For the majority of patients with defects in the midline, supine positioning with the arms tucked works well. The pressure points at the elbow and wrist should be padded (Fig. 2-2). For larger patients, the arm sleds may be required. In patients with defects off the midline or lumbar defects, a bump may be placed under the hip on the side of the hernia, or a true lateral position may be necessary with the aid of a bean bag.

Once initial entry into the abdominal cavity is achieved, at least one and preferably two additional trocars are placed laterally on the side of entry. Typically one can be placed above the initial site once pneumoperitoneum has been initiated, and an additional one can be inserted inferiorly with care not to be too close to the iliac crest. Two trocars are placed on the opposite side to provide additional viewing perspective for adhesiolysis and aid in retraction (Fig. 2-3).

Energy sources should be avoided during adhesiolysis. Ultrasonic energy sources or bipolar coagulating shears should not be used. Thermal injuries seal at the time of dissection and may not be apparent for 3 to 5 days postoperatively. Sharp, cold, endoscopic scissor dissection should dominate the dissection. Blunt bowel graspers are crucial to aid in retraction of the viscera and can be used to provide gentle blunt dissection as well. Typically, during lysis of adhesions, the outer rind of adhesions may be sharply cut, giving way to a “cotton candy” appearance to the loose areolar tissue that comprises most of the adhesions (Fig. 2-4). Blunt dissection with gentle, short sweeps is very effective in this situation.

Previous intraabdominal mesh can pose a real hazard to performing adhesiolysis. If the previous mesh contains a polypropylene or polyester component that becomes directly exposed to the bowel, there is not a plane of dissection. Attempts to mobilize the bowel off the adherent mesh will result in an enterotomy. In this situation, the mesh should be cut down off of the abdominal wall, leaving a swatch of prosthetic attached to the bowel (Fig. 2-5). Certainly, conversion to open is mandatory, if there is any concern for a bowel injury. Some cases of intense adhesion formation to the prosthetic may require a bowel resection.

Measure the defect internally under pneumoperitoneum. A plastic metric ruler is cut in half lengthwise and introduced via a 5-mm trocar. Two Maryland graspers manipulate the ruler and measure the defect between the spinal needles in the abdomen (Fig. 2-6). If the defect is longer than the ruler, insert another spinal needle along the axis of the defect within the length of the ruler. The sum of the two is the true measurement.

Not all hernia defects are perfectly circular, nor are they located exactly in the midline of the abdomen. In order to ensure that the mesh will be centered reliably over the defect every time, it is necessary to draw a grid of the x- and y-axes of the hernia defect on the external abdominal wall (Fig. 2-7).

With a ruler outside the abdomen, measure the distance halfway between the most superior and most inferior spinal needle. This determines the x-axis, the horizontal midpoint of the hernia. Half the horizontal distance between the lateral most spinal needles marks the y-axis, or the vertical midpoint. Draw both axes on the skin with a permanent marker to grid the abdomen and mark the center of the hernia defect. Once the mesh is brought into the abdomen, any attempt to retrieve one of the vertical or lateral cardinal sutures should be done along the corresponding x- or y-axis line. This will align the mesh over the defect and ensure the most accurate placement to achieve desired overlap (Fig. 2-8).

Once rolled, ePTFE mesh can be compressed and twisted to expunge air. Other tissue-separating meshes are soaked in saline and their slick texture makes them easier to introduce through a trocar. The rolled mesh may be passed directly through a 12-mm or 15-mm trocar (Fig. 2-9). Very large pieces of mesh can be dragged into the abdomen by passing a heavy grasper across the abdomen through a 5-mm trocar and out the contralateral side trocar. The cap of the trocar is removed, and the mesh is pulled into the abdominal cavity (Fig. 2-10). Every effort should be made to introduce the mesh through the trocar. This maneuver avoids contact with the patient’s skin.

Once inside the abdominal cavity, the mesh is unfurled. A grasper holds one end of the rolled mesh while the Maryland grasper uncoils the mesh (Fig. 2-11). It is important to maintain the proper orientation of the mesh. It may be helpful with larger pieces to mark a line across the horizontal axis of the mesh before insertion to ensure that the line runs from side-to-side.

After unrolling the mesh, retrieve the cardinal suture at the vertical site where there is the least amount adjustment first. For example, if the defect is in the lower abdomen, the inferior suture should be placed initially to avoid having to move its location caudally towards the bladder when stretching the mesh. Likewise, if the defect approximates the xiphoid, the superior suture is placed first. Mark the edge of the defect at the site of cardinal suture placement with the spinal needle. An additional spinal needle is “walked out” the axis line for a distance of 5-cm to ensure overlap (Fig. 2-12). This measured spot is injected with local anesthesia, and a stab incision is made through which the suture passer is introduced. The suture passer retrieves each tail of the initial cardinal suture through the same small incision but at a different angle to achieve a separate fascial bite. Tag both suture tails but leave them untied.

The assistant pulls on the tagged sutures to bring the mesh against the abdominal wall. The surgeon pulls the site in the vertical axis that is free along the y-axis. Advance a spinal needle through the abdominal wall along the axis. This guides where the suture will be retrieved, ensuring the mesh will be taut (Fig. 2-13). During this maneuver, avoid grasping the suture or the knot as this can weaken it. Measuring the overlap at this point is unnecessary because most prosthetic meshes stretch.

The mesh at the final suture site is grasped adjacent to the knot and stretched along the x-axis. A spinal needle passed along the x-axis marks the spot for final cardinal suture retrieval, just as was done when placing the third suture. The suture passer retrieves the suture tails, and they are secured. Placing a hemostat into the small skin incision and lifting it allows the knot to fall below Scarpa fascia and not dimple the skin (Fig. 2-14).

Once the mesh is secured and overlap ensured, a tacking device is used to fixate the edges of the mesh circumferentially (Fig. 2-15). The purpose of the tacks is not to provide strength to the repair, but rather, to prevent bowel or mesenteric fat from creeping over the top of the mesh, exposing it to the ingrowth side. Fixation devices are both permanent and absorbable.

The strength of the repair is the transabdominal fixation that the permanent sutures provide. After tack fixation at the periphery of the mesh, additional permanent, monofilament sutures are placed every 5 to 7 cm around the circumference of the mesh (Fig. 2-16). Large defects require more frequent sutures; smaller, “Swiss cheese”–type defects may need fewer.