Laparoscopic Pre-peritoneal Repair of Subxiphoid Incisional Hernia

Jennifer Schwartz, MD, Michael P Meara, MD, MBA. The Ohio State University Wexner Medical Center

Background:  Subxiphoid incisional hernia repairs pose an operative challenge due to their proximity to thoracic structures and difficulty with mesh placement.  Laparoscopic pre-peritoneal hernia repairs have the benefit of creating a tissue flap to cover the mesh as well as creating a plane to place mesh.  This video demonstrates a laparoscopic pre-peritoneal repair of a hernia with mesh in a challenging location.

Methods:   
After gaining access to the abdomen and placing three trochars, one in the left upper quadrant, one in the right upper quadrant, and one above the umbilicus, a thorough inspection of the abdomen was performed.
The subxiphoid incisional hernia was identified. A site just below the falciform ligament was chosen and initial dissection was initiated.

Attachments to the anterior abdominal wall were freed laterally to the left.
Dissection was undertaken utilizing a combination of blunt dissection and
electrocautery.  The hernia was reduced into the preperitoneal space
using a combination of blunt dissection, traction and electrocautery. The hernia was defined and the defect was noted to be 3 cm x 3 cm in size.
Dissection was taken finally taken superior and laterally in all quadrants until the preperitoneal space had been entirely cleared. Self fixating mesh was prepared on the back table and introduced into the abdomen. The mesh was aligned with the hernia defect and subsequently spread
along the anterior abdominal wall adequately covering the hernia defect. 
At the end there was adequate coverage of the hernia in all directions.

Conclusion: 
Laparoscopic preperitoneal hernia repair represents a viable option for the repair of ventral hernia which can be performed safely in this difficult position.