video
Cicatricial hernia correction
laparoscopic open technique biologic mesh
Laparoscopic cicatricial hernia correction
Laparoscopic cicatricial hernia correction after open heart surgery, see here
In this example the correction of the cicatrice hernia is done by means of a keyhole-operation (laparoscopy). This means that through a number of small incisions in the abdominal wall from within the abdominal cavity the hernia in the abdominal wall is localized, the contents from the cicatrice hernia are retracted and the defect is covered with an artificial mesh which exists of two materials that on the abdominal wall side adheres to the abdominal wall (polypropyleen). The side of the mesh that is facing the bowel consists of material that does not adhere to the bowel (PTFE).
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The defect in the abdominal wall/cicatrice (1). The contents (fatty tissue) are retracted. Also bowel however can bulge. This patient had a number of small defects. The defects are covered by a mesh (20x25cm, composix, Bard, 2 and 3). The detail shows that the mesh has been secured with staples (3). The bowel is here far from the mesh because CO2 gas has been introduced in the abdomen to be able to perform the operation. After the operation the gas is removed and the bowel will oppose the abdominal wall and the mesh.
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Picture 5 shows another example with two defects in the abdominal wall with protruding fatty tissue. In 6 the fat is removed. Now a (different kind of) mesh with sutures put in the corners, is introduced in the abdominal cavity (7). In 8 you can see the mesh inside. With a special device the sutures are retrieved from the abdomen. The sutures are tied (9, 10). This ensures a good position of the mesh to the abdominal wall (11). Then further fixation is achieved with staplers.
The advantage of the keyhole-operation is faster reconvalescence after the operation, with less pain for the patient. Up to some weeks after the operation the patient can still notice a swelling at the site of the hernia. This is caused by woundfluid in the meanwhile concluded cavity of the hernia. In the long run this will obliterate.
This is an example of a patient 8 weeks after a large umbilical hernia correction with the above mentioned technique. The umbilicus is still thickened, but protruding has been remedied.
Open cicatricial hernia correction
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In this patient a cicatricial hernia is operated upon through a small incision. The mesh is much larger than the incision, as shown in the picture by the different color. Because of a memory coil on the outer part of the mesh it can be introduced in a folded position. Once inside the abdomen it resumes its natural size when released and is then fixed with staples. look at the video for the postoperative position.
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In this patient a large defect in the abdominal wall is the result after an accident with a complicated course after several operations. A very thin layer of skin lies on top of the bowel and in the middle the skin is even not yet closed. A keyhole-operation is not feasible here. Redundant skin is removed carefully. (1-4)
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Now a large mesh (marlex with PTFE) is used as an abdominal wall replacement (5). Sutures are placed (6) to fix the mesh to the remaining abdominal wall which has been freed as wide as possible of the bowel. The mesh is spread out covering the bowel, which is simplified by a pair of elastic rings in the mesh (7-9).
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After the mesh has been tied firstly to the abdominal wall with the sutures previously inserted to the mesh, it is then fixed with sutures at a second level (the interior ring) to the abdominal wall by means of the double layer of the mesh. Then the skin is closed over the mesh. For retrievingg woundfluid two drains are left behind (10-12).
Another example. Click the picture.
Biologic prosthesis in case of high infection risk
One of the biggest problems in correction of a cicatricial hernia is infection. In case of an infection the prosthesis is very likely to be involved and treatment of the infection is almost impossible, depending on the properties of the mesh. Removal of the mesh/prosthesis is often necessary and will probably be followed by a new hernia.
With the use of a biologic mesh, there is a lower infection risk and if there is an infection, treatment has a much higher succesrate and removal of the mesh is often not needed.
Biologic meshes are often made of special treated pig skin and are tolerated well by the human body. Ingrowth of vessels leads to a gradually replacement of the mesh by tissue of the patient. The mesh acts as a carrier. Because the meshes are still very expensive, the use is limited to special occasions.
For an example of an operation, click the picture.
