Patient Education and Consent
Patient education is paramount and centers on dietary modification and avoidance of increased intra-abdominal pressures, avoidance of constipation, smoking cessation, and weight loss. Patients are also taught to recognize the signs and symptoms of wound infection in order to avoid further complications involving recurrence of hernia and other conditions that compromise the patient’s health.
Preprocedural Planning
Prophylactic antibiotic therapy is mandatory. The authors use a first-generation cephalosporin to cover skin bacteria, given 30-60 minutes prior to incision.
The authors routinely use standard deep venous thrombosis prophylaxis according to the indications for each patient, such as compressive stockings or sequential compression devices in the operating room, and continue those until the patient is ambulatory. Prophylactic anticoagulation is initiated within 24 hours unless there is an increased risk of bleeding. The administration of an intravenous proton pump inhibitor is maintained while the patients continue to receive nothing orally.
Equipment
The following equipment is used in laparoscopic incisional hernia repair:
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Laparoscope - A 0° degree scope can be used for the insertion of the first trocar; 30° and 45° scopes are used during the remainder of the procedure
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Blunt graspers (2)
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Hook electrocautery
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Tacking device
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Laparoscopic clip applier and suction irrigator should always be available
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Foley catheter - Recommended as a routine; it is also useful to decompress the bladder in cases of low hernias (ie, Pfannenstiel hernias)
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Trocars - 10 mm (1), 5 mm (3)
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Suture passer (eg, Carter Thomason CloseSure System)
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Laparoscopic scissors with monopolar coagulation
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Mesh - This must be a permanent material large enough to produce a wide (3- to 5-cm) overlap beyond the defect’s edges
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Synthetic mesh - Nonabsorbable (polypropylene, nylon, polytetrafluoroethylene [PTFE], polyester) and absorbable (polyglactin)
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Biologic mesh (porcine dermis, porcine intestinal submucosa, bovine dermis, bovine pericardium, cadaveric dermis)
Patient Preparation
Laparoscopy requires general endotracheal anesthesia with paralytics to relax the abdominal wall musculature. As the repair is performed under no tension, the use of postoperative mechanical ventilation is very rare, as can be seen in the open repair, when fascia closure might produce respiratory compromise.
The patient is placed in a supine position for almost all hernia repairs. If the hernia is an epigastric defect, the lithotomy position with stirrups is also used. Arms are tucked to the sides. If the defect is not midline, the surgeon should stand on the opposite site of the hernia.
Monitoring & Follow-up
Patients are usually released on postoperative day 2 or 3. Patients follow up in the clinic in 2 weeks. If the patient is discharged home with drains, he or she should follow up in one week with strict recording of drain output.
Healing of the repair takes 3-4 months, and the mesh surface can reduce up to 50%, thus bringing the edges of the muscles together. Patients are counseled that the risk of recurrence is approximately 30% and that they should follow up with their surgeon with any concerns for healing or recurrence.
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Ideal port placement. 1. Optical trocar 2,3,4. Working trocars.
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Mesh fixation using transfascial sutures.
