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220
E.M. Pauli and R.M. Juza
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Laparoscopic Ventral Hernia
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Repair
David M. Krpata and Yuri W. Novitsky
Introduction
Ventral herniorrhaphies are among the most commonly performed operations by general surgeons
throughout the world. Incisional hernias, with a
reported incidence of up to 20%, have become an
increasing problem due to the increasing number
of laparotomies performed. In the United States,
approximately 175,000 ventral abdominal hernias are repaired each year. Surgical approaches
to ventral herniorrhaphy have been a subject of
research and technical modifi cations for many
years. Although the routine use of prosthetic
reinforcement for the repair of herniations in
adults has been contested, existing evidence
strongly supports tension-free hernia repairs in
most patients [
popularization of tension-free repairs using prosthetic meshes, the recurrence rates are typically
less than 20% [ 1 , 2 ].
Large abdominal incisions and wide tissue
dissection with the creation of large fl aps are
1 , 2 ]. With the development and
2 1
needed for open placement of adequately sized
mesh [ 3 ]; however, this dissection may result in
high incidence of postoperative morbidity and
wound complications. Not surprisingly, with the
advent of minimally invasive surgery, the use of
laparoscopy for ventral hernia repairs has become
standard [ 4 – 7 ]. The mesh is placed as an intra-
peritoneal underlay with wide coverage of the
hernia defect. Avoidance of large incisions has
substantially reduced wound complications [ 4 ,
6 ]. Overall, the clinical benefi ts of laparoscopic
ventral hernia repair (LVHR) include a faster
convalescence, fewer complications and, importantly, a low recurrence rate [ 4 – 7 ]. Additionally,
the laparoscopic approach can be employed for
the management of more complex hernia locations, such as suprapubic ventral hernias. In this
chapter, we will discuss the technical aspects of
the traditional laparoscopic repairs and address
potential pitfalls and contraindications.
Preoperative preparation
and patient selection
D. M. Krpata , M.D. (*)
General Surgery, Cleveland Clinic Comprehensive
Hernia Center , Cleveland , OH , USA
krpatad@ccf.org
e-mail:
Y. W. Novitsky , M.D., F.A.C.S.
Department of Surgery , Case Comprehensive Hernia
Center, University Hospitals Case Medical Center ,
Cleveland , OH , USA
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_21
The workup of a ventral hernia patient includes a
thorough history and physical examinations. It is
important to obtain all old operative reports. All
pertinent comorbidities, including smoking,
diabetes, and obesity, must be optimized. Bowel
preparation is not given. Abdominal imaging
(with Ultrasound or CT scan) is essentially uniform
223© Springer International Publishing Switzerland 2016
224
D.M. Krpata and Y.W. Novitsky
except for small defects. Information gleaned
from abdominal imaging may not only allow to
delineate the defect(s), but may also affect a
given patient’s suitability for a laparoscopic
repair. In our practice, relative contraindications
to a laparoscopic approach include hernias wider
than 8–10 cm, signifi cant overlying skin changes,
previous intra-peritoneal mesh, as well as repairs
in clean-contaminated or contaminated settings.
Techniques of Laparoscopic VHR
After general anesthesia is induced, the patient is
positioned supine with the arms adducted and
“tucked” at the sides (Fig. 21.1 ). This allows for
adequate space for both primary surgeon and an
assistant on the same side of the patient. We use
two monitors placed on each side of the patient.
In most cases, the bladder and stomach are
decompressed with catheters. An antibiotic, usually a fi rst-generation cephalosporin , is given
prophylactically before the incision was made
and repeated if the operation lasts longer than
4 hours. We routinely use an Ioban™ drape (3M
Company, St. Paul, MN) to minimize mesh contact with the patient skin. Laparoscopic hernia
repair is performed by using a 30° angled laparo-
Fig. 21.1 Patient positioning. The arms should be
“tucked” to allow for operating surgeon and assistant to
stand on the same side and minimize potential interference of the outstretched arms with instrument handles
scope, 5-mm bowel graspers, scissors, and clip
appliers.
Safe access to the peritoneal cavity is a key
fi rst step in LVHR. The access is gained using
either a cut-down technique, an optical trocar, or
a Veress needle. Regardless of the method chosen, access to the abdominal cavity must be performed away from any previous incisions. A
window of access is usually present, even in the
multiply operated abdomen, at the costal margin
between the mid-clavicular or anterior axillary
lines. We prefer an optical trocar technique in the
left upper quadrant just off the rib. Once access is
established, it is imperative to confi rm that no
inadvertent injuries to the abdominal organs or
vessels occurred. Any uncertainties must be followed by a laparoscopic exploration. One should
have a very low threshold to convert to open if the
safety of the initial access cannot be confi rmed.
After pneumoperitoneum is established, we
typically place an additional 5-mm trocar under
direct vision laterally along the anterior-to-midaxillary line. If adhesions are extensive, a third
5-mm trocar is placed to allow for two working
ports and a camera on the same side. Furthermore,
two additional 5-mm trocars are placed on the
contralateral side to facilitate intra-abdominal
mesh introduction and fi xation. This strategy
involves utilization of fi ve 5-mm trocars
(Fig. 21.2 ). For smaller defects, the number of the
access ports could be reduced. However, fewer
working ports result in poor triangulation, reduced
effi ciency, and diffi culties with mesh positioning
and tacking. Given a very low morbidity and scarring associated with a 5-mm port, additional
access sites are well worth it. We strongly advise
to have at least two trocars on each side of the
abdomen for most, if not all, cases.
Following trocar placement , adhesiolysis is
performed sharply with limited use of electrosurgery or ultrasonic coagulators. This is another
critical step for a safe LVHR. Inadvertent and
unrecognized bowel injuries can cause signifi cant morbidity and even mortality. Missed enterotomy during LVHR remains the most common
reason for malpractice litigation. Reduction of
the hernia contents is performed using blunt
graspers and sharp dissection from the inside and
21 Laparoscopic Ventral Hernia Repair
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Fig. 21.2 Typical trocar strategy
for our standard laparoscopic
ventral hernia repair
225
5 mm
5 mm
is facilitated by manual compression from the
outside. The hernia sac is usually left in situ.
Once the adhesiolysis is completed, the hernia defect is measured to determine an appropriate size of a prosthetic mesh. The borders of the
defect are delineated with a combination of laparoscopic vision and external palpation. The
edges of the defect are marked externally. We
utilize trans-abdominal spinal needles to obtain
precise dimensions of the hernia defect
(Fig. 21.3 ). This maneuver is especially impor-
tant in obese patients with large defects as the
externally measured defect size can be dramatically overestimated. A ruler is placed through a
5-mm port, and the dimensions of the hernia
defect are measured directly. Additionally, defect
closure could be performed and is addressed in
detail in Chapter 22 .
The mesh is then tailored to overlap all margins of the hernia by at least 5 cm. Our general
rule of thumb is to obtain overlap of 25–30% of
the defects size on each side. Once the mesh is
cut to the desirable size, four size-0 permanent
monofi lament or ePTFE sutures are placed at the
mid-point of each side of the mesh. Points of
reference on the mesh and corresponding points
5 mm
5 mm
5 mm
on the abdominal wall are marked to aid in
orienting the mesh after its introduction into the
abdomen. The mesh is rolled up and pushed or
pulled into the abdomen through an additional 12
or 15-mm trocar. This port is placed near the hernia defect so that the mesh covers the site, negating the need for fascial closure and minimizing
the risks of trocar-site hernia (Fig. 21.4 ).
Alternatively, (and less desirable in our opinion),
any of the lateral trocars could be up-sized to
allow for mesh introduction.
The mesh is rolled from both edges to facilitate the unfolding step. If the defect size requires
a very large prosthetic, it is usually introduced in
the abdominal cavity by pulling with the grasper
passed through the contralateral trocar
(Fig. 21.5 ). It is important to maintain the appro-
priate mesh orientation during the insertion and
unfolding of the mesh. Modern positioning
devices have signifi cantly facilitated this step,
allowing for rapid and accurate mesh placement.
After the mesh is oriented intra-corporeally, the
sutures are pulled through the abdominal wall
with a suture passer (Fig. 21.6 ). Adequate mesh/
defect overlap is once again confi rmed using spinal needles, similarly to that described above.
226
Fig. 21.3 Intra-corporeal (direct)
measurement of a hernia defect.
Spinal needles allow for more
precise identifi cation of the edges
of the defect. Additional spinal
needles may be used for defects
larger than the length of a ruler
Fig. 21.4 Instead of enlarging a 5-mm
lateral port, the additional 12-mm port,
used for mesh introduction, is placed
close to the edge of the hernia to allow
for subsequent mesh coverage of the
trocar site
D.M. Krpata and Y.W. Novitsky
12 mm
5 mm
5 mm
The top or bottom suture is pulled fi rst. We recommend beginning with the point closest to the
bony margin (xiphoid, pubis, iliac crest, costal
margin, etc.). We subsequently pull the suture
that is opposite to the fi rst one. Once suffi cient
overlap is confi rmed, we tie both sutures with the
knots buried in the subcutaneous tissues. The
other two lateral sutures are then pulled transabdominally and tied ensuring that the overlap is
suffi cient. We recommend starting with the lateral stitch ipsilateral to the camera (#3 in
21.6 ). To facilitate this step, we move the
Fig.
5 mm
5 mm
5 mm
camera to the superior-most trocar. We routinely
reduce pneumoperitoneum to 7–8 mmHg to
ensure the mesh is taut and doesn’t wrinkle after
desufl ation. Once again, having at least two trocars on each side of the abdomen allows for easy
and precise mesh positioning. After correct positioning is confi rmed, the fourth stitch is pulled
through and all stitches are tied.
The perimeter of the mesh is then attached to
the peritoneum with tacks, at approximately 1 cm
intervals to prevent intestinal herniation. Placing
the tacks is facilitated by the external manual
21 Laparoscopic Ventral Hernia Repair
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Fig. 21.5 The mesh could be introduced by “pulling” it in to the abdomen through a trocar
227
Fig. 21.6 Mesh fi xation. Inferior and superior sutures are pulled fi rst, followed by the lateral sutures
228
D.M. Krpata and Y.W. Novitsky
palpation of the tacker’s tip (Fig. 21.7 ). Tactile
feedback is particularly important for tacking the
mesh in the lower abdomen to ensure that the
tacks are placed superiorly to the inguinal
ligament. Similarly, for upper abdominal hernias,
manual counter palpation is paramount to ensure
that the tacks are placed below the costal margin.
Failure to do so may lead to pulmonary and pericardial injuries. If the mesh extends cephalad to
the costal margin and xiphoid process, that portion of the mesh should not be tacked and should
be affi xed to the peritoneum with sutures or glue.
Although some investigators have advocated a
“double-crown” technique of mesh fi xation, we
strongly believe additional suture fi xation is critical to ensure the long-term durability of the
repair. Additional full-thickness stitches are
placed circumferentially every 5–8 cm by using
the suture passer (Fig. 21.8 ). This trans-
abdominal fi xation is crucial to ensure that the
mesh will not be displaced over time. The knots
are tied in the subcutaneous tissues. The skin is
released to avoid dimpling.
Postoperative Ca re
While some patients may be suited for LVHR on
an outpatient basis, most patients with moderate
defects require at least a 1–2 day hospitalization.
This is done to ensure adequate pain control and
resolution of ileus. Factors infl uencing longer
recovery include extensive adhesiolysis, large
incarcerated defects, and multiple transabdominal sutures. We advocate a clear or soft
diet for the fi rst 3–5 days following the repair to
provide for adequate return of normal bowel
function. The abdominal binders are encouraged,
especially in the fi rst 2 weeks. Activities are not
restricted and are guided by patients’ discomfort.
Complications and Outcomes
While LVHR has its benefi ts with relation to
wound morbidity compared to open techniques,
it is not without potential complications. In general, these complications can be categorized into
intra-operative, postoperative, and long-term.
Some complications are associated with laparoscopy and some with ventral hernia repair; the following discussion focuses on complications that
are somewhat unique to LVHR.
Wound and mesh infections are known complications of any hernia repair. Many investigators
have shown that laparoscopy is associated with an
extremely low rate of wound infections and very
rare mesh infections [ 5 – 7 ]. Modern meshes with-
out an ePTFE component have reduced infectious
complications of LVHR even further. However,
Fig. 21.7 Placement of tack is done circumferentially
along the whole length of the mesh to avoid bowel incarceration. External palpation of the abdominal wall facili-
tates placement of the tacks and helps to avoid tacking the
mesh below the inguinal ligament and above costal
margins
21 Laparoscopic Ventral Hernia Repair
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Fig. 21.8 Trans-abdominal suture
fi xation of the mesh
229
any persistent cellulitis and/or persistent fl uid collection around the intra- peritoneal mesh should be
a point of concern for acute or chronic prosthetic
infection, especially if ePTFE-based mesh was
used. Open exploration, mesh removal, primary
hernia repair, and delayed formal reconstruction
are the best and safest ways to approach infected
mesh after LVHR.
Intra-operative complications such as bleeding
or injury to surrounding intra-abdominal structures
are rare. Nonetheless, an enterotomy or missed
enterotomy will signifi cantly impact the outcome
of surgery. An enterotomy identifi ed during surgery
with spillage of enteric content within the abdomen
should cause the surgeon to re-evaluate the operative plan. The enterotomy can be repaired laparoscopically if it is well visualized and ports are
optimally placed. If there is any question about the
integrity of laparoscopic repair of the enterotomy,
conversion to a laparotomy is mandatory. With
gross spillage of enteric content, a formal hernia
repair should be delayed. Missed enterotomy or a
delayed bowel injury from electrocautery resulting
in intra- abdominal sepsis and mesh infection would
require laparotomy, repair of the bowel injury, and
complete excision of the mesh. Failure to completely remove the mesh would almost certainly
lead to persistent intra-abdominal infection.
Seroma formation is one of the most common
complications after LVHR [ 6 ]. Failure to obliter-
ate the potential space within the hernia sac frequently leads to fl uid accumulation in the hernia
sac. The seroma may present as a bulge which
patients may commonly perceive as a hernia
recurrence. Careful physical exam should easily
differentiate between the two. If the diagnosis is
in question, ultrasound or CT scan evaluation can
be used to differentiate between diagnoses.
Management of a seroma should follow a conservative pathway as it will typically resolve without intervention. For persistent seromas, sterile
aspiration can be performed in the offi ce.
However, fl uid may re-accumulate in the potential space after aspiration necessitating additional
aspirations. It is important to realize that any
aspiration and subsequent aspirations put a
patient at risk for converting a sterile seroma into
an abscess. Closing the defect during LVHR with
the “shoelace” technique (Chapter 22 ) can sig-
nifi cantly reduce or even eliminate the risk of
seroma formation.
In the early postoperative period, patients may
complain of pain at the trans-abdominal suture
sites. Conservative management with NSAIDs
may resolve the patient’s pain; however, persistent pain may require injection with local anesthetics. The use of slowly absorbable sutures for
mesh fi xation could be associated with reduced
postoperative pain, but that has not been proven
in prospective trials. While the use of absorbable
tacks has been proposed to reduce chronic pain,
their utilization has been shown to have no effect
on postoperative pain.
Arguably, the most important complication
from an LVHR is a hernia recurrence , as this is
the primary outcome measure of long-term success of the surgery. Recurrence rates in the literature vary from 2 to 20% with the largest series
demonstrating recurrence rates around 5% [ 6 , 7 ].
Long-term, the best chance for a successful
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