Ventral Hernia: Laparoscopic Ventral Hernia Repair



Ventral Hernia: Laparoscopic Ventral Hernia Repair


Samuel Szomstein

Aaron Lee





PREOPERATIVE PLANNING

A ventral hernia can be diagnosed during physical examination. Certain maneuvers will accentuate the hernia such as examining the patient while he or she is standing up, Valsalva maneuver, or abdominal flexion. Although most incisional hernia can be diagnosed without imaging and there is no rule against obtaining one, the authors are proponents of liberal usage of preoperative computed tomography (CT) scan for several different reasons.

The issue first is the inaccuracy of physical examination in determining the size and content of the hernia. This information is important when discussing the subtle details of the procedure with the patient. The size of the mesh, likelihood of bowel injury, and the level of complexity are examples of topics that can be discussed in full detail with the imaging. Also, the patient’s condition may inhibit surgeons from performing a thorough and accurate physical examination such as when the patient is morbidly obese, has severe arthritis, and is wheel chair bound or bed bound secondary to the patient’s existing medical conditions. There are several different imaging techniques available but the author prefers to use the CT as the primary imaging modality.

Once the ventral hernia is diagnosed, it is important to establish the goal of care from both the hernia and colorectal disease standpoint with the patient. The hernia surgeon needs to determine the acuity and the complexity of the hernia and generate a reasonable plan to address it with the patient in terms of overall goal with the colorectal disease as a part of the equation. It is prudent to coordinate with the colorectal department if the surgeon is being referred for the hernia specifically, to address the hernia concomitantly or deferred until the later date. It is common for patients to have temporary ostomy after a colorectal procedure as a protective measure; and for these patients, it is reasonable to wait until the time of the reversal or even later to address the hernia. Also, it is important to know if the primary surgery is going be done laparoscopically or open because it may change the timing and the level of complexity of subsequent procedure depending on the method of the index procedure. Also, it is critical to coordinate with the colorectal surgeon because the hernia operation will most likely require a mesh, due to the infection risk, it is advisable to defer if a colon resection is planned.


SURGERY

The patient should follow the National Surgical Quality Improvement Program (NSQIP) protocol as far as the venous thromboembolism prophylaxis and perioperative antibiotics are concerned. Patients should receive subcutaneous heparin injection or its equivalent; and during the surgery, a sequential compression device should be placed on the patient’s lower extremities. It is the authors’ preference prophylactically to use cefazolin as the antibiotic of choice as long as the patient has no allergy to β-lactam-based antibiotics; and if so, other antibiotics should be given according to the NSQIP guideline. Appropriate aspiration precaution should be followed during intubation. Usually, patients at the author’s institution have a bladder catheter placed for two reasons; to decompress the bladder in case it is necessary to enter the space of Retzius to place the mesh and to accurately measure the urine output.


Positioning

The patient should be positioned supine with both arms tucked, which allows the surgeon and his/her assistant to operate in the most ergonomically comfortable position. Before the positioning of the patient, it is important that the surgeon communicates with the operating room staff exactly what he/she wants. Also, it is critical to remember to place appropriate padding around the pressure points
to prevent any inadvertent ulcer or skin disruption such as the space between the intravenous line and skin, Foley and urethra, below both heels, and so on. The patient is secured with two different straps, one above the knees and one below. Once the patient is positioned and the airway is secured, the entire abdomen from the nipple line to the pubic symphysis is prepped using chlorhexidine prep solution. When draping the patient, it is important to place the sterile towels as wide as possible to place the ports that are necessary to perform the surgery.


Technique

Depending on the location of the hernia and the extent of previous surgeries, different entry techniques can be considered and utilized. If a patient has a large midline incision and previous surgical history that suggests severe peritonitis and is expected to have dense adhesions throughout the abdomen, supraumbilical midline port placement using Hasson technique is a viable option. With reasonable doubt that the patient has minimal adhesion or localized adhesion from the previous history, either right or left midclavicular site can be safely used to enter the peritoneum by a direct visualization trocar technique. The author routinely uses the Optiview technique at the Palmer’s point or the right midclavicular site away from the hernia with a 5-mm camera in a 5-mm trocar slip. When the reciprocal side of the Palmar’s point is being used, it is prudent to be extra careful when entering the peritoneum because the liver may be in the way and potentially get injured. Then pneumoperitoneum is established using high-flow CO2 to obtain minimal 15 mm Hg.

Once the pneumoperitoneum is obtained, the 10-mm 30-degree laparoscope is inserted and the full abdomen should be inspected. Necessary dissection should take place to free up any adhesion and reduce the hernia content. The author uses sharp dissection around any bowel and ultrasonic energy device for any omental adhesion. Extra care should be taken when taking down the content because any content in the hernia sac can potentially be injured during the dissection. Preoperative imaging can provide the surgeon with accurate information of the content in the hernia sac before the surgery. The hernia sac should be dissected and reduced as well. Once the hernia sac and its contents are reduced, the hernia size should be measured. There are several ways to measure the hernia, but the author measures it extracorporeally with full desufflation. On the basis of the measurement, the shape and size of the mesh is selected intraoperatively. The author uses a polypropylene-based mesh with hydrogel filament. The author places Prolene stitches at the four corners of the mesh.

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May 5, 2019 | Posted by in GENERAL | Comments Off on Ventral Hernia: Laparoscopic Ventral Hernia Repair
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