Single access laparoscopic incisional hernia repair using curved and reusable instruments

This video demonstrates a laparoscopic single incision repair of an incisional hernia using bi-curved and reusable instruments.

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Single access laparoscopic incisional hernia repair using curved and reusable instruments

Authors

G Dapri, J Bruyns, J Himpens, GB Cadière

Abstract

This video demonstrates a laparoscopic single incision repair of an incisional hernia using bi-curved and reusable instruments.

Classification

single port, contribution

Keywords

Single access laparoscopic incisional hernia repair, curved and reusable instruments

Media type

Surgical video

Duration

07'27''

Publication

2010-06

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E-publication

WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2972.htm

Single access laparoscopic incisional hernia repair using curved and reusable instruments

1. Introduction 00'18''

Single access laparoscopy can be used for incisional hernia repair. Here of course, it makes sense to keep the damage to the abdominal wall to a minimum in order not to weaken further this abdominal wall. This lady had a para-umbilical incisional hernia present for about 6 months.

2. Skin incision and trocar insertion 00'41''

The incision is performed in the left flank, and the cut down performed down to the fascia. The fascia is opened and a purse string is placed. A reusable trocar is inserted intraperitoneally, connected to the insufflation, and a pressure of 15mm CO2 will be maintained throughout the procedure. The instruments used here have a very special design; they are bicurved, allowing for a straightforward use through a single incision. The biggest problem with this type of surgery is the jamming of the instruments, since they have been inserted in the same opening and therefore these curved instruments provide relief.

3. Bi-curved instrument\'s insertion 01'34''

A bi-curved grasper is introduced. Subsequently a curved coagulating hook is placed inside the peritoneum. The greater omentum trapped in and alongside the defect of the hernia is freed by short dissection. Triangulation can be observed just like in regular laparoscopy. The surgeon is standing perfectly straight in good ergonomic conditions, allowing him to do a good job.

4. Defect dissection 02'44''

The omentum is finally completely freed from the edges and the specific Swiss-cheese defect is seen. The edges must be freed and the peritoneum is removed, containing the fat, in order to provide a good substrate for the fixation later on of the prosthesis. The peritoneum and the underlying fat are removed over a substantial number of centimetres because it is important to provide sufficient overlap later on for the prosthesis. The principles of laparoscopy are observed all along the procedure, triangulation with the optic and the bissector between the surgeon’s tools. The falciform ligament of the liver is completely freed, which is important since stapling the prosthesis in the fat of this ligament would not give sufficient fixation for the prosthesis. The freeing is continued all alongside the circumference around the defect.

5. Evaluation of defect size 03'59''

The defect is then estimated. In order to measure the defect more accurately, needles are placed percutaneously exactly on the edges of the defect, which is here measured at 5 by 6cm. Since a sufficient overlap must be observed, a prosthesis of 10 by 15cm is chosen.

6. Mesh insertion and placement 04'33''

It’s a biface prosthesis, which is introduced through a 10mm trocar using a straight forceps, and the prosthesis pushed well inside the peritoneal cavity with the help of the optic. Once inside the abdomen, the prosthesis is orientated correctly and a straight needle harbouring a stitch is introduced percutaneously in the middle of the defect, pushed inside the peritoneum. It’s allowed to transfix the prosthesis in a U shape, and then, the straight needle with the stitch and thread on the end is pushed again from inside-out just about in the centre of the defect. The needle is snapped outside the abdomen and by pulling on the stitch, the prosthesis is lifted. This provides sufficient stabilization so as to allow fixation by use of absorbable tacks. The prosthesis must not present too many folds, but on the other hand it should not be over-stretched while it is being fixed. Counter-pressure helps with the fixation and one can observe here that the fixation is at all times in denuded muscle and fascia tissue.

7. Mesh fixation 06'32''

The circumference of the prosthesis is secured and then inside that circle, a smaller circle of fixation can be placed for the so-called double-crown technique. It is important to be sure that the smooth surface of the biface prosthesis is placed all along facing the bowel and that the sturdy Marlex tissue will never be in touch with the bowel. The double-crown has been placed; the peritoneum is allowed to be desufflated; the purse-string is tied and the incision appears to be less than 2cm.