CHAPTER 16 Ventral incisional hernia
Step 1. Surgical anatomy
♦ 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.
Step 2. Preoperative considerations
Patient preparation
♦ 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.
♦ Patients who have severe pain may need urgent or even emergent surgery to prevent strangulation of bowel. Sharp pain or peritoneal signs suggest the possibility of bowel strangulation or necrosis.
♦ Laparoscopic ventral hernia repair requires the use of general anesthesia. Patients need to undergo appropriate preoperative evaluation to determine their ability to tolerate the procedure.
♦ A computed tomography (CT) scan may be useful to confirm the diagnosis of hernia or to delineate the size of the hernia when physical exam is difficult, such as in obese patients.
Equipment and instrumentation
♦ Standard laparoscopic instrumentation is required, including scissors and atraumatic graspers.
♦ For access, we prefer using a Veress needle and an optical trocar with a 0-degree endoscope.
♦ 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.
Anesthesia
♦ Sequential compression devices should be placed and subcutaneous heparin should be given for thromboembolic prophylaxis preoperatively.
♦ 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.
♦ Although formal bowel prep is usually not necessary, a bowel prep may be elected at the surgeon’s discretion when a difficult lysis of adhesions is anticipated.
♦ After induction of anesthesia, the stomach and bladder are decompressed with an orogastric and urinary catheter, respectively.
♦ The abdomen is scrubbed and painted with Betadine. The patient’s abdomen may then be covered with Ioban barrier to limit the mesh contact with skin.
Room setup and patient positioning
♦ The patient is placed in the supine position with arms tucked to facilitate a greater range of movement for the surgeon and assistant around the operative table.
♦ The surgeon usually stands on the patient’s right side with an assistant on the opposite side.
There should be two monitors, one on each side of the table, and they can be positioned at the foot or head of the bed depending on the surgeon’s preference.
Step 3. Operative steps
Access and port placement
♦ Pneumoperitoneum can be achieved with either an open or closed technique, but the initial incision should be at least 10 cm away from the closest margin of the defect.
♦ 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.
♦ Ports positioned too close to the hernia may affect visualization and access to the hernia.
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