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Laparoscopic Ventral Hernia Repair Ppt. DR DILIP S.RAJPAL

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Laparoscopic Ventral Hernia Repair Ppt. DR DILIP S.RAJPAL

  1. 1. LAPAROSCOPIC VENTRAL HERNIA REPAIR A COMPREHENSIVE APPROACH DR DILIP S.RAJPAL MS, MAIS, FICS(USA), FMAS, DIPL. IN LAPROSCOPIC SURGERY, FELLOW IN ROBOTIC & ADV LAP. COLO-RECTAL SURGERY (KOREA UNIV.) CONSULTANT GEN. SURGEON LAPROSCOPIST & COLOPROCTOLOGIST HON. SURGEON NOVA MEDICAL CENTERHON. ASS PROF GRANT MED.COLLEGE & HON. SURGEON JJ HOSPITAL EX-ASST. PROF L.T.M.GEN. HOSPITAL
  2. 2. OPEN REPAIR METHODS For Ventral HerniasDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  3. 3. TENSION REPAIR  Quick repair, done under local anesthesia  However tension repair has unacceptably high recurrence rates of ~50%  Regardless of the size of hernia, mesh repair has been proved to be a superior methodDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  4. 4. PROSTHETIC MESH – ONLAY TECHNIQUE  Onlay mesh repair  Primary repair performed  Mesh widely covers the repair  Requires cleaning off the fascia and undermining the skin and subcut for a wide distance  Disadvantages  Still a tension repair  Large subcut dissection can lead to seroma  High infection rate - may be 10-20%DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  5. 5. INLAY MESH REPAIR  Inlay mesh  Sac excised and mesh sewn to fascial edges  This is non tension repair  Must use non adherent mesh such as Physiomesh or Proceed if bowel will be in contact with the mesh  Disadvantage  Possible continued bulge after repairDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  6. 6. RETRO RECTUS / STOPPA REPAIR  A plane is dissected between posterior rectus and peritoneum to put the mesh  This is tension-free repair  Mesh extends well beyond the under edges of the muscle, reinforcing the entire area  Must use non adherent mesh such as Physiomesh or Proceed if bowel will be in contact with the mesh  Disadvantage  Reported recurrence rate of ~10%.Reported infection and mesh removal rate of ~5-10%DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  7. 7. OVERVIEW OF VENTRAL HERNIASDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  8. 8. VENTRAL WALL (INCISIONAL)  Highest incidence in midline and transverse incisions  Upto 20% after laparotomy  1/3 present in 5-10 years postoperatively  Risk factors  Obesity, DM, ascites, steroids, smoking, malnutrition, wound infection  Technical aspects of wound closure  Type of incision  Excessive tension (prone to fascial disruption)DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  9. 9. INCISIONAL HERNIA  Due to failure of fascial tissues to heal and close  Promoted by inhibition of wound healing  10-15% of abdominal incisions  Highest incidence with midline incisionDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  10. 10. INCISIONAL HERNIA  Indications for Surgery  Bulge of abdominal wall deep to skin scar  Cosmetic concern versus discomfort  Worsened with coughing or straining  Incarceration  Less than 1cm  More than 7-8 cm unlikely to incarcerate  Treatment Most should be repaired (unlike groin hernias)  Suture versus mesh repair  Suture repair in one European study showed 60% recurrence  With open mesh repair, recurrence seen at upto 30%DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  11. 11. DIAGNOSISDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  12. 12. INCISIONAL HERNIA  Visible bulge - May be cosmetically upsetting  Pain - May limit activities, pain is increased with lifting, straining and coughing  Incarceration - Severe acute pain with tenderness over the hernia site  Bowel obstruction - Due to acute or chronic incarceration with typical symptoms  Note: In obese patients, hernia may not be evidentDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  13. 13. IMPORTANT QUESTIONS TO CONSIDER  Site  Etiology  Partial vs. complete  Simple vs. strangulated  Fluid and electrolyte status  Operative vs. non-operative managementDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  14. 14. INCISIONAL HERNIA-DIAGNOSIS  CT Scan - Very helpful in obese patients. Frequently, a CT Scan will reveal additional less clinically obvious hernias  Ultrasound - May be useful especially in office setting when PE is uncertain  Laparoscopy - For patients with pain and symptoms suggestive of hernia, but negative PE and imaging studiesDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  15. 15. INCISIONAL HERNIA -DIAGNOSIS  Diastasis recti vs Incisional hernia  Diastasis is a thinning or weakening of the fascial membrane connecting the rectus muscle  It is not a hernia and generally is asymptomatic and will not lead to incarceration. It may be cosmetically unsightly  It is usually located in the upper abdomen and may occur spontaneously  It is recognizable by its diffuse nature, keel formation and lack of a “ring”DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  16. 16. STRANGULATED HERNIAS  Most important signs  Fever  Tachycardia  Localized abdominal tenderness  Leukocytosis  Process is accelerated with closed-loop obstructionDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  17. 17. INCISIONAL HERNIA – CHOICE OF TECHNIQUE  Complex open repairs  Stoppa mesh repair  Component separations repair  Laparoscopic repair  Multiple fascial defects detected  Large on-lay intraperitoneal mesh  5 cm marginal overlap  Recurrent hernias – avoid dissection at previous operative siteDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  18. 18. CONTRAINDICATIONS TO LVHRS  Major loss of abdominal domain  Severe debilitation  Respiratory distress  Pregnancy  Portal hypertension  Renal failure with presence of peritoneal dialysis catheterDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  19. 19. LAPAROSCOPIC TECHNIQUE For Ventral Hernia RepairDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  20. 20. LAP VENTRAL HERNIA REPAIR  Advantages  Less pain, smaller scars, less soft-tissue dissection  Good view of possible other hernias such as swiss- cheese defect, thus reducing chances of recurrences  Decreased wound complications  Effective modality for recurrent hernias that have been repaired anteriorly (open)  Disadvantages  May still have bulge  Possible bowel injury  Seroma rate 15-20%DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  21. 21. SURGICAL TECHNIQUE  Three steps  Access  Adhesiolysis  Mesh insertion / fixation  Key components:  Reduce the hernia contents  “Patch” the defect in the fascia with Mesh  Mesh is incorporated into the abdominal wall by the body  Reinforces the defect in the fascia  Secure the Mesh to the abdominal wall  Prevent movement of the mesh prior to incorporationDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  22. 22. PORTS PLACEMENT  Direct visualization (enter abdomen from sites away from hernia  Controlled insertion  Bowel protectionDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  23. 23. LAPAROSCOPIC REPAIRDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  24. 24. TROCAR SITES SETUP  Left Epigastric hernia  Suprapubic hernia  Upper midline hernia  Lower midline herniaDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  25. 25. DEFECT VISUALIZATION  Proper dissection is facilitated by complete visualization  If you cannot see the defect  Consider placing a fourth 5mm trocar  Opposite to the placement of other trocarsDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  26. 26. ADHESIOLYSIS  Avoid sharp dissection and avoid bowel injuries  Minimize use of electrocautery  Have two monitors, one on each side to have easy visualization when you change side  To get better all-round view of adhesions, keep shifting instrument and camera sitesDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  27. 27. DEFECT MEASUREMENT  The margins of the defect may be marked on the skin  The mesh is measured and trimmed to fit  With the smooth side down, 4-6 large fixation sutures are placed around the mesh and tiedDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  28. 28. THE EXTENT OF THE DEFECT IS ASSESSED.DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  29. 29. PROCEED MESH  PROCEED Mesh has two layers  Soft polypropylene mesh  ORC - a thin, bioresorbable layer that separates its strong, supportive mesh from underlying viscera.  PROCEED mesh is a lightweight construction to improve handling for laparoscopic proceduresDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  30. 30. PHYSIOMESHDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  31. 31. SECURESTRAPDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  32. 32. HANDLING PROCEED MESH / PHYSIOMESH  Mesh is an internal prosthesis  Mesh infections can be devastating and the mesh may need to be removed  Therefore, mesh should be handled aseptically  Change gloves before touching the mesh  Use sterile instruments, and not hands, to handle the mesh as much as possible  Avoid excessive use of electrocoagulation hemostasisDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  33. 33. MESH OVERLAP Pascals principle—wide mesh overlap of defect distributes pressure equally over larger surface area.DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  34. 34. TRANSFASCIAL SUTURES  Transfascial sutures prevent mesh migration  Transfascial sutures should be permanent  Prolene / Ethilon / Ethibond Excel  To prevent chronic post-op pain an air knot is preferred for transfascial sutures  For Proceed and Physiomesh, two transfascial sutures at cephalad and caudad positions are recommended  After tying the knot, pull the transfascial sutures from the skin outwards a couple of times to release any tensionDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  35. 35. MESH FIXATION  The purpose of tacking is  To minimize any dead spaces  To hold the mesh close to the abdominal wall for excellent tissue incorporation  Various types of fixation have been devised  Double crown technique  Eliminates dead space, minimizes seroma formation  Transfascial sutures are still highly recommended  Single crown tacking + absorbable sutures  Single crown tacking + non-absorbable sutures fixationDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  36. 36. PORT SITE HERNIAS Following LVHRsDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  37. 37. TROCAR SITE HERNIA  The incidence of trocar site hernia has been shown to be 0.65% to 2.80%  Midline, periumbilical port sites greater than 5 mm and made with bladed introducers often result in incisional hernia, if not closedDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  38. 38. TROCAR SITE HERNIA  Serious access-related complications appear to be rare but can lead to increased morbidity when they do occur  Bowel through port sites is uncommon and can be difficult to diagnose. Often the diagnosis is delayed, resulting in infarction of the involved bowel segment  Most laparoscopic surgeons agree that the diameter of the cannula or port is the single most common cause of port-site herniasDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  39. 39. TROCAR SITE HERNIA  Overall, if the cannula or port site is 10 mm or larger in diameter, hernias can occur, despite preventive measures such as using a noncutting trocar  Most surgeons do not routinely close lateral port sites because it is commonly thought that the fascial and muscular composition of these sites pose such little risk of herniation that the extra time and effort required to repair them is not justified  However this theory is NOT absoluteDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  40. 40. PORT SITE CLOSURE TECHNIQUEDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  41. 41. COMPLICATIONS Lap Ventral Hernia RepairsDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  42. 42. POSSIBLE COMPLICATIONS  Enterotomy  Respiratory Distress  Wound Infection  Abdominal  Mesh Infection Compartment Syndrome / IVC  Persistent Seroma Compression  Prolonged Pain  Ileus  Bleeding/Hematoma  RecurrenceDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  43. 43. WOUND AND MESH INFECTION  Key question - Is mesh just a large foreign body in an otherwise clean surgical wound?  Many wounds are inflamed but not necessarily infected  Infected wounds need to be opened  Avoid exposing the underlying mesh if possible  Infections that involve polypropylene meshes can be managed with  Surgical drainage  Antibiotics  Excision of exposed segments  Micro-porous/non-porous ePTFE meshes require removal in most cases because they lack tissue ingrowth that could combat the infectionDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  44. 44. SEROMA FORMATION  The development of seroma is virtually guaranteed after lap incisional hernia repair and probably after repair with mesh in general.  Seromas typically resolve spontaneously without intervention and are not considered a complication unless they are clinically apparent for more than 8 weeks postoperatively  Seroma management  Eliminating dead space such as between mesh and the abdominal wall by using sufficient tacks  Purse string suturing of the tissue layersDR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  45. 45. CHRONIC PAIN  In Rives-Stoppa or other open mesh implantation, it occurs in more than 10% of patients  Transabdominal suture site pain after LVHR occurs in 1% - 3% of patients Visual Analog Scale (VAS)DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  46. 46. POINTS TO REMEMBER  Place all ports as far away as possible from the defect  Switch scope position  Keep intraabdominal pressure HIGH during dissection and LOW during closing  And very importantly - MARK THE MESH!!!DR DILIP S.RAJPALCONSULTANT GEN. SURGEONLAPROSCOPIST & COLOPROCTOLOGIST
  47. 47. THANK YOU

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