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Complex Cases and Future Directions for Ventral Hernia Repair

Complex Cases and Future Directions for Ventral Hernia Repair. Bruce Ramshaw MD FACS Consultant, Halifax Health Daytona Beach, FL. Patient Selection. Critical to proceeding safely through the “learning curve” for laparoscopic ventral hernia repair

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Complex Cases and Future Directions for Ventral Hernia Repair

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  1. Complex Cases and Future Directions for Ventral Hernia Repair Bruce Ramshaw MD FACS Consultant, Halifax Health Daytona Beach, FL

  2. Patient Selection • Critical to proceeding safely through the “learning curve” for laparoscopic ventral hernia repair • Avoid large defects, recurrences with previous mesh, chronic bowel incarceration, loss of domain, atypical locations, previous intraabdominal sepsis • Good initial cases: - small recurrences: umbilical - small incisional: appy - small primary: umbilical, epigastric • Good next cases: - moderate incisional: midline - moderate recurrences

  3. Abdominal access • Closed or open • Away from previous incisions • Away from defect • Potential complications - Visceral injury - Bleeding - Port site hernia - Infection

  4. Adhesiolysis • Blunt dissection for favorable adhesions (avascular plane between abdominal wall and adherent viscera) • Sharp dissection for dense adhesions • Avoid energy sources unless bowel is definitely not incorporated in adhesions (if unsure, avoid energy) • Address bleeding/ injury at the time it occurs • High suspicion for delayed/ missed injury (Dictate visual inspection and no sign of injury in operative note)

  5. Technique – Lysis of Adhesions and Hernia Reduction

  6. Enterotomy • Bowel injury • Serosal injury • Thermal injury • Missed injury • Delayed injury

  7. Enterotomy Management • Open, fix bowel, repair hernia • Open, fix bowel, leave hernia • Lap repair bowel, delay hernia repair (3-7 days) • Lap repair bowel, place mesh (synthetic or biologic), antibiotics

  8. Bleeding (Intraabdominal) • Control bleeding (with grasper) • Isolate vessel (suction/irrigation) • Occlude vessel (energy, clip, endoloop, etc.)

  9. Bleeding (Abdominal Wall) • Look for epigastric vessels • Control bleeding with pressure • Tie suture (use additional sutures if needed • Check for hematoma/bleeding at end of case (dictate no bleeding)

  10. Post-operative Seroma

  11. Technical Issues to Minimize Recurrence* • Clear visualization of all defects • Wide coverage of mesh beyond defect edges • Secure fixation of mesh to healthy abdominal wall fascia *Assuming mesh does not move

  12. Migration into hernia defect

  13. Migration uncovering the defect

  14. Chronic Mesh Complications • Chronic seroma • Chronic pain (poor compliance) • Late infection • Mesh erosions/fistulas/sinus tracts

  15. Chronic Seroma

  16. Chronic Seroma- deep to mesh

  17. Mesh erosion into bowel

  18. From Todd Heniford Carolinas Medical center

  19. Mesh Designed for Intraabdominal Placement • Abdominal wall side: ingrowth through peritoneum ideally into fascia • Visceral side: Prevent ingrowth of viscera and ideally prevent adhesions • Products: - DualMesh: all PTFE- smooth + rough - Duelex: all PTFE- smooth + rough - Composix: Heavyweight PP + PTFE - Sepramesh: Heavyweight PP + Seprafilm - Parietex Composite: Polyester + Collagen - Proceed: Lightweight PP + Cellulose - More to come

  20. Explanted PP/PTFE Composix

  21. Difficult Ventral Hernias • Loss of Domain • Atypical Locations - Subxiphoid - Suprapubic - Flank • Parastomal Hernias • Multiple/complex previous abdominal operations (skin grafts, trauma, etc.) • Previous macroporous mesh in the abdominal cavity

  22. Laparoscopic Flank Hernia

  23. Technique: Posterior Fixation

  24. Laparoscopic flank hernia repair Pre-op 3 weeks post-op 6 months post-op

  25. Suprapubic Hernia

  26. Hernia Bladder

  27. Nerves in the groin Ilioinguinal nerve PAIN DOOM

  28. Subxiphoid Hernia

  29. Lap Subxiphoid Hernia Repair Pre-op 5 weeks post-op

  30. Laparoscopic Repair of Giant/LOD Hernias

  31. Parastomal Hernia No slit technique 2 weeks post-op

  32. Patient Selection

  33. Lap Ventral Hernia Reair POD #21

  34. LOD: One Year Post-op

  35. LOD- 6 months post-op

  36. Summary • Be aware of potential complications and their management • Tell patients about pain, seroma and possibility of enterotomy • Use good judgment in selecting patients for laparoscopic ventral hernia repair • Use good technique to prevent recurrence • Use mesh designed for intraabdominal placement • Mesh material options are becoming more biocompatible

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