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26 Component Separation of Abdominal Wall Muscles
Fig. 26.12 Retromuscular plane ready for mesh placement after posterior sheet closure (Published with kind permission of © Yuri Novitsky
2017. All Rights Reserved.)
Conclusion
The separation of muscular components from the abdom-
inal wall is an extremely useful surgical tactic in the
reconstruction of this important structure, which aims at
the restoration of physiology/functionality by the closure
of the midline [13]. There are several alternative methods
described, and the understanding of the laminar anatomy,
vascularization, and innervation of the various compo-
nents is fundamental for the success of the surgery [5]. It
is worth remembering that the relaxation incisions are not
component separations and do not allow large slides for
midline alignment [1, 9].
References
1. Ramirez OM. Inception and evolution of the components
separation technique: personal recollections. Clin Plast Surg.
2006;33(2):241–6.
385
2. Halvorson EG. On the origins of components separation. Plast
Reconstr Surg. 2009;124(5):1545–9.
3. Pauli EM, Rosen MJ. Open ventral hernia repair with component
separation. Surg Clin North Am. 2013;93(5):1111–33.
4. Daes J, Dennis RJ. Endoscopic subcutaneous component separation as an adjunct to abdominal wall reconstruction. Surg Endosc.
2017;31(2):872–6.
5. Grevious MA, Cohen M, Shah SR, Rodriguez P. Structural
and functional anatomy of the abdominal wall. Clin Plast Surg.
2006;33(2):169–79.
6. Harth KC, Rose J, Delaney CP, Blatnik JA, Halaweish I, Rosen
MJ. Open versus endoscopic component separation: a cost comparison. Surg Endosc. 2011;25(9):2865–70.
7. Rosen MJ, Fatima J, Sarr MG. Repair of abdominal wall hernias
with restoration of abdominal wall function. J Gastrointest Surg.
2010;14(1):175–85.
8. Carbonell AM, Cobb WS, Chen SM. Posterior components separation during retromuscular hernia repair. Hernia. 2008;12(4):359–62.
9. Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus
abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am
J Surg. 2012;204(5):709–16.
10. Gibreel W, Sarr MG, Rosen M, Novitsky Y. Technical considerations in performing posterior component separation with transverse abdominis muscle release. Hernia. 2016;20(3):449–59.
11. Blatnik JA, Krpata DM, Novitsky YW. Transversus Abdominis
release as an alternative component separation technique for ventral
hernia repair. JAMA Surg. 2016;151(4):383–4.
12. Jones CM, Winder JS, Potochny JD, Pauli EM. Posterior component separation with transversus abdominis release: technique, utility, and outcomes in complex abdominal wall reconstruction. Plast
Reconstr Surg. 2016;137(2):636–46.
13. Lisiecki J, Kozlow JH, Agarwal S, Ranganathan K, Terjimanian
MN, Rinkinen J, Brownley RC, Enchakalody B, Wang SC, Levi
B. Abdominal wall dynamics after component separation hernia
repair. J Surg Res. 2015;193(1):497–503.
14. Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott
HL, Orenstein SB. Outcomes of posterior component separation
with transversus abdominis muscle release and synthetic mesh sublay reinforcement. Ann Surg. 2016;264(2):226–32.
15. Parent B, Horn D, Jacobson L, Petersen RP, Hinojosa M, Yates
R, Wright AS, Louie O. Wound morbidity in minimally invasive
anterior component separation compared to transversus abdominis
release. Plast Reconstr Surg. 2017;139(2):472–9.
Minimally Invasive Sublay Mesh Repair of Abdominal Wall Hernias with the MILOS Technique (Mini or Less Open Sublay Repair)
Wolfgang Reinpold
27
Primary abdominal wall and incisional hernia repair figure
among the most frequent operations in surgery. The risk of
incarceration is 1–2% per year. The main cause seems to
be genetically determined insufficient cross-links between
the collagen molecules. Since the advent of synthetic mesh
[1, 13, 14], recurrence rates could be reduced from 25–60%
to below 15%.
The open sublay mesh implantation based on techniques
of Jean Rives and René Stoppa and the laparoscopic intraperitoneal onlay mesh plasty (lap IPOM) are the internationally leading procedures for the treatment of incisional hernias
[2–8] (Fig. 27.1a, b).
In open sublay repair, the alloplastic mesh is inserted via
a large skin incision between the peritoneum/posterior rectus sheath and the abdominal wall. Today the sublay mesh
position is considered most advantageous because direct
contact of foreign material with bowel and other viscera is
omitted. Because the intra-abdominal pressure pushes the
alloplastic prosthesis against the abdominal wall, in many
cases only no or minimal atraumatic fixation is necessary.
The disadvantages of the procedure are the more invasive
access trauma and, according to the literature, the higher
infection rates.
Despite the advantages of the small skin incisions in lap
IPOM surgery, the pain level is not low. A further concern is
the implantation of a foreign body in the abdominal cavity,
which is a risk factor for adhesion formation to the bowel
and injuries to the viscera. In addition the mesh has to be fixated with many staples, clips, tacks or extensive sutures to
the pain-sensitive peritoneum [6, 9–11] (Fig. 27.1a).
Expensive implants with adhesion barriers on the area facing
the bowel have to be used. Reoperations have shown that all
IPOM prostheses can lead to massive adhesions and do not
provide secure protection of the viscera. Another disadvan-
W. Reinpold
Department of Surgery and Reference Hernia Center, Gross Sand
Hospital Hamburg Wilhelmsburg, Gross-Sand 3, D-21107
Hamburg, Germany
e-mail: w.reinpold@gross-sand.de
tage of lap IPOM repair is the fact that the hernia defect is
often not fully closed but only bridged by the synthetic prosthesis. This often leads to a persisting protrusion that frequently regresses slowly or not at all. Current data from the
German hernia register “Herniamed” show significantly
more 1 year recurrences after lap IPOM hernia repair than
after open sublay operations. There are only few publications on minimally invasive sublay repair of abdominal wall
hernias [15–17].
For the further reduction of complications and pain in
abdominal wall hernia repair, we developed a new minimally
invasive technique—the mini or less open sublay (MILOS)
repair. The MILOS repair permits insertion of a large mesh
in the retromuscular/preperitoneal space and anatomical
reconstruction of the abdominal wall via a small transhernial
incision. Using the MILOS technique major trauma to the
abdominal wall and entering the abdominal cavity is avoided.
The MILOS operation can be performed mini-open with
light-armed laparoscopic instruments either under direct
vision or endoscopically assisted. Today, in our institution all
primary and incisional abdominal wall hernias are operated
on with the MILOS technique. Exceptions are small hernias
with a hernia defect diameter smaller than 2 cm and extremely
large hernias.
The MILOS operation starts with an incision of 2–6 cm
directly above the centre of the hernia defect. The abdominal
wall is lifted with retractors. The preparation is carried out in
“mini-open” technique under direct vision or endoscopically
assisted. After transhernial mini-open preparation of an
extraperitoneal space of at least 8 cm diameter and closing of
the abdominal cavity, the procedure can be continued as total
extraperitoneal gas endoscopy (Endoscopic TEP of the
abdominal wall) using either standard trocars (Fig. 27.2) or a
transhernial single port (Fig. 27.3) [12].
The MILOS technique enables the extraperitoneal preparation of the whole rectus compartment and both lateral compartments. Very large synthetic meshes can be implanted
(Fig. 27.4) minimal invasively if the size of the hernia
requires it. Posterior component separation can be performed
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_27
387
388
W. Reinpold
a
b
Fig. 27.1 (a) Extensive tack fixation of lap IPOM mesh. (b) Large
incision in open sublay surgery (Published with kind permission of
© Wolfgang Reinpold 2017. All Rights Reserved.)
using the MILOS technique. Thus, a total sublay repair of
the abdominal wall is possible.
The surgical steps of MILOS repair:
1. Small incision directly above the centre of the hernia
defect (Fig. 27.5).
2. Hernia sac preparation.
3. Small incision of the peritoneum for diagnostic
laparoscopy.
4. Resection of abundant peritoneum of the hernia sac.
5. Complete and precise exposure of the fascial edge of the
hernia orifice.
6. While the abdominal wall is lifted with rectangular
retractors (Figs. 27.6b, 27.7, and 27.8), transhernial
extraperitoneal dissection around the hernia gap is performed using laparoscopic instruments armed with a
light tube specifically designed by us and Wolf Company
(Endotorch ™, Figs. 27.9 and 27.6a, b). Via a 4 cm inci-
Fig. 27.2 eMILOS-TEP ventral hernia repair with standard trocars
(Published with kind permission of © Wolfgang Reinpold 2017. All
Rights Reserved.)
Fig. 27.3 eMILOS-TEP ventral hernia repair with single port
(Published with kind permission of © Wolfgang Reinpold 2017. All
Rights Reserved.)
sion, the Endotorch ™ allows circumferential dissection
of the extraperitoneal plane with a radius of up to 20 cm
from the fascial border of the hernia gap.
Transhernial longitudinal incision of the posterior
rectus sheath is performed in all quadrants to correspond
with the mesh size (Figs. 27.7 and 27.8). Figure 27.10
depicts the endoscopic incision of the cranial section of
the left posterior rectus sheath.
7. Closure of the abdominal cavity with absorbable suture.
8. Transhernial extraperitoneal implantation of synthetic
mesh. The posterior rectus sheath is closed if possible
with low tension. If the posterior rectus sheath is not
Hernia defect
27 Minimally Invasive Sublay Mesh Repair of Abdominal Wall Hernias with the MILOS Technique (Mini or Less Open Sublay Repair)
a
b
Fig. 27.4 MILOS operation of the fourth recurrence of an incisional
hernia after open prostatectomy (Published with kind permission of ©
Wolfgang Reinpold 2017. All Rights Reserved.)
Prothesis
389
Skin incision
Fig. 27.5 Incision of 2–6 cm directly above the hernia defect showing
synthetic mesh (black interrupted line). Hernia defect (green).
Incision (red) (Published with kind permission of © Wolfgang Reinpold
2017. All Rights Reserved.)
approximated, the mesh is then placed in the preperitoneal space in the midline and on both sides laterally in
the retromuscular position (Fig. 27.11).
9. Mesh fixation is only necessary in cases where the hernia defect cannot be closed with low tension (bridging of
large hernia defects). The intra-abdominal pressure fixates the mesh between the peritoneum and supporting
abdominal wall. We use large-pore standard polypropylene or polyvinylidene fluoride meshes, which cover the
hernia defect with a radius of 5–25 cm (Figs. 27.12 and
27.4) according to the hernia defect size.
10. The hernia defect is closed anatomically with a running
non-absorbable or long-term absorbable suture.
Fig. 27.6 (a) Endotorch TM: Light-armed 5 mm laparoscopic forceps.
(b) Transhernial dissection with Endotorch TM and laparoscopic 5 mm
instruments (Published with kind permission of © Wolfgang Reinpold
2017. All Rights Reserved.)
The MILOS technique is also appropriate for lateral
abdominal wall hernias. In the case of large incisional
hernias, the surgery is carried out in “less open” technique
(skin incision > 6–12 cm).
MILOS Operation of Diastasis Recti
Surgical repair of symptomatic diastasis recti may be indicated, especially in cases where concomitant primary ventral or incisional hernias are present. An epigastric or
infraumbilical diastasis recti can be closed with the MILOS
technique without extending the incision. While the skin is
elevated with a pair of adequate retractors (s.a.), MILOS
dissection with light-armed endoscopic instruments is performed under direct vision or endoscopically assisted. In
order to prevent an ugly cutaneous rim, the subcutaneous
tissue is detached from the linea alba and medial aspect of
the anterior rectus sheath (2–4 cm on every side). The diastasis recti is anatomically closed by an anterior inverting
non- absorbable running suture (0). Alternatively, a miniopen or endoscopically assisted posterior inverting suture is
390
W. Reinpold
Fig. 27.7 Transhernial
bilateral incision of the
posterior rectus sheath
(Published with kind
permission of © Wolfgang
Reinpold 2017. All Rights
Reserved.)
Peritoneum
Posterior rectus
sheath
Linea Alba
Long small retractors
Anterior rectus
sheath
Bilateral
longitudinal
incision of the
posterior rectus
sheath leaving
the peritoneum
and linea alba
intact.
Fig. 27.8 Incision of the posterior recuts sheath 1 cm lateral of the
medical border of muscle (Published with kind permission of ©
Wolfgang Reinpold 2017. All Rights Reserved.)
Fig. 27.9 Set of MILOS instruments (Published with kind permission
of © Wolfgang Reinpold 2017. All Rights Reserved.)
Fig. 27.10 Single port TEP: Incision of the upper left posterior rectus
sheath (Published with kind permission of © Wolfgang Reinpold 2017.
All Rights Reserved.)
Fig. 27.11 Retromuscular/preperitoneal mesh position; hernia defect
is anatomically closed (Published with kind permission of © Wolfgang
Reinpold 2017. All Rights Reserved.)
27 Minimally Invasive Sublay Mesh Repair of Abdominal Wall Hernias with the MILOS Technique (Mini or Less Open Sublay Repair)
Table 27.2 Size of mesh in incisional hernia operations (MILOS-OP;
n = 865)
Area (in cm2) 0–50 51–100 101–200 >200
Number 0 10 91 764
Table 27.3 MILOS incisional hernia repair at Gross-Sand Hospital
(n = 865) vs. all incisional hernias in the Herniamed Register (40,066)
All incisional
hernia
operations in
Herniamed
Register
(40,066)
Fig. 27.12 Young woman with 3 cm incisional hernia after umbilical
hernia suture repair. MILOS operation with 3 mm instruments, 5 mm
endoscope and 2 cm incision. Implantation of a 15 × 15 cm mesh
(Published with kind permission of © Wolfgang Reinpold 2017. All
Rights Reserved.)
Table 27.1 Size of hernia gap in incisional hernias (MILOS-OP;
n = 865)
Area
(in cm
Number 95 64 115 173 133 173 112
0–5 6–10 11–20 21–50 51–100 101–200 >200
2
)
MILOS
incisional
hernia
operations %
(n = 865)
No complications 95.2 86.3
Total number of complications 4.8 13.7
Surgical complications 3.2 9.6
Haemorrhage/postoperative
haemorrhage
Enterotomy 0.2 0.5
Impaired wound healing 0.3 0.7
Seroma 0.9 4.1
Infection 0.3 1.2
Ileus 0.4 1.2
Revision surgeries 1.9 4.1
General complications 1.6 4.1
Mortality 0.1 0.25
1.0 1.9
391
possible. If mesh augmentation is indicated, we prefer the
insertion in the sublay position. However, onlay mesh repair
is also possible [18].
From January 2010 to February 2017, we carried out 865
MILOS operations for incisional hernias and an approximately equal number of primary abdominal wall hernias. Data
on all patients were documented in the “Herniamed” Register.
The hernia orifices and the size of the mesh are given in
Tables 27.1 and 27.2. Postoperative consumption of analgesics was comparably low. The standard postoperative pain
medication was the non-opioid metamizol 4 × 1 g orally.
Additional opioids are necessary in only 10% of the cases. In
the case of large incisional hernias, an epidural analgesic
catheter is indispensable.
In 42 cases of large ventral and incisional hernias, the MILOS
technique was combined with posterior or anterior endoscopic
component separation (hybrid procedure) in order to achieve a
low-tension anatomical closure of the large hernia defect after
the insertion of a large extraperitoneal synthetic mesh.
The average operating time of MILOS incisional hernia
repair was 102, 7 and 20 min longer than open sublay (95 min)
and lap IPOM repair (82 min), respectively. Complication
rates after MILOS incisional hernia repair are very low
(Tables 27.3 and 27.4). There were two enterotomies of the
small bowel without spillage. The bowel lesions were closed
with absorbable sutures. MILOS mesh repair was performed
without complications. Three superficial wound infections
healed without mesh infection. A recent propensity score
Table 27.4 MILOS incisional hernia operations at Gross-Sand
Hospital (n = 782) vs. all incisional hernia operations documented in
Herniamed Register (n = 33.335) with complete 1 year follow-up
MILOS incisional
hernia surgeries
(n = 782) (%)
Recurrence after
1 year
Pain at rest 3.8 9.4 (9.3 lap IPOM; 9.5
Chronic stressinduced pain
Chronic pain
requiring therapy
1.8 5.8 (6.8 lap IPOM; 3.9
6.6 18.5 (18.6 lap IPOM;
2.6 7.6 (7.9 lap IPOM 6.9
Incisional hernias in
Herniamed Register
(n = 33.335) (%)
open sublay)
open sublay)
17.1 open sublay)
open sublay)
matching of MILOS, lap IPOM and open sublay operations
of the German Herniamed registry revealed significantly
fewer perioperative complications, reoperations, recurrences
and chronic pain after 1 year in the MILOS cohort [19].
Discussion
To further improve abdominal wall hernia surgery and overcome the obvious disadvantages of the currently most widely
used open sublay and lap IPOM repair, we have successfully
developed the MILOS technique which is the first technique
that allows the minimally invasive sublay repair of all pri-
392
W. Reinpold
mary and recurrent abdominal wall hernias, with the exception of giant eventrations. But even in extremely large
primary and incisional ventral hernias, the principles of
MILOS repair help to reduce the surgical trauma to the
abdominal wall. Our experience with 865 MILOS incisional
hernia operations and about the same number of primary
ventral hernia MILOS repairs showed the following advantages of this novel technique:
(1) Minimally invasive extraperitoneal implantation of
(large) standard synthetic meshes without traumatic
mesh fixation.
(2) Closure of hernia gaps and anatomical reconstruction of
the abdominal wall with protection of viable abdominal
wall structures including nerves.
(3) After MILOS operations there were significantly less
perioperative complications, reoperations, general complications, recurrences and chronic pain after 1 year
compared to open sublay and lap IPOM repair.
(4) The MILOS technique allows minimally invasive repair
of rectus diastases.
(5) The MILOS repair can be combined with endoscopic
anterior and posterior component separation.
(6) Very good cosmetic results.
(7) In comparison with lap IPOM operations, there is a sav-
ing of around 1.200 € in material costs per operation.
Prospective analysis of MILOS repair in primary ventral
hernias with 1 year follow-up also revealed very low complication rates.
Conclusion
The novel MILOS technique allows the minimally inva-
sive endoscopically assisted extraperitoneal repair of pri-
mary and incisional eventrations with very low
perioperative morbidity, recurrences and chronic pain
after 1 year. The technique has the potential to revolution-
ize abdominal wall hernia repair if future studies of other
working groups can reproduce our very promising results.
References
1. Usher FC, Ochsner J, Tuttle LL Jr. Use of marlex mesh in the repair
of incisional hernias. Am Surg. 1958;24(12):969–74.
2. Rives J, Pire JC, Flament JB, Convers G. Treatment of large even-
trations (apropos of 133 cases). Minerva Chir. 1977;32(11):749–56.
3. Stoppa R, Warlaumont C, Chantriaux JF. Prosthetic surgical treat-
ment of inguinal hernias. Parietalization of the spermatic cord.
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4. Stoppa RE, Rives JL, Warlaumont CR, Palot JP, Verhaeghe PJ,
Delattre JF. The use of Dacron in the repair of hernias of the groin.
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GG, Chelala E, Dietz UA, Eker HH, El Nakadi I, Hauters P,
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8. den Hartog D, Dur AH, Tuinebreijer WE, Kreis RW. Open surgical procedures for incisional hernias. Cochrane Database Syst Rev.
2008;3:CD006438. Review.
9. Forbes SS, Eskicioglu C, McLeod RS, Okrainec A. Meta-analysis
of randomized controlled trials comparing open and laparoscopic ventral and incisional hernia repair with mesh. Br J Surg.
2009;96(8):851–8.
10. Sajid MS, Bokhari SA, Mallick AS, Cheek E, Baig
MK. Laparoscopic versus open repair of incisional/ventral hernia:
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11. Kapischke M, Schulz T, Schipper T, Tensfeldt J, Caliebe A. Open
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12. Reinpold W. Endoskopisch totalextraperitonealer transhernialer
sublay –Bauchwand-Hernienverschluss in single-port-technik. In:
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Laparoscopic Incisional and Ventral Hernia Repair
Karl A. LeBlanc
28
Introduction
Approximately 350,000–500,000 ventral hernias are repaired
in the USA yearly.1 This common problem has been
approached in a myriad of ways, each with various technical
aspects that contribute to the long-term success or failure of
the repair. Laparoscopic incisional-ventral hernia (LIVH)
repair, as first described by LeBlanc in 1993 [1], builds upon
the strengths of various techniques that improve overall outcome. The significant mesh overlap in the rectro-rectus repair
with transfascial fixation first described by Rives and Stoppa
[2, 3] is technically similar to what is achieved in LIVH repair.
Though some still commonly perform primary suture
repair of ventral hernias, it has been shown to have a recurrence rate of 54–63% [4, 5]. When primary suture repair was
compared to open mesh repair, open mesh repair was found to
have a recurrence rate of 32% [5]. Though some advocate the
recurrence rate to be equivalent between open mesh repair
and LIVH [4, 6], multiple other studies show LIVH to be
superior in the rate of hernia relapse [7, 8]. Three prospective
trials comparing laparoscopic ventral hernia repair to open
mesh repair show the recurrence rate for LIVH to be 2–3.3%
in comparison to open mesh repair which is reported to be
1.1–10% in these studies [6, 8, 9]. LIVH has been generally
shown to be superior to open mesh repair in postoperative
wound complications, hospital length of stay, and identification of multiple defects [6–11]. Recent evidence appears to
favor the laparoscopic repair for recurrent hernias [12].
1
Society of American Endoscopic and Gastrointestinal Surgeons
(SAGES) website (www.sages.org).
This is an updated version of the chapter previously authored by Patrice
Carter and Karl LeBlanc. Patrice Carter has not participated in the revision of the chapter for the 5th edition.
K.A. LeBlanc (*)
Surgeons Group of Baton Rouge/Our Lady of the Lake Physician
Group, Baton Rouge, LA, USA
e-mail: docmba2@yahoo.com
The repair of incisional and ventral hernias by the laparoscopic approach should be performed by high-volume laparoscopic surgeons. The surgeon should be adept at performing
the more common laparoscopic operations and also be comfortable to perform the more complex laparoscopic procedures. The assistance of another surgeon during this operation
is felt to be of great benefit in most occasions. This chapter
will present the concepts, technical aspects, and results of the
LIVH as it is currently performed. There are variations of the
technique that are presented within this chapter, as is common
to every surgical procedure. This methodology is continuing
to evolve and undoubtedly will be modified as newer prosthetic biomaterials and instrumentation are developed in the
future. One such advancement is the laparoscopic approach to
component separation. Multiple studies have shown that
myofascial advancement can be achieved with minimal flap
dissection and improved wound outcome [13–15].
Preoperative Evaluation
In general, if a patient is a medically appropriate candidate
for open hernioplasty, then he or she could be considered a
candidate for the laparoscopic approach. Patients that have
significant cardiac decompensation may experience physiological abnormalities during the procedure because of the
insufflation and resulting decrease in the venous return.
Lower insufflation pressures may decrease the hemodynamic
fluctuations [16]. Preoperative preparation of the patient is
important because postoperative complications are a predictor of recurrence [17].
Generally almost all hernias are candidates for the
LIVH. Even the smaller hernias in obese individuals could
be repaired with this technique. Recurrence rates have been
shown to be higher in obese patients [18–20]. Yet the benefits of less wound complications and the ability to identify
the occult defects that are missed during an open approach
make LIVH a viable option for obese patients. One may opt
to use the open approach in a thin patient if it is apparent that
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_28
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the defect is 3 cm or less [18]. Some even recommend the
avoidance of hernia surgery at all if the body mass index is
greater than 50 [21]. The laparoscopic method, however, is
preferred in this group of patients [22].
A very large fascial defect that nearly encompasses the
entire anterior abdominal wall may pose a difficult problem.
A laparoscopic approach, however, may be feasible. The
decision to attempt the laparoscopic method should be based
upon the experience of the surgeon, the number of prior operative procedures, mesh repairs, the type of prosthetic utilized
in any previous repair(s), and the location of the potential hernia sites. However, there are currently no “hard and fast” rules
about this issue. In those patients with very large defects, a
reasonable option would be to commence the operation laparoscopically and convert to an open repair if that appears to be
the best alternative. More often than not, this proves to be
unnecessary. A probable exception to this sequence is those
individuals that exhibit a “loss of domain” of the abdominal
contents. In these patients, it is usually impossible to actually
enter the abdomen behind the abdominal wall musculature
because this musculature has been displaced so far laterally.
In these cases, conversion to the open method would occur
earlier rather than later. More commonly, however, prudence
dictates that the entire procedure should be of the open type
rather than even attempting the laparoscopic approach.
Absolute contraindications to the use of the laparoscopic
method would be the presence of an acute surgical abdomen.
A relative contraindication is intra-abdominal infection from
any source. The use of a prosthetic biomaterial in the site of
an overt infection may preclude the use of such a product.
However, primary closure of the hernia defect with the assistance of a laparoscopic suture passer and biologic mesh [23]
may have a role in such instances though an open repair may
be indicated for gross contamination. There is data to support
the use of mesh in contaminated fields, however [24].
Similarly, while the presence of incarcerated bowel does not
prevent the performance of the procedure, strangulation of
the bowel necessitates an open hernioplasty.
Because the most common incision of the abdomen is
placed in the midline, most incisional hernias (approximately
90%) occur in the midline. When a surgeon begins to perform laparoscopic incisional hernioplasty, it is recommended
that he or she should repair midline defects initially to gain
confidence in use of the laparoscopic technique. Once this is
accomplished, the presence of a non-midline defect or multiple defects that are not adjacent to each other should not
preclude the use of laparoscopy. Appropriate positioning of
the patient and accurate placement of the trocars will permit
an approach to the entire abdominal cavity in most cases.
Previous intra-abdominal surgery is a major consideration
in the evaluation of a patient for the laparoscopic procedure.
The number and type of earlier operations will influence the
choice of patient position, the method of abdominal entry, tro-
car placement, and the position of the monitors. This preoperative assessment will allow the surgeon to plan the operative
procedure and the operative suite based upon these findings.
Any previous open laparotomies will, of course, be associated with more potential for adhesion formation than procedures that were performed laparoscopically. Additionally,
those patients in whom a previous incisional hernia repair
included the implantation of any “unprotected” prosthesis can
be expected to have dense scarring in all areas in which the
material was exposed to the intra-abdominal contents. This
is very uncommon today. This should not deter experienced
surgeons from attempting a laparoscopic approach because
as many as one-third of these patients will not have any adhesions at all. It is important to note, however, that the difficulty
of the procedure can be greatly magnified because of the dissection of the tenacious scarring that is encountered involving the prosthesis and the bowel and/or omentum. The risk of
enterotomy is significantly increased in such instances.
Patients in whom there is an additional need for a surgical
procedure such as a cholecystectomy, fundoplication of the
stomach, inguinal herniorrhaphy, or biopsy of an intraabdominal or retroperitoneal structure are special subsets
that deserve careful consideration. Hernia repairs in such
cases are discussed later in this chapter.
Laparoscopic incisional hernioplasty should be individualized in patients with known ascites because it may be challenging to maintain a watertight closure that averts ascitic
fluid leakage postoperatively. Moreover, these patients usually have a metabolic problem (e.g., chronic renal failure or
hepatic disease) that can cause poor healing and predispose
them to development of a hernia at the trocar sites. The use
of the 5 mm trocars, however, has made this less problematic, and these patients may also be considered on occasion.
Special trocars that do not cut into the abdominal muscle but
dilate the tissues to enter through the wall of the abdomen
should be used in these patients. The site of entry will be
smaller than the actual trocar itself after it is removed thereby
further minimizing the risk of leakage of ascitic fluid or subsequent herniation. Though the use of a prosthesis in patients
with overt ascites is scarcely reported, some have achieved
success with the LIVH in these patients with maximal optimization of ascites [25–27].
LIVH patients are admitted to the day surgery unit of the
hospital because they can usually be considered for discharge
on the day of surgery. The number and type of comorbid
conditions of the patient, the type and location of the
hernia(s), the presence of incarceration, and the amount of
adhesiolysis required will influence the decision of timing of
discharge from the hospital. Many patients now undergo
laparoscopic incisional hernia repair in an ambulatory surgery center. Appropriate laboratory testing should be
obtained prior to entry on the day of surgery. Patients are
routinely given a preoperative dose of either a first-genera-
28 Laparoscopic Incisional and Ventral Hernia Repair
395
tion cephalosporin or a fluoroquinolone. If a patient has a
history of methicillin- resistant Staphylococcus aureus
(MRSA), vancomycin is used for preoperative prophylaxis.
If there has been a prior mesh infection, it is preferable to
delay surgery for 6 months, if possible, and give the antibiotic used to treat the prior mesh infection preoperatively.
Intraoperative Considerations
Patient Preparation and Positioning
LIVH repair requires the use of general anesthesia to achieve
the necessary degree of relaxation and sedation. In most cases,
it is not necessary to use an orogastric or nasogastric tube
unless the site of initial entry is in the vicinity of the stomach.
A urinary drainage catheter is not used if the procedure is felt
to be short in length. If the operative site is close to the bladder
(e.g., very low midline hernias or concomitant inguinal hernia
repairs) or if the procedure will be prolonged, it is then advisable to insert a urinary drainage catheter; preferably a threeway catheter is used if it becomes necessary to fill the bladder
for identification. Insertion of a nasogastric tube for procedures in which extensive dissection of the bowel is necessary
may help to reduce the postoperative ileus that is likely to
develop. It is seldom necessary to leave this tube beyond the
intraoperative phase of the procedure, however.
Most patients will be placed in the supine position.
Operations upon lateral defects of the abdominal wall, such as
those in a subcostal or flank incision, will be facilitated by use
of a semidecubitus or full decubitus position. The use of a
“beanbag” or “jelly roll” in these instances will greatly aid in
the positioning of the patient. The additional use of the tilt
capabilities of the operating table will assist in the manipulation of the bowel during dissection. Steep Trendelenburg or
reverse Trendelenburg positions will cause the abdominal contents to move into positions that will make visualization of the
contents of both the hernia and the abdomen easier. The
patient’s arms should be tucked in close to the body to allow
sufficient room to move around the patient; this is especially
important if the defect is in the lower abdomen. Occasionally
this may not be feasible due to the size of the individual, but,
in general, it is preferred when possible. Use of a protective
transparent adhesive drape to cover the skin is recommended.
pressures difficult resulting in inadequate visualization
throughout the procedure. This method also requires the use
of a larger trocar thereby posing a risk of postoperative herniation at that site despite the best attempts at fascial closure.
In the patient with a primary ventral hernia or a single
small defect, a Veress needle could be considered for insufflation before introduction of the first trocar. A “safe” area
for needle insertion is usually in the right upper quadrant
because it is generally free of adhesions of bowel and omentum. A site in the upper midline could also be used if it can
be placed far enough away from the hernia so as not to interfere with the repair of the hernia.
Another method to gain access into the abdominal cavity
uses an “optical” trocar for abdominal entry. These nonbladed trocars are designed to provide visualization of each
layer of the abdominal wall as the trocar passes through
them. This is accomplished because the laparoscope is
inserted into the trocar, and these structures are seen as the
trocar is passed. This is gaining in popularity (Figs. 28.1,
28.2, and 28.3).
Fig. 28.1 A typical optical trocar with a clear non-cutting tip
Abdominal Entry
It is understood that the method of access into the abdomen
should always be the safest approach possible. Many surgeons use the open type of Hassan entry because it is familiar
to them. An open entry such as this could result in a poor seal
around the trocar, which makes maintenance of insufflation
Fig. 28.2 View of subcutaneous layer through an optical trocar