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Yuri W. Novitsky, MD, B. Lauren Paton, MD, and B. Todd Heniford, MD, FACS
the grasper passed through the contralateral trocar. It is im- suture passer (Figs. 7 and 8). This transabdominal fixation is
portant to maintain the appropriate orientation of the mesh crucial to ensure that the mesh will not be displaced over
during the insertion and unfolding of the mesh. Two Mary- time. The knots are tied in the subcutaneous tissues. The skin
land graspers are best used to unfold the mesh. After the is released to avoid dimpling.
mesh is oriented intracorporeally, the sutures are pulled
through the abdominal wall with a suture passer (Fig. 5). A 4
cm mesh/defect overlap is once again confirmed using spinal
Conclusion
needles, as described above. The suture pulled first is usually Laparoscopic ventral hernia repair has reliably been shown to
closest to the “sensitive” border (xiphoid, pubis, iliac crest, be superior to the open approach. Overall LVHR is associated
costal margin, colostomy, etc.). We subsequently pull the with a decreased perioperative pain, reduced hospital stay,
suture that is adjacent (not opposite) to the first one. Once and faster recovery. Postoperative complications are also less
sufficient overlap is confirmed, we tie both sutures with the frequent in the laparoscopic group (23.2% vs. 30.2%) as well
knots buried in subcutaneous tissues. The other two sutures as the incidence of wound and mesh infections (Table 1). In
are then pulled transabdominally and tied ensuring that the addition, the recurrence rate is 4% for the laparoscopic group
overlap is sufficient and that the mesh is taut (Fig. 5). The and 16.5% for the open technique.
perimeter of the mesh is then stapled to the posterior fascia Overall, numerous studies demonstrate that laparoscopic
with 5-mm spiral tacks at approximately 1 cm intervals to ventral hernia repair is an effective and safe approach to the
prevent intestinal herniation. Placing the tacks is facilitated abdominal wall hernia. It can be performed in complex sur-
by the external manual palpation of the tacker’s tip (Fig. 6). gical patients with a low rate of conversion to open surgery, a
This is particularly important for tacking the mesh in the short hospital stay, a moderate complication rate, and a low
lower abdomen to ensure that the tacks are placed superiorly risk of recurrence. With additional long-term follow-up to
to the inguinal ligament. Additional full-thickness stitches support the safety and durability of the procedure, LVHR will
are placed circumferentially every 3 to 6 cm by using the likely be considered the standard of care in the future.1–9
6 Y.W. Novitsky, B.L. Paton, and B.T. Heniford
Figure 2 Access to the abdominal cavity using cut-down techniques utilizing pediatric Kocher clamps. This is usually
safely accomplished in the left upper quadrant area.
Figure 3 Intracorporeal (direct) measurement of a hernia defect. Spinal needles allow for more precise identification of
the edges of the defect. Additional spinal needles may be used for defects larger than the length of a ruler (typically 12
cm).
Laparoscopic ventral hernia repair 7
Figure 4 Rolling of the mesh before its introduction into the abdominal cavity.
Figure 7 Placement of tack is done circumferentially along the whole length of the mesh to avoid bowel incarceration.
External palpation of the abdominal wall facilitates placement of the tacks and helps to avoid tacking the mesh below
the inguinal ligament and above costal margins.
Laparoscopic ventral hernia repair 9