PREOPERATIVE DIAGNOSIS:
Multiple ventral and incisional hernias.
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POSTOPERATIVE DIAGNOSIS:
Multiple ventral and incisional hernias.
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OPERATION PERFORMED:
1. Laparoscopic repair of multiple ventral and incisional hernias utilizing 33 cm portion of echo mesh, with laparoscopic lysis of intraabdominal adhesions, difficult case modifier due to the extent of the adhesions in size of the multiple hernias requiring approximately an additional 45 minutes of additional dissection.
2. Exploratory laparotomy, lysis of intraabdominal adhesions, and primary repair of lower abdominal midline hernia.
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DESCRIPTION OF OPERATION:
The patient was brought to the operating room, placed recumbent. The area of the abdomen was prepped and sterilely draped. Surgical time-out was performed. Local anesthesia was infused and we began with a Veress needle in the left upper quadrant insufflating the abdomen quite easily after performance of a saline drop test. A 10 mm port was placed using a 0 degree scope under direct visualization and using the Visiport to enter the abdomen, it was no identifiable adhesions were present in the left upper quadrant. However, there were numerous adhesions and hernias present throughout the abdominal wall as described below. Under direct visualization, a second port was placed in the left lower quadrant and we performed lysis of visible omental adhesions in the left abdomen allowing visualization of the right side of the abdomen then, under direct visualization, a second 10 and a second 5 mm were placed on the right side. We continued with our dissection reducing and clearing from around the adhesions in the umbilical region where there were multiple small hernias and at the old stoma site where there was a single identifiable hernia. Once this has been done, we switched to the right side of the abdomen and performed same procedure with primary concern directed at the lower most hernia, which was wide-mouth and contained small bowel which was markedly adherent to the hernia sac. Given this fact, I did not feel it was prudent to try to dissected this free and we released the pneumoperitoneum, and made a small midline incision measuring about 8-10 cm over the lower midline hernia sac. Once this has been done, the hernia sac was opened and using Metzenbaum scissor dissection, the small bowel was extricated from the hernia sac reducing it into the abdominal cavity. Much of the hernia sac was excised and by grasping with the residual fascia with Kocher’s, we were able to perform intraabdominal adhesiolysis circumferentially around the defect. We extended this downward into the pelvis to allow visualization when we re-insufflated the abdomen and also to visualize the bladder. Of note is that a Foley catheter had been positioned in the beginning of the case.
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We now closed the midline defect utilizing the residual hernia sac and markedly attenuated fascia using a running looped PDS suture. Subcutaneous tissues were approximated with a running Vicryl and the skin was approximated with surgical staples. We now re-insufflated the abdomen.
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Visualization was now excellent with all adhesions having been cleared away from either side of the abdomen and in the midline. Measurement between the defects superiorly and inferiorly was approximately 25 cm requiring a 33 cm portion of mesh. The mesh was soaked in saline, rolled, and inserted in the abdomen directly through a slightly enlarged trocar incision in the right upper quadrant. This mesh would have been impossible to insert into the abdomen through the trocar. Directly between the defects, the Carter-Thomason device was used to grasp the insufflating catheter, which was pulled up to the anterior abdominal wall and the balloon on the mesh was insufflated. The mesh was oriented at the 12 o’clock position requiring takedown of a portion of the falciform ligament. We then tacked the mesh circumferentially from the left and right side of the abdomen using the OptiFix tacking device, but did not tack it at its lower end. At this point, the patient was placed in the Trendelenburg position and the bladder was distended with about 700 mL of saline to identify the dome and we tacked the mesh well above this with the bladder still distended. Now, the pneumoperitoneum was partially released in the central portion of the mesh was tacked in place to be sure it remained adherent to the anterior abdominal wall. We continued to watch the mesh as the pneumoperitoneum was completely released. The abdomen had been examined for hemostasis. The visible small and large bowel have been examined and there was no evidence of injury. The trocars were withdrawn and the final pneumoperitoneum was released. The wounds were closed with running subcuticular sutures of Monocryl and Dermabond. Additional Marcaine was injected as indicated. The patient tolerated the procedure well. Counts were correct at completion of surgery.