Reconstruction of the Anterior Abdominal Wall with Bilateral Endoscopic Component Separation, Laparoscopic Assisted Medialization of the Rectus and Laparoscopic Mesh Placement

Standard laparoscopic repair of a large midline ventral hernia with mesh is frequently associated with seroma formation. In addition the rectus muscles cannot be medialized in large defects, thereby potentially leading to a less functional abdominal wall.

We present a novel approach of repairing the midline abdominal wall defect while repairing the hernia laparoscopically with a mesh. We begin with bilateral endoscopic component separation and then medialize the rectus muscles with laparoscopically placed transfascial sutures. With bilateral component separation, we are able to completely close the hernia defect. We then reinforce the repair with a laparoscopically placed mesh.

A transverse skin incision is made two fingerbreadths below the costal margin at the anterior axillary line. The external oblique aponeurosis is identified and incised. A space is created between the external and internal oblique aponeurosis, by blunt finger dissection. A balloon dissector is then introduced in this space and further dissection is done under vision, with a 10mm 0-degree scope in the balloon. The balloon dissector is then removed and 10mm balloon port is placed. Carbon Dioxide is then insufflated into this space to a pressure of 12 to 15mm of Hg. A 5mm port is placed inferiorly at the lateral aspect of the space created. The lateral border of the rectus sheath is identified and the external oblique aponeurosis one to two cm lateral to the rectus sheath is incised with a hook or scissors connected to electrocautery. Scarpa’s fascia is also incised to obtain additional release. The release incision extends from the pubic tubercle inferiorly to several centimeters above the costal margin superiorly. After completion of the myofascial release and advancement, this technique is repeated on the opposite side.
We then enter the peritoneal cavity using the same skin incisions and pneumoperitoneum is created. After the hernia is reduced and all adhesions are taken down, we make tiny stab incisions in the midline and use transfascial sutures with laparoscopic assistance to bring the rectus sheath to the midline. After medialization of the rectus muscle, we proceed with laparoscopic placement and fixation of mesh in the standard fashion.

We have successfully performed this procedure on 4 patients and on follow up, have one small asymptomatic seroma with excellent patient satisfaction.

Session: Podium Video Presentation

Program Number: V016

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