Laparoscopic Ventral Hernia Repair Ppt. DR DILIP S.RAJPAL
1. LAPAROSCOPIC VENTRAL HERNIA REPAIR
A COMPREHENSIVE APPROACH
DR DILIP S.RAJPAL
MS, MAIS, FICS(USA), FMAS,
DIPL. IN LAPROSCOPIC SURGERY,
FELLOW IN ROBOTIC & ADV LAP. COLO-RECTAL SURGERY (KOREA UNIV.)
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
HON. SURGEON NOVA MEDICAL CENTER
HON. ASS PROF GRANT MED.COLLEGE & HON. SURGEON JJ HOSPITAL
EX-ASST. PROF L.T.M.GEN. HOSPITAL
2. OPEN REPAIR METHODS
For Ventral Hernias
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
3. TENSION REPAIR
Quick repair, done under local anesthesia
However tension repair has unacceptably high
recurrence rates of ~50%
Regardless of the size of hernia, mesh repair has
been proved to be a superior method
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
4. PROSTHETIC MESH – ONLAY TECHNIQUE
Onlay mesh repair
Primary repair performed
Mesh widely covers the repair
Requires cleaning off the fascia and
undermining the skin and subcut for a wide
distance
Disadvantages
Still a tension repair
Large subcut dissection can lead to seroma
High infection rate - may be 10-20%
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
5. 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 be in
contact with the mesh
Disadvantage
Possible continued bulge after repair
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
6. RETRO RECTUS / STOPPA REPAIR
A plane is dissected between posterior rectus and
peritoneum to put the mesh
This is tension-free repair
Mesh extends well beyond the under edges of the
muscle, 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%
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
7. OVERVIEW OF VENTRAL HERNIAS
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
8. VENTRAL WALL (INCISIONAL)
Highest incidence in midline
and transverse incisions
Upto 20% after laparotomy
1/3 present in 5-10 years
postoperatively
Risk factors
Obesity, DM, ascites, steroids,
smoking, malnutrition, wound
infection
Technical aspects of wound
closure
Type of incision
Excessive tension (prone to
fascial disruption)
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
9. INCISIONAL HERNIA
Due to failure of fascial tissues to heal and
close
Promoted by inhibition of wound healing
10-15% of abdominal incisions
Highest incidence with midline incision
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
10. INCISIONAL HERNIA
Indications for Surgery
Bulge of abdominal wall deep to skin scar
Cosmetic concern versus discomfort
Worsened with coughing or straining
Incarceration
Less than 1cm
More than 7-8 cm unlikely to incarcerate
Treatment
Most should be repaired (unlike groin hernias)
Suture versus mesh repair
Suture repair in one European study showed 60% recurrence
With open mesh repair, recurrence seen at upto 30%
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
12. INCISIONAL HERNIA
Visible bulge - May be cosmetically upsetting
Pain - May limit activities, pain is increased with
lifting, straining and coughing
Incarceration - Severe acute pain with tenderness
over the hernia site
Bowel obstruction - Due to acute or chronic
incarceration with typical symptoms
Note: In obese patients, hernia may not be evident
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
13. IMPORTANT QUESTIONS TO CONSIDER
Site
Etiology
Partial vs. complete
Simple vs. strangulated
Fluid and electrolyte status
Operative vs. non-operative management
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
14. INCISIONAL HERNIA-DIAGNOSIS
CT Scan - Very helpful in obese patients. Frequently, a
CT Scan will reveal additional less clinically obvious
hernias
Ultrasound - May be useful especially in office setting
when PE is uncertain
Laparoscopy - For patients with pain and symptoms
suggestive of hernia, but negative PE and imaging
studies
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
15. INCISIONAL HERNIA -DIAGNOSIS
Diastasis recti vs Incisional hernia
Diastasis is a thinning or weakening of the fascial
membrane connecting the rectus muscle
It is not a hernia and generally is asymptomatic and will
not lead to incarceration. It may be cosmetically
unsightly
It is usually located in the upper abdomen and may
occur spontaneously
It is recognizable by its diffuse nature, keel formation
and lack of a “ring”
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
16. STRANGULATED HERNIAS
Most important signs
Fever
Tachycardia
Localized abdominal tenderness
Leukocytosis
Process is accelerated with closed-loop obstruction
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
17. INCISIONAL HERNIA – CHOICE OF TECHNIQUE
Complex open repairs
Stoppa mesh repair
Component separations repair
Laparoscopic repair
Multiple fascial defects detected
Large on-lay intraperitoneal mesh
5 cm marginal overlap
Recurrent hernias – avoid dissection at previous
operative site
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
18. CONTRAINDICATIONS TO LVHRS
Major loss of abdominal domain
Severe debilitation
Respiratory distress
Pregnancy
Portal hypertension
Renal failure with presence of peritoneal dialysis
catheter
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
19. LAPAROSCOPIC TECHNIQUE
For Ventral Hernia Repair
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
20. LAP VENTRAL HERNIA REPAIR
Advantages
Less pain, smaller scars, less soft-tissue dissection
Good view of possible other hernias such as swiss-
cheese defect, thus reducing chances of recurrences
Decreased wound complications
Effective modality for recurrent hernias that have been
repaired anteriorly (open)
Disadvantages
May still have bulge
Possible bowel injury
Seroma rate 15-20%
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
21. SURGICAL TECHNIQUE
Three steps
Access
Adhesiolysis
Mesh insertion / fixation
Key components:
Reduce the hernia contents
“Patch” the defect in the fascia with Mesh
Mesh is incorporated into the abdominal wall by the body
Reinforces the defect in the fascia
Secure the Mesh to the abdominal wall
Prevent movement of the mesh prior to incorporation
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
22. PORTS PLACEMENT
Direct visualization (enter abdomen from sites away
from hernia
Controlled insertion
Bowel protection
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
24. TROCAR SITES SETUP
Left Epigastric hernia
Suprapubic hernia
Upper midline hernia
Lower midline hernia
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
25. DEFECT VISUALIZATION
Proper dissection is facilitated by complete
visualization
If you cannot see the defect
Consider placing a fourth 5mm trocar
Opposite to the placement of other trocars
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
26. ADHESIOLYSIS
Avoid sharp dissection and avoid bowel injuries
Minimize use of electrocautery
Have two monitors, one on each side to have easy
visualization when you change side
To get better all-round view of adhesions, keep
shifting instrument and camera sites
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
27. 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
sutures are placed around the mesh and tied
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
28. THE EXTENT OF THE DEFECT IS ASSESSED.
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
29. PROCEED MESH
PROCEED Mesh has two layers
Soft polypropylene mesh
ORC - a thin, bioresorbable layer that separates its
strong, supportive mesh from underlying viscera.
PROCEED mesh is a lightweight construction to
improve handling for laparoscopic procedures
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
32. HANDLING PROCEED MESH / PHYSIOMESH
Mesh is an internal prosthesis
Mesh infections can be devastating and the mesh
may need to be removed
Therefore, mesh should be handled aseptically
Change gloves before touching the mesh
Use sterile instruments, and not hands, to handle
the mesh as much as possible
Avoid excessive use of electrocoagulation
hemostasis
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
33. MESH OVERLAP
Pascal's principle—wide mesh overlap of defect distributes
pressure equally over larger surface area.
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
34. TRANSFASCIAL SUTURES
Transfascial sutures prevent mesh migration
Transfascial sutures should be permanent
Prolene / Ethilon / Ethibond Excel
To prevent chronic post-op pain an air knot is
preferred for transfascial sutures
For Proceed and Physiomesh, two transfascial
sutures at cephalad and caudad positions are
recommended
After tying the knot, pull the transfascial sutures
from the skin outwards a couple of times to release
any tension
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
35. MESH FIXATION
The purpose of tacking is
To minimize any dead spaces
To hold the mesh close to the abdominal wall for
excellent tissue incorporation
Various types of fixation have been devised
Double crown technique
Eliminates dead space, minimizes seroma formation
Transfascial sutures are still highly recommended
Single crown tacking + absorbable sutures
Single crown tacking + non-absorbable sutures fixation
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
36. PORT SITE HERNIAS
Following LVHRs
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
37. 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 5 mm
and made with bladed introducers often result in
incisional hernia, if not closed
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
38. TROCAR SITE HERNIA
Serious access-related complications appear to be
rare but can lead to increased morbidity when they
do occur
Bowel through port sites is uncommon 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
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
39. TROCAR SITE HERNIA
Overall, if the cannula or port site is 10 mm or
larger in diameter, hernias can occur, despite
preventive measures such as using a noncutting
trocar
Most surgeons do not routinely close lateral port
sites because 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
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
40. PORT SITE CLOSURE TECHNIQUE
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
41. COMPLICATIONS
Lap Ventral Hernia Repairs
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
43. WOUND AND MESH INFECTION
Key question - Is mesh just a large foreign body in
an otherwise clean surgical wound?
Many wounds are inflamed but not necessarily
infected
Infected wounds need to be opened
Avoid exposing the underlying mesh if possible
Infections that involve polypropylene meshes can
be managed with
Surgical drainage
Antibiotics
Excision of exposed segments
Micro-porous/non-porous ePTFE meshes require
removal in most cases because they lack tissue
ingrowth that could combat the infection
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
44. SEROMA FORMATION
The development of seroma is virtually guaranteed
after lap incisional 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 postoperatively
Seroma management
Eliminating dead space such as between mesh and the
abdominal wall by using sufficient tacks
Purse string suturing of the tissue layers
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
45. CHRONIC PAIN
In Rives-Stoppa or other open mesh implantation, it
occurs in more than 10% of patients
Transabdominal suture site pain after LVHR occurs
in 1% - 3% of patients
Visual Analog Scale (VAS)
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
46. POINTS TO REMEMBER
Place all ports 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!!!
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST