Laparoscopic Repair of Abdominal Wall

Laparoscopic repair is less painful than conventional repair, both in the short and long term. It allows for shorter hospitalisation and the patients are able to resume normal activities at an earlier stage.

What is a hernia?

A hernia is a weakness or hole in the abdominal muscle wall through which abdominal contents protrude causing a bulge. The protruding contents push out a pouch of the abdominal lining or peritoneum through the weakness forming the “sac of the hernia”.

Why do they occur?

There are sites of potential weakness in the abdominal wall. The areas in which hernias most commonly develop are the umbilicus, the groin and where there has been an abdominal incision.

There is frequently an opening in the muscle layer at the umbilicus that may have been present since birth. It may enlarge due to anything that causes raised abdominal pressure, such as muscular strain or pregnancy. A hernia may then appear.

In male patients, blood vessels running through the groin muscles to the testicle create a weak area where an indirect inguinal hernia may develop. Strain or muscle deterioration can enlarge this weak spot and force through it, abdominal contents resulting in the development of a hernia. Inguinal hernias may occur in women, although less commonly, and follow the round ligament of the uterus.

Other causes include incisions from old operations which may weaken the abdominal wall, if they do not heal properly after surgery or are weakened by infection. Muscle wall deterioration with age, inactivity or strain which may allow the muscle wall to tear or bulge, resulting in the development of various forms of hernias.

Why should it be repaired?

There are a number of reasons for advising repair. In decreasing order of importance they are:

  1. The possibility of intestines being caught in the hernial sac causing bowel obstruction. Without urgent surgical intervention this may lead onto strangulation, cutting off the blood supply to the bowel, with resultant death of the loop of bowel. This in turn causes peritonitis. This is a life threatening situation.
  2. Pain or discomfort in the hernia especially on standing for long periods or walking long distances. The discomfort, in the case of inguinal hernias in male patients, may radiate to the testicle.
  3. Difficulty lifting as strain forces abdominal contents into the hernia causing discomfort and a feeling of weakness.
  4. Progressive enlargement of the size of the hernia with increasing likelihood of the above complications and increasing difficulty with repair.
  5. The presence of a bulge of which the patient is aware and which may be visible causing embarrassment.

What types of hernia are there?

The most common type is the groin or inguinal hernia. Herniae may also occur through the umbilicus (umbilical hernia), through old abdominal scars (incisional hernia), through the muscles in the upper abdomen (ventral hernia) or alongside blood vessels running into the thigh (femoral hernia). Laparoscopic repair is mainly used for inguinal or femoral hernia repairs, although increasingly ventral hernias are being repaired by laparoscopic techniques.

How are hernias repaired?

Various forms of repairs have been utilised over the years. The defect or hole in the muscle layer may be repaired by stitching the muscles on each side of the defect together and allowing them to heal together, thus closing the opening. This is the traditional method of repair. Hernias may also be repaired by placing a synthetic mesh to cover the opening in the muscle layer. The body’s tissue will then grow through the mesh creating a strong new layer, thus repairing the hernia. Laparoscopic repair employs a mesh to repair the defect.

Why choose laparoscopic repair?

The only disadvantages are that the procedure requires a general anaesthetic and that there are more equipment expenses namely; the laparoscopic ports, the mesh and the hernia tacker, that is used to fix the mesh in place. As mentioned however, hospital stays and convalescent times tend to be shorter than with open repairs.

How is it performed?

This description refers to extra-peritoneal laparoscopic repair for an inguinal or femoral hernia.

Under a general anaesthetic, three small incisions are made in the abdominal wall. The largest of these is a vertical incision about 2cm just below the umbilicus. A small transverse incision in the superficial sheath of the rectus abdominus muscle, the only cutting of muscle in this procedure, is made and a balloon dilating device is passed downwards to the pubic bone between the abdominal muscles and the lining of the abdomen, the peritoneum. The balloon is blown up separating the peritoneum from the muscle layer. This separates easily with little bleeding. The balloon is withdrawn after deflation and replaced by a tube-like structure called a laparoscopic port. The space is inflated with CO2 and a telescope inserted into the space. The abdominal cavity is not entered during this procedure, therefore greatly reducing the likelihood of damage to the abdominal organs or production of adhesions.

Two further 0.5 cm incisions are made between umbilicus and pubic bone on the opposite side of the abdominal wall to the hernia to puncture into the space two fine 0.5 cm diameter ports to accommodate operating instruments. The peritoneum is then gently pushed away from the muscle layer until a sizeable space is created and the muscle defect is revealed. The sac of the hernia is pulled back into this space. Other structures that are revealed include the back of the pubic bone and the blood vessels running to the leg and, in a male patient, those running to the testicle and the abdominal wall. Once the muscle layer is cleared a piece of flexible polypropylene mesh measuring 12 X 15cm approximately, is then slid down the large port and manoeuvred so as to cover the hole in the muscle and also all other potential areas where hernias can occur in this area. The mesh is held in place with approximately 8-10 tiny absorbable tacking devices. The space is filled with local anaesthetic and the ports withdrawn.

The positive pressure in the abdominal cavity pushes the peritoneum onto the mesh trapping it like the meat in a sandwich. Any increase in the abdominal pressure, as in straining, simply pushes the mesh firmly against the abdominal wall. Straining therefore, does not have the effect of pulling apart the repair as it does in sutured repairs. This contributes enormously to the strength and durability of the repair. As the repair is tension free, it is less painful than sutured techniques. Skin wounds are closed with dissolving sutures.