Ventral and umbilical hernia: simultaneous laparoscopic management

The laparoscopic repair of abdominal wall hernias to treat both spontaneous and incisional hernias has good results. We report the case of a patient presenting with two concomitant pathologies, an umbilical hernia and a linea alba hernia situated on a previous incision’s scar that were treated simultaneously. Currently this patient has a heart transplant.

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Ventral   and   umbilical   hernia:   simultaneous   laparoscopic   management

Authors
C Callari, D Mutter, J Marescaux
Abstract
The laparoscopic repair of abdominal wall hernias to treat both spontaneous and incisional hernias has good results. We report the case of a patient presenting with two concomitant pathologies, an umbilical hernia and a linea alba hernia situated on a previous incision’s scar that were treated simultaneously. Currently this patient has a heart transplant.
Mots-clés
ventral umbilical hernia simultaneous laparoscopic management
Type de vidéo
Durée
20'00''
Publication
2010-06
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Sous-titres
en
E-publication
WeBSurg.com, Jun 2010;10(06).
URL: http://www.websurg.com/doi-vd01en2971.htm

Ventral   and   umbilical   hernia:   simultaneous   laparoscopic   management

9. Positioning and anchoring of the mesh 06'05''
Thanks to these landmark threads, the mesh can be positioned ideally. These threads will be used to maintain or anchor the mesh into position in order to prevent its migration within the orifice of the incisional hernia. The ideal positioning of the mesh can be achieved thanks to the transparietal puncture. Using a small incision (a few millimetres), a system will be introduced: it will allow to progressively extract the first and the second reinforcement thread. This will allow to achieve the strong fixation of the mesh transparietally. In the present case, the inferior stitch is first placed. It is important not to place traction on the threads immediately in order to leave the mesh in contact to the bowel, keeping the view to the abdominal wall. In the current case, the mesh is placed at the limit of the xiphoid process. It is impossible to place it higher. Once again, a first transparietal stitch is placed. Then the second thread is placed using a different route. This will also facilitate and achieve the anchoring of the mesh cephalad. Some authors propose to use multiple anchoring points. Once the positioning threads are placed, traction is placed on the two threads in order to bring the mesh in contact to the posterior abdominal wall intraperitoneally. The correct position of the mesh is controlled by palpation and if need be by placement of transparietal stitches. The mesh should be perfectly deployed in contact to the posterior abdominal wall. It is sometimes necessary to slightly increase the peritoneal dissection previously achieved.
10. Mesh fixation with circular staples 08'48''
Once the mesh has been applied in a flat fashion, it will be progressively fixed by circular staples. The correct positioning of these staples is controlled by a transparietal palpation. The operator’s finger is placed in contact to the fixation line. Stitches are placed progressively every 2cm in order to ensure a perfect adherence between the mesh and the wall, hence avoiding the incarceration of a potential intestinal loop between the mesh and the wall. In case the fold to lower the peritoneum is an obstacle, the latter is cut to be resected; the mesh should be positioned without any bridge in contact to the posterior abdominal wall. A small additional dissection is sometimes necessary. All manipulations should avoid altering the quality of the collagen-coated layer. Indeed, this collagen-coated layer only placed on the intra-abdominal aspect of the mesh will ensure an anti-adhesive effect, preventing the small bowel loops to come into contact with the mesh. The polyester mesh is known to induce massive adhesions in case of direct contact with the small bowel loops. The collagen layer will allow for the creation of a neo-peritoneum before the formation of its dense adhesions. Slight adhesions are in any case found following this type of reinforcement. The mesh can be further fixed into position. Here we can see the interest of having the optical port situated very laterally at more than 10cm from the lateral border of the incisional hernia. This will allow to have enough distance between the external border of the prosthesis and the camera in order to preclude any viewing problems. The quality of the collagen-coated layer should also be preserved during mesh manipulation. When the mesh has been totally fixed, we usually apply a few staples on the periphery of the perforation itself. The objective is to limit or avoid too early a migration of the mesh within the perforation’s orifice. The landmark needles that had been placed presently serve to identify the margins of the incisional hernia, which are no longer visible through the prosthetic reinforcement. Finally the two fixation stitches can be knotted using the knot placed subcutaneously.
13. Mesh insertion and positioning 14'11''
In the present case, one can see that prostheses are often larger than previously thought and a 12cm mesh is required here. As previously described, the circular mesh is rolled onto itself, protected and introduced into the abdomen. Once the mesh into place, the landmarks are slightly withdrawn in order to apply the mesh in contact to the abdominal wall despite the presence of the needles. The umbilical reinforcement mesh also carries two fixation threads. Once again, the objective is to place transparietal stitches in order to solidly fix the mesh onto the abdominal wall and prevent its migration within the umbilical hernia orifice. The two meshes finally find themselves in contact to one another. However, these two repairs can be performed without skin incisions and by preserving the part of the abdominal wall that is not harbouring any defect. One of the main objectives is to avoid any early or late recurrence related to a substantial peritoneal incision that would have resulted in a conventional management of this double incisional hernia. This second stitch is placed at the most inferior part of the incisional hernia landmark. In the present case, since the mesh is fairly high situated and that there is no bridge with the remnants of the umbilical arteries, the mesh will be applied directly on to the peritoneum. The two fixation stitches will allow for a very precise positioning with a large covering of the incisional hernia orifice. Once again, circular staples will be applied every 2cm in order to strongly fix the mesh on to the peritoneum. A correct positioning of the collagen-coated layer is required in order to avoid postoperative adhesions. Thanks to the threads placed superiorly and inferiorly, the mesh is maintained firmly into place also during the staples’ application. The epigastric pedicle is seen in transparency and attention must be paid to avoid placing a staple inside this pedicle. The distal portion is oftentimes fixed first, then the proximal portion is fixed. The interest of using a 30 degree scope is to allow for a better visualization of the abdominal wall laterally. Here we can see that the 2 orifices have been repaired through the placement of a reinforcement dual mesh, one adhesive surface made up of polyester and another anti-adhesive composed of collagen. The latter will allow for a re-epithelialization of the abdominal wall in order to restore the integrity of the peritoneum.