Laparoscopic treatment of recurrent abdominal incisional hernia with double layer mesh

The management of patients with recurrent incisional hernia continues to test the skills and judgments of gastrointestinal surgeons. Several different surgical techniques and types of mesh prostheses are available for repair. The purpose of this video is to show a technique for a recurrent epigastric incisional hernia following the laparoscopic placement of an intraperitoneal prosthesis. The prosthesis was a collagen dual mesh that was placed after a previous recurrence via an anterior approach for an epigastric incisional hernia.

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Laparoscopic treatment of recurrent abdominal incisional hernia with double layer mesh

Authors

J Leroy, J Marescaux

Abstract

The management of patients with recurrent incisional hernia continues to test the skills and judgments of gastrointestinal surgeons. Several different surgical techniques and types of mesh prostheses are available for repair. The purpose of this video is to show a technique for a recurrent epigastric incisional hernia following the laparoscopic placement of an intraperitoneal prosthesis. The prosthesis was a collagen dual mesh that was placed after a previous recurrence via an anterior approach for an epigastric incisional hernia.

Classification

new techniques

Keywords

Laparoscopic treatment, recurrent abdominal incisional hernia, dual mesh

Media type

Surgical video

Duration

07'10''

Publication

2009-10

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E-publication

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2607.htm

Laparoscopic treatment of recurrent abdominal incisional hernia with double layer mesh

1. Introduction 00'08''

The purpose of this video is to show a technique for a recurrent epigastric incisional hernia following the laparoscopic placement of an intraperitoneal prosthesis. The prosthesis was a collagen double layer mesh (Parietex™ Composite PCO Mesh) that was placed after a previous recurrence via an anterior approach for an epigastric incisional hernia.

2. Trocar placement 00'42''

The procedure starts with the placement of a 12mm trocar in the left flank to introduce the optical system and explore the abdominal cavity. We are immediately surprised by the numerous adhesions despite the fact that the prosthesis was coated with collagen.

3. Dissection of adhesions 01'04''

The adhesions are situated mostly on the greater omentum and are quite easy to bring down by exerting traction and using monopolar scissors as a spatula electrode, as it slips over the surface of the prosthesis. We can also clearly see the staples used to fix the prosthesis. The procedure consists in continuing the dissection until we are above the liver and in freeing the omentum that is stuck at the level of the peritoneum.

4. Defect identification 01'49''

We begin to identify the defect located at the superior border of the prosthesis. This defect explains the incisional hernia’s aspect that was located at the level of the epigastric region. We continue to detach the omentum in order to have a complete view of the prosthesis’ attachments and to identify the limits of this prosthesis in relation to the parietal defect. As can be seen here, the dissection requires to divide the liver’s suspensory ligament to better understand the limits of the zone to dissect. This division is performed with monopolar electrode scissors and we notice that there are no adhesions where there is no prosthesis. Such adhesions in contact to the prosthesis let us think that even when using a collagen-based prosthesis, there is a risk of adhesion formation. The adhesions seem to be much denser around the stapling areas, in particular around the Protack® staples. Here we see the division of the liver’s suspensory ligament to better identify the incisional hernia.

5. Orifice closure 03'35''

In order to fill this defect and have a better closure, we decide to close this orifice by turning the hernia sac over using Ethibond® suspension stitches placed on the borders of the defect and on the hernia sac. The knots are performed extracorporeally with a knot-pusher, here Ethicon’s Endo-suture system, which allows to perform interestingly strong knots and a rather easy closure of the defect. We also use curved needles as they allow, with an appropriate rotation of the needle holder, to weave the peritoneum before using the defect’s border stitches as support, similarly to what we would do in open surgery. We complete this by placing a knot and the closure using the knot-pusher that is integrated to the sutures. We complete this suturing with additional stitches while keeping the hernia sac upside down: this will avoid seroma formation and persistent effusions that can be observed in surgeries that do not excise nor revert the hernia sac and turn the aponeurosis upside down. Once the first connection stitch has been tightened, we complete with other stitches to reduce tension.

6. Prosthesis placement 06'05''

By placing a complementary and similar type of prosthesis, we complete the defect’s covering: it is a polyester prosthesis with double collagen coat on its abdominal surface.

7. Fixation with AbsorbaTack™ 06'25''

It is fixed using absorbable AbsorbaTack™ staples as we can see here. The stapling allows to place the prosthesis correctly and will resist to abdominal pressure until there is a complete fixation. As the defect has been closed, tension on the defect and prosthesis will be limited. Here we see the defect that has been entirely filled and the port sites.