Laparoscopic hernia repair, IPOM following lower laparotomy

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Topographical anatomy of the abdominal wall; internal aspect of the anterior abdominal wall

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    (1) Diaphragm, (2) umbilicus, (3) medial umbilical folds, (4) median umbilical fold, (5) external iliac artery and vein, (6) iliopsoas muscle, (7) bladder, (8) transverse fascia, (9) inferior epigastric vessels, (10) lateral inguinal fossa, (11) spermatic duct, (12) anastomosis between inferior epigastric artery and obturator artery, (13) Cooper ligament, (14) lacunar ligament of Gimbernat

  • Surgical anatomy of the anterior abdominal wall

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    1. Anterior abdominal muscles

    Rectus abdominis: Long abdominal strap muscle encased by the rectus sheath, crossed by 3 – 4 tendinous intersections intimately adherent to the anterior lamina of the sheath.

    Pyramidalis: Originates at the superior pubic ramus and attaches to the linea alba; it is anterior to the rectus abdominis muscle and is enclosed in its own sheath within the anterior lamina of the rectus sheath.

    2. Layered structure of the anterior abdominal wall

    Rectus sheath: Covers the rectus abdominis; superior to the midpoint between the umbilicus and symphysis there is a distinct anterior and posterior lamina; the inferior margin of the posterior lamina ends in a tendinous raphe, the arcuate line; above this line, the external oblique muscle inserts in the anterior layer of the rectus sheath, while the internal oblique inserts in both the anterior and posterior laminae, and the transversus abdominis into the posterior lamina.

     Linea semilunaris: Transition zone between the aponeuroses of the muscles of the lateral abdominal wall and the lateral margin of the rectus sheath.

    Linea alba: About 1 cm wide tendinous raphe between the left and right rectus sheath from the xiphoid process to the symphysis.

    Transversalis fascia: Cephalad to the arcuate line it covers the inside of the posterior lamina of the rectus sheath and caudad it is in intimate contact with the rectus abdominis.

    3. Internal aspect of the abdominal wall

    Median umbilical fold: Median peritoneal plication extending from the umbilicus to the bladder and comprising the median umbilical ligament (strand of connective tissue = remains of the urachus).

    Medial umbilical fold: Bilateral peritoneal plication comprising the medial umbilical ligament = obliterated remains of the bilateral umbilical artery.

    Lateral umbilical fold: Bilateral peritoneal plication superior to both inferior epigastric arteries, each with two comitant veins.

    4. Vessels and nerves

    A) Arteries

    Superior epigastric: Branch of the internal thoracic artery, anastomosed with the inferior epigastric artery at the level of the umbilicus.

    Inferior epigastric: Branch of the external iliac artery, coursing like the latter along the posterior surface of the rectus abdominis in the rectus sheath.

    Superficial epigastric: Branch of the femoral artery; after crossing the inguinal ligament it fans out in the subcutaneous tissue of the anterior abdominal wall.

    Posterior intercostals VI – XI and subcostal artery: Derived from the thoracic aorta; their final course takes them inferiorly and obliquely between the internal oblique and transverse abdominal muscles, reaching the rectus sheath laterally, where they anastomose with the inferior and superior epigastric arteries.

    b) Veins

    Superior epigastric: They accompany the eponymic artery, anastomose with branches of the inferior epigastric vein, and drain into the internal thoracic veins.

    Inferior epigastric: Fans out into comitant veins of the inferior epigastric artery and drains into the external iliac vein.

    Superficial epigastric: Parallels the eponymic artery (see above).

    c) Lymphatic vessels

    Superficial lymphatic vessels: Cephalad to the umbilicus they course to the axillary lymph nodes and caudad to the inguinal lymph nodes.

    Deep lymphatic vessels: Usually, they parallel the blood vessels and course to the parasternal, lumbar, and external iliac lymph nodes.

    d) Nerves

    Intercostals VI – XII: Anterior branches of the thoracic nerves VI – XII; posterior to the costal cartilages they course to the abdominal wall between the internal oblique and transversus abdominis; motor branches supply the anterior and lateral muscles of the abdominal wall and sensory branches the abdominal skin.

    Iliohypogastric, ilioinguinal, and genitofemoral: Contribute to the motor and sensory innervation of the genital and lower abdominal region.

  • Klinikum Mittelbaden

    Prof. Dr. med. Dieter Berger

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  • Indication

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative Management

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date of publication: 21.05.2012
  • Klinikum Mittelbaden

    Prof. Dr. med. Dieter Berger

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  • Determining the mesh size

    117-5

    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

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    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

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    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.

  • Klinikum Mittelbaden

    Prof. Dr. med. Dieter Berger

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  • Intraoperative complications

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  • Postoperative complications

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  • Klinikum Mittelbaden

    Prof. Dr. med. Dieter Berger

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