Laparoscopic hernia repair, IPOM following lower laparotomy - general and visceral surgery

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  • Determining the mesh size

    Determining the mesh size

    Before establishing the pneumoperitoneum, the edge of the scar plus sufficient overlap is traced in all directions, thereby determining the size of the mesh.

    Since in this case the fascia defect extends mostly to the right, the mesh must be placed asymmetrically.

  • Establishing pneumoperitoneum and inspecting the abdominal cavity

    Establishing pneumoperitoneum and inspecting the abdominal cavity

    After previous gynecologic surgery via lower midline laparotomy, establish pneumoperitoneum through a Verres needle in the untouched right upper quadrant; another option would be a mini-laparotomy.

    Insert a threaded 10 mm trocar and inspect the abdominal cavity.

  • Trocar insertion

    Trocar insertion

    Insert another 10 mm trocar in the right mid-abdomen and one 5 mm trocar each in the left and right lower quadrants.

    Note: In case of previous surgery where a free left upper quadrant can be expected, a mirrored trocar setup is also possible.

  • Adhesiolysis

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    Perform careful adhesiolysis only with scissors (no RF-electrosurgery, no ultrasonic scalpel!) in cephalocaudal direction. This is the only way to avoid thermal injury with secondary intestinal perforation. Only in sharp dissection will the carbon dioxide enter the adhesions and increase the distance between the abdominal wall and its adherent structures.

    Tip: Outside pressure of the non-dominant hand on the abdominal wall can help facilitate the preparation.

  • Dissecting the prevesical space

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    In order to ensure a wide overlap with the prevesical space, first transect the parietal peritoneum and the medial umbilical folds. Free the bladder wall off the anterior abdominal wall and clear the symphysis and the pubic rami.

    Note: In epigastric access transection of the ligamentum teres hepatis and the falciform ligament ensures mesh placement cephalad of the costal arch with sufficient superior overlap.

  • Parietalizing the peritoneum

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    Unwrinkled unfurling of the mesh in the prevesical space, covering the freed inguinal hernia orifices, demands consistent dissection with extensive parietalization of the peritoneum; in women the round ligaments of uterus should be transected

    Note: The mesh planned for the incisional hernia repair can also adequately cover any direct and femoral inguinal hernias. Indirect inguinal hernias require an additional mesh as in the formal TAPP technique.

  • Mesh insertion

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    Trim the mesh whose parietal face is identified by a ready-made green suture in the midline. The inferior corners may be rounded off.

    Generally, arm the mesh with 5 additional non-absorbable monofilament stay sutures 2/0. Place one of the caudad stay sutures in the midline about 4-5 cm superior to the inferior edge of the mesh, thereby permitting extensive overlap of the prevesical space. Insert the furled up mesh into the abdominal cavity through the 10 mm trocar.

    Note: Insert meshes larger than 20 cm x 30 cm through a 12 mm trocar.

  • Catching the stay sutures

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    Once the mesh has been unfurled, insert a suture grasper through stab incisions into the abdominal cavity and first grab the midline stay sutures; this helps to place the mesh in the ideal position. Then catch the sutures farthest from the camera and finally those closest to it. This prevents the mesh from dropping down before the camera like a curtain, which otherwise would complicate catching the stay sutures farthest from the camera.

    As support later on, leave a 2-3 mm wide bridge of tissue between both ends of each stay suture.

  • Mesh fixation

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    Once all stay sutures have been caught and tightened, placing the camera posterior to the mesh allows ideal placement of the corners in the prevesical space.

    Mesh fixation is continued with helical tacks; here, the non-dominant hand exerts mild counterpressure which helps to insert the tacks perpendicular to the abdominal wall. In the prevesical space fixate the mesh directly to the symphysis and the pubic rami. The tacks should be spaced at 2-3 cm intervals.

    Do not refixate the peritoneum dissected off the anterior abdominal wall.

    In the final step, gently tie the transfascial stay sutures on the outside and bury them subcutaneously.

    Notes: The tacks may also be of the absorbable type. Lowering the intra-abdominal pressure to 6-8 mmHg helps fixate the mesh without wrinkles. However, since reducing the pressure severely curtails the view it is not recommended, particularly for larger meshes.

    Furthermore, it is possible to overlap several meshes of different size.