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Open and laproscopic repair of incisional hernia
1. Open and laparoscopic repair of
Incisional hernia/ventral hernia
Moderator- DR.NISHANT KUMAR
DR. ANIL NEGI
2. VENTRAL HERNIA
• Highest incidence in midline and transverse
incision
• Upto 20% after laparotomy
• 1/3 present in 5-10 year postoprative
RISK FACTOR-
• Obesity , DM, ascites , steroids , smoking ,
malnutrition , wound infection
• Technical aspect of wound closure – type of
incision , excessive tension.
3. • Due to failure of fascial tissue to heal and
close
• Promoted by inhibition of wound healing
• 10-15 % of abdominal incision
• Highest incidence with midline incision
4. Incisional hernia
Indication for surgery
• Bulge of abdomen wall deep to skin scar
• Cosmetic concern versus discomfort
• Worsened with coughing or straining
• Incarceration – less than 1 cm
more than 7-8 cm unlikely to
incarcerate
5. TREATMENT
• Most should be repair (unlike groin hernia )
• Suture versus mesh repair
- Suture repair in one europian study showed 60%
recurrence
- With open mesh repair recurrence seen at upto 30%
6. Diagnosis
• Visible bulge may be cosmetically upsetting
• Pain –may limit activities pain is increased
with lifting , straining and coughing.
• Incarceration –sever acute pain with
tenderness over the hernia site
• Bowel obstruction –due to acute or chronic
incarceration with typical symptom
• Note-in obese patient ,hernia may not be
evident
7. • Important questions to consider
1. Site
2. Etiology
3. Partial vs. complete
4. Simple vs. strangulated
5. Fluid and electrolyte status
6. Operative vs. non-oprative management
8. Imaging
• Ultrasound w/a.
• Ct scan- very helpful in obese patient.
Frequently ,a ct scan will reveal additional less
clinical obvious hernia
• Laparoscopy- for patient with pain and
symptoms suggestive of hernia ,but negative
on examination and imaging Studies.
9. DIASTASIS RECTI VS INCISIONAL HERNIA
1. Diastasis is a thinning or weakening of the fascial
membrane connecting the rectus muscle.
2. It is not a true hernia and generally is
asymptomatic and will not lead to incarceration.
It may be cosmetically unsightly.
3. It is usually located in the upper abdomen and
may occur spontaneously.
4. It is reconisable by it’s diffuse nature, keep
formation and lack of ring.
10. STRANGULATED HERNIA
• Most important sign
- FEVER
- TACHYCARDIA
- LOCALISED ABDOMINAL TENDERNESS
- LEUKOCYTOSIS
• Process is accelerated with closed loop
obstruction.
11. INCISIONAL HERNIA- CHICE OF
TECHNIQUE
• Complex open repair
1. Stoppa mesh repair
2. Component separation repair
• Laparoscopic repair
- Multiple fascial defects detected
- Large on-lay intraperitoneal mesh
- 5 cm marginal over lay
- Recurrent hernias- avoid dissection at previous
operated site
12. OPEN REPAIR METHODS
• Tension repair
- Quick repair under local anesthesia
- However it has unacceptably high recurrence
rate of 50%
- Regardless of the size of hernia, mesh repair
has been proven to be a superior method
13. PROSTHETIC MESH- ONLAY
TECHNIQUE
• On-lay mesh repair
- Primary repair performed
- Mesh widely covers the repair
- Requires cleaning of the fascia and undermining
the skin and subcut for a wide distance
• Disadvantages
1. Still a tension repair
2. Large subcut dissection can lead to seroma
3. High infection rate- 10-20%
14.
15. INLAY MESH REPAIR
• Inlay mesh
- Sac excised and mesh sewn to fascial edges
- This is non tension repair
- Must use non adherent mesh, such as,
Physiomesh or Proceed if bowel will e in
contact with mesh
• Disadvantage
- Possible continued bulge after repair
16. RETRO RECTUS/ STOPPA REPAIR
• A plane is dissected b/w the posterior rectus and
peritoneum to put the mesh
• This is a tension free repair
• Mesh extends well beyond the under edges of
muscles, reinforcing the entire area
• Must use non adherent mesh such as Physiomesh
or Proceed, if bowel will be in contact with the
mesh
• Disadvantage- reported recurrence rate of 10%.
Reported infection and mesh removal rate of 5-
10%
22. CONTRAINDICATIONS OF LVHRs
• Major loss of abdominal domain
• Severe debilitation
• Respiratory distress
• Pregnancy
• Portal HTN
• Renal failure with presence of peritoneal
dialysis catheter
23. LAPAROSCOPIC TECHNIQUE OF
VENTRAL HERNIA REPAIR
ADVANTAGES-
– LESS PAIN SMALLER SCAR , LES SOFT TISSUE
DISSECTION
– GOOD VIEW OF POSSIBLE OTHER HERNIAS SUCH
AS SWISS-CHEESE DEFECT, THUS REDUCING
CHANCES OF RECURRENCE
– DECREASED WOUND COMPLICATION
– EFFECTIVE MODALITY FOR RECURRENT HERNIAS
THAT HAVE BEEN REPAIRED ANTERIORLY
26. Key components
• Reduce the hernia contents
• Patch the defect in the fascial with
-Mesh is incarporated in to the abdominal wall by the body .
-Reinforce the defect in fascia
• Secure the mesh to the abdominal wall
-Prevent movement of the mesh prior o incorporation
27. Ports placement
• Direct visulization (enter abdomen from sites
away from hernia )
• Controlled insertion
• Bowel protection
29. Direct visualization
• Proper dissection is facilitated by complete
visualization
• If we cannot see the defect
-Consider placing a fourth 5mm trocar
-Opposite to the placement of other trocar.
30. Adhesiolysis
• Avoid sharp dissection and bowel injuries
• Minimize role of electrocautery
• Have 2 monitor, one on each side to have easy
visualization when u change side
• To get better all around view of adhesion
,keep shifting instrument and camera sites
31. Defect measurement
• The margins of the defect may be marked on
the skin
• The mesh is measured and trimmed to fit
• With the smooth side down 4-6 large fixation
suture are placed around the mesh tied.
33. Proceed mesh
• Proceed mesh has two layer
-Soft polypropyline mesh
-ORC athin ,bioresorbable layer that seprate its strong ,
supportive mesh from underling viscera
PROCCED mesh is a light wt constructed to
improve handling for laparoscopic procedures
36. Handling proceed mesh
• Mesh is an internal prosthesis
• Mesh infection can be devastating and the mesh
may need to be removed .
• There fore , mesh should be handled aseptically
• Change glove before touching the mesh
• Use sterile instrument and not hand , to handle
the mesh as mush as possible
• Avoid excessive use of electrocoagulation
hemostasis .
37. • Mesh overlap
Pascal’s principle- wide mesh overlap of defect
distributes pressure equally over large surface
area .
38. Trans fascial suture
• Trans fascial sutures prevent mesh migration
• Transfascia suture should be parmanent
Proline /ethilon/ethibond excel
• To prevent chronic post –op pain an air knot is
preferd for transfascial suture.
• for proceed and physiomesh , two transfacial
suture at cephalad and caudal position are
recommended.
• After tying the knot , pull the transfascial sutures
from the skin outwords a couple of time to relese
any tension
39. MESH FIXATION
• The purpose of tacking is
1. To minimize any dead spaces
2. To hold the mesh close to the abdominal wall for
excellent tissue incorporation.
• Various types of fixation have been devised
• Double crown technique – elliminates dead , minimize seroma
formation
• Transfascial suture are still highly recommended.
40. • Single crown tacking + absorbable sutures
• Single crown tacking + non absorbable suture
fixation
41. Trocar site hernia
• The incidence of trocar site hernia has been
shown to be 0.65 to 2.80%.
• Midline , periumbilical port sites greater than
5mm and made with bladed introducer often
result in incisional hernia , if not closed .
42. Trocar site hernia
• Serious access- related complications appear be
rare but lead to increased morbidity when they
do occur.
• Bowel through port sites is uncommen and can
be difficult to diagnose . Often the diagnosis is
delayed, resulting in infarction of the involved
bowel segment.
• Most laparoscopic surgeons agree that the
diameter of the cannula or port is the single most
common cause of port-site hernias.
43. TROCAR SITE HERNIA
• Overall , if the cannula or port site is 10mm or
large in diameter, hernias can occur, despite
preventive measures such as using a noncutting
trocar.
• Most surgeons do not routinely close lateral port
site becouse it is commonly thought that the
fascial and muscular composition of these sites
pose such little risk of herniation that the extra
time and effort required to repair them is not
justified
• However this theory is not absolute
45. WOUND AND MESH INFECTION
• Key Q- is mesh just a large foreign body in an other
clean surgical wound?
• Many wound are inflamed but not necessarily
infected,
• Infected wounds need to be opened
- Avid exposing the underlying mesh if posible
• Infections that invole polypropylene meshes can
be managed with
1. Surgical drainage
2. Antibiotics
3. Excision of exposed segments
46. • Micro-porous /non-porous ePTFE meshes
require removal in most cases becouse they
lack tissue ingrowth that could combat yhe
infection .
47. SEROMA FORMATION
• The development of seroma is virtually
guaranteed after lap incision hernia repair and
probably after repair with mesh in general.
• Seromas typically resolve spontaneously
without intervention and are not considered a
Complication unless they are clinically apparent
for more than 8 weeks postopratively
48. Seroma management
• Eliminating dead space such as between mesh
and the abdominal wall by using sufficient
tacks .
• Purse string suturing of the tissue layers
49. CHRONIC PAIN
• In Rives- stoppa or other open mesh implant ,it
occurs In more than 10% of patient
• Transabdominal suture site pain after LVHR
occure in 1-3% of patients.
50. Take home massage
• Place all port as far away as possible from the
defect
• Switch scope position
• Keep intraabdominal pressure –high during
dissection and low during closing
• And very importantly -MARK THE MESH!!!!!!
