A novel approach to extraction of incarcerated omentum and mesh insertion in laparoscopic ventral hernia repair.

During laparoscopic ventral hernia repair (LVHR), it is not always possible to reduce incarcerated omentum through a tight defect and it may tear or require transection within the abdomen. This leaves an ischemic mass of tissue within the hernia sac which can cause pain, infection, or the appearance of hernia recurrence postoperatively. We describe a technique which allows extraction of any retained omentum within the hernia sac, mesh insertion, and laparoscopic completion of the procedure using only 5 mm trocars. After obtaining access to the abdomen with a 5 mm optical trocar in select patients, lysis of adhesions is performed as needed. When incarcerated omentum that cannot be safely reduced is discovered, it is transected at the level of the abdominal wall using electrocoagulation or ultrasonic dissection. At this point, we make a 2-3 cm skin incision overlying the retained omentum, open the hernia sac, and remove the amputated omentum. The rolled up piece of mesh utilized for the repair is then inserted through this opening. The hernia sac is closed with absorbable suture, allowing reinsufflation of the abdomen and completion of the laparoscopic repair. This method enables us to safely remove any retained omentum from the hernia sac and utilize the same incision for mesh insertion. We utilize only 5 mm trocars without the need for a larger port through which to place the mesh into the abdomen. This reduces the risk of postoperative trocar site hernias as the opening for mesh insertion is covered by the mesh after it is fixed in place. This technique may also decrease the need for conversion to open hernia repair by allowing an alternative approach to reduce incarcerated omentum.