Small Incisional Hernia Repair: Low-Cost Minimally Invasive Technique for Rural Areas

By Dr. J. Gnanaraj and Mr. Joshua W.J.

Incisional/ventral hernias are defects of the abdominal wall that appear after a prior surgery, at the site of the incision. They represent a significant drawback to invasive abdominal surgery and can develop in up to 20% of patients who have abdominal surgeries (1). In addition to the poor cosmesis, there could be social embarrassment and impaired quality of life. While it is no longer necessary to debate the use of suture vs. mesh repairs, there are still varying opinions on whether laparoscopic surgery is a reasonable alternative to open surgery for mesh repairs. There are benefits to laparoscopic incisional hernia repair, such as lower post-op pain, shorter hospital stays, and higher patient satisfaction. Meta-analysis shows the advantage of laparoscopic hernia repair (2). However, due to the high cost of the mesh, the cost of laparoscopic repair is very high, with the direct costs quoted as equivalent to INR 2,00,000 (3). We describe a low-cost technique for doing the smaller incisional hernia or epigastric or paraumbilical hernia, using the low-cost Prolene mesh (INR 2000).

Technique

Surgery is performed under general anesthesia with Foley’s catheter and a nasogastric tube in place, and with the patient cleaned and draped in the supine position. The 10 mm port for the camera is placed at an appropriate place, about six inches away from the hernia. A blunt trocar is placed using the open placement technique, so that there is no injury to the intra-abdominal organs. Two 5 mm ports are placed on either side, in an arc with the hernia at focal point. A 10 mm 30-degree telescope is used, facing upwards to the hernia. It is important to hold the camera the 12 o’clock position correctly, to have proper orientation.

diagrammatic representation - dr g

Figure 1: Diagrammatic representation

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inside view - dr g

Figure 2: Hernia view from inside

A hook dissector is used to incise the peritoneum around the orifice and to dissect the peritoneum in all directions, for about seven to ten centimeters from the hernia orifice. A small skin incision is placed over the hernia, and the hernia sac is dissected, assisted by the gas in the abdomen. Figures 1 and 2 show this dissection. The gas flow is stopped, and the hernia sac is opened, and then the hernia sac is removed. The peritoneum is closed after holding the edges of the defect with Allis clamps and lifting them up. The Prolene mesh is cut in such a way that it would extend for about 5 centimeters all around the hernia orifice. It is placed in the gap between the peritoneum and the muscle layer, as shown in Figure 3. A few anchoring sutures are used to fix the mesh, and a few more sutures are used to close the defect without much tension.

the completed repair - dr g

Figure 3: The completed repair

Discussion

Incisional hernias that occur after laparotomy usually are caused by the fascia failing to heal. Generally, technical and biological factors are involved. (4). About half of these occur within the first two years after surgery, and another 25% during the third year (5). The first reported case of laparoscopic incisional hernia repair with synthetic mesh was by LeBlanc, in 1993 (6).

Usually, with the laparoscopic technique, the mesh will be placed in an intraperitoneal location, or sometimes in the preperitoneal location, where any rise of intra-abdominal pressure is diffused along each square inch of the mesh, and not along a tenuous suture line, as it would with conventional suture repairs. When the intra-abdominal pressures increase, the mesh is held in place by the pressure, instead of being displaced by it, as it would in a conventional overlay repair. However, the drawback is that the hernia sac is not resected, and normal anatomy is not restored. The incidence of seromas is also greater with laparoscopic repair (7). The recommendation by Andrew Kingsnorth is that hernias less than 10 cm in diameter could be successfully repaired laparoscopically, if a suitably skilled surgeon is available, while larger hernias are better repaired by open surgery (8).

A wide variety of meshes have been used for laparoscopic incisional hernia repair (9). The reason is that they are placed intraperitoneally, and it is necessary to prevent adhesions because the mesh is in direct contact with the intestine (10). The method that we describe has the following advantages:

  1. It has the peritoneum covering the mesh (like inguinal hernia repair), and hence the low cost mesh could be used
  2. It has the advantages of both open and laparoscopic surgery. For instance the hernia sac is excised, and hence there would be less chance of seroma
  3. It is much less expensive in terms of cost of mesh and also does not use a tacking device
gnanaraj Dr. J. Gnanaraj MS, MCh [Urology], FICS, FARSI, FIAGES is a urologist and laparoscopic surgeon trained at CMC Vellore. He has been appointed as a Professor in the Electronics and Instrumentation Engineering Department of Karunya University and is the Director of Medical Services of the charitable organization SEESHA. He has a special interest in rural surgery and has trained many surgeons in remote rural areas while working in the mission hospitals in rural India. He has helped 21 rural hospitals start minimally invasive surgeries. He has more than 150 publications in national and international journals, most of which are related to modifications necessary for rural surgical practice. He received the Barker Memorial award from the Tropical Doctor for the work regarding surgical camps in rural areas. He is also the recipient of the Innovations award of Emmanuel Hospital Association for health insurance programs in remote areas and the Antia Finseth innovation award for Single incision Gas less laparoscopic surgeries. During the past year, he has been training surgeons in innovative gas less single incision laparoscopic surgeries.
joshua Mr. Joshua W.J. completed his M.Sc in Counselling Psychology at Global School of Counselling, Bangalore. He is currently working as a Counsellor at Seesha Karunya Community Hospital, Coimbatore.

References (click to show/hide)

  1. Tom Dehn. Incisional hernia repair – Laparoscopic or Open surgery? Ann R Coll Surg Engl. 2009 Nov; 91(8): 631–636.
  2. Ayan Banergea and Aman Bhargava. The case for laparoscopic Incisional hernia repair. Ann R Coll Surg Engl. 2009 Nov; 91(8): 634–636.
  3. Beldi G, Ipaktchi R, Wagner M, Gloor B, Candinas D. Laparoscopic ventral hernia repair is safe and cost effective. Surg Endosc. 2006 Jan;20(1):92-5. Epub 2005 Dec 7.
  4. Pollock AV, Evans M. Early prediction of late incisional hernias. Br J Surg. 1989. 76:953–954.
  5. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J (Clin Res Ed). 1982. 284:931–933.
  6. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Laparosc Endosc. 1993. 3:39–41.
  7. Juan Luis Calisto, Vikram Kate, et. al. Laparoscopic incisional hernia repair. Medscape (Available from: http://emedicine.medscape.com/article/1892407-overview#showall accessed on June 20, 2015).
  8. Andrew Kingsnorth. The Benefits of Open incisional hernia repair. Ann R Coll Surg Engl. 2009 Nov; 91(8): 631–633.
  9. Brown CN, Finch JG. Which mesh for hernia repair? Ann R Coll Surg Engl. 2010 May; 92(4): 272–278.
  10. Pradeep K Chowbey, Anil Sharma, Rajesh Khullar, et. al. Laparoscopic repair of ventral / incisional hernia. J Minim Access Surg. 2006 Sep; 2(3): 192–198.

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2 Comments

  1. Girijadutt Sharma
    Posted Sep 2015 at 5:57 pm | Permalink

    Dear sir , please put up more unedited vedio of lift surgery , so that those who cannot reach u physically may too benefit from your skill. I m keen to start lift operations as I cater to poor and needy, I work in poorer belt of Haryana
    Regards
    Gdsharma
    CMC Ludhiana

  2. Dr. J. Gnanaraj
    Posted Sep 2015 at 12:36 pm | Permalink

    Dear Sir We are working out with LapGuru to post recorded unedited videos after surgical camps in remote areas. it should work out soon

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