Laparoscopic treatment of an incisional umbilical hernia

Laparoscopy, when applied to the management of incisional hernias, provides good results in terms of safety and minimal recurrence. This is the case of a 50-year-old patient who underwent laparoscopic treatment for a recurrent umbilical hernia. This treatment was carried out using an anterior approach, followed by a suture to close a dehiscence at the level of the umbilical hernia.

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Laparoscopic treatment of an incisional umbilical hernia

Authors

J D'Agostino, J Marescaux

Abstract

Laparoscopy, when applied to the management of incisional hernias, provides good results in terms of safety and minimal recurrence. This is the case of a 50-year-old patient who underwent laparoscopic treatment for a recurrent umbilical hernia. This treatment was carried out using an anterior approach, followed by a suture to close a dehiscence at the level of the umbilical hernia.

Mots-clés

Laparoscopic, treatment, incisional umbilical hernia

Type de vidéo

Vidéo chirurgicale

Durée

10'56''

Publication

2010-09

Popularité

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Sous-titres

E-publication

WeBSurg.com, Sept 2010;10(09).
URL: http://www.websurg.com/doi-vd01en3023.htm

Laparoscopic treatment of an incisional umbilical hernia

1. Clinical case presentation 00'19''

This is the case of a 50-year-old patient who underwent laparoscopic treatment for a recurrent umbilical hernia. This treatment was carried out using an anterior approach, followed by a suture to close a dehiscence at the level of the umbilical hernia.

2. Trocar position 00'36''

As usually performed, the procedure is commenced by introducing an umbilical port, far away from the operated area. Two 5mm ports are placed in line in order to obtain a perfect triangulation. The exploration of the abdominal cavity shows a hernia obstruction. The defect is occupied by the small bowel and the omentum.

3. Hernia sac dissection 01'00''

The dissection starts at the level of the hernia orifice, which can be seen here. The dissection is carried out using 25 kW, low-grade traction and monopolar cautery. The objective is to reintroduce the structures in the incisional hernia sac. The main reason for using a low current is to limit the risk of a diathermic lesion as much as possible.

4. External view 01'37''

As can be seen here, this is the external view. It shows the position of the trocars and the umbilical incision line. The internal view demonstrates the presence of two orifices —it is a multi-orifice incisional hernia. An approximately 2cm-diameter orifice is located cephalad to the primary orifice. The dissection is pursued using the scissors, since the attachments between the adhesions at the level of the hernia sac and the digestive loops are, as can be seen, rather narrow.

5. Hernia reduction 02'37''

The dissection is continued in order to introduce the whole hernia content in the abdomen, leaving the hernia sacs and the protrusion of the omentum at that level. The hernia orifices will not be connected, nor the incisional hernia sac will be closed, since, according to several studies, the risk of recurrence and seroma formation has nothing to do with the closure of the continuity solution. As can be seen here, the portions of the omentum are reintroduced. They take some of the sac’s place. The hernia orifice is finally freed, as shown here. The adhesions still remain to be freed. Attention is then turned to the superior portion of the sac, which presents some adhesions at the level of the greater omentum.

6. Large dissection of hernia borders 03'56''

The objective is to gain a sufficiently large space exceeding at least 5 cm from both borders of the incisional hernia. This is why, at this time in the procedure, the falciform ligament is dissected using monopolar cautery. This will allow for a subsequent good positioning of the 14cm-diameter mesh. The mesh has two sides: one of them is in contact to the incisional hernia area to facilitate the connection of the wall; the other one will be placed in contact to the digestive loops. No adhesions will be generated.

7. Mesh transcutaneous fixation 04'51''

Here, the transcutaneous fixation of the mesh is carried out upwards and inwards, allowing to keep the mesh into position in order to fix it later in the procedure.

8. Sac eversion 05'31''

Then, the incisional hernia sac is everted in order to attenuate the patient’s sensation of recurrence, since, as said before, the eversion does not decrease the risk of serum formation or recurrence. It is just psychological.

9. Mesh fixation with ProTacks™ 06'12''

An external traction is carried out through the thread used before. The mesh is fixed using non-absorbable ProTacks™. They will be placed every 2cm around the mesh, since recurrences always occur at its external limits. The fixation can be performed in contact to the previous perforation orifice. This way, the procedure is complete. The 10 and 12mm trocar introduction sites are closed using a figure-of-eight suture. The other orifices will not be closed. The patient is allowed food.