Laparoscopic Ventral Incisional Hernia Repair Consent Form.pdf

Trocar Placement

Objective: Will require minimum 4 ports, sometimes more required.  Typically 3 on left side of abdomen w/ 1-2 ports on right side.

Port 1: LUQ 5mm port. Veress access in L subcostal anterior axillary line, & sometimes more lateral required depending on size of hernia defect.  If port is too medial, there is risk that mesh will have to overly port site. After pneumoperitoneum achieved, remove veress needle and place ioban drape, cut ioban over incision and place port.

Port 2: 5mm port. Lateral left abdomen, ant axillary line or more lateral, again depending on hernia/mesh size.

Port 3: 5mm port.  Lateral L abdomen more caudal than port 2, at minimum hand’s width apart from port 2

Port 4: Right 5mm port.  Typically right mid-abdomen depending on size of defect and location of hernia.

Port 5: additional 5mm port on right abdomen as needed.

Step One: Reduction of hernia and contents

Objective: 1) General exploration of abdomen; paying special attention to all hernia(s) visible and their contents (bowel, omentum, etc) 2) lysis of adhesions to hernia & ant abdominal wall 3) reduction of hernia sac 4) exploration of reduced contents for bleeding/injury

Tools/Instruments: 1. Gator &/or duckbill 2. Endoshears 3. +/- harmonic/ligasure or energy device

1.General exploration of hernia contents with two graspers; safe to start with two duckbills to assess for bowel content in hernia.  If bowel a significant component of hernia typically use duckbill graspers to avoid iatrogenesis.  If omentum a significant component usually safe and more effective to use gator. 

2.Depending on hernia contents, begin to lyse adhesions to anterior abdominal wall.  If bowel requires reduction typically use duckbill in left hand and endoshears in right hand.  Carefully lyse adhesions erring more to abdominal wall then bowel side of adhesions.  Typically once plane started pneumoperitoneum will help identify correct plane.  Some adhesiolysis can be done bluntly w/ shears and grasper.

If omentum a significant component of hernia typically safe to use energy device of choice for lysis.  Must pay attention to sac and avoid dividing omentum and leaving devitalized tissue in hernia. 

For some cases external pressure from assistant will assist in completely reducing hernia.

3.Once hernia reduced and sac excised if able; gently explore reduced contents looking for serosal injuries, bleeding etc and treat appropriately.

Step Two: Measure hernia defect & preparing mesh

Objective: 1) measure size of hernia defect accurately, 2) determine size/shape of mesh—require at least 3cm overlap of defect, 3) select appropriate mesh and place Gortex suture in cardinal directions, 4) orient mesh externally

Tools/Instruments: 1. Spinal needle 2. Marking pen 3. Ruler 4. Mesh 5. Gore-tex suture 6. Gator

1.Once hernia completely reduced; spinal needle used from outside to measure defect by placing through at border of defect.  Assistant then marks on ioban w/ marking pen the four cardinal directions of defect.

2.Deflate pneumoperitoneum keeping ports in place.  Using ruler measure size of hernia defect and then measure out appropriate overlap (typically 3cm overlap in all directions). And draw w/ ruler size of mesh on Ioban—will assist w/ suture passer later.

3.Select appropriate size mesh (usually Parietex composite for elective hernia repair) and trim if needed.  Place Gore-tex sutures in all four cardinal directions and tie down.  Using marking pen mark “Top” on cranial portion of mesh for intracorporeal setup.

4.Once all sutures placed, moisten mesh and roll mesh from both long sides toward middle.

5.Re-establish pneumoperitoneum

6.Using gator place through port 2 and through port 4---tip of gator outside on pt’s right side at this point.  Remove port 4 over gator and grasp rolled mesh and pull inside of abdomen.  Assistant may need to assist by pushing or using tonsil to get mesh through skin.

Step Three: Pass sutures, tacking mesh, completing sutures

Objective: 1) unroll mesh in abdomen 2) use suture passer to grasp sutures and pull through abdominal wall 3) tack mesh circumferentially 4) pass additional sutures between those placed originally

Tools/Instruments: 1. Duckbill/gator
2. Laparoscopic right-angle
3. Spinal needle
4. 11-blade
5. suture passer
6. Snaps x 4
7. Absorbable tacking device
8. Gore-tex sutures w/o needle x 4

1.Once mesh in abdomen will need to be un-rolled.  Using grasper in left hand and right angle in right hand orientate mesh and unroll w/ right angle tip pointed down.

2.When mesh is unrolled make sure sutures are unfurled in appropriate directions and separated from each other.

3.Using spinal needle and using guide drawn on ioban locate approx place of “north” stitch.  Using 11-blade make small nick in skin to allow suture passer to pass.  Grasping suture passer in dominant hand—keeping needle closed--- insert into abdomen.  Assistant will then pass suture into passer and keeping tight grip on suture passer pull through abdominal wall and place snap on suture.  Once second string from same knot pulled through snap together.  Repeat above steps for all four sutures in order of north, east, south and west.  Mesh at this point should be relatively flat and tight, may need to adjust sutures accordingly.  Tie sutures down on outside and cut.

4.Using tacker first through L sided ports, place L hand where you want to apply tack on mesh from outside for counter traction.  Once tacker in place on inside and can feel pressure from tacker on other finger on outside fire tacker.  Continue circumferentially around mesh.  Surgeon on pt’s right side will do left side of mesh.

5.Once circumferentially tacked, 4 additional Gore-tex sutures are placed in between original sutures.  Using technique in step 3 above.  Assistant may need to provide counter traction w/ duckbill to safely get suture passer through mesh.  Make sure to snap sutures in place.  When all four placed tie down on outside and cut

6.Again inspect abdomen for missed injury and bleeding, irrigate if needed.

Step Four: Closure & Dressing

Objective: 1) hemostasis at incisions 2) port closure 3) pressure dressing

Tools: 1. Indermil/dermabond 2. 4-0 polysorb 3. Steri-strips 4. 4x4’s 5. Opsite dressing

1.Release pneumoperitoneum and close incisions.  For suture passer nicks re-approximate w/ indermil/dermabond.  Close ports in standard fashion.

2. 2.Using 4x4’s apply pressure dressing over mesh site and secure w/ opsite dressing.  Dressing should stay on for 2 wks.
   

Ben Kautza, MD