Abstract:
A method of repairing a patient&#39;s ventral hernia involves the steps of joining the patient&#39;s left and right rectus sheaths on opposite sides of the hernia, thereby closing the hernia, and cutting through the joined sheaths thereby forming one sheath interior containing the left and right rectus muscles. Next, a piece of surgical mesh is positioned in the joined rectus sheath interior and is sutured over the area of the closed hernia to further reinforce the closure. Additionally, sutures joining the left and right rectus sheaths are reinforced with reinforcing material.

Description:
BACKGROUND OF THE INVENTION 
   (1) Field of the Invention 
   The present invention pertains to a method of repairing a patient&#39;s ventral hernia. More specifically, the present invention pertains to a method of repairing a ventral hernia where the patient&#39;s left and right rectus sheaths on opposite sides of the hernia are brought together and sutured, closing the hernia and forming one sheath interior containing the left and right rectus muscles. The method also involves suturing a piece of surgical mesh in the joined rectus sheath interior with the mesh positioned over the area of the closed hernia to further reinforce the closure. Additionally, the sutures joining the left and right rectus sheaths are reinforced with suture reinforcing material. 
   (2) Description of the Related Art 
   A ventral hernia typically occurs in the abdominal wall of an individual where the abdominal muscles have weakened, or where a previous surgical incision was made. Weakened abdominal muscles can result in a bulge or a tear forming in the surrounding tissue of the abdominal muscles. The inner lining of the abdomen can then push through the weakened area of the abdominal wall to form a hernia sack or bulge. Where a surgical incision was previously made in the individual&#39;s abdomen, portions of the abdominal wall that have been sutured together can separate or tear between sutures over time. This also can result in the inner lining of the abdomen pushing through the tear of the abdominal wall to form a bulge or hernia sack. 
   Tens of thousands of ventral hernia repairs are performed in the United States each year. The conventional surgical repair procedure, or “open” method requires that a large incision be made in the patient&#39;s abdomen exposing the area of the hernia. The hernia is closed by sutures and/or surgical mesh. The incision is then closed. Because a large incision is made in the abdomen, the “open” method of repair can result in increased post-operative pain, an extended hospital stay, and a restrictive diet. 
   Laparoscopic procedures have been developed for repairing ventral hernias. These procedures repair the hernia opening in the abdominal wall using small incisions in the abdomen. Laparoscopes and surgical mesh are used in a typical procedure. The mesh is inserted through a trocar and positioned at the surgical site in the abdomen to reinforce the abdominal wall in the area of the hernia. The laparoscopic method of repair can result in decreased post-operative pain and a shorter hospital stay. However, the laparoscopic procedure has also experienced some adverse affects. For example, the positioning of the surgical mesh in the abdomen can result in the mesh irritating the intestines or other abdominal contents. In addition, the surgical mesh can move in the abdomen from its original position, exposing the hernia sight and creating the potential for the development of another ventral hernia. 
   SUMMARY OF THE INVENTION 
   The present invention provides a novel procedure for repairing a patient&#39;s ventral hernia that overcomes the disadvantages associated with prior art methods. 
   The method of the invention employs many of the steps that are typically used in the prior art methods of repairing a ventral hernia of a patient. For example, with the patient in a supine position, an incision is made through the exterior layers of the abdomen slightly above the position of the hernia. The incision is made to expose the anterior layers of the rectus sheaths. 
   Incisions are then made through the anterior layers of the rectus sheaths, exposing the muscle tissues in the interiors of the sheaths. 
   From the incisions in the rectus sheaths, the rectus sheaths are separated from the rectus muscle tissue along lengths of the rectus sheaths on opposite sides of the hernia. The separated muscle tissue is pushed laterally outwardly from the linea albo connecting the rectus sheaths, creating interior voids in the rectus sheaths between the displaced muscle tissue and the portions of the sheaths adjacent the hernia. 
   The jaws of a linear cutter are then inserted through the incisions in the rectus sheaths and through the interior voids created in the sheaths. The linear cutter jaws are positioned in the sheaths on opposite sides of the hernia. In the preferred method of performing the hernia repair, the type of linear cutter used is disclosed in a copending patent application assigned to the assignee of this application. That linear cutter includes pieces of suture reinforcing material that are secured to the jaws of the cutter in positions where sutures discharged from the cutter will also pass through the pieces of the suture reinforcing material. 
   The jaws of the linear cutter are then closed, bringing together the two portions of the left and right rectus sheaths on opposite sides of the hernia opening. The staples of the linear cutter are discharged, forming an upper line of suture between the left and right rectus sheaths and forming a lower line of suture between the left and right rectus sheaths. Simultaneously, the cutter of the linear cutter forms an opening through the portions of the left and right rectus sheaths between the upper and lower lines of sutures. The upper and lower lines of sutures, and the cut formed by the linear cutter all form the left and right rectus sheaths as one continuous sheath in the area of the now closed hernia opening. 
   A piece of surgical mesh is next inserted into the joined interiors of the left and right rectus sheaths. The surgical mesh is positioned over the lower line of sutures in the area of the now closed hernia opening. The surgical mesh is positioned extending across the closed hernia opening and the lower line of sutures, beneath the left and right rectus muscles and above the left and right posterior layers of the rectus sheaths. In an improvement over prior art methods, the surgical mesh is dimensioned to extend across the posterior layers of the left and right rectus sheaths, and the laterally outer edge portions of the surgical mesh are positioned adjacent the laterally outer sides of the left and right rectus muscles. The laterally outer edge portions of the surgical mesh are sutured in place adjacent the laterally outer sides of the left and right rectus muscles. Preferably, the sutures extend through the left and right rectus sheaths, and most preferably are sutured to the exterior layers of the abdomen. 
   With the surgical mesh secured in place, the incisions in the left and right rectus sheaths are then closed, and the incision in the abdominal wall is then closed. This completes the hernia repair method of the invention. 

   
     BRIEF DESCRIPTION OF THE DRAWINGS 
     Further features of the inventive method are set forth in the following detailed description of the preferred embodiment of practicing the method, and in the drawing figures wherein: 
       FIG. 1  is a representation of the initial incision made through the abdominal wall of the patient; 
       FIG. 2  is a representation of the incision made through the anterior layer of the right side rectus sheath; 
       FIG. 3  is a representation of the incision made through the left side rectus sheath; 
       FIG. 4  is a representation of a cross-section of the left and right rectus sheaths showing the positions of the incisions through the rectus sheaths and the position of the ventral hernia to be repaired; 
       FIG. 5  is a representation of the step of creating interior voids in the left and right rectus sheaths; 
       FIG. 6  is a representation of the step involving inserting the jaws of a linear cutter into the voids of the left and right rectus sheaths; 
       FIG. 7  is a representation of the jaws of the linear cutter in the left and right rectus sheaths; 
       FIG. 8  is a representation of the step involving closing the jaws of the linear cutter to produce the upper and lower lines of sutures in the left and right rectus sheaths, and to cut the opening between the lines of sutures; 
       FIG. 9  is a representation of a cross-section of the left and right rectus sheaths, showing the positions of the upper and lower lines of sutures and the opening formed between the sheaths; 
       FIG. 10  is a representation of the step of inserting a piece of surgical mesh into the incision; and, 
       FIG. 11  is a representation of the cross section through the left and right rectus sheaths showing the position of the surgical mesh at the completion of the ventral hernia repair. 
   

   DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT 
   The present invention provides a novel procedure for repairing a patient&#39;s ventral hernia that overcomes the disadvantages associated with prior art methods by providing a quality hernia repair that is easy to perform, has a low recurrence rate, has a minimal peri-operative morbidity, and is cost effective. The method is a retrorectus repair of an abdominal wall hernia that uses minimally invasive techniques and is performed with the assistance of an angled laparoscope and laparoscopic equipment. 
   The method begins by positioning the patient in a supine position, which is typical in abdominal surgery. In order to determine the location of the hernia opening inside the abdomen, a conventional cut-down method is used to enter the abdominal cavity at a site away from the hernia. The initial incision of the cut-down method is no more than 10-12 mm. This initial incision allows for the placement of a blunt trocar through the incision and into the peritoneal cavity. With the trocar in place, the abdomen is insufflated with 15 mm Hg pressure of carbon dioxide gas. A laparoscope is then introduced through the trocar to inspect the interior of the abdomen and the abdominal wall. If the inspection reveals any evidence of adhesions near the hernia site which are required to be lysed or dissolved, or of incarceration or confinement of tissues, which needs to be reduced, additional 5 mm trocars and laparoscopic working instruments are introduced into the abdomen under direct vision for this, purpose. 
   Once the above procedures are completed, the carbon dioxide is allowed to escape from the abdomen. Next, a transverse 4 cm incision is made across the midline of the hernia location approximately 5 cm cephalade to the hernia, or above the hernia relative to the patient&#39;s abdomen. This incision  12  is represented in  FIG. 4 . The incision  12  is carried down through the subcutaneous tissue of the abdomen to the level of the anterior sheaths  14 ,  16  of the rectus muscles. 
   Next, as represented in  FIGS. 2 ,  3 , and  4 , a pair of 1 cm longitudinal incisions  18 ,  22  are made in the anterior sheaths  14 ,  16  of both the right  24  and left  26  rectus muscles. The incisions  18 ,  22  are made at the medial edges of the muscles above the location of the hernia opening  28 . 
   The medial edges of the right rectus muscle  24  and left rectus muscle  26  are then retracted laterally outwardly away from the area of the hernia  28 . As represented in  FIG. 5 , a long blunt clamp  32  is used to separate the right posterior sheath  34  from the right rectus muscle  24 , and to separate the left posterior sheath  36  from the left rectus muscle  26  along the opposite sides of the hernia opening  28 . The muscles  24 ,  26  are retracted laterally and held in their retracted positions by conventional Army/Navy or “S” type retractors. 
   Once the lateral retraction of the right  24  and left  26  rectus muscles in their respective sheaths is complete, a linear cutter, preferably a 100 mm linear cutter with 4.5 mm staples is separated at its hinge separating the jaws  38 ,  42  or limbs of the device. The type of linear cutter used in the preferred method of the invention is disclosed in a co-pending patent application assigned to the assignee of this application. That linear cutter includes pieces of suture reinforcing material that are secured to the opposing jaws  38 ,  42  of the cutter in positions where the sutures discharged from the cutter jaws will also pass through the pieces of reinforcing material. One of the linear cutter jaws  38  is inserted through the incision  18  in the right anterior sheath  14  and the other of the jaws  42  is inserted through the incision  22  in the left anterior sheath  16 . This step of the procedure is represented in  FIG. 6 . The linear cutter jaws  38 ,  42  are inserted through the interior voids created by retracting the right  24  and left  26  rectus muscles in their respective sheaths  14 ,  16 . The two jaws  38 ,  42  of the linear cutter are then again joined at their hinge connection, as represented in  FIG. 6 . The positions of the jaws  38 ,  42  opposite each other and on opposite sides of the hernia opening  28  in the right  14  and left  16  rectus sheaths is represented in  FIG. 7 . 
   With the linear cutter jaws  38 ,  42  positioned in the interior voids in the respective right  14  and left  16  rectus sheaths, the jaws are then closed, bringing together the two portions of the right  14  and left  16  rectus sheaths on opposite sides of the hernia opening  28 . This step of the procedure is represented by  FIG. 8 . Closing the linear cutter jaws  38 ,  42  is done against some tension of the right  14  and left  16  rectus sheaths, as bringing together the two portions of the sheaths will force approximation of the two rectus sheaths and collapse the hernia opening  28 . Once the right  14  and left  16  rectus sheaths are closed over the hernia opening  28 , the stapler is fired in a conventional manner and the staples of the linear cutter are discharged, forming an upper line of suture  44  between the right  14  and left  16  rectus sheaths, and forming a lower line of suture  46  between the right  14  and left  16  rectus sheaths. Simultaneously, the cutter of the linear cutter cuts an opening  48  through the portions of the right  14  and left  16  rectus sheaths between the upper  44  and lower  46  lines of sutures. The firing of the staples from the linear cutter jaws  38 ,  42  and the cut formed by the linear cutter also secures portions of suture reinforcing material  52 ,  54 ,  56 ,  58  on the opposite sides of the upper line of sutures  44  and on the opposite sides of the lower lines of sutures  46 . The reinforcing material  52 ,  54 ,  56 ,  58  reinforces the sutures  44 ,  46  joining the portions of the right  14  and left  16  rectus sheaths above and below the cut opening  48  formed through the rectus sheaths by the linear cutter. The upper  44  and lower  46  lines of sutures, and the cut opening  48  cut by the linear cutter all form the right  14  and left  16  rectus sheaths as one continuous sheath in the area of the now closed hernia opening  28 , as shown in  FIG. 9 . The jaws  38 ,  42  of the linear cutter are then removed from the incisions  18 ,  22  in the right  14  and left  16  rectus sheaths. 
   Permanent O-O suture may be used to reinforce the upper line of sutures  44  and lower line of sutures  46  in lieu of the reinforcing material  52 ,  54 ,  56 ,  58 . 
   A piece of surgical mesh  62 , preferably a sheet of monofilament, polypropylene mesh  62  is then cut or formed to the dimensions of the newly formed interior rectus space  64  that extends through the cut opening  48  and includes the joined interiors of the right  14  and left  16  rectus sheaths.  FIG. 10  shows the insertion of the surgical mesh  62  into the joined rectus sheath interiors  64 .  FIG. 10  shows the insertion of the surgical mesh  62  through the abdominal incision  12  and the rectus sheath incisions  18 ,  22 .  FIG. 11  represents the positioning of the surgical mesh  62  in the joined rectus sheaths interiors  64 . 
   As shown in  FIG. 11 , the surgical mesh  62  is positioned over the lower line of sutures  46  in the area of the now closed hernia opening. The surgical mesh  62  is positioned extending across the closed hernia opening and the lower line of sutures  64 , beneath the right rectus muscle  24  and the left rectus muscle  26 , and above the right posterior sheath  34  and the left posterior sheath  36 . The surgical mesh  62  is dimensioned to extend across the right posterior sheath  34  and the left posterior sheath  36  with the laterally opposite outer edge portions  66 ,  68  of the surgical mesh  62  being positioned adjacent the laterally outer edges of the right rectus muscle  24  and the left rectus muscle  26 . This positioning of the surgical mesh  62  is checked with the use of an angled laparoscope (not shown) with the space in the joined rectus sheath interiors  64  being held open with a lighted retractor (not shown). The mesh  62  is flattened as shown in  FIG. 11 , and the retractor is removed allowing the right rectus muscle and the left rectus muscle  26  to return to their normal positions in their respective rectus sheaths  14 ,  16 . Sutures  72 ,  74  are then placed through the respective right side portion  66  and left side portion  68  of the surgical mesh  62 , securing the mesh in place adjacent the laterally outer sides of the right  24  and left  26  rectus muscles as shown in  FIG. 11 . Small incisions can be made into the abdomen to position the securing sutures  72 ,  74  beneath the outer layers of the abdomen as shown in solid lines in  FIG. 11 . Alternatively, as shown in dashed lines, the securing sutures  76 ,  78  can extend through the right  14  and left  16  rectus sheaths as well as the right  66  and left  68  side portions of the surgical mesh  62  and through the exterior layers of the abdomen in securing the surgical mesh in place. 
   With the surgical mesh  62  secured in place as shown in  FIG. 11 , the incisions  18 ,  22 , through the right and left rectus sheaths are closed, and the incision  12  through the abdominal wall is closed. The abdomen can then again be insufflated at low pressure to allow an internal view of the repair using the angled laparoscope. If all appears well, the trocars are removed. This completes the hernia repair method of the invention. 
   Although the method of the invention for repairing a hernia has been described above in repairing a patient&#39;s ventral hernia, it should be understood that the concept of the method of the invention may be employed in repairing various different types of hernias, and it should be understood that modifications and variations could be made to the method of the invention described above without departing from the intended scope of the following claims.