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Laparoscopic repair of recurrent incisional hernias represents a significant advancement in minimally invasive surgery. This article aims to elucidate the techniques and benefits of laparoscopic repair for recurrent incisional hernias, providing insights for both surgical professionals and those interested in the field.

Understanding Incisional Hernias:

Incisional hernias occur at the site of a previous surgical incision. They are a common complication, arising due to the weakening of the abdominal wall post-surgery. Recurrent incisional hernias, where the hernia reappears after an initial repair, pose a particular challenge due to scar tissue and altered anatomy.

Laparoscopic Approach – A Paradigm Shift:

Traditionally, open surgery was the standard approach for hernia repairs. However, the advent of laparoscopic techniques has revolutionized this field. Laparoscopy offers a minimally invasive alternative, involving small incisions and the use of a laparoscope (a thin tube with a camera and light) to guide the procedure.

Technique Overview:

Preoperative Preparation: Patient evaluation includes a thorough medical history, physical examination, and imaging studies like CT scans to assess the hernia.

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World Laparoscopy Hospital
Cyber City, Gurugram
NCR Delhi, India

World Laparoscopy Training Institute
Bld.No: 27, DHCC, Dubai, UAE

World Laparoscopy Training Institute
5401 S Kirkman Rd Suite 340
Orlando, FL 32819, USA

Anesthesia: General anesthesia is administered for patient comfort and safety.

Access and Port Placement: Small incisions are made to insert the laparoscope and surgical instruments. The number and position of ports vary based on the hernia's location and size.

Adhesiolysis: This step involves separating the adhesions (scar tissue) from the previous surgeries to access the hernia defect.

Defect Closure and Mesh Placement: The hernia defect is closed, often using sutures. A synthetic mesh is then placed over the defect to reinforce the abdominal wall.

Securing the Mesh: The mesh is secured in place using tacks, sutures, or adhesive to prevent migration.

Closure: The ports are removed, and incisions are closed, typically with absorbable sutures.

Advantages of Laparoscopic Repair:

Reduced Postoperative Pain: Smaller incisions lead to less postoperative discomfort.
Quicker Recovery: Patients generally have a faster return to normal activities.
Lower Recurrence Rates: The use of mesh and minimal tissue disruption contribute to lower recurrence rates.
Cosmetic Benefit: Smaller incisions result in less noticeable scarring.

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Learning
Transcript
00:00hello friends this patient has recurrent incisional hernia so two time laparotomy was done and
00:10two time hernia was also done by open surgery so we will do now laparoscopic repair this
00:16is a swiss cheese pattern of the hernia so we will enter with the misra's point and the
00:24various needle is introduced here you will get three click and various should be pointed
00:35towards the stomach now this is irrigation suction and hanging drop test just you confirm
00:46that various needle is in proper space and this is hanging drop test this is
00:57disposable various needle so there is a ball which should be sucked inside and now
01:04we will start pneumoperitonium we can see this tension is started 3.5 liter of the
01:15gas was introduced and the pneumoperitonium is created we can see the
01:21distension now variation will be taken out incision is enlarged to 11 mm after
01:41pneumoperitonium misra point will automatically stretch down to become the
01:47palmer's point and this is 10 mm port is introduced here we will do the surgery
01:56only by two port this is hissing sound trocar is introduced and telescope is
02:04introduced now another port we will introduce approximately 10 cm below and we
02:23will try to perform by two port if it is required then later third port will be
02:28introduced under vision second port is introduced and now this is harmonic and we
02:42will start adhesiolysis these are the adhesions due to the previous hernia surgery we can see
02:50proline there this proline is due to the previous repair of hernia and this hernia
02:59has become Swiss cheese pattern so multiple defects are there this is a proline which
03:08was due to the previous surgery and these all momentum were adhered due to previous
03:15open surgery so the first step is adhesiolysis and we can see multiple defects and there is
03:40a breeze in between the multiple defect little bit oozing was there so this is just the
04:01fulguration with the harmonic in previous surgery mesh was not used and probably that was the cause
04:14of recurrence we can see proline sutures are there and the all the adhesion is removed after that we
04:25are using here titanized mesh this mesh has a titanium coating and this is made
04:31for intraperitoneal application so this is 20 by 15 size of the mesh and we will do the trans facial
04:41fixation of the corner sutures of the mesh so this is little expensive mesh titanized mesh is supposed to
04:49use intraperitoneal and it is claimed that it doesn't create adhesion so we have already done the marking
04:59of the corner of the corner of the mesh and this is trans facial fixation is carried out this is on the right
05:09iliac fossa and then right hypochondrium
05:13so one by one suture will be taken out with the same skin prick but different rectus prick so it's a large mesh and we can see the falsiform ligament is coming in between
05:40so little bit dissection of the separation of the falsiform ligament is necessary so that mesh can be easily spreaded and it should cover the entire defect
05:58so this was a fatty part of falsiform ligament now this is membranous part of falsiform ligament
06:20and now other corners of the mesh will be fixed this is left iliac fossa
06:29one is medial to infi epigastic another is lateral to infi epigastic
06:47you should take care that infi epigastic should not be pricked
06:53and last corner is the left hypochondric
07:05so all the corner trans facial is fixed and now we will do outer crowning and then inner crowning
07:22so these are the tackers
07:25first it should be fixed in the middle of the all the borders and then in between
07:32large mesh is used so all the corner
07:44and all the defect this is just spreading from the midline
07:48so that mesh should be nicely stretched
08:03again outer crowning is continued
08:08left hand should must press it so that the tacker should be perpendicular
08:15we can see uterus is also adhered
08:21but that is not a concern
08:25because this patient family is already complete
08:29and tubeectomy is already done in the past
08:32and tubeectomy is already done in the past
08:36and tubeectomy is already done in the past
08:44under 80 miles
08:50and now we will run in the past
08:51and central to the branch
08:53so as if we're όlico
08:54that actually does not work
08:55is not a concern
08:56so we can put it in bisschen
08:57until we are not able to
08:58acknowledge the same thing
08:59and the same thing
09:00that we are not able to do
09:01we are not able to do
09:02with our most vulnerable
09:04and comfortable
09:05to the same thing
09:06so you can see
09:07how do we do
09:08have a best way
09:09so that we can do
09:10Left hand is pressing the abdominal wall to bring it perpendicular to the tacker.
09:24And then all the outer crowning is performed.
09:35And now we will do inner crowning.
09:39Some of the tacker may be fired.
09:41This is left side outer crowning.
09:49And some of the tacker can be fired over the bridges of the Swiss cheese pattern of the
09:56hernia.
10:03This is inner crowning.
10:12The tacker should not be applied where the defect is there.
10:17You can fire on the periphery of the ring of the defect or over the bridges.
10:31So, it is almost done.
10:34This is inner crowning which is going on.
10:39And now the fixation is complete.
10:41So, it is over.
10:53After that, we will fix the trans-facial fixation.
10:56After removing the gas, CO2 is removed and corner suture is fixed with the trans-facial fixation.
11:14It has to cut very short.
11:16So, 6-7 knot is required.
11:18Generally, we use Vicryl so that the patient should not have any pain.
11:25And then it will be cut short.
11:28And the abdominal valve will be pulled.
11:31So, it should go subcutaneous.
11:34And the knot is tightened in all the four corners.
11:40And trans-facial fixation is over.
11:44You have to pull it to just bring the…
11:49This corner is done first.
11:51Already it was done before.
11:54And now it is over.
11:57After that, we will give strapping.
12:00This strapping, first we will apply the…
12:03Only two port you can see were used here in this surgery.
12:08So we will apply waterproof adhesive.
12:13And before that, tacker with the skin stapler is applied.
12:17So one port is 10 mm and another is only 5 mm.
12:23This is costal margin.
12:24So after removal of the gas, automatically misra point will go up over the rib.
12:30And now we will give strapping.
12:32Strapping is very important to prevent shiroma.
12:35So this is… dressing is done over the port side.
12:43And then you will use two big sponge.
12:52And this big sponge, this is streptomycin we are putting over the trans-facial fixation
12:57wound.
12:58And just rub this powder.
13:00It will make a scab.
13:02So these powders are covering the trans-facial skin defect.
13:09And after these two big tetra is put over the incisional hernia site.
13:15And then we will use elastic adhesive from one posterior axillary line to another posterior
13:20axillary line.
13:22This support is very important and over that patient will use abdominal binder as well.
13:29So this will not allow any bulge to happen and dead space will not be created.
13:36And we give a lot of antibiotic before so any infection should not happen due to the pressure
13:42of the bowel.
13:46And this is the support.
13:50So now it's over.
13:52So thank you very much for watching this video.

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