Laparoscopic Incisional Hernia Repair
- 5mm ports x 2 (if a 5mm scope used exclusively - NEEDS TO BE OF HIGH QUALITY
- 12mm port x 1 (if a 30 degree 10mm laparoscope is used)
- Fenestrated 5mm grasper
- Scissors (5mm Ethicon)
- Appropriate mesh (Parietex composite, Bard Dulux, Erthicon Proceed or Gor-Tex Dualmesh)
- '1' Ethibond sutures (straight needle)
- 5mm ProTacker
General anaesthesia, iv antibiotics, urinary catheter, modified Lloyd Davis with hips extended.
For the point of access, choose a site distant from the hernia and the previous surgical incision. Typically this is in either the right or left upper quadrant. We believe that open access provides the safest way of establishing a pneumoperitoneum. All secondary ports are placed under direct vision. Place the trocars as far lateral as possible and vew the hernia.
Undertake the adhesiolysis under DIRECT vision using a combination of sharp dissection and bimanual palpation of the abdominal wall. Blunt dissection can be dangerous if the bowel is fixed in several points. We would recommend that you avoid using energy sources and monopolar diathermy. Free-up the whole of the anterior abdominal wall. If you have any suspicion of making an enterotomy you will need to suture/repair straight away (possibly needing an additional 12mm port). Consider conversion to an open procedure.
It is very easy to underestimate a serosal tear and miss an enterotomy.
Once the hernia is reduced, mark out the extent of the hernia defect on the skin (include all the defects) and measure it. Cut your patch a minimum of 3cm larger than the defect in all directions. Mark out the mesh on the skin. If large, pull back the hernia sac and excise it. Remove in a retrieval bag.
All the composite meshes on the market have two distinct surfaces - a smooth surface for placing next to the bowel (brown if you use mesh impregnated with antibiotic) and a rough macromesh for sitting up against the abdominal wall. Mark the inferior and superior aspects of the mesh. Place four sutures at the margin of the mesh (1 prolene). Role the mesh up along its long axis and inserted through the 12mm port.
Unroll and orientate the mesh - remember your markings. Incise skin with No 11 blade about 2cm outside the margin of the patch drawn on the skin. Grasp a suture and pull through the abdominal wall using a suture passer (rpt using another separate pass). Tie the two suture ends securely onto the anterior rectus sheath (too tight and they will cause a degree of ischaemia).
Use a ProTacker to fix the edge of the mesh every cm. Keep everything under tension (will slacken once the pneumoperitoneum is released).
Introduce additional sutures every 4cms using either a grasping/awl or a straight needle (1cm from the margin of the patch). Remove, after ensuring a fascial bridge has been created) by putting the needle tip into a spinal needle introduced from outside. Tie and close the skin with tissue glue etc.
Release the pneumoperitoneum, remove the ports and close the 12mm defect.
Individualise postoperative care/analgesia etc on extent of surgery. Be warned, incisional hernia repair can be very painful, probably due to inducing a local contavt peritonitis. Warn your patients!
Meta-analyses, Systemic reviews and randomised controlled trials