Perioperative management - Laparoscopic hernia repair, IPOM following lower laparotomy

  1. Indication

    Incisional hernias following major abdominal surgery can be expected in 5% to 20% and more, irrespective of how the abdominal wall was closed.

    Generally, the prosthetic must be sized large enough to overlap the hernia orifice by at least 5 cm.

    In incisional hernias following lower midline laparotomy, primary subcostal access to the abdominal cavity is always gained on the side where a free upper quadrant can be expected. Following epigastric midline laparotomy, primary access is always gained by mini-laparotomy in the left or right lower quadrant.

    At the time of diagnosis, the previous procedure should be at least 6 months in the past.

    Alternative procedures:

    Open incisional hernia repair (onlay, sublay, Ramirez procedure with separation of the components).

  2. Contraindications

    • Giant hernia (diameter > 20 cm) or no trocar access and poor conditions for pneumoperitoneum and laparoscopic instruments
    • Decompensated cardiopulmonary failure
    • Assess the possible risks and benefits of laparoscopy in severe prior cardiopulmonary disorders, since monitored (blood pressure, heart rate, ECG, oxygen saturation) laparoscopy is feasible even in higher grade heart failure and pulmonary impairment
    • Bacterial peritonitis (in case of inflammation no foreign body/mesh)
    • Ileus with pending bowel perforation
    • Previous laparostomy/necrosis with split-thickness skin grafts

    Relative contraindications for laparoscopy include severe coagulation disorders (PT < 50%, PTT > 60 sec, platelets < 50/nL) and marked portal hypertension with caput medusae. In both cases primarily because of possible bleeding from abdominal wall vessels.

  3. Preoperative diagnostic work-up

    • Ultrasonography to determine the size of the hernia and the content of its sac
    • Adhesion ultrasonography to assess organ (liver, bowel loops, omentum) mobility relative to the abdominal wall
    • If standard diagnostic work-up with ultrasonography is not possible, including a more detailed assessment of adhesions and the relation of the hernia to the adjacent organs, hernia size may have to be studied by CT
    • In extensive findings, reducing the eviscerated intestines will increase intra-abdominal pressure, therefore mandating a thorough work-up of the cardiopulmonary function
  4. Special preparation

    Perioperative intravenous single-shot antibiotic (because of the foreign body/mesh), possibly to be continued if intraoperative bacterial contamination and signs of inflammation are present.

  5. Informed consent

    • Bleeding/hematoma
    • Seroma (usually present but without therapeutic consequences)
    • Intestinal perforation
    • Injury of adjacent structures
    • Postoperative ileus
    • Infection
    • Thrombosis
    • Embolism
    • Recurrence
    • Reoperation
    • Secondary healing
    • Synthetic implant material (risk of inflammation and implant rejection)
    • Limited postoperative exercise tolerance for about 3-4 weeks, possibly with a work disability of 2-3 weeks. In jobs severely straining the abdominal wall → no lifting of heavy loads, possibly for 6-12 weeks.
    • Chronic pain syndrome

General anesthesia in pneumoperitoneum ... - Operations in general, visceral and transplant surgery

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