Open Incisional Hernia Repair with Mesh and Unilateral Posterior Component Separation with Excision of Unstable Scar
Hany M. Takla, MD, FACS, FASMBS, DABS-FPMBS
Wentworth-Douglass Hospital
Yuri Novitsky’s description of the posterior component separation in 2012 has revolutionized the world of ventral hernia repairs. While large hernia defects above 10 to 12 centimeters seemed impossible to close primarily without tension, the technique of transversus abdominis release as described helped achieve posture as well as anterior abdominal wall closure without tension in addition to providing a highly vascularized medium for mesh integration in between these layers. Not only does the posterior component separation allow for medialization of the posterior rectus sheath to be closed in the midline, but it also gives a release to the anterior components of the abdominal wall to allow for recreation of the linea alba without tension.
Open Onlay Hernia Repair for Recurrent Incisional Hernia
Samuel J. Zolin, MD; Eric M. Pauli, MD, FACS, FASGE
Penn State Health Milton S. Hershey Medical Center
An 80-year-old patient underwent an open onlay repair of a recurrent incisional hernia. This approach was chosen due to the patient’s prior retromuscular repair, age, history of adhesions, and religious preference against blood products. Following safe abdominal entry and adhesiolysis, a subcutaneous pocket extending 5 centimeters in all directions from the hernia was created. Fascia was closed using mesh-suture and a 12 x 12-centimeter macroporous, medium-weight polypropylene mesh was secured to the anterior fascia with staples and fibrin glue. A subcutaneous drain was placed. This case highlights the utility of an onlay approach for selected circumstances.
Laparoscopic Totally Extraperitoneal (TEP) Left Indirect Inguinal Hernia Repair with Mesh
Victoria J. Grille, MD; Randy S. Haluck, MD
Penn State Health Milton S. Hershey Medical Center
This video demonstrates the surgical technique for a laparoscopic totally extraperitoneal (TEP) left inguinal hernia repair with mesh. This is a technically challenging operation with a steep learning curve; however, it is one useful option for patients with bilateral hernias, recurrent hernias, or when a minimally-invasive approach is desired. It provides tension-free repair and allows exposure to the entire groin area to evaluate and repair indirect, direct, and femoral hernias. The only absolute contraindication to laparoscopic TEP repairs is the inability to undergo general anesthesia due to significant cardiopulmonary disease or other factors.
Robotic-Assisted Laparoscopic (rTAPP) Umbilical Hernia Repair with Intra-abdominal Preperitoneal Underlay Mesh (IPUM)
Chloe A. Warehall, MD1; Divyansh Agarwal, MD, PhD1; Charu Paranjape, MD, FACS1,2
1Massachusetts General Hospital
2Newton-Wellesley Hospital
An umbilical hernia occurs due to weakened umbilical fascia or at the site where the involuted umbilical vessels exited. Depending on the hernia contents—preperitoneal fat, omentum, or small intestine—symptoms may include a new bulge at the umbilical site, abdominal pain, tenderness to palpation, color changes to the surrounding skin, as well as obstructive symptoms such as nausea, emesis, and constipation. Given that umbilical hernias tend to have narrow necks compared to size of the sac, incarceration and strangulation are relatively common. Elective repair of symptomatic umbilical hernias is done to minimize these risks.
Here we present the case of an 81-year-old male with a recurrent umbilical hernia who first presented secondary to obstructive symptoms caused by an incarcerated umbilical hernia. After reduction was successful, he underwent an elective robotic transabdominal (rTAPP) umbilical hernia repair with intra-abdominal preperitoneal underlay mesh (IPUM). This article and the associated video describe the pertinent history, evaluation, and operative steps of the procedure.
Rives-Stoppa Retromuscular Repair for Incisional Hernia
Katherine Albutt, MD; Peter Fagenholz, MD
Massachusetts General Hospital
There is no consensus on the optimal method of ventral hernia repair, and the choice of techniques is typically dictated by a combination of patient factors and surgeon expertise. Component separation techniques allow medial advancement of the rectus abdominis muscle to create a midline tension-free fascial closure.
In this case, we describe a posterior component separation with retrorectus mesh placement, also known as a Rives-Stoppa retromuscular repair. With low morbidity and mortality, this technique provides a durable repair with low rates of recurrence and surgical site infection while providing dynamic muscle support and physiologic tension, preventing eventration, and allowing incorporation of mesh into the existing abdominal wall.
Robotic-Assisted Laparoscopic (rTAPP) Bilateral Inguinal Hernia Repair
David Lourié, MD, FACS, FASMBS
Huntington Memorial Hospital
There are over 1 million hernia repairs performed annually in the US, and robotics is revolutionizing the adoption of minimally-invasive hernia repairs. From 2015 to 2018, robotic laparoscopic hernia repairs have explosively grown from less than 2% to 20% of all hernia repairs performed in the US.
Hernia repairs are among the most basic procedures for general surgeons, and there is substantial enthusiasm on the part of surgeons regarding the rapid changes in techniques as well as the best methods of teaching them. Surgical training programs may find it difficult to maintain training for their residents and fellows in the face of rapidly evolving technology. Here, Dr. Lourié presents the case of a 28-year-old male with bilateral inguinal hernias that were repaired using a robotic-assisted laparoscopic approach.
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