Endoscopic-assisted linea alba reconstruction

The patient is positioned supine with the left arm tucked at the side and the right arm abducted. The video-endoscopic equipment is positioned to the left of the patient. The video-endoscopic equipment needed includes the camera, optics, and light source. The patient is given preoperative single-shot antibiotic prophylaxis. The entire abdomen is thoroughly sterilized and draped (Fig. 10). The access route consists of a half loop on the left around the umbilicus, extending 2–3 cm cranially in the midline (Fig. 10). Diathermy dissection of the subcutaneous tissue is performed, already revealing in most cases the umbilical, trocar, and/or epigastric hernia (Fig. 1). Any fatty tissue in the hernia sac can be removed with a clamp. Circular exposure of an umbilical hernia is performed, and the hernia sac is opened and resected at the hernia margin, thus separating the umbilicus from the fascia. The hernia sac content of an umbilical hernia are either repositioned or likewise resected. Next, depending on the RAD clinical findings, the anterior layer of the rectus sheath is exposed on both sides from the xiphoid process and extends several centimeters below the umbilicus. Now the wafer-thin RAD membrane, the former linea alba, can be identified (Fig. 2). The anterior layer of the rectus sheath is detached on both sides with a width of around 4–5 cm from the subcutaneous tissue. Using the optics and the video-endoscopic equipment light source, dissection is performed superior to the skin incision beneath the abdominal skin and the subcutaneous tissue and the anterior rectus sheath. The surgeon has a direct view of the surgical area via the skin incision, but needs the light source to that effect, while the two assistants watch the monitor of the video-endoscopic equipment positioned to the right of the patient. Once the anterior layers of both rectus sheaths have been adequately exposed, an incision is made with a scissors around 2 cm from the medial margin of the rectus sheath (Fig. 3). Again, the incision runs bilaterally from the xiphoid process to the subumbilical area, thus exposing the bellies of both rectus muscles (Fig. 4). After that, the abdominal wall is restored to its normal anatomy. To that effect, the two resected medial segments of the anterior layer of the rectus sheath are sutured together using continuous, non-absorbable loop sutures (Fig. 5). This can be accomplished with relatively little tension thanks to myofascial release. Inward plication of the RAD is effected (Fig. 6). A new linea alba is formed once suturing is complete, all defects and the RAD are closed, and both rectus muscles are restored to their position at the midline adjacent to the reconstructed linea alba (Fig. 7). This is followed by placement of a polypropylene mesh for augmentation of myofascial release. The mesh is first optimally tailored to the size of the defect in the anterior layers of the rectus sheaths. Only then is the mesh sutured to the incision margin of the anterior layer of the rectus sheath using continuous non-absorbable suturing material. The depth of the fascial sutures should be at least 1 cm throughout to assure secure mesh fixation (Fig. 8). Following bilateral, circular mesh fixation to the incision margin of the anterior layer of the rectus sheath, stabile augmentation of the defect and RAD closure following myofascial release and reconstruction of the linea alba are assured (Fig. 9). Next, a Redon drain is inserted between the mesh and subcutaneous tissue (Fig. 10). Once the subcutaneous tissue is sutured, the skin is closed with an intracutaneous suture (Fig. 10). Patients wear an abdominal binder for 6 weeks after the operation. The drain is removed once 24-h fluid production is less than 30 ml, as is generally the case after 3 days.

Between 15 June 2015 and 1 January 2017, a total of 140 patients were operated on with this technique. These were 90 men and 50 women. All patients signed an informed consent. As the described operation technique was performed for many years via larger incision in our hospital and results are reported in many publications in the literature, approval by an ethics committee was not necessary.

The mean age was 54.7 years with range of 25–85 years. The indications were RAD with symptomatic umbilical hernias (n = 17), epigastric hernias (n = 8), umbilical and epigastric hernias (n = 75), and incisional hernias (n = 40), which were mainly trocar hernias resulting from periumbilical insertion of a 10-mm trocar during laparoscopic operation. The patients had a mean body mass index (BMI) of 29.9 with range of 18–50. The mean defect length was 8.6 cm (range: 3–15 cm) and the defect width, 5.9 cm (range: 4–11 cm).