Ventral hernias in the anterior abdominal wall include both spontaneous or primary hernias (e.g., umbilical, epigastric, and spigelian) and, most commonly, incisional hernias after an abdominal operation. Small primary ventral hernias less than 1 cm in diameter are often closed successfully with primary tissue repairs. However, larger ones have a recurrence rate of up to 30%–40% when a tissue repair alone is performed. It is estimated that up to 40% of all abdominal operations result in an incisional hernia. This explains the predominance of such hernias. The use of mesh has revolutionized the repair of abdominal wall hernias, affording patients decreased recurrence in the long term. The development of dual-sided mesh has allowed for intraperitoneal placement posterior to the hernia defect. These meshes present an intraperitoneal surface to minimize adhesions and a bare side for adherence and incorporation into the peritoneum and posterior abdominal wall. The dual-sided meshes can be placed laparoscopically for many ventral hernias, but very large hernias or those associated with extensive, dense intra-abdominal adhesions (e.g., peritoneal dialysis, prior peritonitis, multiple previous prostheses) are relative contraindications. The main advantage of laparoscopic ventral hernia repair is reduced surgical-site infections. Patients should be counseled to expect seroma formation that usually resolves with time. Finally, laparoscopic repair enables the detection and repair of multiple defects—a common finding in midline incisional hernias.
Respiratory function should be optimized with cessation of smoking and appropriate pulmonary function evaluation. If bowel is contained with the hernia, endoscopic visualization, contrast studies, or imaging may be performed, and the patient may be given a bowel preparation with a liquid diet and cathartics for 1–2 days prior to surgery. The major factors in the occurrence of this hernia, as well as the preceding operative note, should be reviewed.
General anesthesia with an endotracheal intubation is required.
Patients are placed in a supine position with a pillow placed to produce mild flexion of the hips and knees. This helps to relax the abdominal wall. For ventral hernias that are not midline, patients may be positioned with pillows for some lateral elevation of the chest, flank, and hips. The arms are tucked and carefully padded to allow the surgeon to stand in any position around the patient.
Patients are given perioperative antibiotics. An orogastric tube is passed for gastric decompression. A Foley catheter is placed, and pneumatic sequential stockings are applied. The skin is prepared in routine manner. Sterile drapes are applied according to the surgeon’s specifications. Then a time-out is performed.
Placement of the 10-mm laparoscope port (O) and the 5-mm operating ports (X) is a function of the position of the hernia defect and the preference of the surgeon ...