Ashwin A Masurkar, Dr. Masurkar Hospital
INTRODUCTION: There has been a need to devise a feasible, reliable and replicable Laparoscopic technique for Ventral / Incisional hernias; with Retro-muscular mesh placement. The reports of complications with Intra-peritoneal Onlay repair using composite meshes makes Retro-muscular mesh placement a safer option. This study is from a small town private hospital in South India.
METHODS AND PROCEDURES: The aim is Laparoscopic placement of a polypropylene mesh into the retro-muscular plane with midline closure. The approach is trans-peritoneal and three techniques were devised based on hernia size & location. Technique 1 For small umbilical & infra-umbilical hernias; 3 ports are used in the upper abdomen. After adhesiolysis and reduction of sac contents; a transverse incision is taken on the peritoneum-posterior sheath complex, 6 cm proximal to the defect. A retro-muscular space is created by raising a flap of posterior sheath peritoneum complex. Intra-abdominal pressure is reduced. The Anterior sheath & Rectus muscles are approximated using no 1 Polydiaxanone (PDS) sutures. A Polypropylene Mesh of desired size is parked into the space and anchored to muscles using 1-0 Polypropylene sutures. The incision and hernial defect are closed using 1-0 PDS sutures creating a natural mesh-bowel barrier. Technique 2:- For large central defects; 6 ports were used. 3 supra and 3 infra-umbilically; to create two flaps superiorly and inferiorly. Next, trocars are withdrawn into retro-muscular space. The Sheath-Peritoneum flap & hernial defect are approximated followed by insertion and anchoring of mesh of required size. One or two meshes upto 30x30cm are used. Technique 3 Devised for large defects with wide divarication; uses the previous technique with addition of Posterior component separation by Transversus abdominis release to facilitate midline closure.
Results: Study period 2010 to present. Uncomplicated hernias with defect size 2cm to 15cm without large redundant skin fold were selected. Large hernias with loss of domain or excess redundant skin were offered open Rives-Stoppa repair. Total cases operated-57. Primary ventral 15 (Umbilical 14, Epigastric-1). Incisional 42 (Previous surgery C-section 20; Hysterectomy- 7; Sterilisation 10 Exploratory laparotomy 3 Appendicectomy 2). Average operating time 160 minutes Complications:-Intra-operative bleeding 3. Conversion to open 2, Bowel injury nil. Mesh infection 1. Seroma 7. Bowel obstruction 0. Recurrence early nil, late 2. Mortality nil. Average length of stay 5 days.
Conclusion: Laparoscopic Trans-Abdominal Retro-muscular (TARM) repair using polypropylene mesh is safe, effective and inexpensive. It delivers the benefits of Rives-Stoppa repair via Laparoscopy
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87615
Program Number: V002
Presentation Session: Hernia Session
Presentation Type: Video
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