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INDICATIONS

Laparoscopic ventral hernia repair can be considered for all primary abdominal wall hernias and the majority of secondary incisional hernias, including recurrent hernias. The laparoscopic approach has several advantages. First, laparoscopy allows the surgeon to clearly define the edges of the defect from within the peritoneum with the abdominal wall completely relaxed. Second, if pneumoperitoneum can be obtained, the hernia reduced, and adhesions taken down without bowel injury, the surgeon can place a widely underlapping prosthesis that should result in a lower recurrence rate than a traditional open repair. The increased durability of the repair results from tissue ingrowth from the peritoneum to the mesh over a wide surface area rather than from simple defect-edge to mesh-edge suture approximation, which is commonly used for open repair. Finally, postoperative pain and time to recovery are reduced when the mesh is placed laparoscopically.

The main disadvantage of the minimally invasive approach is its technical difficulty. The surgeon must be cautious during laparoscopic hernia reduction and adhesiolysis to avoid bowel injury. As well, the laparoscopic repair may not be ideal for giant incisional hernia, where a large bridging piece of mesh may not provide adequate abdominal wall reconstruction. Under these conditions, component separation techniques, usually performed with an open approach, may be a better option.

PREOPERATIVE PREPARATION

Patients with ventral hernias usually complain of mild abdominal pain associated with a noticeable bulge. In the majority of patients, physical examination alone will define the dimensions of the hernia defect. The contents of the hernia, such as omentum or bowel, can also be palpated as they readily reduce from the sac back into the peritoneum. Unless the surgeon cannot determine the presence of a hernia on physical exam, a computed tomography (CT) scan generally adds little to the preoperative planning. If the patient is obese and the hernia shows no evidence of incarceration, significant preoperative weight loss is advisable but often not feasible. The same is true for smoking—smokers are known to have a higher hernia recurrence rate. Smokers should be advised that postoperative coughing may compromise the stability of the repair. The patient should stop all anticoagulants and antiplatelet agents 10 days prior to surgery. The surgeon can consider a bowel prep for larger hernias, although it is not mandatory.

Patients with erythema, skin discoloration, severe pain, very tender hernias, or symptoms consistent with bowel obstruction may have incarcerated bowel and should be emergently or urgently taken to the operating room for open reduction and repair. Experienced laparoscopic surgeons may consider a laparoscopic approach to incarcerated hernias, but open exploration is more appropriate in most cases.

ANESTHESIA

General anesthesia with neuromuscular blockade is required for this operation. An intravenous dose of an antistaphylococcal antibiotic should be given 30 minutes prior to skin incision. An orogastric tube decompresses the stomach, and a urinary catheter drains the bladder.

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