Laparoscopic incisional hernia repair

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Surgical anatomy of the anterior abdominal wall

    1. Anterior abominal 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 arch 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; at 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.

  • Hernias of the abdominal wall

    • Paid content (image)
    • Location depending on previous surgery (intestinal, gynecologic, hepato-pancreato-biliary, cardiac, renal, gastric).
    • Prosthetic size must be large enough to overlap the hernia orifice (3-5 cm).
    • Preoperative CT study may be required to accurately assess the size of the wall defect – whenever the mesh does not overlap enough, consider a Ramirez procedure with separation of the components, complemented by additional subfascial mesh augmentation.

    The topographic relation depends on the location of the abdominal wall hernia.
    Subxiphoid hernias present special problems: Their vicinity to the pericardium!
    Since they are immediately adjacent to the bladder and venous plexus, which might be injured during the procedure, suprasymphyseal hernias are also challenging.

  • Sana Kliniken Düsseldorf GmbH, Plastische und Ästhetische Chirurgie

    Dr. med. Andreas Wolter

  • Krankenhaus Merheim

    Prof. Dr. med. Markus Heiss

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  • Indications

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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: 12.09.2008
  • Sana Kliniken Düsseldorf GmbH, Plastische und Ästhetische Chirurgie

    Dr. med. Andreas Wolter

  • Krankenhaus Merheim

    Prof. Dr. med. Markus Heiss

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  • Mini-laparotomy

    • 11-5

    After administering local anesthetic at the site of the incision, perform a mini-laparotomy (anterior axillary line, midway between the costal margin and iliac crest). After digital intraperitoneal examination clear a space between the abdominal wall and the intestinal loops. Follow this with blunt insertion of the 10/12 mm trocar through the mini-laparotomy. Apply the pneumoperitoneum through this trocar.

  • Trocar positioning

    • 11-6

    Insert two additional 5 mm trocars along the same line 3-5 cm craniad and caudad under direct vision.

  • Adhesiolysis and reduction of the hernia sac content

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  • Measuring the fascia defect

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  • Determining the mesh size

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  • Mesh insertion

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  • Mesh fixation

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  • Double-crown technique

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  • Mini-laparotomy closure

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  • Sana Kliniken Düsseldorf GmbH, Plastische und Ästhetische Chirurgie

    Dr. med. Andreas Wolter

  • Krankenhaus Merheim

    Prof. Dr. med. Markus Heiss

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  • Intraoperative complications

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  • Postoperative complications

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  • mibeg-Institut Medizin

    PD Dr. med. Stefan Sauerland

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