CHAPTER 16 Ventral incisional hernia
♦ Ventral hernia repair is a common operation in the United States. With the realization that mesh is more durable than primary closure alone, fascial defects greater than 3 cm are often repaired with mesh reinforcement. More and more, the laparoscopic approach has gained popularity.
♦ The laparoscopic approach may lessen the morbidity by avoiding a laparotomy and lowering the incidence of hernia recurrence by providing wide mesh coverage of the defect. Additionally, direct laparoscopic visualization of the abdominal cavity can help the surgeon to identify “Swiss cheese” multiple fascial defects.
♦ Because the risk of recurrence is relatively high for these procedures, not all hernias need to be repaired when discovered. Elective repair should be considered for patients who have pain or in whom the hernia has enlarged over time.
♦ Once the procedure is underway, it is helpful to use a 5-mm, 30-degree endoscope to allow viewing through any of the 5-mm ports. At least one larger port will be required to introduce the mesh into the abdominal cavity.
♦ Equipment for hemostasis is necessary even though it is used sparingly. It can be helpful to have electrocautery and clip appliers, and in some cases, ultrasonic coagulation can be used for vessel ligation and hemostasis.
♦ Intravenous antibiotics, usually a first-generation cephalosporin, should be administered prophylactically to cover skin flora. Broader coverage for gram-negative organisms may be added in case of an enterotomy.
♦ For a midline abdominal incisional hernia, we will often start with a Veress needle in the left subcostal location. After drop test and insufflation with carbon dioxide to create a pneumoperitoneum, we use a 12-mm optical trocar Visiport (Covidien, Mansfield, Massachusetts) for initial access. This is placed far from the midline incision and the hernia (Figure 16-1).
♦ After assuring there is no iatrogenic injury with a straight scope, we will switch to an angled scope (30 or 45 degrees) to achieve better visualization. Two subsequent 5-mm ports should be placed under direct visualization in the right and left flanks. While a 5-mm scope can allow viewing from all ports, at least one larger port will be required to introduce the mesh into the abdominal cavity.