Complex Cases and Future Directions for Ventral Hernia Repair

Bruce Ramshaw MD FACSConsultant, Halifax Health

Daytona Beach, FL

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

Abdominal access

Closed or open Away from previous incisions Away from defect Potential complications

- Visceral injury

- Bleeding

- Port site hernia

- Infection

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)

Technique – Lysis of Adhesions and Hernia Reduction

Enterotomy Bowel injury

Serosal injury

Thermal injury

Missed injury

Delayed injury

Enterotomy ManagementEnterotomy 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

Bleeding (Intraabdominal)Bleeding (Intraabdominal)

Control bleeding (with grasper)

Isolate vessel (suction/irrigation)

Occlude vessel (energy, clip, endoloop, etc.)

Bleeding (Abdominal Wall)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)

Post-operative Seroma

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

Migration into hernia defect

Migration uncovering the defect

Chronic Mesh Complications

Chronic seroma

Chronic pain (poor compliance)

Late infection

Mesh erosions/fistulas/sinus tracts

Chronic Seroma

Chronic Seroma- deep to mesh

Mesh erosion into bowel

From Todd HenifordCarolinas Medical center

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

Explanted PP/PTFE Composix

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

Laparoscopic Flank Hernia

Technique: Posterior Fixation

Pre-op 3 weeks post-op

Laparoscopic flank hernia repair

6 months post-op

Suprapubic Hernia

Bladder Hernia

Nerves in the groin

PAIN

DOOM

Ilioinguinal nerve

Subxiphoid Hernia

Lap Subxiphoid Hernia Repair

Pre-op 5 weeks post-op

Laparoscopic Repair of Giant/LOD Hernias

Parastomal Hernia

2 weeks post-opNo slit technique

Patient Selection

Lap Ventral Hernia Reair POD #21

LOD: One Year Post-op

LOD- 6 months post-op

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

Thank You