A hybrid laparoscopic ventral hernia repair technique with closing of the defect.
July 22, 2011
When there is a risk for a high incidence of hernia recurrence with primary sutured closure, I fundamentally think that it does not make sense to close the defect under tension. Having recently adopted the endoscopic components separation technique for my open ventral hernias, where we divide the external oblique through lateral incisions using the laparoscopic trocars and instruments, I decided I could utilize that endoscopic approach for the components separation and marry it with a laparoscopic ventral hernia repair to perform what I refer to as the truly minimally invasive abdominal wall reconstruction. So now, through division of the external oblique muscles with the endoscopic approach, and a laparoscopic ventral hernia repair, I can then close the midline hernia defect in a tension-free manner. Using a suture passer placed through the full thickness of the abdominal wall via 1 mm skin incisions placed on either side of the incision, I make a series of these needle holes on either side. I close the defect primarily, and then perform a reinforcing mesh-based repair.
Now that I’ve closed the defect in a tension-free manner, I typically don’t need to use nearly as large of a piece of mesh as I would have otherwise. I still abide by my principles of laparoscopic ventral hernia repair, where I cover the defect by at least 5 cm in all directions.
However, now that the defect has been closed, I need a 10 cm wide mesh, and the length of the graft is 5 cm greater than the length of the incision in each direction. So, typically, it’s a 10 cm by 20 or 30 cm long piece of mesh to reinforce the entire incision since it’s been closed in a tension-free manner.
I believe the benefit of getting the midline back together is that the abdominal continuity is restored. In doing so, there is a benefit in improving or augmenting abdominal wall function. Research has shown that components separation increases abdominal wall function up to 40 percent. I believe that is related to resetting the Starling Curve. By getting the rectus muscles back to the midline, we now create a stable insertion for the oblique muscle, optimize the curve and augment abdominal wall function.
By getting the rectus muscles back in the midline, we are using the rectus muscles as a means to an end. The main purpose of getting the rectus muscles back together is to optimize our oblique function – a far more important muscle group from the standpoint of abdominal wall function. We use them for all torsional activities. When we put on a seat belt, when we take our keys out of our pocket, we use them frequently throughout the day. Whereas our rectus muscles, while important, have a less crucial role. For example, we use our rectus muscles for pelvis stabilization as well as some abdominal wall flexion. However, after about 30 degrees of abdominal wall flexion, we use our Psoas muscles to a much greater extent. Getting the midline back together, getting the rectus muscles back together really augments oblique function.
Currently, I perform this technique on relatively fit patients with moderate-sized defects. With a minimal width defect, there may not be as much of an advantage from a functional standpoint. Furthermore, when patients have significant separation, the ability to close the defect is going to be limited. It’s certainly not as feasible to get the midline close in massive hernias.
Typically, a defect wider than 12 or 15 cm is too large to perform this abdominal wall reconstruction technique. The intermediate defects ranging from 5 to 6 cm up to about 10 to 12 cm in width are ideal for a minimally invasive abdominal wall reconstruction.