Between 02.03.2017 – 10.28.2018 in both Departments of surgery, 15 procedures were performed.
The patient's position on the operating table is in dorsal decubitus with the legs distant and lowered below the body, with the left hand near the body.
The surgeon and cameraman are initially positioned on the left side of the patient.
The retromuscular space is approached by an open technique or using an optic port inside the lateral edge of the left rectus abdominis muscle at a point located on the umbilical line. A 10 or 5 mm camera port is retromuscular inserted and the CO2 is insufflated with a pressure of 12 – 14 mmHg.
The retromuscular space is bluntly dissected using the scope. Two 5 mm ports are introduced under direct vision on the same line with the optic port superior and inferior to it. The left retro rectus space is dissected. When the dissection is complete the midline is crossed in the plane of the falciform ligament and outside the defect. This step is facilitated by the wide linea alba, and are must be taken not to penetrate it and enter the subcutaneous space (Fig. 1).
The right side rectus muscle with its investing sheath is identified and the posterior leaf of the sheath is incised longitudinally on its endoabdominal surface at 0.5 cm from the medial aspect.
The right side retro rectus space is dissected in the same manner as on the left side and after that we proceed to dissect the hernia defect (Fig. 2).
Usually during the hernia sac dissection, the peritoneal cavity is opened without any notable consequences on the procedure conduct. For the small defects when the protrusion is only preperitoneal fat, the peritoneum could be maintained closed. The dissection is completed superiorly under the xyphoid process and inferiorly for minimum 5 cm below the defect.
Two more additional trocars are inserted now: a 10 mm port on the midline in the inferior point of dissection and a 5 mm one in the right iliac fossa. All peritoneal leaks are closed using a barbed absorbable suture (V-Loc 2/0) (Fig. 3).
Next operative step is to close the anterior sheath with narrowing of the linea alba using a running suture with non-absorbable barbed suture (V-Loc 0). The surgeon is positioned between patient legs. The insufflation pressure is dropped to 9 mmHg. With the needle holder in the subombilical port, the linea alba and the defect are closed from both extremities. (Fig. 4, 5).
Figures 4 and 5
The left hand of the operative surgeon giving gentle pressure on the abdominal wall also helps in applying the sutures.
A large peritoneal hernia sac can be excised using a small skin incision on top of it (hybrid technique).
The newly created retro-muscular space is measured and the mesh is cut to fit the size. Mesh is inserted through the median 10 mm port and arranged in order to maintain flat. Usually the mesh is fixed with a non-absorbable 2/0 suture to the posterior sheath in its upper extremity (Fig. 6).
No systematic drainage. Exsuflation under direct vision. The final aspect is presented in Fig.7.