WeBSurg.com, Feb 2005;5(02).
1. Landmarks 00'10''This is a mesh covered with collagen in order to be placed intraperitoneally. It is round-shaped and is 12cm in diameter. The objective is to completely cover the defect of the hernia with this mesh. The potential size of the mesh with its covering of collagen is around 12cm so we place the landmarks of the mesh, which will potentially cover the hernia defect.
2. Trocar placement 00'47''We have to place the optic out of this circle in order to avoid any contact between the mesh and the optic itself; in the same way, we will place two working 5mm ports on the right and left side of the optic in order to have a very good view of the defect. The objective is to fix the mesh on the border of the defect and laterally in order to cover completely the defect. We will place our first port laterally at about 10cm of the border of the defect in order to have good mobilization of the camera. We use a 30° angle scope, which will allow to perform a very good dissection of the defect. After performing the insertion of the ports, we insufflate the patient. We can see the umbilical hernia and here we see that we have some fat tissue into the umbilicus, which will have to be removed in order to free the umbilical ring completely. Here we have the hernia defect, if we use the 30 degree scope, we see that we have fat into the umbilicus, which is at the origin of the patient’s pains. We place two further 5mm ports laterally. The ports are placed under visual control.
3. Peritoneal and hernia sac dissection 03'00''Using two graspers, we can identify the umbilical defect, we have to mobilize the peritoneum around the defect because the mesh has to be placed on the aponeurosis and not on the peritoneum. The first step of the procedure is to open the peritoneum in order to completely free the umbilical hernia from the internal side. We are used to perform a lot of dissection with the use of monopolar cautery by performing gentle traction on the tissues. Monopolar cautery allows complete dissection of all the elements. We know that the content of the hernia is frequently vascularized; for this reason, greater attention must be paid to the hemostasis, which has to be performed immediately and in a regular way. I put a finger in the defect to be sure of the place of dissection. Dissection is performed all around the umbilicus. Here we can identify the hernia sac and here the hernia contents. We will continue the dissection on the inferior part of the ring. Here we have the opposite side of the ring with the posterior aspect of the rectus muscle. Here we identify again the contents of the hernia with the hernia sac, which will be progressively dissected from the adhesion into the umbilicus. This adhesion will be freed and some remaining sac in the defect has no postoperative consequence. Some parietal bleeding may ideally be controlled using bipolar cautery. In fact, umbilical adhesions are frequently well vascularized and the best way to control them is to use bipolar cautery. The dissection of the posterior aspect of the rectus muscle is continued on the opposite side. Here we can identify the hernia very well by applying some pressure on the parietal wall. There is a small hole, the hernia is left in place. The posterior adhesions of the peritoneum are freed in order to place the mesh on the vascular aponeurosis and to avoid placing the mesh only on the peritoneum. In fact, the placement of the mesh on the peritoneum increases the risk of mesh migration into the hernia defect. We have 2 major landmarks in our operative field, one is the ring of the umbilical hernia, the 2nd is the size of our mesh identified on the parietal wall. Potential bleeding is immediately controlled using bipolar cautery. Externally, we have a complete area to place our mesh, on the opposite side we also have the possibility to place the mesh completely on the parietal wall, we have to continue the dissection in order to place the mesh completely on the posterior aspect of the rectus muscle. Inferiorly, the dissection of the preperitoneal space is very easy. The dissection is continued low enough to place the mesh in the retroperitoneum. Inferiorly, our landmark is also identified and is done in the same way as above.
4. Mesh placement 08'51''I will have to place the mesh in the abdomen. We are going to place a polyester mesh, which has 9cm covered with a hydrophilic film and is 12cm in diameter. This means that one side will be placed in contact with the bowel, the hydrophilic fibres, and one side will be placed on the parietal wall. We moisturize the mesh by pouring saline on it, we then roll the mesh and insert it into the abdomen. In order to make the manipulation in the abdomen easier, we identify the centre of the mesh, roll it and then place it in the abdomen. Correct orientation of the mesh allows it to be unrolled in the correct position immediately, the hydrophilic part of the mesh is placed on the bowel, the centre of the mesh is identified. The objective is to place the mesh correctly and completely on the defect. Usually for this placement, we like to use our landmarks but in this case, the patient is too fat and the landmarks will not be very useful. We use our landmark for the placement of the mesh, we know that this is the lateral border of the mesh. So the first landmark is placed to fix the mesh, so we are going to place the second landmark close to our trocar. The landmark must be placed through the polyester mesh in order to avoid a rupture of the collagen. We bend the needle slightly in order to keep the mesh placed in the correct position. We unroll completely the mesh in order to laterally place the third landmark, which appears a little too central but we will keep it in this position. We have to mobilize the peritoneum slightly in order to place the mesh completely on the parietal wall. When the mesh is completely unrolled and flat, you can perform the circular fixation of the mesh. We have to place enough staples to avoid a possible migration of small bowel between the staples. The landmarks can be removed, we apply slight parietal pressure on the mesh in order to allow the tacker to be placed on the aponeurosis. When the mesh is completely applied, we are going to place some tackers just around the defect in order to avoid a quick migration of the mesh into the umbilicus. We place 4 staples on this side for this preperitoneal repair in the abdomen. The prosthesis is partially covered, it is well fixed laterally, it covers completely the defect, one tacker is used to perform the complete fixation of the mesh, the defect is here in the middle. We have our peritoneum; in selected cases, we have the possibility to overlap the small bowel with the peritoneum. After completing the covering of the defect, the ports are removed under direct control and the optical port will be closed with a single stitch after being removed under direct control.