Laparoscopic spigelian herniorraphy

Position patient supine on OR Table, skin prep and drape (sterile!): Entire abdomen from costal arches to symphysis pubis. Incise skin on opposite side of hernia and enter abdomen in open fashion. Bluntly insert the 10 mm trocar and accomplish the pneumoperitoneum with an intra-abdominal pressure of about 12-15 mmHg.

Note:

It is up to the surgeon how he/she gains access to the abdomen. Open access is preferred. Because of numerous unnoticed injuries with at times lethal outcome, medical experts in legal proceedings have become more and more wary of the Verres needle.

Insert the laparoscope with the camera and inspect for possible injury and bleeding: In particular, carefully check for any adhesions in the immediate vicinity. Laparoscopic overview: Inspect all organs and look out for any pathologies. Insert the first 5 mm trocar. Always do this under visual camera control to minimize any risk of injury. The surgeon will determine the exact location based on his/her experience and preference. The second 5 mm working trocar will be inserted later on.

Inspect the hernia orifice Typically, this will be located between the aponeurosis of the transversus abdominis or internal oblique muscle (lateral margin) and the rectus sheath (medial margin) at the level of the arcuate line. The lateral margin is called linea semilunaris or Spieghelius line.

Mark the center of the hernia orifice with a percutaneous needle. The exact location of the center of the hernia orifice must be known because otherwise it is impossible to determine the required size of the mesh. First, gently free any omentum or intestine incarcerated in the hernia. Carefully measure the exact diameter of the hernia orifice. Determine the precise edges of the hernia with the needle and mark them on the skin.

Position the second 5 mm trocar under visual camera control.  After having marked the precise edges of the hernia orifice on the skin, determine the best size of the mesh. The mesh should overlap the outer edge of the hernia orifice by at least 5 cm on all sides. Mark the mesh diameter and the puncture sites for the stay sutures on the skin. This ensures that the stay sutures arming the mesh will exit at exactly as planned and that the mesh will best cover the hernia orifice.