Laparoscopic Ventral Hernia Repair
Yuri W. Novitsky, MD, B. Lauren Paton, MD, and B. Todd Heniford, MD, FACS
V
entral 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 because of 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 modifications for many years. Although the routine use of prosthetic reinforcement for the repair of herniations in adults has
been contested, existing evidence strongly supports tensionfree hernia repairs in most patients. With the development
and popularization of tension-free repairs using prosthetic
meshes, the recurrence rates are typically less than 20%.
Large abdominal incisions and wide tissue dissection with
the creation of large flaps needed for open placement of adequately sized mesh; however, this dissection often leads to a
high incidence of postoperative morbidity and wound complications. Recently, open ventral herniorrhaphy has been
challenged by reports of successful implementation of minimally invasive techniques. The principles of retro-rectus
prosthetic reinforcement have been adapted for laparoscopic
ventral hernia repair. The mesh is placed as an intraperitoneal
onlay with wide coverage of the hernia defect. Avoidance of
large incisions has substantially reduced wound complications. Overall, the clinical benefits of laparoscopic ventral
hernia repair include a faster convalescence, fewer complications and, importantly, a low recurrence rate.
Techniques of
Laparoscopic VHR
After general anesthesia is induced, the patient is positioned
supine with the arms adducted and “tucked” at the sides. 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 (Fig. 1). In most cases,
the bladder and stomach are decompressed with catheters.
An antibiotic, usually a first-generation cephalosporin, is
given prophylactically before the incision is made and re-
Department of Surgery, Division of Gastrointestinal and Minimally Invasive
Surgery, Carolinas Medical Center, Charlotte, NC.
Address reprint requests to Dr. Yuri W. Novitsky, Department of Surgery,
Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas
Medical Center, 1000 Blythe Blvd, MED 601, Charlotte, NC 28203.
E-mail: [email protected]
4
1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.optechgensurg.2006.04.004
peated if the operation lasts longer than 2 hours. We routinely use an Ioban drape to minimize mesh contact with the
patient skin. Laparoscopic hernia repair is performed by using a 30-degree angled laparoscope, 5-mm bowel graspers,
scissors, and clip appliers. Access to the peritoneal cavity is
gained using a cut-down technique (Fig. 2). A window of
access is usually present, even in the multiply operated abdomen, below the patient’s costal margin between the midclavicular or anterior axillary lines. The initial entry site is
chosen just inferior to the tip of the eleventh rib, usually on
the left side. We often prefer to then use a balloon-tipped
trocar to avoid air leakage. A total of three trocars are placed
under direct vision laterally along anterior-to-mid-axillary
line. Often, a fourth 5-mm port is placed contralaterally to
facilitate intra-abdominal mesh introduction and fixation.
Port placement for less common defects (subxyphoid, suprapubic, parailiac, spigelian, etc.) is adjusted based on the location of the hernia. On entrance to the abdominal cavity,
adhesiolysis is performed sharply with limited use of electrosurgery or ultrasonic coagulators. Reduction of the hernia
contents is performed using blunt graspers and sharp dissection from the inside and 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 abdominal wall defect are delineated with a
combination of laparoscopic vision and external palpation.
The edges of the defect are marked externally. Often, placement of spinal needles through the abdominal wall at the
internally visualized defect edges is needed to accurately determine the size of the hernia (Fig. 3). This maneuver is
especially important in obese patients with large defects as
externally measured size of a defect can be dramatically overestimated. A ruler is placed through a 5-mm port, and the
dimensions of the hernia defect to allow for the direct measurement of the defect. The mesh is than tailored to overlap
all margins of the hernia by at least 4 cm.
Once the mesh is cut to the desirable size, four size-0
permanent monofilament or ePTFE sutures are placed at the
mid-point of each side of the mesh. Points of reference on the
mesh and corresponding points on the abdominal wall are
marked to aid in orienting the mesh after its introduction into
the abdomen. The mesh was rolled up and pushed or pulled
into the abdomen through a 5- or 10-mm trocar site. The
mesh is rolled from both edges to facilitate the unfolding step
(Fig. 4). If the defect size dictates a very large prosthetic it is
usually introduced in the abdominal cavity by pulling with
Laparoscopic ventral hernia repair
5
Figure 1 Patient positioning, room set-up, and our trocar strategy.
the grasper passed through the contralateral trocar. It is important to maintain the appropriate orientation of the mesh
during the insertion and unfolding of the mesh. Two Maryland graspers are best used to unfold the mesh. After the
mesh is oriented intracorporeally, the sutures are pulled
through the abdominal wall with a suture passer (Fig. 5). A 4
cm mesh/defect overlap is once again confirmed using spinal
needles, as described above. The suture pulled first is usually
closest to the “sensitive” border (xiphoid, pubis, iliac crest,
costal margin, colostomy, etc.). We subsequently pull the
suture that is adjacent (not opposite) to the first one. Once
sufficient overlap is confirmed, we tie both sutures with the
knots buried in subcutaneous tissues. The other two sutures
are then pulled transabdominally and tied ensuring that the
overlap is sufficient and that the mesh is taut (Fig. 5). The
perimeter of the mesh is then stapled to the posterior fascia
with 5-mm spiral tacks at approximately 1 cm intervals to
prevent intestinal herniation. Placing the tacks is facilitated
by the external manual palpation of the tacker’s tip (Fig. 6).
This is particularly important for tacking the mesh in the
lower abdomen to ensure that the tacks are placed superiorly
to the inguinal ligament. Additional full-thickness stitches
are placed circumferentially every 3 to 6 cm by using the
suture passer (Figs. 7 and 8). This transabdominal fixation 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.
Conclusion
Laparoscopic ventral hernia repair has reliably been shown to
be superior to the open approach. Overall LVHR is associated
with a decreased perioperative pain, reduced hospital stay,
and faster recovery. Postoperative complications are also less
frequent in the laparoscopic group (23.2% vs. 30.2%) as well
as the incidence of wound and mesh infections (Table 1). In
addition, the recurrence rate is 4% for the laparoscopic group
and 16.5% for the open technique.
Overall, numerous studies demonstrate that laparoscopic
ventral hernia repair is an effective and safe approach to the
abdominal wall hernia. It can be performed in complex surgical patients with a low rate of conversion to open surgery, a
short hospital stay, a moderate complication rate, and a low
risk of recurrence. With additional long-term follow-up to
support the safety and durability of the procedure, LVHR will
likely be considered the standard of care in the future.1–9
6
Y.W. Novitsky, B.L. Paton, and B.T. Heniford
Figure 2 Access to the abdominal cavity using cut-down techniques utilizing pediatric Kocher clamps. This is usually
safely accomplished in the left upper quadrant area.
Figure 3 Intracorporeal (direct) measurement of a hernia defect. Spinal needles allow for more precise identification of
the edges of the defect. Additional spinal needles may be used for defects larger than the length of a ruler (typically 12
cm).
Laparoscopic ventral hernia repair
7
Figure 4 Rolling of the mesh before its introduction into the abdominal cavity.
Figure 5 Initial four-point mesh fixation.
8
Y.W. Novitsky, B.L. Paton, and B.T. Heniford
Figure 6 Transabdominal suture fixation of the mesh.
Figure 7 Placement of tack is done circumferentially along the whole length of the mesh to avoid bowel incarceration.
External palpation of the abdominal wall facilitates placement of the tacks and helps to avoid tacking the mesh below
the inguinal ligament and above costal margins.
Laparoscopic ventral hernia repair
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Figure 8 Final appearance of the hernia repair.
Table 1 Comparison studies of laparoscopic and open ventral hernia repairs
# Patients
Mesh
infection
Morbidity
Wound
infection
Recurrence
Study
Year
Lap
Open
Lap
Open
Lap
Open
Lap
Open
Lap
Open
McGreevy
Raftopoulos
Wright
Robbins
DeMaria
Chari
Carbajo
Ramshaw
Park
Holzman
Percent
2003
2003
2002
2001
2000
2000
1999
1999
1998
1997
65
50
90
18
21
14
30
79
56
21
71
22
90
31
18
14
30
174
49
16
5
14
15
—
13
2
20
15
10
5
23.2
15
10
31
—
13
2
6
46
18
5
30.2
2
1
1
1
1
0
0
1
2
0
2.0
0
0
1
4
2
1
3
5
1
1
3.5
0
1
1
1
1
—
0
6
0
1
2.6
7
1
8
0
4
—
5
2
2
0
5.8
—
1
1
—
1
—
1
2
6
2
4.0
—
4
5
—
0
—
2
36
17
2
16.5
References
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ventral hernias: Nine years’ experience with 850 consecutive hernias.
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hernia repair. Surg Endosc 17:123-128, 2003
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repair with mesh repair for incisional hernia. N Engl J Med 343:392-398,
2000
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Endosc 14:326-329, 2000
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