Onlay Mesh Repair

Morris E. Franklin Jr.

Karla Russek

Indications/Contraindications

Incisional hernias develop in 2% to 20% of laparotomy incisions, necessitating approximately 90,000 ventral hernia repairs per year in the United States. About a third of these patients experience serious discomfort, aesthetic complaints, intestinal obstruction, or acute strangulation warranting hernia repair. In general, primary hernia repair has been abandoned owing to unacceptably high recurrence rates, and mesh placement is now considered the standard technique. Mesh placement in the posterior position (onlay technique), rather than anterior placement or within the abdominal musculature, is associated with the lowest recurrence and infection rates.

The onlay mesh technique can be used for basically any type of intraabdominal hernias (incisional, spigelian, inguinal, etc.). The laparoscopic approach to hernia repair seeks to apply the sound principles associated with the Rives–Stoppa, but with modifications in the technique for mesh placement. Once implanted, inflammatory tissue grows from the underlying peritoneum between the mesh interstices, creating a solid tissue-prosthesis aponeurosis that is the basis for the IPOM repair.

Using the laparoscopic approach, a large prosthetic mesh can still be placed on the anterior abdominal wall (internal rather than external to the posterior fascia or peritoneum), overlapping the defect by several centimeters in all directions. However, with this technique, there is no need for the extensive soft tissue dissection seen in the open approach and its attendant complications. Furthermore, the patient can expect to receive all the other benefits of a minimally invasive procedure, such as decreased hospital stay, lower round complication rates, and decreased pain.

Preoperative Planning

There is an ongoing controversy regarding patients’ selection criteria for laparoscopic onlay mesh technique with respect to number of prior hernia repairs, hernia size and location, number of previous operations, body mass index (BMI), and history of intraabdominal sepsis. Technical difficulty as well as postoperative morbidity and mortality may be related to definable preoperative risk factors.

Surgery

The technique demands general anesthesia as well as placement of a nasogastric tube and a Foley catheter.

Positioning

The patient must be firmly attached to the table to allow for alterations in position to Trendelenburg, reverse Trendelenburg, or extreme side-to-side “airplaning” to allow adhesions to be dissected. We prefer to secure the patient to the table with tape at the shoulder level. Sequential compression devices are applied to the legs, and the video monitors are positioned at the foot of the table or at a place convenient for viewing by all involved.

Technique

Insufflation, usually from a non-midline location, is begun with a Veress needle. The initial ports are most commonly placed lateral to the rectus muscles. The adhesions opposite the initial ports are carefully taken down, and additional ports are placed as adhesions are cleared. Each of these additional trocars should be considered as a port through which a stapler (or laparoscope) or mesh (Fig. 19.1) can be placed. Therefore, 10 to 12 mm trocars are desirable at all ports, although 5 mm ports may be used with corkscrew fixation devices. Bleeding must be meticulously controlled and bowel injury avoided as the anterior abdominal wall is being cleared. We practice closure of large defects with nonabsorbable suture (Fig. 19.2

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