2134 Part VIII: Nongastrointestinal Transabdominal Surgery as epidermolysis, necrosis, or infection 12%
to 20% of the time and it is catastrophic if the
prosthesis gets infected. Drains are placed in
the subcutaneous space and any excess skin
and fat are excised to give a good cosmetic
result. We then close the dermis with
interrupted 4-0 PDS® sutures and skin with
staples that are removed 3 days later. We do
not close the subcutaneous layer since this
only leads to fat necrosis.
Intraperitoneal Mesh Repair
The previously described method of repair
was developed in order to place a large piece
of mesh behind the hernia defect but to keep
it off of the viscera since the only two
meshes available at the time were un-coated
polyester and polypropylene. As mentioned
earlier, there are now several meshes that can
be safely placed in contact with the viscera
and this allows an intrap-eritoneal placement
of the mesh. This can be done as in the
Fig. 10. Reverdin needle.
classic Rives repair with the interrupted
sutures being brought up through the skin,
but we developed a method where the
suturing is continuous and below the skin.
The technique, devel-oped in the 1990s,
utilized ePTFE mesh since it was the only
mesh at that time that could be safely placed
against the viscera. After the incision is
made, the hernia sac is entered and
adhesiolysis is done just as in the classic
Rives repair. Once all of this is done, skin
and subcutaneous flaps are de-veloped on
both sides back into good fascia and far
enough laterally so that the rectus muscles
and fascia can be approximated to cover the
mesh after it has been implanted (Fig. 12).
The proper size of mesh is deter-mined by
bringing the two mobilized rectus muscles to
the midline with Kocher clamps. We then
measure 6 to 8 cm laterally onto good fascia
Fig. 11. Sutures through abdominal wall. on either side to determine the width needed
and similar overlap into good fascia
superiorly and inferiorly. One or more
disposable visceral retractors (“fish”) are
used (it can be trimmed to fit and we re-move
the rigid plastic bar for easier re-moval) and
they are placed in the abdomi-nal cavity over
the intestines. The mesh is then placed in the
abdominal cavity and a 1 and 2 Prolene that
is 60 cm long is placed at the 6 o’clock
position as a “U” stitch through the mesh and
through the fascia back at the previously
determined point and the suture is tied. A
similar separate suture is placed at the 12
o’clock position and tied, thus an-choring the
mesh in such a way that the fol-lowing suture
placement will not pull it too much to one
side or the other (Fig. 13). The suture (either
one) is then run in a continu-ous fashion as a
series of “U” stitches going through the mesh
and through the strong
Fig. 12. Skin and subcutaneous flaps.
