1. LAPAROSCOPIC VENTRAL HERNIA REPAIR
A COMPREHENSIVE APPROACH
DR DILIP S.RAJPAL
MS, MAIS, FICS(USA), FMAS,
DIPL. IN LAPROSCOPIC SURGERY,
FELLOW IN ROBOTIC & ADV LAP. COLO-RECTAL SURGERY (KOREA UNIV.)
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST
HON. SURGEON NOVA MEDICAL CENTER
HON. ASS PROF GRANT MED.COLLEGE & HON. SURGEON JJ HOSPITAL
EX-ASST. PROF L.T.M.GEN. HOSPITAL

2. OPEN REPAIR METHODS
For Ventral Hernias
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

3. TENSION REPAIR
 Quick repair, done under local anesthesia
 However tension repair has unacceptably high
recurrence rates of ~50%
 Regardless of the size of hernia, mesh repair has
been proved to be a superior method
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

4. PROSTHETIC MESH – ONLAY TECHNIQUE
 Onlay mesh repair
 Primary repair performed
 Mesh widely covers the repair
 Requires cleaning off the fascia and
undermining the skin and subcut for a wide
distance
 Disadvantages
 Still a tension repair
 Large subcut dissection can lead to seroma
 High infection rate - may be 10-20%
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

5. INLAY MESH REPAIR
 Inlay mesh
 Sac excised and mesh sewn to fascial edges
 This is non tension repair
 Must use non adherent mesh such as
Physiomesh or Proceed if bowel will be in
contact with the mesh
 Disadvantage
 Possible continued bulge after repair
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

6. RETRO RECTUS / STOPPA REPAIR
 A plane is dissected between posterior rectus and
peritoneum to put the mesh
 This is tension-free repair
 Mesh extends well beyond the under edges of the
muscle, reinforcing the entire area
 Must use non adherent mesh such as
Physiomesh or Proceed if bowel will be in contact
with the mesh
 Disadvantage
 Reported recurrence rate of ~10%.Reported infection
and mesh removal rate of ~5-10%
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

7. OVERVIEW OF VENTRAL HERNIAS
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

8. VENTRAL WALL (INCISIONAL)
 Highest incidence in midline
and transverse incisions
 Upto 20% after laparotomy
 1/3 present in 5-10 years
postoperatively
 Risk factors
 Obesity, DM, ascites, steroids,
smoking, malnutrition, wound
infection
 Technical aspects of wound
closure
 Type of incision
 Excessive tension (prone to
fascial disruption)
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

9. INCISIONAL HERNIA
 Due to failure of fascial tissues to heal and
close
 Promoted by inhibition of wound healing
 10-15% of abdominal incisions
 Highest incidence with midline incision
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

10. INCISIONAL HERNIA
 Indications for Surgery
 Bulge of abdominal wall deep to skin scar
 Cosmetic concern versus discomfort
 Worsened with coughing or straining
 Incarceration
 Less than 1cm
 More than 7-8 cm unlikely to incarcerate
 Treatment
Most should be repaired (unlike groin hernias)
 Suture versus mesh repair
 Suture repair in one European study showed 60% recurrence
 With open mesh repair, recurrence seen at upto 30%
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

11. DIAGNOSIS
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

12. INCISIONAL HERNIA
 Visible bulge - May be cosmetically upsetting
 Pain - May limit activities, pain is increased with
lifting, straining and coughing
 Incarceration - Severe acute pain with tenderness
over the hernia site
 Bowel obstruction - Due to acute or chronic
incarceration with typical symptoms
 Note: In obese patients, hernia may not be evident
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

13. IMPORTANT QUESTIONS TO CONSIDER
 Site
 Etiology
 Partial vs. complete
 Simple vs. strangulated
 Fluid and electrolyte status
 Operative vs. non-operative management
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

14. INCISIONAL HERNIA-DIAGNOSIS
 CT Scan - Very helpful in obese patients. Frequently, a
CT Scan will reveal additional less clinically obvious
hernias
 Ultrasound - May be useful especially in office setting
when PE is uncertain
 Laparoscopy - For patients with pain and symptoms
suggestive of hernia, but negative PE and imaging
studies
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

15. INCISIONAL HERNIA -DIAGNOSIS
 Diastasis recti vs Incisional hernia
 Diastasis is a thinning or weakening of the fascial
membrane connecting the rectus muscle
 It is not a hernia and generally is asymptomatic and will
not lead to incarceration. It may be cosmetically
unsightly
 It is usually located in the upper abdomen and may
occur spontaneously
 It is recognizable by its diffuse nature, keel formation
and lack of a “ring”
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

16. STRANGULATED HERNIAS
 Most important signs
 Fever
 Tachycardia
 Localized abdominal tenderness
 Leukocytosis
 Process is accelerated with closed-loop obstruction
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

17. INCISIONAL HERNIA – CHOICE OF TECHNIQUE
 Complex open repairs
 Stoppa mesh repair
 Component separations repair
 Laparoscopic repair
 Multiple fascial defects detected
 Large on-lay intraperitoneal mesh
 5 cm marginal overlap
 Recurrent hernias – avoid dissection at previous
operative site
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

18. CONTRAINDICATIONS TO LVHRS
 Major loss of abdominal domain
 Severe debilitation
 Respiratory distress
 Pregnancy
 Portal hypertension
 Renal failure with presence of peritoneal dialysis
catheter
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

19. LAPAROSCOPIC TECHNIQUE
For Ventral Hernia Repair
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

20. LAP VENTRAL HERNIA REPAIR
 Advantages
 Less pain, smaller scars, less soft-tissue dissection
 Good view of possible other hernias such as swiss-
cheese defect, thus reducing chances of recurrences
 Decreased wound complications
 Effective modality for recurrent hernias that have been
repaired anteriorly (open)
 Disadvantages
 May still have bulge
 Possible bowel injury
 Seroma rate 15-20%
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

21. SURGICAL TECHNIQUE
 Three steps
 Access
 Adhesiolysis
 Mesh insertion / fixation
 Key components:
 Reduce the hernia contents
 “Patch” the defect in the fascia with Mesh
 Mesh is incorporated into the abdominal wall by the body
 Reinforces the defect in the fascia
 Secure the Mesh to the abdominal wall
 Prevent movement of the mesh prior to incorporation
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

22. PORTS PLACEMENT
 Direct visualization (enter abdomen from sites away
from hernia
 Controlled insertion
 Bowel protection
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

23. LAPAROSCOPIC REPAIR
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

24. TROCAR SITES SETUP
 Left Epigastric hernia
 Suprapubic hernia
 Upper midline hernia
 Lower midline hernia
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

25. DEFECT VISUALIZATION
 Proper dissection is facilitated by complete
visualization
 If you cannot see the defect
 Consider placing a fourth 5mm trocar
 Opposite to the placement of other trocars
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

26. ADHESIOLYSIS
 Avoid sharp dissection and avoid bowel injuries
 Minimize use of electrocautery
 Have two monitors, one on each side to have easy
visualization when you change side
 To get better all-round view of adhesions, keep
shifting instrument and camera sites
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

27. DEFECT MEASUREMENT
 The margins of the defect may be marked on the
skin
 The mesh is measured and trimmed to fit
 With the smooth side down, 4-6 large fixation
sutures are placed around the mesh and tied
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

28. THE EXTENT OF THE DEFECT IS ASSESSED.
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

29. PROCEED MESH
 PROCEED Mesh has two layers
 Soft polypropylene mesh
 ORC - a thin, bioresorbable layer that separates its
strong, supportive mesh from underlying viscera.
 PROCEED mesh is a lightweight construction to
improve handling for laparoscopic procedures
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

30. PHYSIOMESH
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

31. SECURESTRAP
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

32. HANDLING PROCEED MESH / PHYSIOMESH
 Mesh is an internal prosthesis
 Mesh infections can be devastating and the mesh
may need to be removed
 Therefore, mesh should be handled aseptically
 Change gloves before touching the mesh
 Use sterile instruments, and not hands, to handle
the mesh as much as possible
 Avoid excessive use of electrocoagulation
hemostasis
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

33. MESH OVERLAP
Pascal's principle—wide mesh overlap of defect distributes
pressure equally over larger surface area.
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

34. TRANSFASCIAL SUTURES
 Transfascial sutures prevent mesh migration
 Transfascial sutures should be permanent
 Prolene / Ethilon / Ethibond Excel
 To prevent chronic post-op pain an air knot is
preferred for transfascial sutures
 For Proceed and Physiomesh, two transfascial
sutures at cephalad and caudad positions are
recommended
 After tying the knot, pull the transfascial sutures
from the skin outwards a couple of times to release
any tension
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

35. MESH FIXATION
 The purpose of tacking is
 To minimize any dead spaces
 To hold the mesh close to the abdominal wall for
excellent tissue incorporation
 Various types of fixation have been devised
 Double crown technique
 Eliminates dead space, minimizes seroma formation
 Transfascial sutures are still highly recommended
 Single crown tacking + absorbable sutures
 Single crown tacking + non-absorbable sutures fixation
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

36. PORT SITE HERNIAS
Following LVHRs
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

37. TROCAR SITE HERNIA
 The incidence of trocar site hernia has been shown
to be 0.65% to 2.80%
 Midline, periumbilical port sites greater than 5 mm
and made with bladed introducers often result in
incisional hernia, if not closed
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

38. TROCAR SITE HERNIA
 Serious access-related complications appear to be
rare but can lead to increased morbidity when they
do occur
 Bowel through port sites is uncommon and can be
difficult to diagnose. Often the diagnosis is delayed,
resulting in infarction of the involved bowel segment
 Most laparoscopic surgeons agree that the
diameter of the cannula or port is the single most
common cause of port-site hernias
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

39. TROCAR SITE HERNIA
 Overall, if the cannula or port site is 10 mm or
larger in diameter, hernias can occur, despite
preventive measures such as using a noncutting
trocar
 Most surgeons do not routinely close lateral port
sites because it is commonly thought that the
fascial and muscular composition of these sites
pose such little risk of herniation that the extra time
and effort required to repair them is not justified
 However this theory is NOT absolute
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

40. PORT SITE CLOSURE TECHNIQUE
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

41. COMPLICATIONS
Lap Ventral Hernia Repairs
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

42. POSSIBLE COMPLICATIONS
 Enterotomy  Respiratory Distress
 Wound Infection  Abdominal
 Mesh Infection Compartment
Syndrome / IVC
 Persistent Seroma
Compression
 Prolonged Pain
 Ileus
 Bleeding/Hematoma
 Recurrence
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

43. WOUND AND MESH INFECTION
 Key question - Is mesh just a large foreign body in
an otherwise clean surgical wound?
 Many wounds are inflamed but not necessarily
infected
 Infected wounds need to be opened
 Avoid exposing the underlying mesh if possible
 Infections that involve polypropylene meshes can
be managed with
 Surgical drainage
 Antibiotics
 Excision of exposed segments
 Micro-porous/non-porous ePTFE meshes require
removal in most cases because they lack tissue
ingrowth that could combat the infection
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

44. SEROMA FORMATION
 The development of seroma is virtually guaranteed
after lap incisional hernia repair and probably after
repair with mesh in general.
 Seromas typically resolve spontaneously without
intervention and are not considered a complication
unless they are clinically apparent for more than 8
weeks postoperatively
 Seroma management
 Eliminating dead space such as between mesh and the
abdominal wall by using sufficient tacks
 Purse string suturing of the tissue layers
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

45. CHRONIC PAIN
 In Rives-Stoppa or other open mesh implantation, it
occurs in more than 10% of patients
 Transabdominal suture site pain after LVHR occurs
in 1% - 3% of patients
Visual Analog Scale (VAS)
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

46. POINTS TO REMEMBER
 Place all ports as far away as possible from the
defect
 Switch scope position
 Keep intraabdominal pressure
HIGH during dissection and
LOW during closing
 And very importantly - MARK THE MESH!!!
DR DILIP S.RAJPAL
CONSULTANT GEN. SURGEON
LAPROSCOPIST & COLOPROCTOLOGIST

47. THANK YOU