Incisional hernia after laparoscopic Roux-en-Y gastric bypass: laparoscopic management

This video shows the laparoscopic management of an incisional hernia after laparoscopic Roux-en-Y gastric bypass in a 50-year-old woman. Her initial BMI was 45. Now it is 23. The patient regularly complains of pain in the left hypochondrium just opposite an incisional hernia on a trocar introduction site. This trocar introduction site will be used to introduce the circular stapler for gastrojejunostomy. The suggestion has been adopted that this incisional hernia be managed laparoscopically.

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Incisional hernia after laparoscopic Roux-en-Y gastric bypass: laparoscopic management

Authors

M Vix, D Mutter, J Marescaux

Abstract

This video shows the laparoscopic management of an incisional hernia after laparoscopic Roux-en-Y gastric bypass in a 50-year-old woman. Her initial BMI was 45. Now it is 23. The patient regularly complains of pain in the left hypochondrium just opposite an incisional hernia on a trocar introduction site. This trocar introduction site will be used to introduce the circular stapler for gastrojejunostomy. The suggestion has been adopted that this incisional hernia be managed laparoscopically.

Keywords

Incisional hernia, laparoscopic Roux-en-Y gastric bypass

Media type

Surgical video

Duration

08'57''

Publication

2010-10

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E-publication

WeBSurg.com, Oct 2010;10(10).
URL: http://www.websurg.com/doi-vd01en3012.htm

Incisional hernia after laparoscopic Roux-en-Y gastric bypass: laparoscopic management

1. Introduction 00'19''

This 50-year-old woman benefited from a gastric bypass procedure three years ago. Her initial BMI was 45. Now it is 23. The patient regularly complains of pain in the left hypochondrium just opposite an incisional hernia on a trocar introduction site. This trocar introduction site will be used to introduce the circular stapler for gastrojejunostomy. The suggestion has been adopted that this incisional hernia be managed laparoscopically.

2. Trocar introduction 00'50''

A 12mm umbilical trocar is introduced. It will allow to identify adhesions. Two 5mm trocars are placed respectively in the right and left flank.

3. Dissection of omental adhesions 01'06''

The first surgical step consists in detaching the omental adhesions from the wall in order to identify the incisional hernia orifice. The dissection is carried out using monopolar scissors. A bowel loop, which is stuck to the wall, is found close to the incisional hernia orifice. A cautious dissection is performed so as not to cause any injury, particularly any thermal lesion.

4. Hernia neck dissection 01'56''

The incisional hernia orifice measures approximately 3cm. Exploration helps to find a relatively significant peritoneal tissue in the incisional hernia sac. It will have to be resected in order to avoid any later recurrence and postoperative seroma. The hernia neck is completely dissected.

5. Hernia sac reduction 03'02''

The sac’s content can now be replaced inside in the abdomen. Some omental fat can be found in the sac. It has slipped into the orifice. All incarcerated structures through the hernia orifice will be placed again in the abdomen and will be partially resected. A landmark stitch is found on the bowel loop. It had been placed in order to mark the upper portion of the anastomosis at the foot of the loop. Once the sac’s content has been replaced inside the abdomen, the dissection is completed so as to fully empty the sac and not to have any peritoneal tissue left in the hernia pouch. This maneuver is supposed to limit the risk of postoperative seroma. It will also allow to sharpen the incisional hernia orifice margins.

6. Mesh placement 05'14''

Dissection is pursued in order to gain a 5cm radius around the incisional hernia orifice. Once the whole tissue has been lowered, the hernia orifice is found. A double-sided mesh will be placed on it. This way it will stay in contact to the loops. The mesh is delivered using two fixation threads, which have already been placed. They will allow to position the mesh on the wall and to stabilize it. A needle with an eye at its extremity allows to retrieve these threads. The sac, which remains in the hernia pouch, is replaced inside. It will then be fixed by means of staples in order to reduce the residual subcutaneous space and to prevent, once again, a seroma from occurring. The mesh has two sides: an aponeurotic side made of polypropylene, and an intraperitoneal side made of collagen.

7. Mesh fixation 07'38''

The mesh is fixed using absorbable staples all around it. This will allow to skirt the orifices, hence preventing bowel loops or omental tissue from showing up between the mesh and the wall. The staples are placed by exerting external pressure on the abdomen. Some staples are placed on the borders of the incisional hernia orifice. As previously said, the mesh has two layers: one is made of polypropylene and will be placed in contact to the aponeurosis, adhering to it; the other is made of collagen and may be placed inside the abdomen. It will cause very few adhesions with the bowel loops. Once the mesh has been placed, the trocars are removed under visual control. The absence of any bleeding at the detached area is controlled.