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Laparoscopic management of a recurrent suprapubic incisional hernia

Authors

Abstract

The objective of this video is to demonstrate the laparoscopic treatment of a recurrent voluminous suprapubic incisional hernia after the laparoscopic repair of a suprapubic incisional hernia.

Classification

tips and tricks

Keywords

Laparoscopic management, recurrent suprapubic incisional hernia

Media type

Duration

09'53''

Publication

2011-02

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E-publication

WeBSurg.com, Feb 2011;11(02).
URL: http://www.websurg.com/doi-vd01en3019.htm

Laparoscopic management of a recurrent suprapubic incisional hernia

1. Introduction 00'20''

The objective of this video is to demonstrate the laparoscopic treatment of a recurrent voluminous suprapubic incisional hernia after the laparoscopic repair of a suprapubic incisional hernia. The recurrence occurred after placement of a mesh whose staples and fabric situated higher up can be seen here. The recurrence has occurred suprapubically, just above the pubic symphysis. It is a direct hernia. Decision is made to reduce the hernia sac as in a direct inguinal hernia. The transversalis fascia is retracted by the pressure of the pneumoperitoneum suprapubically.

2. Peritoneal detachment 01'20''

The peritoneum is progressively detached from all its anterior structures in order to open the Retzius’ space staying in contact to the aponeurosis so as to avoid the risk of bladder injury. Electrocautery scissors have a main advantage: they allow for the division and coagulation of different tissues that are strongly attached to the aponeurosis. The freeing is carried on from the posterior aspect of the abdominal wall to progressively get closer to the iliopubic branches, here to the left and then to the right, opening up the Retzius’ space, anterior to the bladder, as will be demonstrated shortly.

3. Dissection of bladder anterior aspect 02'21''

Here the interest of using electrocautery for division purposes is demonstrated. It helps to find back an ideal plane in the Retzius’ space. Traction exerted by the left hand also allows to increase the pressure of the pneumoperitoneum, which aids in dissecting the space and in opening the cellular spaces. The dissection towards the anterior aspect of the bladder is visible here.

4. Transversalis fascia fixation 02'05''

Once this dissection has been completed, decision is made to fix the transversalis fascia by means of stitches leaning on the edges of the defect. This is meant to invert the bag and close again this pouch in order to prevent seroma formation. This is not the treatment of the incisional hernia but the closure of this defect using extracorporeal knots (Ethibond sutures) that are fastened by means of the Endosuture™ system. Several stitches will be necessary to re-approximate this defect and to retrovert the suprapubic fascia that has been pushed back by the abdominal pressure through the defect. The advantage of using highly effective suture systems with extracorporeal knots is clearly demonstrated here. Indeed, they are really powerful and allow for a strong fastening as could be performed with extracorporeal knots pushed by one’s finger. The knot pusher system replaces one’s fingertip as in open surgery. The second stitch is made here. Three stitches will be necessary in this case as this is not a major defect. One of the advantages of this closure system, in addition to avoiding seroma formation at the level of the defect and the suprapubic aponeurosis, is to tighten the defect margins and to reinforce the wall before the placement of a mesh. The mesh will be positioned around the defect. Thanks to this closure, any mesh migration through the defect will be avoided. Therefore, any mesh migration will be prevented in the event of major abdominal pressure, and especially so in obese patients or in patients with respiratory insufficiency.

5. Mesh positioning 05'20''

The placement of a non-woven polypropylene mesh is visible here. It offers the advantage of being porous and yet sufficiently solid and strong to cover the whole area and allow for an excellent fixation at the level of the iliopubic branch.

6. Mesh fixation using Protack™ staples 05'46''

As can be seen here, the fixation is carried out using titanium Protack™ staples on the pubic symphysis, on Cooper’s ligament, then further, medially, on the posterior abdominal wall, and then at the superior border of the mesh, close to the anchored subumbilical mesh that had been formerly placed. The excess mesh is trimmed and the mesh is then covered with the peritoneum. Before doing so, a better anchoring of the mesh is achieved on the iliopubic branch and on the pubic symphysis using Ethibond sutures. Such anchoring is far better than any one performed with staples. This safety measure may be unnecessary, but it is another means of fixation using future threads that prove beneficial, as they allow for an excellent anchoring. On the contrary, staples might move under the pressure effect, especially so if the defect persists. It can be seen here that the mesh perfectly fits in and becomes impregnated with blood. It presses closely against the anterior abdominal wall on its posterior aspect suprapubically. Fixation by means of separate stitches can now be performed. This may be carried out directly, or, as it is the case here, after placing Protack™ staples. Some authors suggest performing a glue fixation, which allows for a correct fixation but not for a true anchoring of the mesh in case of important migration, especially if there is a risk of sliding.

7. Peritoneal flap closure using Absorbatack™ staple 07'50''

The next step of the procedure will be the overlapping closure of the peritoneum, as can be seen here. In this case, Absorbatack™ staples, and not Protack™ staples, will be used with absorbable staples, allowing for a correct fixation of the peritoneum. In bigger defects, or if there is a risk of tension, it is preferable to perform the closure by means of a suture with monofilament, which slides much better. In this case, Maxon 3/0 material is used, along with intracorporeal knots. The best option would be to use a thin thread with quite a large needle, which can be introduced through a 5mm trocar. This thread slides perfectly. No immediate traction is necessary. The different stitches can be passed, and the thread can be slid at the end, this being a time-saving technique. Knots are tied intracorporeally in order to avoid excessive traction. The closure can be performed. A small defect can be seen here at the top. It needs to be closed so as to avoid adhesions at the level of the mesh or even incarceration of the small bowel. It should be closed either using another stitch or another Protack™ staple, as can be seen here. This way, the defect will be perfectly closed.

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