DEPT. OF MINIMAL ACCESS SURGERY &
ALLIED SURGICAL SPECIALTIES
SIR GANGA RAM HOSPITAL
NEW DELHI - 110 060
An incisional hernia is a unique clinical entity as it is the only abdominal wall hernia to have an iatrogenic origin. The incidence of incisional hernias varies from 2-11%1-4. Treatment for incisional hernias requires closure or bridging of the fascial defect. Conventionally repair of ventral hernias has been achieved either by approximating the separated ends of the fascia [Pure tissue repair] or by reinforcing this repair using prosthetic material [Prosthetic repair]. There have however been instances when the edges of the defect have been too widely spaced precluding anatomical approximation. Such cases have been repaired by using natural or synthetic prosthetics is to bridge the gap. This technique formed the basis of repairing incisional hernias by laparoscopy. Whatever the repair type, there are certain principles of hernia repair which improve the efficiency of these repairs making them last longer. These are :-
Appropriate suture placement Approximation done utilizing healthy fascial sheath Using the right suture size Prevention of undue tension on the suture line Prevention of wound infection1
Use of synthetic prosthetics in hernia repair became popular following the introduction of plastic meshes of which PTFE and polypropylene5-8 enjoy considerable popularity. While using the mesh in hernia repair certain principles need to be followed in addition to the ones previously mentioned. These include:-
An overlap of 4-8mm. of the mesh on the fascia Secure fixation of the mesh to the fascia to prevent it slipping or rolling.
Apart from this the properties of an ideal prosthetic material comprise a high intrinsic tensile strength and induction of extensive tissue in growth. The latter however, may be disadvantageous in laying the mesh intraperitoneally. The PTFE mesh holds a distinct advantage here as it incites minimal tissue reaction, consequently it relies more on its intrinsic tensile strength which is adequately provided by a 2mm thick mesh9. The use of mesh resulted in a decrease in the failure rate from 30-50%3,9,10 recurrences to about 10% recurrences. The aim of repairing incisional hernias by laparoscopy thus targets an incidence of 10% or less recurrence.
Almost all ventral hernias are amenable to laparoscopic repair Hernias with multiple sieve like defects (swiss cheese hernias) get greatly benefitted by this approach as all defects get directly visualised and appropriately covered by the mesh.
Patients with large hernias and associated cardiorespiratory disorders, where an open repair may lead to significant cardiorespiratory embarrasment11 .
Are few and comprise of very large hernias with a thinned out redundant skin covering, requiring an abdominoplasty for repair.
Patients desiring a better cosmetic result.
Patients with dense intra abdominal adhesions precluding access into the peritoneal cavity.
The patient lies supine with the arms by the side to allow a greater degree of freedom of movement to the operating surgeon. The positions of the surgeon, the first assistant and the monitor vary depending on the site of hernial defect (As shown in Fig. 1,2,3,4). The operating surgeon, the hernial defect and the monitor should all be in a straight line. Carbondioxide insufflation is begun by placing the veress needle intra-abdominally in an area well away from the defect and least likely to have adhesions. The left hypochondriun is the preferred site in most midline and lower abdominal defects. Alternatively an open technique may be used for accessing the peritoneal cavity in cases of suspected adhesions. Once pneumoperitoneum is established the first trocar is placed atleast 10cms away from the edge of the hernial defect, preferably in the left hypochondrium where it is least likely to traumatize the thick walled mobile stomach. The remaining two trocars are placed in line with the first trocar under vision. The inter trocar distance is kept to a minimum of 5cm. The port placement may vary in case of subcostal defects. However the same principles of placement apply as the distance of the trocars from the defect defines the field of vision and provides space for safe overlapping of the mesh for a distance of at least 3 cm from the hernial edge and the site of the previous scar.
A 30° Telescope provides excellent view of the abdominal wall and facilitates proper mesh fixation under vision. The repair begins by reducing the contents of the sac. This is facilitated by external pressure applied manually over the defect. Once all contents are reduced and adhesions lysed, the edge of the defect / defects get clearly defined.
The next step comprises of placing the appropriate sized mesh over the defect. This may be done using percutaneous sutures or marking the centre of the mesh with a suture knot for correct placement over the hernias defect. The mesh is then fixed along the margins using tackers to ensure a close approximation of the mesh to the abdominal wall. The omentum may then be optionally spread out over the bowel as a barrier between it and the mesh. There are a lot of advocates for using Goretex mesh to minimize adhesion formation. Its lack of memory makes it a difficult material to handle and being expensive is a major barrier its for widespread use. We have been using a polypropylene mesh in all our patients, which has served well as a prosthetic material, having so far not encountered any complication related to the prosthesis. It is possible to perform this procedure simultaneously with any other laparoscopic procedure. A word of caution though is that cases where one encounters infection (e.g. Empyema G.B., Koch's abdomen) in the primary procedure being performed, the hernia repair must be avoided. A mesh infection in such cases is possible and can have disastrous complications. The procedure thus completed the trocar sites are closed as usual
Seroma formation has been known to occur in about 30% of patients in the redundant sac remaining. However the incidence falls about to 18% with the use of pressure dressing left in place for 10-14 days.
Recurrence is a complication unique to hernia repair. Strict adherence to surgical principles can minimize its occurrence. These include a minimum of 3 cm overlap all around beyond the fascial defect and the previous scar by the mesh. The mesh needs to be placed under some but not excessive tension across the defect. The tacking should be such that there is no space between the mesh and the abdominal wall where the bowel may herniate.
The potential for bowel adhesions and fistula formation exists. This may be minimized by careful handling of the tissues during dissection. Serosal trauma should be avoided. The bowel may be covered by the omentum to prevent its direct contact with the mesh12. It is however well documented that laparoscopic surgery is associated with reduced incidence of adhesion formation13,14. This may be attributed to reduced ischemia and lower bacterial contamination during laparoscopic surgery.
Wound infection can be kept to a minimum by ensuring adequate sterility and preoperative antibiotic cover.
In our opinion a Laparoscopic ventral hernia repair offers a high advantage and a very viable option to patients suffering from this deforming ailment.
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I am thankful to Dr. Vandana Mann, my colleague in the Department of Minimally Invasive Surgery for actively participating in Laparoscopic - Incisional Hernia project and preparing this article.
My sincere thanks to my colleagues in the Department of Minimally Invasive Surgery, Dr. Rajesh Khullar, Dr. Anil Sharma, Dr.Manish Baijal and Dr. Ashish Vashistha, for their constant, positive and supportive help in all the ongoing projects and progress made in the department.
I sincerely thank Ms. Aenu Batra, Mr. Pankaj Gupta and Mr.Satish Jha for their excellent secretarial help and support.