How I do it: laparoscopic repair for recurrent incisional hernia
Chowbey, P.K. (2002) How I do it: laparoscopic repair for recurrent incisional hernia. In: TAGM/ASM of The College of Surgeons, Academy of Medicine of Malaysia, 16-18 May 2002, Pahang, Malaysia.
Full text available as:
Laparoscopic repair of incisional hernia has gradually gained acceptance and has shown t results which compare favorably to open hernia repair. Pure tissue repays are known to have unacceptably high recurrence rates. These patients with recurrences have been found to have some element of intrinsic tissue weakness which make them ideal candidate for a laparoscopic hernia repair. This surgical approach is well away from the previous surgery site, is tensionless and uses prosthetic materials for closing the defect greater maneuverability of position. The hands are placed by the patients side permitting the surgeon adequate freedom of movement. We prefer to initiate insufflation using the jveress needle placed well away from the previous surgical site. So far this method has fared well in establishing a pneumoperitoneum and only where this method has failed has an open access been performed. We find the Palmer's point in the left hypochondrium to be a safe area for the initial puncture as the thick walled and mobile stomach is less prone to injury splenomegaly having been ruled out. On accessing the peritoneal cavity a meticulous laparoscopy is performed. Working ports are placed such that the monitor, the operating site, the surgeon and the working ports lie in a straight line (Fig 1-4). Adhesiolysis is performed using sharp dissection and judicious use of cautery avoids injury to bowel. Using a 30° telescope and changing the laparoscope port helps in looking around adhesions for presence of bowel and overcoming the two dimensional vision. The size of prolene mesh used should be such as to give a margin| of at least 3 cm around the hernial defect and cover the entire incision area to prevent further recurrences. In our series of over 700 laparoscopic ventral hernia repair over the Bast 8 years including 123 recurrent hernia repairs, no complication has been Encountered relating to the prolene mesh. The spiral tacks are placed 2.5 to 3 cm apart along the mesh edge and at the edge of the hernial defect to ensure a firm fixation. A layer lof omentum is placed over the bowel at the end of the procedure. Ten mm sized ports are closed using a port closure needle to prevent the possibility of port site herniation. A firm compression dressing on the redundant, skin covering the hernial sac reduces the incidence of seroma formation, a benign however distressing complication for the patient which may require prolonged counselling as is the commonest cause of patient dissatisfaction. In our experience careful selection of cases, adhesiolysis avoiding the likelihood of an accidental enterotomy and a well placed mesh, covering the entire weakened area, fixed with appropriately placed spiral tacks ensure a successful outcome of the surgical procedure.
Archive Staff Only: edit this record