Laparoscopic hernia repair, IPOM following lower laparotomy

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.

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.

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.

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.

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.