Hernias can be internal or external and abdominal or thoracic. Where both these hernias are spontaneous in occurrence due to congenital defects, incisional hernias are very common and often occur after surgery. They can range from small to large defects. Loss of domain is a condition where the hernial defect is so large that the contents become irreducible due to a chronically injured abdominal wall. Incisional hernias are a result of technical and biological factors when the fascia does not heal after the surgery. Due to the mechanical failure the myofascial defect is concealed by the healing skin and gets enlarged. The bundles of collagen along the abdominal wall are oriented transversely suggesting that a transverse suture line provides mechanical stability. Fibers are encircled rather than split. Higher incidences of an incisional hernia formation are observed in upper midline hernias and perioperative shocks.
Diagnosis and Indications
Incisional hernias are asymptomatic but are easy to diagnose. The defect can be delineated and palpated effortlessly. If patients are obese, a computed tomography is recommended. Indications for an incisional hernia repair are:
- Aggravated symptoms of abdominal enlargement and pain
- Hernial sacs having a small neck containing the bowel are at a risk of incarceration
Laparoscopic incisional hernia repair is a technically challenging procedure. Preprocedural care may involve the discontinuation of warfarin and antiplatelet drugs. This minimizes the risk of hemorrhage. Lifestyle changes such as cessation of smoking have to be followed at least two weeks before the operation. Laparoscopic hernia repair works on three basic surgical principles ???
- Mesh usage ??? if a mesh is not used, there is a high risk of recurrence of incisional hernias
- No tension – the mesh is placed with no tension so that herniation of the abdominal cavity content is prevented
- Appropriate placement of trocar ??? Depending on the location of the hernia and the abdominal wall size, the trocars are used. An attempt is made at traction, countertraction and triangulation as considerations to maintain surgical principles.
The patient is administered first-generation cephalosporin 60 minutes prior to incision to cover bacteria in the skin. Mandatory prophylactic antibiotic therapy is provided. Unless there is an increased risk of bleeding prophylactic anticoagulation is commenced in 24 hours.
- The patient is managed with general endotracheal anaesthesia. Paralytics are also given to relax the musculature of the abdominal wall.
- With the patient in supine position, access is gained to the abdominal cavity.
- Two 5-mm ports, one 10-mm optical port and one 5-mm port to deploy fixation tacks is placed contralateral to the optical port. Pneumoperitoneum is established.
- 12 mm Hg pressure is maintained throughout the procedure.
- Adhesions are lysed with the help of blunt dissections, sharp scissors or electrocautery.
- The sac is reduced within the abdominal cavity, and any bleeding is controlled with sutures, staples and endoscopic loops.
- The 10-mm trocar is used to place a dual-surface mesh. The swatch should overlap at least 5 cm from the edges of the hernia.
- Two lines of tacks are used to create double-circle configuration.
- Transfasical sutures are placed to prevent migration from the mesh.
- A figure eight absorbable suture is done to close the 10 mm port, and a 4-0 absorbable suture closes the skin.