominal wall with relief of symptoms.

We employ laparoscopic repair most often in patients with smaller defects where the defect is bridged and overlapped, but the defect itself is not closed. With proper patient selection, this will provide symptomatic relief and prevent incarceration of the hernia.

Technically, access to the abdominal cavity is chosen at a site remote from the defect, allowing for visualization of the defect and its contents (Figure 113.2

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