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aparoscopic Ventral Hernia Repairuri W. Novitsky, MD, B. Lauren Paton, MD, and B. Todd Heniford, MD, FACS

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entral herniorrhaphies are among the most commonlyperformed operations by general surgeons throughout

he world. Incisional hernias, with a reported incidence of upo 20%, have become an increasing problem because of thencreasing number of laparotomies performed. In the Unitedtates, approximately 175,000 ventral abdominal hernias areepaired each year. Surgical approaches to ventral hernior-haphy have been a subject of research and technical modi-cations for many years. Although the routine use of pros-hetic reinforcement for the repair of herniations in adults haseen contested, existing evidence strongly supports tension-ree hernia repairs in most patients. With the developmentnd popularization of tension-free repairs using prostheticeshes, the recurrence rates are typically less than 20%.Large abdominal incisions and wide tissue dissection with

he creation of large flaps needed for open placement of ad-quately sized mesh; however, this dissection often leads to aigh incidence of postoperative morbidity and wound com-lications. Recently, open ventral herniorrhaphy has beenhallenged by reports of successful implementation of mini-ally invasive techniques. The principles of retro-rectusrosthetic reinforcement have been adapted for laparoscopicentral hernia repair. The mesh is placed as an intraperitonealnlay with wide coverage of the hernia defect. Avoidance ofarge incisions has substantially reduced wound complica-ions. Overall, the clinical benefits of laparoscopic ventralernia repair include a faster convalescence, fewer complica-ions and, importantly, a low recurrence rate.

echniques ofaparoscopic VHR

fter general anesthesia is induced, the patient is positionedupine with the arms adducted and “tucked” at the sides. Thisllows for adequate space for both primary surgeon and anssistant on the same side of the patient. We use two moni-ors, placed on each side of the patient (Fig. 1). In most cases,he bladder and stomach are decompressed with catheters.n antibiotic, usually a first-generation cephalosporin, isiven prophylactically before the incision is made and re-

epartment of Surgery, Division of Gastrointestinal and Minimally InvasiveSurgery, Carolinas Medical Center, Charlotte, NC.

ddress reprint requests to Dr. Yuri W. Novitsky, Department of Surgery,Division of Gastrointestinal and Minimally Invasive Surgery, CarolinasMedical Center, 1000 Blythe Blvd, MED 601, Charlotte, NC 28203.

uE-mail: yuri.novitsky@carolinas.org

1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2006.04.004

eated if the operation lasts longer than 2 hours. We rou-inely use an Ioban drape to minimize mesh contact with theatient skin. Laparoscopic hernia repair is performed by us-

ng a 30-degree angled laparoscope, 5-mm bowel graspers,cissors, and clip appliers. Access to the peritoneal cavity isained using a cut-down technique (Fig. 2). A window ofccess is usually present, even in the multiply operated ab-omen, below the patient’s costal margin between the mid-lavicular or anterior axillary lines. The initial entry site ishosen just inferior to the tip of the eleventh rib, usually onhe left side. We often prefer to then use a balloon-tippedrocar to avoid air leakage. A total of three trocars are placednder direct vision laterally along anterior-to-mid-axillary

ine. Often, a fourth 5-mm port is placed contralaterally toacilitate intra-abdominal mesh introduction and fixation.ort placement for less common defects (subxyphoid, supra-ubic, parailiac, spigelian, etc.) is adjusted based on the lo-ation of the hernia. On entrance to the abdominal cavity,dhesiolysis is performed sharply with limited use of electro-urgery or ultrasonic coagulators. Reduction of the herniaontents is performed using blunt graspers and sharp dissec-ion from the inside and is facilitated by manual compressionrom the outside. The hernia sac is usually left in situ. Oncehe adhesiolysis is completed, the hernia defect is measuredo determine an appropriate size of a prosthetic mesh. Theorders of the abdominal wall defect are delineated with aombination of laparoscopic vision and external palpation.he edges of the defect are marked externally. Often, place-ent of spinal needles through the abdominal wall at the

nternally visualized defect edges is needed to accurately de-ermine the size of the hernia (Fig. 3). This maneuver isspecially important in obese patients with large defects asxternally measured size of a defect can be dramatically over-stimated. A ruler is placed through a 5-mm port, and theimensions of the hernia defect to allow for the direct mea-urement of the defect. The mesh is than tailored to overlapll margins of the hernia by at least 4 cm.

Once the mesh is cut to the desirable size, four size-0ermanent monofilament or ePTFE sutures are placed at theid-point of each side of the mesh. Points of reference on theesh and corresponding points on the abdominal wall arearked to aid in orienting the mesh after its introduction into

he abdomen. The mesh was rolled up and pushed or pullednto the abdomen through a 5- or 10-mm trocar site. The

esh is rolled from both edges to facilitate the unfolding stepFig. 4). If the defect size dictates a very large prosthetic it is

sually introduced in the abdominal cavity by pulling with

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Laparoscopic ventral hernia repair 5

he grasper passed through the contralateral trocar. It is im-ortant to maintain the appropriate orientation of the meshuring the insertion and unfolding of the mesh. Two Mary-

and graspers are best used to unfold the mesh. After theesh is oriented intracorporeally, the sutures are pulled

hrough the abdominal wall with a suture passer (Fig. 5). A 4m mesh/defect overlap is once again confirmed using spinaleedles, as described above. The suture pulled first is usuallylosest to the “sensitive” border (xiphoid, pubis, iliac crest,ostal margin, colostomy, etc.). We subsequently pull theuture that is adjacent (not opposite) to the first one. Onceufficient overlap is confirmed, we tie both sutures with thenots buried in subcutaneous tissues. The other two suturesre then pulled transabdominally and tied ensuring that theverlap is sufficient and that the mesh is taut (Fig. 5). Theerimeter of the mesh is then stapled to the posterior fasciaith 5-mm spiral tacks at approximately 1 cm intervals torevent intestinal herniation. Placing the tacks is facilitatedy the external manual palpation of the tacker’s tip (Fig. 6).his is particularly important for tacking the mesh in the

ower abdomen to ensure that the tacks are placed superiorlyo the inguinal ligament. Additional full-thickness stitches

Figure 1 Patient positioning, ro

re placed circumferentially every 3 to 6 cm by using the l

uture passer (Figs. 7 and 8). This transabdominal fixation isrucial to ensure that the mesh will not be displaced overime. The knots are tied in the subcutaneous tissues. The skins released to avoid dimpling.

onclusionaparoscopic ventral hernia repair has reliably been shown toe superior to the open approach. Overall LVHR is associatedith a decreased perioperative pain, reduced hospital stay,

nd faster recovery. Postoperative complications are also lessrequent in the laparoscopic group (23.2% vs. 30.2%) as wells the incidence of wound and mesh infections (Table 1). Inddition, the recurrence rate is 4% for the laparoscopic groupnd 16.5% for the open technique.

Overall, numerous studies demonstrate that laparoscopicentral hernia repair is an effective and safe approach to thebdominal wall hernia. It can be performed in complex sur-ical patients with a low rate of conversion to open surgery, ahort hospital stay, a moderate complication rate, and a lowisk of recurrence. With additional long-term follow-up toupport the safety and durability of the procedure, LVHR will

t-up, and our trocar strategy.

ikely be considered the standard of care in the future.1–9

6 Y.W. Novitsky, B.L. Paton, and B.T. Heniford

Figure 2 Access to the abdominal cavity using cut-down techniques utilizing pediatric Kocher clamps. This is usually

safely accomplished in the left upper quadrant area.

Figure 3 Intracorporeal (direct) measurement of a hernia defect. Spinal needles allow for more precise identification ofthe edges of the defect. Additional spinal needles may be used for defects larger than the length of a ruler (typically 12

cm).

Laparoscopic ventral hernia repair 7

Figure 4 Rolling of the mesh before its introduction into the abdominal cavity.

Figure 5 Initial four-point mesh fixation.

8 Y.W. Novitsky, B.L. Paton, and B.T. Heniford

Figure 6 Transabdominal suture fixation of the mesh.

Figure 7 Placement of tack is done circumferentially along the whole length of the mesh to avoid bowel incarceration.External palpation of the abdominal wall facilitates placement of the tacks and helps to avoid tacking the mesh below

the inguinal ligament and above costal margins.

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eferences. Heniford BT, Park A, Ramshaw BJ, Voeller G: Laparoscopic repair of

ventral hernias: Nine years’ experience with 850 consecutive hernias.Ann Surg 238:391-399, 2003

. Novitsky YW, Cobb WS, Kercher KW, Matthews BD, Sing RF, HenifordBT: Laparoscopic ventral hernia repair in obese patients: A new standardof care. Arch. Surg 141:57-61, 2006

. Rosen M, Brody F, Ponsky J, et al: Recurrence after laparoscopic ventralhernia repair. Surg Endosc 17:123-128, 2003

. Carbonell AM, Kercher KW, Matthews BD, Sing RF, Cobb WS, HenifordBT: The laparoscopic repair of suprapubic ventral hernias. Surg Endosc19:174-177, 2005

Figure 8 Final appea

able 1 Comparison studies of laparoscopic and open ventra

Study Year

# Patients Morbidit

Lap Open Lap Op

cGreevy 2003 65 71 5 15aftopoulos 2003 50 22 14 10right 2002 90 90 15 31

obbins 2001 18 31 — —eMaria 2000 21 18 13 13hari 2000 14 14 2 2arbajo 1999 30 30 20 6amshaw 1999 79 174 15 46ark 1998 56 49 10 18olzman 1997 21 16 5 5ercent 23.2 30

. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel

J: Long-term follow-up of a randomized controlled trial of suture versusmesh repair of incisional hernia. Ann Surg 240:578-583, 2004

. Luijendijk RW, Hop WC, van den Tol MP, et al: A comparison of suturerepair with mesh repair for incisional hernia. N Engl J Med 343:392-398,2000

. Stoppa RE: The treatment of complicated groin and incisional hernias.World J Surg 13:545-54, 1989

. DeMaria EJ, Moss JM, Sugerman HJ: Laparoscopic intraperitoneal poly-tetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Pro-spective comparison to open prefascial polypropylene mesh repair. SurgEndosc 14:326-329, 2000

. Carbajo MA, Martin del Olmo JC, Blanco JI, et al: Laparoscopic treat-ment vs open surgery in the solution of major incisional and abdominal

f the hernia repair.

ia repairs

Meshinfection

Woundinfection Recurrence

Lap Open Lap Open Lap Open

2 0 0 7 — —1 0 1 1 1 41 1 1 8 1 51 4 1 0 — —1 2 1 4 1 00 1 — — — —0 3 0 5 1 21 5 6 2 2 362 1 0 2 6 170 1 1 0 2 22.0 3.5 2.6 5.8 4.0 16.5

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wall hernias with mesh. Surg Endosc 13:250-252, 1999