After being placed supine on the operating room table, anesthesia was induced and the patient intubated
without difficulty. The area of the entire abdominal wall was then prepped and draped in a sterile fashion and
a final time out then performed confirming right site and right patient.
A ten blade scalpel was used to make an upper midline celiotomy incision. Electrocautery was used for
hemostasis and to continue the dissection through all subcutaneous layers until the anterior fascia of the
rectus musculature could be identified. Electrocautery dissection was used to dissect subcutaneous tissues off
of the anterior abdominal wall fascia along the entire length of the midline incision until the rectus muscle
separation was completely exposed. The midline of the diastasis recti was then opened exposing the
abdominal cavity completely. At this point, a moderate sized diastasis recti with a small supra-umbilical
ventral hernia could be identified.
Using electrocautery, excess subcutaneous tissues and midline fascia was excised and discarded into order to
restore the normal boundaries of the medial aspect of the rectus musculature bilaterally. All layers of the
anterior abdominal wall were then re-approximated in the midline using running looped 0 PDS sutures. This
included completely re-approximating the inferior hernia defect primarily. The entire surgical field was then
copiously irrigated using diluted Betadine solution. The midline abdominal wall soft tissues were then reapproximated
in the midline in a layered and centrally mattressed fashion using interrupted 3-0 Vicryl
sutures. The midline incision was then closed using skin staples.
The primary hernia repair and plication of the diastasis recti complete, attention was now turned to the
laparoscopic portion of the hernia repairs with mesh implantation. After placing a left upper quadrant
abdominal port under direct visualization, pneumoperitoneum was achieved to a pressure of 15 mm Hg.
Three additional trocars were placed in the other anterior abdominal wall quadrants sequentially using a 15
blade scalpel to make separate transverse incisions and the laparoscope for direct visualization. Harmonic
scalpel dissection was then used to separate the Falciform ligament from the superior aspect of the primarily
re-approximated abdominal wall defect as well as adhesive disease inferior to the umbilicus to allow for a
smooth posterior abdominal wall surface for mesh attachment. Once cleared, the defect was measured and a
20 x 7 cm piece of Proceed composite mesh fashioned for fixation. Two corner 2-0 PDS sutures were placed
along the textured surface of this graft which was then irrigated using diluted Betadine solution, rolled,
passed into the abdominal cavity, and unrolled without difficulty. A suture passer was then used to
exteriorize each fixation suture through a small stab incision made in the anterior abdominal wall using an 11
blade scalpel. These sutures then allowed the mesh to lie smoothly across the midline ventral defects in an
underlay fashion. The patch was further secured in place using a 5 mm SecureStrap device at approximately
1.5 cm intervals circumferentially.
At this point, all ports were removed under direct visualization and pneumoperitoneum released in full. All
remaining skin incisions were then irrigated using diluted Betadine solution and re-approximated using
staples. The port site incisions were cleaned, dried and dressed sterilely using Bacitracin, Telfa gauze, and
Tegaderm. The suture passer incisions were closed using staples and the entire abdominal wall midline then
dressed using Bacitracin and an Aquacel Ag surgical coverlet. Sponge and instrument counts were confirmed