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:

Laparoscope - A 0° scope can be used for the insertion of the first trocar; 30° and 45° scopes are used during the remainder of the procedure
Blunt graspers (2)
Hook electrocautery
Tacking device
Laparoscopic clip applier and suction irrigator should always be available
Foley catheter - Recommended as a routine; it is also useful to decompress the bladder in cases of low hernias (ie, Pfannenstiel hernias)
Trocars - 10 mm (1), 5 mm (3)
Suture passer (eg, Carter Thomason CloseSure System)
Laparoscopic scissors with monopolar coagulation
Mesh - This must be a permanent material large enough to produce a wide (3- to 5-cm) overlap beyond the defect’s edges
Synthetic mesh - Nonabsorbable (polypropylene, nylon, polytetrafluoroethylene [PTFE], polyester) and absorbable (polyglactin)
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.

Technique

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Media Gallery

Ideal port placement. 1. Optical trocar 2,3,4. Working trocars.
Mesh fixation using transfascial sutures.

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Author

Juan Luis Calisto, MD Resident Physician, Department of Surgery, University of Oklahoma Health Sciences Center

Juan Luis Calisto, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Luciano Poggi, MD Resident Physician, Department of Surgery, Oklahoma University Health Sciences Center

Luciano Poggi, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Alessandra Landmann, MD Resident Physician, Department of Surgery, University of Oklahoma College of Medicine

Alessandra Landmann, MD is a member of the following medical societies: American College of Surgeons, American Medical Association

Disclosure: Nothing to disclose.

Jeffrey S Bender, MD Director of Minimally Invasive Surgery, University of Oklahoma Medical Center; Professor of Surgery, University of Oklahoma College of Medicine; Assistant Professor of Surgery, Uniformed Services University of the Health Sciences

Jeffrey S Bender, MD is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Association for Academic Surgery, Association of Military Surgeons of the US, Midwest Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Critical Care Medicine, Southeastern Surgical Congress, Southern Surgical Association

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, PhD, MS, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, FFST(Ed), MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, FFST(Ed), MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Fellow of the Faculty of Surgical Trainers (RCSEd), Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Acknowledgements

The Chief Editor would like to acknowledge the assistance of Dr Gurushankari Balakrishnan, Senior Resident, and Dr Lekshmi Satheesh, Resident, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER), Pondicherry, India, in updating the review of this article.