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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 25
Figure 2-2.
26 Section II • Laparoscopic Repairs
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2. Gaining Abdominal Access
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A Foley catheter is placed for bladder decompression and may be used to insufflate the
bladder for identification in the repair of suprapubic defects. Gastric decompression is
usually reserved for the patient requiring a difficult orotracheal intubation and may be
achieved with orogastric tube decompression.
An iodine-impregnated adhesive drape is applied to the skin of the prepped and draped
patient. This protects the biomaterial from the patient’s skin flora.
Abdominal entry can be the most difficult step in the patient who has undergone multiple
abdominal operations. Selecting the location for entry can be challenging because many of
these patients have had numerous abdominal incisions. The upper quadrant at the tip of
the eleventh rib is generally a safe place to gain access even in such cases. The side of entry
should avoid previous incisions. For example, in the patient with an open cholecystectomy
incision, the left upper quadrant should be chosen.
Several safe methods for initial access have been described. A cut-down technique works
very well. Through a small incision in the upper quadrant, each layer of the abdominal
wall is divided down to the peritoneum. The peritoneum can be sharply entered with a
scalpel or bluntly penetrated with the finger to gain safe access to the abdominal cavity.
The optical trocar can be used safely in the upper quadrant just below the rib line as well.
Some surgeons prefer the Veress needle. The best technique is the one the surgeon is most
comfortable and familiar with.
Once initial entry into the abdominal cavity is achieved, at least one and preferably two
additional trocars are placed laterally on the side of entry. Typically one can be placed
above the initial site once pneumoperitoneum has been initiated, and an additional one
can be inserted inferiorly with care not to be too close to the iliac crest. Two trocars are
placed on the opposite side to provide additional viewing perspective for adhesiolysis and
aid in retraction (Fig. 2-3).
3. Adhesiolysis
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The Achilles’ heel of the laparoscopic ventral hernia repair is the lysis of adhesions. This
step can be the most time consuming and usually determines the length and complexity of
the case.
A 30-degree laparoscope is mandatory to adequately visualize the anterior abdominal wall.
A 5-mm laparoscope provides more flexibility in moving the camera; however, if the visual
clarity is poor, a 10-mm scope should be used.
Energy sources should be avoided during adhesiolysis. Ultrasonic energy sources or bipo-
lar coagulating shears should not be used. Thermal injuries seal at the time of dissection
and may not be apparent for 3 to 5 days postoperatively. Sharp, cold, endoscopic scissor
dissection should dominate the dissection. Blunt bowel graspers are crucial to aid in retraction of the viscera and can be used to provide gentle blunt dissection as well. Typically,
during lysis of adhesions, the outer rind of adhesions may be sharply cut, giving way to a
“cotton candy” appearance to the loose areolar tissue that comprises most of the adhesions
(Fig. 2-4). Blunt dissection with gentle, short sweeps is very effective in this situation.
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 27
Tip of 11th rib
10/12 mm
5 mm
5 mm
(optional)
Figure 2-3.
SHARP ADHESIOLYSIS
5 mm
5 mm
ASIS
LOCATION OF TROCARS
Figure 2-4.
28 Section II • Laparoscopic Repairs
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External pressure applied on the abdominal wall by the assistant provides help during
adhesiolysis. This move can be critical in the morbidly obese patient or in the situation
where adhesions are up in the hernia sac. By bringing the dissection into the abdomen
with pressure, visualization of the proper tissue planes is made possible.
Previous intraabdominal mesh can pose a real hazard to performing adhesiolysis. If the
previous mesh contains a polypropylene or polyester component that becomes directly
exposed to the bowel, there is not a plane of dissection. Attempts to mobilize the bowel
off the adherent mesh will result in an enterotomy. In this situation, the mesh should be
cut down off of the abdominal wall, leaving a swatch of prosthetic attached to the bowel
Fig. 2-5). Certainly, conversion to open is mandatory, if there is any concern for a bowel injury.
(
Some cases of intense adhesion formation to the prosthetic may require a bowel resection.
Bleeding during adhesiolysis can be very problematic. Slight oozing that typically occurs
should be largely ignored. It rarely continues, and chasing it, especially with cautery, may
lead to a bowel injury. If the area of oozing can be isolated from viscera, judicious monopolar cautery may be used. An oozing area of adipose tissue can be lifted away from underlying bowel and cauterized. Endoscopic hemoclip appliers can be extremely helpful in
controlling bleeding in areas adjacent to bowel or where the location of bowel is unknown.
Endoscopic pretied suture loops assist with bleeding sections of omentum or mesenteric
fat. Be careful not to secure around a loop of bowel.
Clearing the abdominal wall of all adhesions for the entire extent of the prior surgical inci-
sion is imperative. “Swiss cheese” defects not apparent preoperatively may become evident
at this time. Extra time in this step is worthwhile to avoid the “early recurrence”—actually
a defect missed at the initial repair.
For defects above the umbilicus, the falciform ligament will have to be taken down to
allow for flush placement of mesh against the abdominal wall. This move is best performed
with electrocautery attached to the endoshears. The falciform is divided just below its
insertion to the underside of the abdominal wall fascia.
4. Sizing the Hernia Defect
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Measuring the defect is a critical step in the procedure. Many times, particularly following
a lengthy adhesiolysis, this step may not be given much attention. A durable repair relies
on adequate mesh overlap with proper placement, which are both directly a result of accurately measuring the defect.
The edges of the hernia defect are best delineated with the aid of 3.5-in, 20-gauge spi-
nal needles placed at each edge of the defect. Insert the needle into the abdominal wall
at a 90-degree angle to the floor, so the needle can emerge at the defect edge within the
abdomen. Use a metric ruler to measure the vertical and horizontal dimensions of the
defect between the needles. For multiple defects, place the needles to encompass all fascial
defects, measuring them as one large defect.
Three techniques have been described for measuring the defect: (1) externally with abdo-
men insufflated, (2) externally with abdomen desufflated, and (3) internally with abdomen insufflated. Because the mesh is being placed intracorporeally, it makes sense to make
all measurements internally. The external measuring techniques overestimate the defect,
which is more pronounced in larger defects and obese patients with thick anterior abdominal walls.
Measure the defect internally under pneumoperitoneum. A plastic metric ruler is cut in
half lengthwise and introduced via a 5-mm trocar. Two Maryland graspers manipulate the
ruler and measure the defect between the spinal needles in the abdomen (Fig. 2-6). If the
defect is longer than the ruler, insert another spinal needle along the axis of the defect
within the length of the ruler. The sum of the two is the true measurement.
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 29
Leaving swatches of
prosthetic on bowel
Figure 2-5.
CUTTING DOWN PREVIOUS MESH
Figure 2-6.
30 Section II • Laparoscopic Repairs
5. Mesh Introduction and Orientation
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Not all hernia defects are perfectly circular, nor are they located exactly in the midline of
the abdomen. In order to ensure that the mesh will be centered reliably over the defect
every time, it is necessary to draw a grid of the x- and y-axes of the hernia defect on the
external abdominal wall (Fig. 2-7).
With a ruler outside the abdomen, measure the distance halfway between the most supe-
rior and most inferior spinal needle. This determines the x-axis, the horizontal midpoint of
the hernia. Half the horizontal distance between the lateral most spinal needles marks the
y-axis, or the vertical midpoint. Draw both axes on the skin with a permanent marker to
grid the abdomen and mark the center of the hernia defect. Once the mesh is brought into
the abdomen, any attempt to retrieve one of the vertical or lateral cardinal sutures should
be done along the corresponding x- or y-axis line. This will align the mesh over the defect
and ensure the most accurate placement to achieve desired overlap (Fig. 2-8).
The type of mesh chosen for repair should have a favorable adhesion profile. Expanded
polytetrafluoroethylene (ePTFE) has an excellent antiadhesion profile and works well for
intraabdominal placement. Various absorbable barriers that coat polypropylene or polyester have been shown to provide reduction in adhesions as well. The infection profile of the
biomaterial also should be considered.
Before introducing the mesh into the abdomen, simply fold the sheet in half vertically and
horizontally. Mark the midpoint of each mesh edge. Then place the cardinal sutures at the
4 midpoints, taking a 1-cm bite in from the edge. PTFE suture works well because it has
less memory and recoil. Tuck in the tails of the cardinal sutures and roll the mesh from
both ends toward the middle like a scroll along the horizontal axis.
Once rolled, ePTFE mesh can be compressed and twisted to expunge air. Other tissue-sep-
arating meshes are soaked in saline and their slick texture makes them easier to introduce
through a trocar. The rolled mesh may be passed directly through a 12-mm or 15-mm
trocar (Fig. 2-9). Very large pieces of mesh can be dragged into the abdomen by passing
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 31
Figure 2-7. Figure 2-8.
MESH ROLLED AROUND GRASPER AND
PASSED THROUGH 10+ MM TROCAR
Figure 2-9.
32 Section II • Laparoscopic Repairs
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a heavy grasper across the abdomen through a 5-mm trocar and out the contralateral side
trocar. The cap of the trocar is removed, and the mesh is pulled into the abdominal cavity
(Fig. 2-10). Every effort should be made to introduce the mesh through the trocar. This
maneuver avoids contact with the patient’s skin.
Once inside the abdominal cavity, the mesh is unfurled. A grasper holds one end of the
rolled mesh while the Maryland grasper uncoils the mesh (Fig. 2-11). It is important to
maintain the proper orientation of the mesh. It may be helpful with larger pieces to mark
a line across the horizontal axis of the mesh before insertion to ensure that the line runs
from side-to-side.
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 33
Figure 2-10.
LARGE MESH PULLED THROUGH
FROM CONTRALATERAL SIDE GRASPER
Figure 2-11.
34 Section II • Laparoscopic Repairs
6. Securing the Mesh
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After unrolling the mesh, retrieve the cardinal suture at the vertical site where there is the
least amount adjustment first. For example, if the defect is in the lower abdomen, the inferior suture should be placed initially to avoid having to move its location caudally towards
the bladder when stretching the mesh. Likewise, if the defect approximates the xiphoid,
the superior suture is placed first. Mark the edge of the defect at the site of cardinal suture
placement with the spinal needle. An additional spinal needle is “walked out” the axis line
for a distance of 5-cm to ensure overlap (Fig. 2-12). This measured spot is injected with
local anesthesia, and a stab incision is made through which the suture passer is introduced.
The suture passer retrieves each tail of the initial cardinal suture through the same small
incision but at a different angle to achieve a separate fascial bite. Tag both suture tails but
leave them untied.
Retrieve the lateral suture farthest from the camera. Measure a 5-cm overlap and mark the
point for suture retrieval with an additional spinal needle placed along the x-axis. Bring
this suture out of the abdomen, tag it, and leave it untied.
The assistant pulls on the tagged sutures to bring the mesh against the abdominal wall.
The surgeon pulls the site in the vertical axis that is free along the y-axis. Advance a spinal
needle through the abdominal wall along the axis. This guides where the suture will be
retrieved, ensuring the mesh will be taut (Fig. 2-13). During this maneuver, avoid grasping the suture or the knot as this can weaken it. Measuring the overlap at this point is
unnecessary because most prosthetic meshes stretch.
The three cardinal sutures are pulled up to approximate the mesh to the underside of the
abdominal wall. If the mesh appears to be centered over the defect and is taut, the sutures
are secured.