2006, vol.8, no.1, techniques of laparoscopic hernia repair

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Volume 8, Number 1 March 2006

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Techniques of Laparoscopic Hernia Repair

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here are few surgical topics that so perfectly exemplifythe general surgeon’s task, as does the repair of a hernia.

ll surgeons know the mighty tome first edited by Nyhus andondon entitled “Hernia” that at last count had over 600ages, a testament to the complexity, variety, and difficultyresented by the treatment of this uniquely surgical condi-ion. With the advent and accelerating role of laparoscopy inll surgical conditions, naturally the hernia would be targetedor care. With its intrinsic advantage of minimizing the size ofhe incision necessary to access the site of the hernia itself,aparoscopy is now considered by some to be the highlyreferred method for surgical management. Its role continueso rapidly expand. As evidenced by the topics presented inhis issue of Operative Techniques in General Surgery, everore complex and demanding hernia repairs are now stan-
ard material for the laparoscopic technique. Todd Heniford
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n his introductory editorial admirably summarizes and high-ights the revolution that has taken place in hernia surgerysing the laparoscope. All of the authors that he has drawn ono contribute to this issue are leaders in the field, some havingriginated and defined the techniques they describe. Theeader is thus witness to another advance in that age-oldvolution of the surgical care of the venerable hernia.

Walter A. Koltun, MDProfessor of Surgery,

Peter and Marshia CarlinoProfessor of Inflammatory Bowel Disease

Chief, Section of Colon and Rectal Surgery,Penn State College of Medicine,

Milton S. Hershey Medical Center

Editor-in-Chief

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Volume 8, Number 1 March 2006

2

Introduction

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was particularly pleased to be asked to organize an editionof this journal dedicated to the laparoscopic management

f abdominal and inguinal hernias. Hernias and abdominalall complications have been a problematic mainstay forhysicians since the first recordings of medical history. In-eed, the significance of abdominal wall defects has dissi-ated very little. From the belts and trusses that are so ele-antly depicted in drawings from the middle ages to theideos of today that demonstrate laparoscopes, dissectingalloons, and preformed meshes, few topics allow one tonalyze the origins and evolution of surgical theory and ther-py as well as the study of hernias. Despite more than oneillion hernia operations performed annually in this coun-

ry, the perfect hernia repair, which should offer no recur-ences, little patient discomfort, and normal body function,oes not exist. Significant to this edition, two importantoints can be made: (1) laparoscopic herniorrhaphy tech-iques have earned the status of a legitimate means to managebdominal and groin defects; and (2) surgeon familiarity withhese techniques directly impacts their patients’ outcome.ence, I consider this journal, as composed by busy, expert

urgeons, as particularly timely and important.Changes in the management of hernias have followed our

nderstanding of their origins and, perhaps more impor-antly, our failures in their repair. Sutured repair continues tolay a valuable role in herniorrhaphy, but suturing a defectnder tension or using tissues of questionable strength re-ults in a repair that is doomed to fail. Bridging a hernia withprosthetic mesh has established a valid position in the re-air of not only large or recurrent hernias but also in primaryepairs of ventral, lateral, and groin defects. The need for atrong prosthetic that is well tolerated by the human body isot a new thought or concept. In 1857, Bilroth stated, “If weould artificially produce tissue of the density and toughnessf fascia and tendon, the secret of the radical cure of theernia repair would be discovered.” Nearly 150 years later wenderstand the importance of that statement. Industry alsoecognizes its worth, both in improving patient outcomesnd in providing materials to a million-cases-a-year market.esearch in the area of prosthetic mesh has soared over the

ast decade. This is especially true for the laparoscopic arena,iven that most laparoscopic hernia repairs take advantage ofhe concept of a tension-free repair and require mesh place-ent. Specific biomaterials have been engineered for place-ent inside the abdomen, in the preperitoneal space, with

nonstick” surfaces or antimicrobial coatings, preformed for h

1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2006.04.003

eft or right-sided inguinal hernias (in small, medium, orarge sizes), “lightweight” textiles, etc. There is no perfectiomaterial, but outstanding, well-tolerated choices exist.The organization of this text is fairly simple, but it is de-

igned to cover the majority of the hernias that a surgeonight encounter. The authors are notable experts in theirelds, and many of them have the largest series in the world

iterature on their assigned topic. I thank them for taking theime to provide insight into understanding the anatomic ba-is of the hernias, supplying me with their proven tactics forhe laparoscopic approach for repair of their assigned hernia,nd working with the artists to give us insightful drawings. Ineviewing each section, I see particular points that are not toe missed. Specific technical tips and tricks that have takenhese notable authorities time and repeated cases to perfectre abundant. Reading Dr Ramshaw’s description of the lum-ar hernia repair (one of the most difficult hernias to concep-ualize, much less fix) and his interpretation of using mesh assling from the pubis, iliac crest, para-spinal muscles, and

ibs is remarkably insightful and is not to be found in any textut this one. He has undoubtedly spoken to or taught moreurgeons about abdominal hernias and their repair than anyne person on Earth. Each time I hear him or read his work,benefit from the experience. The sections covering the TEPPnd TAPP inguinal hernia repairs complement each othericely; they demonstrate the same anatomy from differenterspectives, and separately, but together, assert why manyhink these repairs offer excellent coverage of the floor of thebdomen. But, these authors also show why a real under-tanding of the anatomy and a large piece of mesh separateheir results from those in some printed reports by less expe-ienced surgeons and resident surgeons.

Dr. Sing has the largest documented series in the world ofraumatic diaphragmatic hernias repaired laparoscopically.e has utilized his trauma and laparoscopic know-how torovide a description and pictorial demonstration of bothesh and primary closure that makes the work seem easy.

ndeed, the depiction of leaving sutures untied and taggedith clips to allow complete visualization of the final few

titches is simple but brilliant; those having been there willertainly understand. In the laparoscopic ventral hernia sec-ion, Dr. Novitsky provides practiced insight to one of theost difficult aspects of the operation. Mastering a straight

orward method for sizing the mesh appropriately and mak-ng sure that the prosthetic is taut as it is being secured will
elp prevent surgeons from having the unfortunate experi-

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Introduction 3

nce of an early recurrence because of a mesh that does notdequately cover the defect or a lax mesh that, unfortunately,arachutes into the hernia and forms an “expensive herniaac.” Dr. Carbonell has the largest published experience inhe darning of supra-pubic hernias, and he very competentlyemonstrates the anatomy, mesh placement, and fixation ofhe prosthetic in this not-so-easy hernia repair. Having seenim operate “live” previously, this description matches histeps in the operating room perfectly. If one reads the TAPPanuscript and follows it with this supra-pubic paper, it will

e easy to see why we frequently teach our trainees theseechniques in tandem. Dr. Rosen’s and Dr. Carbonell’s papersomplement one another nicely.

Consensus regarding the approach to specific hernias willot be found, even among experts, but these surgeons haveocumented admirable outcomes with their described tech-iques. I must, however, emphasize that there is more thanne way to fix a hernia. For the surgeon reviewing this text, aaparoscopic technique that fits his or her strengths and dis-
osition should be appropriately described. However, there
s no method in this text that is a “quick fix.” There are few ofhose in surgery, and almost none in hernia repair. If thereas, one should expect that it would have been discovered in

he millions of herniorrhaphies that are antecedent to thisext. As I was taught early on, there are simple, straightfor-ard, and wrong ways to do things. The techniques pre-

ented here have stood the test of time, as short as it is foraparoscopy, and proven to provide excellent outcomes.

Again, I hope that the text provides needed insight to thoseooking for it, and I thank the experts who provided theirnowledge and time to put this together.

B. Todd Heniford, MD, FACSChief, Division of Gastrointestinaland Minimally Invasive Surgery,

Director, Carolinas Hernia CenterCarolinas Medical CenterCharlotte, North Carolina

Guest Editor

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aparoscopic Ventral Hernia Repairuri W. Novitsky, MD, B. Lauren Paton, MD, and B. Todd Heniford, MD, FACS

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entral herniorrhaphies are among the most commonlyperformed operations by general surgeons throughout

he world. Incisional hernias, with a reported incidence of upo 20%, have become an increasing problem because of thencreasing number of laparotomies performed. In the Unitedtates, approximately 175,000 ventral abdominal hernias areepaired each year. Surgical approaches to ventral hernior-haphy have been a subject of research and technical modi-cations for many years. Although the routine use of pros-hetic reinforcement for the repair of herniations in adults haseen contested, existing evidence strongly supports tension-ree hernia repairs in most patients. With the developmentnd popularization of tension-free repairs using prostheticeshes, the recurrence rates are typically less than 20%.Large abdominal incisions and wide tissue dissection with

he creation of large flaps needed for open placement of ad-quately sized mesh; however, this dissection often leads to aigh incidence of postoperative morbidity and wound com-lications. Recently, open ventral herniorrhaphy has beenhallenged by reports of successful implementation of mini-ally invasive techniques. The principles of retro-rectusrosthetic reinforcement have been adapted for laparoscopicentral hernia repair. The mesh is placed as an intraperitonealnlay with wide coverage of the hernia defect. Avoidance ofarge incisions has substantially reduced wound complica-ions. Overall, the clinical benefits of laparoscopic ventralernia repair include a faster convalescence, fewer complica-ions and, importantly, a low recurrence rate.

echniques ofaparoscopic VHR

fter general anesthesia is induced, the patient is positionedupine with the arms adducted and “tucked” at the sides. Thisllows for adequate space for both primary surgeon and anssistant on the same side of the patient. We use two moni-ors, placed on each side of the patient (Fig. 1). In most cases,he bladder and stomach are decompressed with catheters.n antibiotic, usually a first-generation cephalosporin, isiven prophylactically before the incision is made and re-

epartment of Surgery, Division of Gastrointestinal and Minimally InvasiveSurgery, Carolinas Medical Center, Charlotte, NC.

ddress reprint requests to Dr. Yuri W. Novitsky, Department of Surgery,Division of Gastrointestinal and Minimally Invasive Surgery, CarolinasMedical Center, 1000 Blythe Blvd, MED 601, Charlotte, NC 28203.

uE-mail: [email protected]

1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2006.04.004

eated if the operation lasts longer than 2 hours. We rou-inely use an Ioban drape to minimize mesh contact with theatient skin. Laparoscopic hernia repair is performed by us-

ng a 30-degree angled laparoscope, 5-mm bowel graspers,cissors, and clip appliers. Access to the peritoneal cavity isained using a cut-down technique (Fig. 2). A window ofccess is usually present, even in the multiply operated ab-omen, below the patient’s costal margin between the mid-lavicular or anterior axillary lines. The initial entry site ishosen just inferior to the tip of the eleventh rib, usually onhe left side. We often prefer to then use a balloon-tippedrocar to avoid air leakage. A total of three trocars are placednder direct vision laterally along anterior-to-mid-axillary

ine. Often, a fourth 5-mm port is placed contralaterally toacilitate intra-abdominal mesh introduction and fixation.ort placement for less common defects (subxyphoid, supra-ubic, parailiac, spigelian, etc.) is adjusted based on the lo-ation of the hernia. On entrance to the abdominal cavity,dhesiolysis is performed sharply with limited use of electro-urgery or ultrasonic coagulators. Reduction of the herniaontents is performed using blunt graspers and sharp dissec-ion from the inside and is facilitated by manual compressionrom the outside. The hernia sac is usually left in situ. Oncehe adhesiolysis is completed, the hernia defect is measuredo determine an appropriate size of a prosthetic mesh. Theorders of the abdominal wall defect are delineated with aombination of laparoscopic vision and external palpation.he edges of the defect are marked externally. Often, place-ent of spinal needles through the abdominal wall at the

nternally visualized defect edges is needed to accurately de-ermine the size of the hernia (Fig. 3). This maneuver isspecially important in obese patients with large defects asxternally measured size of a defect can be dramatically over-stimated. A ruler is placed through a 5-mm port, and theimensions of the hernia defect to allow for the direct mea-urement of the defect. The mesh is than tailored to overlapll margins of the hernia by at least 4 cm.

Once the mesh is cut to the desirable size, four size-0ermanent monofilament or ePTFE sutures are placed at theid-point of each side of the mesh. Points of reference on theesh and corresponding points on the abdominal wall arearked to aid in orienting the mesh after its introduction into

he abdomen. The mesh was rolled up and pushed or pullednto the abdomen through a 5- or 10-mm trocar site. The

esh is rolled from both edges to facilitate the unfolding stepFig. 4). If the defect size dictates a very large prosthetic it is
sually introduced in the abdominal cavity by pulling with

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Laparoscopic ventral hernia repair 5

he grasper passed through the contralateral trocar. It is im-ortant to maintain the appropriate orientation of the meshuring the insertion and unfolding of the mesh. Two Mary-

and graspers are best used to unfold the mesh. After theesh is oriented intracorporeally, the sutures are pulled

hrough the abdominal wall with a suture passer (Fig. 5). A 4m mesh/defect overlap is once again confirmed using spinaleedles, as described above. The suture pulled first is usuallylosest to the “sensitive” border (xiphoid, pubis, iliac crest,ostal margin, colostomy, etc.). We subsequently pull theuture that is adjacent (not opposite) to the first one. Onceufficient overlap is confirmed, we tie both sutures with thenots buried in subcutaneous tissues. The other two suturesre then pulled transabdominally and tied ensuring that theverlap is sufficient and that the mesh is taut (Fig. 5). Theerimeter of the mesh is then stapled to the posterior fasciaith 5-mm spiral tacks at approximately 1 cm intervals torevent intestinal herniation. Placing the tacks is facilitatedy the external manual palpation of the tacker’s tip (Fig. 6).his is particularly important for tacking the mesh in the

ower abdomen to ensure that the tacks are placed superiorlyo the inguinal ligament. Additional full-thickness stitches

Figure 1 Patient positioning, ro

re placed circumferentially every 3 to 6 cm by using the l

uture passer (Figs. 7 and 8). This transabdominal fixation isrucial to ensure that the mesh will not be displaced overime. The knots are tied in the subcutaneous tissues. The skins released to avoid dimpling.

onclusionaparoscopic ventral hernia repair has reliably been shown toe superior to the open approach. Overall LVHR is associatedith a decreased perioperative pain, reduced hospital stay,

nd faster recovery. Postoperative complications are also lessrequent in the laparoscopic group (23.2% vs. 30.2%) as wells the incidence of wound and mesh infections (Table 1). Inddition, the recurrence rate is 4% for the laparoscopic groupnd 16.5% for the open technique.

Overall, numerous studies demonstrate that laparoscopicentral hernia repair is an effective and safe approach to thebdominal wall hernia. It can be performed in complex sur-ical patients with a low rate of conversion to open surgery, ahort hospital stay, a moderate complication rate, and a lowisk of recurrence. With additional long-term follow-up toupport the safety and durability of the procedure, LVHR will

t-up, and our trocar strategy.

ikely be considered the standard of care in the future.1–9

6 Y.W. Novitsky, B.L. Paton, and B.T. Heniford

Figure 2 Access to the abdominal cavity using cut-down techniques utilizing pediatric Kocher clamps. This is usually
safely accomplished in the left upper quadrant area.
Figure 3 Intracorporeal (direct) measurement of a hernia defect. Spinal needles allow for more precise identification ofthe edges of the defect. Additional spinal needles may be used for defects larger than the length of a ruler (typically 12
cm).


Figure 4 Rolling of the mesh before its introduction into the abdominal cavity.

Figure 5 Initial four-point mesh fixation.

8 Y.W. Novitsky, B.L. Paton, and B.T. Heniford

Figure 6 Transabdominal suture fixation of the mesh.

Figure 7 Placement of tack is done circumferentially along the whole length of the mesh to avoid bowel incarceration.External palpation of the abdominal wall facilitates placement of the tacks and helps to avoid tacking the mesh below
the inguinal ligament and above costal margins.

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eferences. Heniford BT, Park A, Ramshaw BJ, Voeller G: Laparoscopic repair of

ventral hernias: Nine years’ experience with 850 consecutive hernias.Ann Surg 238:391-399, 2003

. Novitsky YW, Cobb WS, Kercher KW, Matthews BD, Sing RF, HenifordBT: Laparoscopic ventral hernia repair in obese patients: A new standardof care. Arch. Surg 141:57-61, 2006

. Rosen M, Brody F, Ponsky J, et al: Recurrence after laparoscopic ventralhernia repair. Surg Endosc 17:123-128, 2003

. Carbonell AM, Kercher KW, Matthews BD, Sing RF, Cobb WS, HenifordBT: The laparoscopic repair of suprapubic ventral hernias. Surg Endosc19:174-177, 2005

Figure 8 Final appea

able 1 Comparison studies of laparoscopic and open ventra

Study Year

# Patients Morbidit

Lap Open Lap Op

cGreevy 2003 65 71 5 15aftopoulos 2003 50 22 14 10right 2002 90 90 15 31

obbins 2001 18 31 — —eMaria 2000 21 18 13 13hari 2000 14 14 2 2arbajo 1999 30 30 20 6amshaw 1999 79 174 15 46ark 1998 56 49 10 18olzman 1997 21 16 5 5ercent 23.2 30

. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel

J: Long-term follow-up of a randomized controlled trial of suture versusmesh repair of incisional hernia. Ann Surg 240:578-583, 2004

. Luijendijk RW, Hop WC, van den Tol MP, et al: A comparison of suturerepair with mesh repair for incisional hernia. N Engl J Med 343:392-398,2000

. Stoppa RE: The treatment of complicated groin and incisional hernias.World J Surg 13:545-54, 1989

. DeMaria EJ, Moss JM, Sugerman HJ: Laparoscopic intraperitoneal poly-tetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Pro-spective comparison to open prefascial polypropylene mesh repair. SurgEndosc 14:326-329, 2000

. Carbajo MA, Martin del Olmo JC, Blanco JI, et al: Laparoscopic treat-ment vs open surgery in the solution of major incisional and abdominal

f the hernia repair.

ia repairs

Meshinfection

Woundinfection Recurrence

Lap Open Lap Open Lap Open

2 0 0 7 — —1 0 1 1 1 41 1 1 8 1 51 4 1 0 — —1 2 1 4 1 00 1 — — — —0 3 0 5 1 21 5 6 2 2 362 1 0 2 6 170 1 1 0 2 22.0 3.5 2.6 5.8 4.0 16.5

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wall hernias with mesh. Surg Endosc 13:250-252, 1999

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aparoscopic Repair of Suprapubic Ventral Herniaslfredo M. Carbonell, DO

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he laparoscopic approach to ventral hernia repair ap-pears to be superior to the traditional open operation.

he use of laparoscopy is associated with less pain, a betterosmetic result, a lower incidence of mesh and wound com-lications, and possibly a lower recurrence rate. As a result ofheir low prevalence, hernias located in atypical areas mayot be seen as frequently by surgeons, leading to a relative

nexperience in their repair; and a subsequent higher recur-ence rate. The suprapubic incisional hernia is one which isocated in close proximity to the pubic bone, arising afterrologic or gynecologic procedures. The repair of these her-ias can be difficult because of the complexity of dissectionnd their anatomic proximity to bony, vascular, and nervetructures. This technique article gives the operating surgeonthorough understanding of the nature of suprapubic her-ias and an illustrated step by step approach to the laparo-copic repair of this difficult problem; particularly the trans-bdominal suture fixation to the bony and ligamentoustructures of the pelvis. Although technically demanding andime-consuming, the laparoscopic repair of suprapubic her-ias yields a durable hernia repair. It is safe, technically fea-ible, results in a low recurrence rate, and is applicable toarge or multiply recurrent hernias.

Incisional hernias can develop in up to 20% of patientsndergoing laparotomy, and, after a primary repair, theseernias may recur in up to 63% of patients.1 With the devel-pment of laparoscopic techniques, the recurrence rate forentral hernia repair is frequently reported to be below 4%.2-5

ased on the open, retrorectus, Rives-Stoppa6 repair mandat-ng wide coverage of the hernia defect, the laparoscopic ap-roach is associated with few recurrences, rapid hospital dis-harge, improved cosmesis, a reduced risk of infection, andossibly less postoperative pain.2-5 Certain critical steps areequired to ensure a reliable laparoscopic ventral hernia re-air, such as a minimum of 4 to 5 cm mesh overlap of theernia defect, and mesh fixation with both full-thicknessransabdominal sutures and helical tacks.7,8 Although no ran-omized, prospective studies have been performed, a strongssociation has been made in the literature between herniaecurrences and the lack of mesh fixation with full-thickness

ivision of General Surgery, Minimally Invasive Surgery Center, VirginiaCommonwealth University Medical Center, Richmond, VA.

ddress reprint requests to Alfredo M. Carbonell, D.O., Division of GeneralSurgery, Virginia Commonwealth University Medical Center, 1200East Broad Street, PO Box 980519, Richmond, VA 23298. E-mail:

[email protected]

0 1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2006.04.005

ransabdominal sutures.2,7,8 Additionally, animal studiesave demonstrated the superior fixation strength of suturesompared with tacks for mesh fixation.9,10

The terms suprapubic and parapubic are often used inter-hangeably. When used to describe hernias, they refer tohose located just above the symphysis pubis. They may oc-ur as a result of low mid-line, Pfannenstiel, Maylard, andherney incisions used principally for gynecologic, prostatic,r rectal procedures.11 These hernias have also been reportedfter suprapubic catheterization.12 There is limited experi-nce with the repair of these difficult hernias using both thepen11,13-15 and laparoscopic approach.16-18

The abdominal oblique aponeurosis, rectus abdominususculature, and rectus sheath insert on the symphysis pu-

is. In the event an incision is placed in proximity to thisusculotendinous insertion, a hernia may develop as a result

f inadequate tissue purchase inferiorly when re-approximat-ng the fascia. The complexity of dissection and the closeroximity of these hernias to bony, vascular, and nerve struc-ures make the repair of suprapubic hernias a formidableperation. We developed a unique technique in the repair ofhese hernias, and present our 10-year experience, discussingn detail the operative approach.

reoperative Workupatient selection for the laparoscopic approach is up to the

ndividual surgeon. Preoperative workup should include ahorough history of all past surgeries and review of operativeeports, particularly if a previous hernia repair with mesh wasndertaken. On physical examination the surgeon shouldalpate the entire incision both in the supine and uprightosition. Provocative maneuvers should be used to accentu-te the hernia bulge and attempt to delineate the inferior-ost edge of the defect. For the laparoscopic ventral hernia

epair, a minimum 4 cm overlap of mesh past the edge of theernia defect is recommended; as a result, hernias less than 4m from the pubic symphysis are defined as suprapubic andill require this modified approach to repair. Computed to-ography (CT) is helpful in determining the exact size of theernia, its contents, and the relation of the inferior edge to theubic symphysis. Although we do not typically have the pa-ient undergo CT before hernia repair, we will do so if there isquestion regarding proximity of the hernia to the pubic

ymphysis or if there has been a previous mesh repair. Arevious repair with mesh may make the laparoscopic ap-
roach difficult, particularly if polypropylene mesh was used

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Laparoscopic repair of suprapubic ventral hernias 11

r a previous laparoscopic repair attempted. This informa-ion helps plan out the operative approach.

quipmentnstrumentation for the repair is similar to that of the typicalaparoscopic ventral hernia repair. We use from three to fourrocars for the procedure; at least one being 10 mm in size,he rest may be 5 mm. Because most of the trocars are 5 mm,e use a 5 mm, 30-degree angled laparoscope that will allow

he surgeon to change the position of the camera betweenultiple ports. The angle allows the surgeon to “look around

orners” during difficult portions of the procedure. A Mary-and dissector, atraumatic graspers, and laparoscopic shearsre required for the lysis of adhesions. We refrain from these of ultrasonic coagulating shears to take down adhesionsecause this can result in an unnoticed thermal injury to the

ntestine. Sharp division of adhesions is advised. Simple mo-opolar cautery attached to the scissors should suffice if nui-ance bleeding arises. The use of a 5 mm clip applier canerve as an added measure for hemostasis. For mesh we usexpanded polytetrafluoroethylene (ePTFE, DualMesh Gore-ex, WL Gore & Associates, Flagstaff, AZ), however, severalther tissue-separating mesh products are available that areafe to use in direct contact with the intestine. The four car-inal sutures used to initially hold the mesh in place are CV-0utures constructed of ePTFE (Gore-Tex, WL Gore & Asso-iates). The additional fixation sutures should be size #0 or1 polypropylene or polybutester that are both nonabsorb-ble. Our preferred fixation construct device is the ProTackUnited States Surgical, Norwalk, CT) that employs titaniumpiral tacks. Several other fixation construct devices are avail-ble as well. For passing and retrieving the transabdominalutures, a Gore Suture Passer (WL Gore & Associates) issed.

atient Set-upfter anesthetic induction, a three-way Foley catheter is
laced into the bladder. This is used to instill saline into the i
ladder as a tumescent to aid in determination of the blad-er’s location in the preperitoneal space so as to avoid injuryo it during the procedure. Should an injury be suspected,ethylene blue can be instilled in the irrigant to help identifycystotomy. The patient is positioned supine with both armsadded and tucked. This allows the surgeon and the assistanto work on the same side of the patient without interferencerom the patient’s extended arm. With more obese patients,adding to elevate the tucked arm will ensure there is nondue traction placed on the brachial plexus. The pubic hair

s shaven to ensure complete access to the area of the pubicymphysis during the operation. Using a standard iodine skinrep, the abdomen is prepped up to the nipple line, as far

ateral as the arms allow, and down onto the thighs. An io-ine-impregnated skin drape is used on the abdomen for andded antimicrobial barrier.

rocar Placementhe procedure commences with an open cutdown to enter

he abdomen safely away from any previous incisions andlacement of a 10-mm trocar. The incision can be made inhe midline above the umbilicus, distant to the hernia defect.lacing the first trocar this far above allows a more expandediew of the abdomen and ensures the trocar is out of the wayhould it be required to place a large piece of mesh. Twodditional 5 mm trocars are placed in a horizontal line.

ysis of Adhesionshe procedure proceeds with a sharp enterolysis, avoiding

njury to any hollow viscus. Care should be taken in dissect-ng the inferior-most aspect of the hernia because it oftenontains herniated bladder. The herniated contents shoulde completely reduced, and no effort made to remove theernia sac. At this point, a metric ruler is placed into thebdomen to determine the proximity of the inferior edge ofhe hernia defect to the pubic symphysis. If this measures lesshan 4 cm, plans should be made to proceed with this mod-
fied technique.

12 A.M. Carbonell

Operative Technique

Figure 1 After initial access to the abdomen via an open cutdown technique, laparoscopic ports are placed in ahorizontal configuration far above the hernia defect to allow manipulation and placement of a large enough piece ofmesh without interfering with the ports. This picture demonstrates the surgeon working in the pelvis on a suprapubichernia associated with a large Pfannenstiel incision. (Color version of figure appears online.)


Figure 2 With suprapubic hernias the inferior edge of the defect may be intimately associated with the superior edge ofthe bladder. (A) The intraoperative photo demonstrates the bladder filled with saline and the hernia defect completelyabutting the pubic bone. (B) The CT shows a portion of the bladder herniating into the defect. When the hernia edgelies within 4 cm of the superior most aspect of the pubic bone the surgeon must create a peritoneal flap to enter theprevesical space of Retzius so as to identify the proper bony and vascular structures for safe suture mesh fixation. (Colorversion of figure appears online.)

14 A.M. Carbonell

Figure 3 If the hernia defect edge is less than 4 cm from the pubis, then a peritoneal flap will need to be created to enterthe space of Retzius and Bogros to expose the posterior aspect of the pubic bone, Cooper’s ligaments, and the inferiorepigastric vessels bilaterally. Identification of these key structures will allow the surgeon to place the transabdominalsutures and tacks with pinpoint precision, avoiding injury to any of the surrounding neurovascular structures. Theperitoneum is grasped in the midline at the median umbilical ligament at a level immediately below the hernia defectedge. The surgeon can avoid injury to the bladder at this point by instilling approximately 200 mL of saline through thethree-way Foley catheter, allowing the bladder to become more visible. The peritoneum is sharply incised in ahorizontal fashion toward the epigastric vessels (Lateral umbilical ligaments) on either side. The prevesical space ofRetzius is entered and blunt dissection similar to that used for the laparoscopic, transabdominal, preperitoneal,
inguinal hernia repair is performed. (Color version of figure appears online.)
Figure 4 The flap is raised inferiorly to expose the underlying bony pelvic structures. The dissection proceeds until theposterior aspect of the pubic bone, Cooper’s ligaments, and the inferior epigastric vessels are identified bilaterally.
(Color version of figure appears online.)


Figure 5 (A) After completely delineating the edges of the hernia, 3.5� long 20 gauge spinal needles are placed at theextreme edges of the hernia defect. These spinal needles mark the edges of the hernia, helping to measure the exact sizeof the hernia using an intracorporeally placed thin, plastic, metric ruler. Once the maximum vertical and horizontalmeasurements of the hernia are taken, the overlap superiorly and laterally should be no less than 4 cm. (B) Inferiorly,the overlap onto the pubic bone is calculated as the distance from the edge of the hernia to the superior most aspect ofthe pubic bone plus 1 to 2 cm for overlap below the pubis. (Color version of figure appears online.)

16 A.M. Carbonell

Figure 6 Pretied CV-0 ePTFE sutures are placed with a 1 cm bite, 1 cm in from the mesh edge at the four corners of themesh to serve as the initial transabdominal fixation sutures. Because the inferior portion of the mesh will overlap ontothe pubic bone, the inferior suture should be placed 2 cm from the actual mesh edge. (Color version of figure appearsonline.)


Figure 7 (A) The mesh is rolled from the top and the bottom concomitantly like a scroll. (B) This allows for the meshto be dragged directly into the abdomen. (C) The mesh is then unrolled without having to reorient the mesh once it isin the abdomen. (Color version of figure appears online.)

18 A.M. Carbonell

Figure 8 After unrolling the mesh, the inferior transabdominal suture needs to be retrieved first to ensure adequateoverlap inferiorly where it is most important. (A,B) The suture passer is advanced into the abdomen, puncturing theperiosteum of the pubic bone and grasping one limb of the inferior suture, a second path through the periosteum graspsthe second limb of the suture and brings the inferior portion of the mesh against the pubic bone. (C) Note, the inferiorsuture is not tied down immediately, rather, the suture limbs are held under tension with a hemostat. (Color version offigure appears online.)


Figure 8 Continued

20 A.M. Carbonell

Figure 9 (A) The superior suture and the two lateral sutures are then retrieved transabdominally ensuring a minimumof 4 cm mesh-defect overlap. When the mesh lies tight against the anterior abdominal wall, then the superior and lateralsutures are tied. (B) The superior and lateral portion of the mesh is then fixated to the abdominal wall with spiral tacksevery 1 to 2 cm apart and interrupted #1 permanent suture every 4 to 6 cm. (Color version of figure appears online.)


Figure 10 (A–F) While holding the inferior-most midline suture untied outside the body, a minimum of two additional#1 polypropylene transabdominal sutures are passed through the periosteum of the pubis approximately 2 cm lateralto the first inferior midline suture. The suture must be taken in with the suture passer, advanced through the mesh anda second pass through the mesh retrieves the suture, forming a U-stitch. These sutures are not secured until all of theinferior sutures are placed. This allows the surgeon to hold the mesh loosely upwards with a grasper to allow directvisualization of the suture passer safely traversing the abdominal wall and periosteum. A minimum of three sutures areplaced through the periosteum. More may be placed as space allows. After placing all the inferior sutures, they are
individually tied. (Color version of figure appears online.)

22 A.M. Carbonell

Figure 10 Continued


Figure 10 Continued

24 A.M. Carbonell

Figure 11 (A,B) Further mesh fixation is achieved with spiral tacks every 1 cm and transabdominal #1 polypropylenesuture every 4 to 5 cm circumferentially around the mesh, avoiding placement of sutures or tacks below the iliopubictract. Although several tacks are placed directly into the posterior pubis and Cooper’s ligament laterally, care should betaken because of the close proximity to neurovascular structures. It is unnecessary to reconstruct the peritoneal defect.(Color version of figure appears online.)

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rocedure Outcomese published our outcomes in 36 patients (26 females and

0 males) with a mean age of 55.9 years (range, 33-76) and aean BMI of 31.0 kg/m2 (range, 22-67) underwent LRSPH.19

wenty-two (61%) of the repairs were for recurrent hernias,ith an average of 2.3 previously failed open repairs each

range, 1-11). The mean hernia size was 191.4 cm2 (range,0-768), with an average mesh size of 481.4 cm2 (range,93-1428). All repairs were performed with ePTFE. Meanperating room time was 178.7 minutes (range, 95-290),ith a mean blood loss of 40 mL (range, 20-100). One pa-

ient undergoing her fifth repair required conversion becausef adhesions to previously placed polypropylene mesh. Hos-ital stay averaged 2.4 days (range, 1-7). Mean follow up was1.1 months (range, 1-70). Complications (16.6%) in-luded: deep venous thrombosis,1 prolonged pain greaterhan 6 weeks,1 trocar site cellulitis,1 ileus,1 prolonged se-oma,1 and Clostridium difficile colitis.1 Hernias recurred inwo of our first nine patients, for an overall recurrence rate of.5%. Since initiating the technique of applying multiple su-ures directly to the pubis and Cooper’s ligament (in theubsequent 19 patients), no recurrences have been docu-ented.

iscussionermann Johann Pfannenstiel’s first description of his epon-

Figure 12 At the conclusion of the procedure the 10 mmpasser. All sutures are tied, skin is closed in the standardadmitted to the hospital and discharged once their painappears online.)

mous incision in 51 patients in 1900, reported no incisional p

ernias after a 2-year follow up.20 Recent authors cite a 0.04%o 2.1% incisional hernia rate after Pfannenstiel incision.21,22

here is a paucity of literature regarding the technical aspectsf the repair of suprapubic ventral hernias. Bendavid11 re-orted the Shouldice Clinic experience repairing parapubicernias via an open technique in seven patients. All of hisatients presented with a denuded pubis lacking fascia. Hepproached the defect preperitoneally through the space ofetzius, and placed a polypropylene mesh anchored to theubis and Cooper’s ligaments inferiorly, and full-thicknessbdominal wall sutures superiorly. Although recurrence wasot reported, his results were favorable after a 5 to 48 month

ollow-up with no infections or seromas. Hirasa17 reportedhe first laparoscopic experience with the repair of suprapu-ic hernias. They employed a composite mesh with a 2 to 3m overlap, fixated only with spiral tacks and no transab-ominal sutures in seven patients. After a 4 to 9 month followp in six of the patients, one hernia (14.3%) recurred at 8onths as a result of the mesh pulling off of the abdominalall.There is some evidence to support the use of full-thickness

ransabdominal sutures to ensure adequate mesh fixation.2,7,8

nother important aspect of ventral hernia repair is an ade-uate overlap of mesh from the edge of the hernia defect.2,7

btaining adequate overlap to provide the necessary surfacerea for mesh-host tissue integration is difficult to achieve inernias occurring just above the pubic bone. We develop a

r site is closed with a permanent suture using a suture, and sterile dressings are applied. Patients are typicallytrolled and a diet is tolerated. (Color version of figure

trocafashionis con

eritoneal flap inferiorly similar to the dissection plane for

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26 A.M. Carbonell

aparoscopic, transabdominal, preperitoneal, inguinal herniaepair to identify the critical pelvic structures, and allow forhe safe placement of fixation constructs directly to Cooper’sigaments and the pubic bone. We believe this represents thetrongest tissue of the pelvis, holding suture well enough toely on them almost exclusively for the inferior fixation of theesh. The two recurrences reported in our series occurred in

he first nine patients (5.5% overall recurrence rate).19 Theecurrences occurred just above the pubis before we began tomploy full-thickness, transabdominal sutures incorporatinghe periosteum of the pubis. After this modification, no re-urrences have been documented. This underscores the im-ortance of adequate mesh fixation with sutures to the strongony or ligamentous structures as opposed to the attenuateduscle at the hernia’s border.Although technically demanding, the LRSPH is technically

easible, safe, and results in a low recurrence rate. It can beerformed with low morbidity in very large and recurrenternias. Transabdominal suture fixation to the bony and lig-mentous structures yields a durable hernia repair.

eferences1. Burger JW, Luijendijk RW, Hop WC, et al: Long-term follow-up of a

randomized controlled trial of suture versus mesh repair of incisionalhernia. Ann Surg 240:578-583, 2004; discussion 583-585

2. Heniford BT, Park A, Ramshaw BJ, Voeller G: Laparoscopic repair ofventral hernias: Nine years’ experience with 850 consecutive hernias.Ann Surg 238:391-399, 2003; discussion 399-400

3. DeMaria EJ, Moss JM, Sugerman HJ: Laparoscopic intraperitoneal poly-tetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia.Prospective comparison to open prefascial polypropylene mesh repair.Surg Endosc 14:326-329, 2000

4. Park A, Birch DW, Lovrics P: Laparoscopic and open incisional herniarepair: A comparison study. Surgery 124:816-821, 1998; discussion821-822

5. Ramshaw BJ, Esartia P, Schwab J, et al: Comparison of laparoscopic andopen ventral herniorrhaphy. Am Surg 65:827-831, 1999; discussion
831-832
6. Stoppa RE: The treatment of complicated groin and incisional hernias.World J Surg 13:545-554, 1989

7. Koehler RH, Voeller G: Recurrences in laparoscopic incisional herniarepairs: A personal series and review of the literature. JSLS 3:293-304,1999

8. LeBlanc KA: The critical technical aspects of laparoscopic repair ofventral and incisional hernias. Am Surg 67:809-812, 2001

9. Joels CS, Matthews BD, Kercher KW, et al: Evaluation of adhesionformation, mesh fixation strength, and hydroxyproline content afterintraabdominal placement of polytetrafluoroethylene mesh secured us-ing titanium spiral tacks, nitinol anchors, and polypropylene suture orpolyglactin 910 suture. Surg Endosc 19:780-785, 2005

0. van’t Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ, et al: Tensilestrength of mesh fixation methods in laparoscopic incisional herniarepair. Surg Endosc 16:1713-1716, 2002

1. Bendavid R: Incisional parapubic hernias. Surgery 108:898-901, 19902. Lobel RW, Sand PK: Incisional hernia after suprapubic catheterization.

Obstet Gynecol 89(Pt 2):844-846, 19973. Losanoff JE, Richman BW, Jones JW: Parapubic hernia: Case report and

review of the literature. Hernia 6:82-85, 20024. Norris JP, Flanigan RC, Pickleman J: Parapubic hernia following radical

retropubic prostatectomy. Urology 44:922-923, 19945. el Mairy AB: A new procedure for the repair of suprapubic incisional

hernia. J Med Liban 27:713-718, 19746. Carbonell AM, Kercher KW, Matthews BD, et al: The laparoscopic

repair of suprapubic ventral hernias. Surg Endosc 19:174-177, 20057. Hirasa T, Pickleman J, Shayani V: Laparoscopic repair of parapubic

hernia. Arch Surg 136:1314-1317, 20018. Matuszewski M, Stanek A, Maruszak H, Krajka K: Laparoscopic treat-

ment of parapubic postprostatectomy hernia. Eur Urol 36:418-420,1999

9. Huang CS, Huang CC, Lien HH: Prolene hernia system compared withmesh plug technique: A prospective study of short- to mid-term out-comes in primary groin hernia repair. Hernia 9:167-171, 2005

0. Pfannenstiel H: Ueber die vortheile des suprasymphysaren fascienquer-schnitts fur die gynakologischen koliotomien. Samml Klin Vortr 268:1735-1756, 1900

1. Luijendijk RW, Jeekel J, Storm RK, et al: The low transverse Pfannen-stiel incision and the prevalence of incisional hernia and nerve entrap-ment. Ann Surg 225:365-369, 1997

2. Griffiths DA: A reappraisal of the Pfannenstiel incision. Br J Urol 48:
469-474, 1976

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aparoscopic Repair of Traumaticiaphragmatic Hernia

arc Zerey, MD, FRCSC, B. Todd Heniford, MD, FACS, andonald F. Sing, DO, FACS, FCCP

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iaphragmatic injuries are not uncommon with rates ashigh as 5% for patients hospitalized after motor vehicle

ccidents, and 15% for patients after penetrating injuries tohe lower chest and upper abdomen.1-3 Left-sided rupture isore common than right-sided rupture (68.5% vs. 24.2%,

espectively), owing to hepatic protection and increasedtrength of the right hemidiaphragm.4

During the initial evaluation and hospitalization of therauma patient, diaphragmatic injuries from either penetrat-ng or blunt thoracoabdominal trauma frequently are missed.nvestigative techniques to diagnose traumatic diaphrag-atic injuries [chest roentgenogram, diagnostic peritoneal

avage, ultrasound, and computed tomography (CT) scan]re limited by their low sensitivity and high false-negativeates.5,6 Reports have documented the effectiveness of lapa-oscopy as a means to diagnose intraabdominal injury inenetrating thoracoabdominal trauma. The surgeon may ef-

ectively visualize abnormal fluid collections as well as injuryo the peritoneum or diaphragm with the introduction of aaparoscope. If there are no apparent signs of visceral injury its mandatory that the surgeon perform a systemic examina-ion of the supra- and infracolic compartment and pelvis. Thentestines should be run using as many additional ports asecessary and the lesser sac inspected through a defect in the

esser omentum and gastric traction and elevation. When aiaphragmatic laceration or hernia has been identified, repair

s mandatory. Latent repair of missed traumatic diaphrag-atic hernias has been associated with a 20% to 36% mor-

ality rate.7,8

Over the past decade, a select group of trauma surgeonsnd advanced laparoscopic surgeons have applied minimallynvasive surgical techniques for the repair of acute diaphrag-

atic lacerations and chronic traumatic diaphragmatic her-ias.9-12 The laparoscopic repair in the acute setting is limitedy the frequent presence of concomitant injuries that reflect

epartment of Trauma, Division of Gastrointestinal and Minimally InvasiveSurgery, Carolinas Medical Center, Charlotte, NC.

ddress reprint requests to Ronald F Sing, DO, FACS, FCCP, Department ofTrauma, Division of Gastrointestinal and Minimally Invasive Surgery,Carolinas Medical Center, 1000 Blythe Blvd MEB 601, Charlotte NC

d28203. E-mail: [email protected]


he severity of the traumatic event. The laparoscopic repair ofhronic diaphragmatic hernias is more difficult because ofntrapment of organs and presence of adhesions. Symptomsf a chronic diaphragmatic hernia are related to the incarcer-tion of abdominal contents in the defect or to impingementf the lung, heart, or thoracic esophagus by abdominal vis-era and include abdominal pain, respiratory distress, andardiac dysfunction.

Nevertheless, with the recent increase in the proficiency inaparoscopic technique, the number of patients having thisondition dealt with laparoscopically is increasing.

Once the diagnosis is made, operative repair is mandated.he decision to proceed laparoscopically depends on theernia itself, the patient, and the surgeon. A hernia amend-ble to laparoscopic repair is one that is typically located onhe left side, that may or may not communicate with thesophageal hiatus but that is less than 10 cm in diameter. Theurgeon must possess advanced laparoscopic skills to per-orm dissection and intracorporeal knot tying. The presencef multiple injuries is not necessarily a contraindication toaparoscopic repair unless the patient is unstable.

perative Techniquesositioning of Patient and Surgeonhe patient is placed in the supine position with legs apartnough to accommodate the operating surgeon (see Fig. 1).he first assistant is located to the patient’s left and secondssistant (laparoscope operator) to the patient’s right. Weavor entry into the abdominal cavity using the open Hassonechnique where a 10-mm port will be placed. Use of a 30-egree (and occasionally a 45-degree) laparoscope is re-uired. After CO2 insufflation, an exploratory laparoscopy iserformed to verify the presence of concomitant injuries oronditions in addition to visualizing the hernia. Four addi-ional 5-mm ports are placed along the subcostal margin athe right midclavicular, subxiphoid, left midclavicular, andeft anterior axillary positions.

rimary Repair of Diaphragmatic Injuryollowing visualization of the hernia defect (see Fig. 2), the
ecision to repair primarily depends on the ability to approx-
27

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mate the edges without undue tension. The standard repairnvolves placement of simple, horizontal mattress (Fig. 2B,) or figure-of-eight zero or number one nonabsorbableraided sutures. After the suture is placed across the defecthe needle is cut and the two free ends are kept together usingtitanium clip. This process is repeated to avoid blindinglylacing a needle across the defect and injuring structures inhe chest or mediastinum. Once all the sutures have beenlaced the clip is removed and sutures are progressively tied

ntracorporeally. A red rubber catheter may be placed in theleural cavity and the air suctioned as the final suture is tiedo minimize a postoperative pneumothorax. Alternatively, ahest tube should be placed in the presence of lung injury.

epair of Diaphragmatic Injury Usingrosthetic Biomaterialaparoscopic visualization reveals incarcerated abdominaliscera through diaphragmatic defect (see Fig. 3). Laparo-copic grasper and scissors are used to reduce hernia con-ents. Use of electrocautery or harmonic instruments isvoided to prevent injury to hernia contents and structuresresent in thoracic cavity and mediastinum (Fig. 3B). When

t has been determined that hernia will be unable to be closedithout undue tension, prosthetic biomaterial is required

Fig. 3C). Prosthetic repairs are performed with expandedolytetrafluoroethylene (ePTFE) mesh (Soft Tissue Patch,

Figure 1

.L. Gore & Associates, Flagstaff, AZ) secured by 0 or 1 (

onabsorbable braided suture, ensuring some overlap be-ond the diaphragmatic defect (Fig. 3D).

esultse recently reported on the feasibility and limitations of a

aparoscopic approach for the repair of acute traumatic dia-hragmatic lacerations and chronic traumatic diaphragmaticernias.13 Thirteen traumatic diaphragmatic injuries were re-aired laparoscopically with four (two acute and twohronic) requiring conversion. Among the laparoscopicallyepaired diaphragmatic injuries, three defects (chronic) wereepaired using ePTFE and nine were repaired primarily. Theean length of the diaphragmatic defects was 4.6 cm (range,

.5-12 cm). The mean operative time was 134.7 minutesrange, 55-200 minutes). The mean estimated blood loss was08.5 mL (range, 30-500 mL), and the postoperative lengthf stay was 4.4 days (range, 1-12 days). There were no intra-perative complications, but three patients developed pul-onary complications (atelectasis/pneumonia). Follow-up

valuation was available for 11 patients. There were no doc-mented recurrences after a mean follow-up period of 7.9onths (range, 1 week to 24 months). Conversion resulted

rom a reluctance or inability to perform laparoscopic suturef transverse diaphragmatic lacerations longer than 10 cmnterior to the esophageal hiatus and adjacent to the pericar-ium (n � 2) or communicating with the esophageal hiatus

oning.

n � 2). The four patients undergoing laparotomy had a

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Laparoscopic repair of traumatic diaphragmatic hernia 29

ean postoperative discharge date of 8.7 days (range, 6-14ays).The feasibility of repairing acute diaphragmatic lacerations

nd chronic traumatic diaphragmatic hernias laparoscopi-ally appears to be based mostly on experience but also onocation. Hernias directly communicating with the esopha-

Figure 2 (A) Diaphragmatic hernia seen laparoscopicallyNJ) across defect; (C) intracorporeal knot tying to close

eal hiatus or anterior to the esophageal hiatus and adjacent a

o the pericardium are extremely difficult to repair using ainimally invasive approach. Anterior to the esophageal hi-

tus the diaphragm is thin, taut, relatively immobile, and inlose proximity to the pericardium. The immobility of theiaphragm anterior to the esophageal hiatus also impedesisualization cephalad into the mediastinum, even with an

lacement of Ethibond suture (Ethicon Inc., Somerville,; (D) repaired diaphragmatic hernia.

; (B) p

ngled laparoscope. Sutures placed too deep in this location


Figure 2 Continued


Figure 3 (A) Diaphragmatic hernia with incarcerated abdominal viscera; (B) reduction of hernia contents and mobili-zation of hernia sac; (C) placement of ePTFE mesh onto diaphragmatic defect; (D) repaired diaphragmatic hernia with
ePTFE mesh.


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ay violate the pericardium, and sutures placed too superfi-ially risk hernia recurrence. The hemidiaphragm is moreobile laterally and near the central tendon, and greater vi-

ualization is provided by retracting the edges of the defectnd placing the laparosocope into the hemithorax. Table 1

eferences1. Brandt ML, Luks FI, Spigland NA, et al: Diaphragmatic injury in chil-

dren. J Trauma 32:298-301, 19922. Ward RE, Flynn TC, Clark WP: Diaphragmatic disruption secondary to

blunt abdominal trauma. J Trauma 21:35-38, 1981

able 1 Indications and contraindications of laparoscopic re-air of diaphragmatic hernia

Indications Contraindications

resence of hernia Unstable patient (absolute)Hernia > 10 cm (relative)Hernia communicating with

esophageal hiatus (relative)

3. Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic

laparoscopy for penetrating abdominal trauma: A multicenterexperience. J Trauma 42:825-829, 1997; discussion 829-831

4. Shah R, Sabanathan S, Mearns AJ, Choudhury AK: Traumatic ruptureof diaphragm. Ann Thorac Surg 60:1444-1449, 1995

5. Aronoff RJ, Reynolds J, Thal ER: Evaluation of diaphragmatic injuries.Am J Surg 144:571-575, 1982

6. Schneider C, Tamme C, Scheidbach H, et al: Laparoscopic managementof traumatic ruptures of the diaphragm. Langenbecks Arch Surg 385:118-123, 2000

7. Hegarty MM, Bryer JV, Angorn IB, Baker LW: Delayed presentation oftraumatic diaphragmatic hernia. Ann Surg 188:229-233, 1978

8. Madden MR, Paull DE, Finkelstein JL, et al: Occult diaphragmaticinjury from stab wounds to the lower chest and abdomen. J Trauma29:292-298, 1989

9. Cougard P, Goudet P, Arnal E, Ferrand F: Treatment of diaphragmaticruptures by laparoscopic approach in the lateral position. Ann Chir125:238-241, 2000

0. Matz A, Landau O, Alis M, et al: The role of laparoscopy in the diagnosisand treatment of missed diaphragmatic rupture. Surg Endosc 14:537-539, 2000

1. Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic inju-ries: Spectrum of radiographic findings. Radiographics 18:49-59, 1998

2. Simpson J, Lobo DN, Shah AB, Rowlands BJ: Traumatic diaphragmaticrupture: Associated injuries and outcome. Ann R Coll Surg Engl 82:97-100, 2000

3. Matthews BD, Bui H, Harold KL, et al: Laparoscopic repair of traumatic
diaphragmatic injuries. Surg Endosc 17:254-258, 2003

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aparoscopic Total Extraperitonealnguinal Hernia Repairruce Ramshaw, MD, FACS

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he laparoscopic approach for inguinal hernia repairwas first reported by Ger, who performed a high liga-

ion of the sac without mesh placement.1 In the early990s, a variety of trans-abdominal laparoscopic ap-roaches were reported, with the trans-abdominal pre-eritoneal (TAPP) approach and the intraperitoneal onlayesh (IPOM) techniques being the most common. Be-

ause of reports of high recurrence rates, the IPOM tech-ique quickly fell out of favor. In 1993 the laparoscopicotal extraperitoneal (TEP) approach was reported by

cKernan.2 The TEP approach allows for mesh placementithin the preperitoneal space, without entering the ab-ominal cavity. Another benefit of this approach is thevoidance of the incision and closure of the peritoneumypically required in the TAPP approach.

I had the fortune of being a resident in Atlanta in 1993,llowing me to travel only a few miles to watch Barry Mc-ernan perform several laparoscopic TEP hernia repairs.ith the help of fellow residents and my attendings, we

ntegrated this technique into all general surgery practices ateorgia Baptist Medical Center that year. Because it is anxtremely difficult procedure to learn, it was advantageous toave over 10 surgeons helping each other learn the tech-ique. On completing residency, the laparoscopic TEP ap-roach became my procedure of choice for essentially all

nguinal hernia repairs in my practice. Contraindications forerforming the TEP technique include age (prepubertal chil-ren) and the inability to tolerate general or regional anes-hesia. Relative contraindications include large scrotal her-ias, previous lower midline abdominal surgery, andrevious mesh placement in the preperitoneal space. I cur-ently use a TAPP approach without reperitonealization, us-ng mesh designed for intraabdominal placement, in theseatients.The primary barrier to performing a successful laparo-

copic TEP inguinal hernia repair is the difficulty associatedith learning the technique. Once mastered, the repair cane performed faster, with better visualization and wider mesh

ivision of General Surgery, University of Missouri Hospital & Clinics, OneHospital Drive, MC414 McHaney Hall, Columbia, MO.

ddress reprint requests to Bruce Ramshaw, MD FACS, Associate Professorof Surgery, Chief, Division of General Surgery, University of MissouriHospital & Clinics, One Hospital Drive, MC414 McHaney Hall, Colum-

mbia, MO 65212. E-mail: [email protected]


overage than the commonly performed open tension-freenguinal hernia repairs, especially for bilateral and recurrenternias. There are several barriers to learning the technique.irst, access to the extraperitoneal space through a small

nfra-umbilical incision is not something a general surgeonas typically done. The extraperitoneal dissection of the

ower abdomen, exposing the myopectineal orifice bilater-lly, can be a daunting task. Balloon dissectors can signifi-antly help a surgeon perform a safe, consistent extraperito-eal dissection, especially early in the learning curve.owever, even with the balloon, accidental placement into

he subcutaneous tissue, within the rectus muscle and insidehe abdominal cavity has occurred. A laparoscopic viewhrough the balloon helps ensure that it has been placed inhe correct space. Usually, the pubis and Cooper’s ligamentre the first structures visualized when the balloon is placedorrectly. However, even when placed in the correct space,nflation of the balloon can injure the bowel or bladder, es-ecially in patients with previous lower abdominal surgery.irecting the balloon more laterally toward the side of theefect and inflating it less than usual can minimize the like-

ihood of injury in these patients, including those who havendergone previous open prostatectomy.Another barrier is the variability of the initial presentation

f the anatomy. Significant preperitoneal fat, presence of annreduced direct hernia, bleeding from the balloon dissec-ion, and previous lower abdominal surgery, can obscure thenatomy. Probably the most dangerous portion of the oper-tion is the lateral dissection, where dissecting too far poste-iorly can increase the risk of inadvertent iliac vessel injury.o minimize this dangerous complication, lateral dissectionhould be done near the anterior extraperitoneal plane, justosterior to the rectus muscle and inferior epigastric vessels.ll structures posterior and lateral to the epigastric vesselshould be carefully dissected posteriorly and medially topen up the lateral extraperitoneal space.Probably the most difficult dissection, even in experienced

ands, is the reduction of a chronic, large indirect sac that isften adherent to the cord and surrounding structures. Re-uction of the indirect sac can add several minutes to therocedure in experienced hands, and may necessitate con-ersion to an open approach for the surgeon early in theearning curve. Another barrier to learning the operation ishe mesh manipulation. Manipulating and orienting a large
esh in a relatively small space can be challenging.

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Laparoscopic total extraperitoneal inguinal hernia repair 35

Operative Technique

igure 1 (A–C) The skin incision is made athe inferior aspect of the umbilicus. Dissec-ion is carried down to the anterior fascia ofhe rectus muscle just lateral to the midline.f the incision is made away from the hernia,here will be less dissection of that groin byhe balloon (more dissection in the ipsilat-ral groin). However, there will be moreoom to work because the 10 mm trocar andcope will be farther away from the groinith the hernia defect. If the hernia is bilat-

ral, I usually place the incision on the sideway from the larger hernia defect, to allowore room to work there. If, however, there

s previous lower abdominal surgery on oneide or the other (a previous RLQ appy scaror example), I will direct the balloon to theontralateral side, away from the previouscar to minimize the chance of tearing theeritoneum. (Color version of figure appearsnline.)

36 B. Ramshaw

Figure 2 (A–D) Following the anterior fascia incision, I use my finger to sweep the rectus muscle off the posterior fasciafrom the midline. This is important to ensure proper balloon dissector placement. If this space cannot be entered, or ifthe peritoneum is injured, the same dissection may be performed on the contralateral side. There are advantages anddisadvantages of placing the balloon dissector on the side of the hernia. The dissection is better; however, the balloonmay dissect the inferior epigastrics off the anterior abdominal wall, making the repair more difficult. Also, with thelaparoscope closer to the ipsilateral groin, there is a smaller space in which to work. (Color version of figure appears
online.)

Ft1rama


Figure 3 (A–C) The balloon dissector is placed in the space between rectus muscle and posterior fascia, and directeddown to the pubis. The canula is removed and the zero degree, 10 mm laparoscope is used. The dissector is inflatedwhile the space is viewed laparoscopically. The pubis and Cooper’s ligaments should be identified as well as rectusmuscle fibers, which are seen anteriorly, not posteriorly, through the balloon. After appropriately dissecting thepreperitoneum, the balloon is left in place briefly for tamponade and then deflated and removed. (Color version of
figure appears online.)
igure 4 A 10 mm balloon tip or other Hassan type trocar is placed, andhe extraperitoneal space is insufflated to a maximum pressure of 10 to2 mmHg. Two 5 mm trocars are placed in the low midline between theectus muscles. I usually place the first trocar about one finger breadthbove the pubis and the final trocar halfway between the end of the 10m trocar and the suprapubic 5 mm trocar. (Color version of figure

ppears online.)

38 B. Ramshaw

Figure 5 (A–D) Medial dissection is usually accomplished by the balloon dissector. However, an unreduced directhernia will obscure the medial anatomy. Careful reduction of the hernia sac and counter traction of the weakenedtransversalis fascia with graspers will allow for complete reduction and exposure of the medial anatomy. Hernias mayalso be reduced from the femoral space, between the iliopubic tract and Cooper’s ligament, and the obturator space,
posterior to Cooper’s ligament. (Color version of figure appears online.)


Figure 5 Continued

40 B. Ramshaw

Figure 6 (A,B) The lateral anatomy is usually not exposed by the balloon dissection and it is important to attempt toidentify inferior epigastic vessels to guide initial lateral dissection. The vessels should be retracted anteriorly and all cordcontents should be carefully dissected off of the anterior and lateral abdominal wall to expose the lateral anatomy. Thetransversus arch fibers join the iliopubic tract to form the lateral border of the indirect space. The iliopubic tract travelslaterally, parallel and deep to the inguinal ligament. The cutaneus nerves (lateral femoral cutaneous, femoral branch ofthe genitofemoral and their branches) usually travel on the psoas muscle and leave the extraperitoneal space at or nearthe level of the iliopubic tract. For this reason, fixation lateral to the cord and posterior to iliopubic tract is avoided.However, it is possible, because of previous surgery or anatomic anomaly, for nerves to course anterior to the iliopubictract. Therefore, fixation anterior to the iliopubic tract should be approached with caution. (Color version of figure
appears online.)


Figure 7 (A,B) Once the lateral dissection is complete, the cord is explored for an indirect sac and/or a lipoma of thecord. The indirect hernia sac will usually be located on the anteriomedial portion of the cord and may be more difficultto reduce than a direct hernia. A lipoma of the cord is usually found at the end of the sac anteriolaterally on the cord.Fatty tissue within the cord vessels or fat posterior to the iliopubic tract will bleed if grasped and reduced, but a lipomaof the cord will usually reduce easily from the internal ring, with minimal or no bleeding. (Color version of figure
appears online.)

42 B. Ramshaw

Figure 8 The vas deferans lies posteriomedially and the vessels lie on the psoas muscle posteriolaterally. They join at theinternal ring and form a triangle (with the peritoneal reflection forming its base) called the triangle of doom, where theiliac vessels are found posteriorly. Posteriolaterally, the peritoneal reflection should be taken back to the level of theumbilicus by gently peeling the peritoneum off the cord structures, psoas muscle, and lateral abdominal wall. Medially,the peritoneum should be dissected off the iliac vein and obturator foramen. Sometimes, a plug of preperitoneal fattytissue may be reduced from the obturator space. This dissection will allow for appropriate placement of a large mesh
and minimize the chance of herniation around the mesh edges. (Color version of figure appears online.)


Figure 9 (A,B)With theTEP technique for inguinalhernia repair, there are traditionally two typesofmeshpreparation: ameshwitha slit or a mesh without a slit. The mesh that is slit is passed around the cord allowing the cord to hold the mesh down posteriorly,preventing herniation at the posterior edge of the mesh. The slit should be overlapped and fixed, attempting to prevent herniationthrough the mesh slit. If the mesh is not slit it is very important to make sure that the peritoneum does not protrude under the meshwith the cord. To avoid recurrence, the peritoneum is dissected to the level of the umbilicus, and the posterior edge of the mesh isheld down with a grasper during deflation of the extraperitoneal space. There are now newer meshes with different shapes anddesigns, adapted for laparoscopic inguinal hernia repair. I currently use a mesh that is shaped to conform to the preperitonealinguinal anatomy. It has a posterior flap with a velcro-like patch that is placed behind the cord. Another flap is then placed anteriorto the cord and fixed to the velcro-like patch to provide fixation posteriolaterally where point fixation devices cannot be used. Thismeshwasdesignedtominimize thechanceofherniationthroughaslit in themesh,or fromunder theposterioredgeofmesh.Otherpotential solutions include using an additional piece of mesh to completely cover the slit if a slit mesh is used or using a glue to fixthe mesh posteriolaterally if a mesh without a slit is used. I continue to use minimal point fixation because of the possibility of meshcontractionormigration,and/or folding thatmayoccurwithany typeofmeshmaterial.Multipleanimal studiesappear toshowthatheavyweight polypropylene mesh is more likely to contract than polyester or lightweight polypropylene. I usually use three pointsof fixation in addition to the velcro-like fixation posteriolaterally. One is at the superiolateral corner of the mesh. This corner islocatedat the lateral abdominalwall above the iliaccrestat the levelof theumbilicus,well away fromthenervesat risk for injury.Theother two points of fixation are medial, to Cooper’s ligament posteriorly and anteriorly to the lower rectus muscle. For bilateralhernias, the mesh should overlap at the midline and the mesh overlap is fixed in two areas, one near the pubis and one at the lowerrectus muscles. The mesh should cover all hernia and potential hernia defects and widely cover the myopectineal orifice. It is fixed
well away from the nerves. (Color version of figure appears online.)

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44 B. Ramshaw

ummaryhe patient is usually able to go home on the day of surgerynd is allowed to return to activity as tolerated. A prescriptionor pain medicine is given to the patient and the patient issually able to switch to antiinflammatories in the first feways. Bruising and swelling of the groin, penis, and scrotum

s not uncommon and ice and/or a jockstrap may be used foromfort. Urinary retention in the first 24 hours and consti-ation in the first few days are also possible and managementtrategies should be discussed with the patient. Significantound and mesh complications are extremely rare with the

aparoscopic TEP inguinal hernia repair. Drainage from the0 mm incision is the most common wound complicationnd usually only requires a dry dressing. After the repair ofarge hernias, seromas, and/or hematomas are possible as aesult of serous fluid and/or blood collection in the spacereated by the hernia reduction. The patient should be edu-
ated and forewarned of this possibility and told that usually
o treatment is required. Rarely, aspiration may be consid-red if there are significant symptoms.

In conclusion, the total extraperitoneal approach for lapa-oscopic inguinal hernia repair can be utilized for almost alldult inguinal hernias. The ability to visualize the entire groinilaterally, widely cover the myopectoneal orifice, and se-urely fix the mesh to healthy abdominal wall tissue awayrom nerves will result in a highly effective repair.

cknowledgmentshe author thanks Bill Winn (Medical Illustrator) and Brandytockton (Administrative Assistant).

eferences. Ger R, Monroe K, Duvivier R, Mishrick A: Management of indirect in-

guinal hernias by laparoscopic closure of the neck of the sac. Am J Surg159:370-373, 1990

. McKernan JB, Laws HL: Laparoscopic repair of inguinal hernias using a
totally extraperitoneal prosthetic approach. Surg Endosc 7:26-28, 1993

LIM

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aparoscopic Transabdominal Preperitonealnguinal Hernia Repairichael J. Rosen, MD

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hen considering a laparoscopic approach for repairinginguinal hernias, the surgeon has several options. Ini-

ially laparoscopic repairs involved an intraperitoneal onlayesh. Using this technique, the surgeon placed a large piece ofesh in an intraperitoneal position, similar to a laparoscopic

entral hernia repair. This approach has largely been abandonedecondary to high recurrence rates and the drawbacks of intra-eritoneal mesh. The remaining two techniques include a totallyxtraperitoneal (TEP) and a transabdominal preperitonealTAPP) approach. The main difference between these two tech-iques is the sequence of gaining access to the preperitonealpace. In the TEP approach, the dissection begins in the preperi-oneal space with a balloon dissector. In the TAPP approach, thereperitoneal space is accessed after initially entering the perito-eal cavity. Each approach has its own merits. Using the TEPpproach, the preperitoneal dissection is quicker, and the po-ential risks of intraperitoneal visceral damage are minimized.owever, the use of dissection balloons can be costly, the work-

ng space is more limited, and in the case of prior preperitonealurgery or mesh the space may be impossible to create. Addi-ionally, if large tears in the peritoneal flap are created during aEP, the potential working space can become obliterated neces-itating conversion to a transabdominal approach. For theseeasons, knowledge of a transabdominal technique is essentialhen performing laparoscopic inguinal hernia repairs. The

ransabdominal approach allows immediate identification of theroin anatomy before extensive dissection and disruption ofatural planes. The larger working space of the peritoneal cavityan make early experience with the laparoscopic approach safernd easier. The TAPP is the preferred approach of the author andill be described herein.There are no absolute contraindications to laparoscopic

nguinal hernia repair other than the inability to tolerate gen-ral anesthesia. Patients who have had extensive prior lowerbdominal surgery can require significant adhesiolysis anday be best approached anteriorly. In particular patientsho have had a radical retropubic prostatectomy with thereperitoneal space previously dissected can make accurateafe dissection challenging.

epartment of Surgery, University Hospitals of Cleveland, Case WesternReserve School of Medicine, Cleveland, OH.

ddress reprint requests to Michael J. Rosen, Assistant Professor of Surgery,Department of Surgery, University Hospitals of Cleveland, Euclid Ave,

mCleveland, OH 44106. E-mail: [email protected]


reoperativeoutine use of Foley catheterization is not performed. Theatients are instructed to empty their bladder before enteringhe operating room. A single dose of a first generation ceph-losporin is given and sequential compression devices arepplied. The patient is placed under general anesthesia, bothrms are tucked at the patients’ side, and the abdomen androin are sterilely prepped. The surgeon stands on the sidepposite the hernia and the first assistant stands on the ipsi-ateral side of the hernia along with the scrub nurse. The lapa-oscopic tower is positioned at the foot of the table (Fig. 1).

rocar Positioninghe abdomen is accessed via an open Hasson technique

hrough an infraumbilical incision. The abdomen is insuf-ated to 15 mmHg. A 5 mm 30 degree laparoscope is then

nserted and a general inspection of the abdominal cavity iserformed. The pelvic floor is evaluated and the pathology ofhe inguinal anatomy is examined (Fig. 2). Two additional-mm ports are placed in line with the umbilicus and just

ateral to the inferior epigastric vessels. These trocars shouldemain above the umbilicus to avoid interference with thereperitoneal flap dissection. Additionally, placing these tro-ars too far laterally can result in difficulty navigating instru-ents across the abdominal viscera (Fig. 3). Using an angled

-mm laparoscope, the surgeon can stand on the oppositeide of the hernia and use the middle trocar as a working port.he camera operator uses the lateral 5-mm port ipsilateral to

he defect for visualization.

eritoneal Flap Dissectionhe patient is placed in a slight Trendelenberg position. Theissection begins at the ipsilateral medial umbilical fold. Thereperitoneal flap is raised from a medial to lateral directionsing the curved scissors with monopolar cautery. It is impor-ant to begin this dissection rather cephalad on the abdominalall to leave enough space for reduction of the hernia and place-ent of an appropriately sized piece of mesh (Fig. 4). Addition-

lly, as the initial incision is carried laterally, one should avoidhe temptation to drift inferiorly toward the inguinal canal, againompromising the eventual space necessary for mesh place-
ent. The proper incision carries transversely across the ab-
45

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46 M.J. Rosen

ominal wall toward the anterior superior iliac spine. Whenraversing across the plane, one must be cautious and avoid thepigastric vessels. Achieving the appropriate dissection plane isritical to the success of the operation. Although the dissection is

Figure 1 Patient positioning and operating room setup forusing middle and lateral trocar working ports. First assistucked bilaterally at sides, with monitor at foot of bed.

ypically below the arcuate line there tends to be an attenuated a

ransversalis fascia that is adherent to the rectus muscle. Theppropriate plane is just superficial to the peritoneum. By grasp-ng the inferior cut edge of the peritoneum and retracting ceph-lad the preperitoneal space is created by gently pushing away

guinal hernia. Surgeon stands on opposite side of herniaands on ipsilateral side of hernia with camera. Arms are

left intant st

nd dividing the loose filmy attachments (Fig. 5). The first struc-

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Transabdominal preperitoneal inguinal hernia repair 47

ure identified is Cooper’s ligament. By sweeping down the blad-er staying high on the anterior abdominal wall one eventuallyncounters this white firm ligament. Even in unilateral hernias,routinely sweep the bladder far medially past the midline torovide adequate mesh overlap. Cooper’s ligament is cleared off

aterally until a fairly constant crossing vessel is identified. Thiso-called “aberrant” obturator vessel is present in over 75% ofatients. Next, the lateral dissection is begun. Unlike the medialissection plane which typically can be developed bluntly allow-

ng the preperitoneal fatty tissue to divide in its natural plane, theppropriate plane for the lateral dissection is directly on theeritoneum which can typically be quite thin. The lateral dissec-ion is carried medially until the spermatic vessels and then theas deferens are encountered. One must use extreme cautionhen using electrocautery in the preperitoneal space, as a loopf intestine can be just below the peritoneal flap with energyasily transmitted through the flap.

issection of Hernia Sact this point the hernia sac should be reduced (Fig. 6). If airect defect is encountered, the hernia contents are graspednd the attenuated transversalis fascia is gently teased away.

Figure 2 Inguinal anatomy of the right side. Location ofvessels.

f an indirect hernia is identified, the sac is likewise grasped i

nd retracted while bluntly sweeping off attachments to theord structures. Large chronic indirect sacs can be particu-arly challenging. In cases where the hernia sac cannot beompletely reduced, it can be transected and either suturedr closed with an endoloop leaving the distal end open. Anyord lipoma typically located inferior and lateral to the cordtructures should be completely reduced to avoid potentialonfusion as a recurrence. These lipomas do not need to beesected and can be left in the preperitoneal space. Once theernia sac is completely reduced, the peritoneal flap shoulde dissected at least 3 cm off the vessels and cord structures torevent any drag coefficient from allowing peritoneum toneak under the mesh, predisposing to recurrence. The up-er flap of peritoneum is then grasped and retracted cephalado develop a larger pocket for the mesh.

lacement of Mesht least a 12 � 14 cm piece of polypropylene mesh is utilized.e do not place a slit for wrapping around the cord struc-

ures as recurrences have occurred through these defects.he mesh is grasped at the medial aspect. We do not roll theesh tightly as this just makes unraveling more difficult once

ct and direct space in relation to the inferior epigastric
indire
nside the patient. The mesh is brought in through the

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48 M.J. Rosen

0-mm trocar and tucked medially into the pocket. The su-erior medial corner of the mesh is grasped and broughtnteriorly while the inferior instrument pushes the meshgainst the abdominal wall. While some groups advocate noesh fixation, we currently believe some form of mesh fixa-

ion is important to prevent migration. Once the mesh isituated we place one tack in Cooper’s ligament. By onlylacing one tack, the mesh can still be rotated to obtain ideal

ateral placement. However, the mesh will not migrate duringateral retraction. We then place a spiral tack at the superiorateral aspect of the mesh. It is critical that the tip of the tackeran be palpated with the nondominant hand of the surgeonhrough the anterior abdominal wall before deploying anyacks. If the tacker can not be palpated it indicates that it isikely below the iliopubic tract and therefore the lateral fem-ral cutaneous, genital-femoral, or femoral nerve could be

Figure 3 Trocar positioning. Note two lateral ports arecus.

ntrapped. We then place one tack just lateral to the inferior s

pigastric and one at the superior medial border of the mesh.inally, another tack is placed in Cooper’s ligament (Fig. 7).t the conclusion, the peritoneum is re-examined with par-

icular concern over the vessels to ensure it is not encroachingnderneath the mesh. No tacks can be placed in the “trianglef doom” bordered by the vas deferens medially and thepermatic vessels laterally which contains the iliac artery andein.

eritoneal Closurehe peritoneal flap is then secured to the anterior abdominalall. This can be completed with spiral tacks, staples, or

uturing. Any defects in the peritoneum should be closed.ccasionally, the reduced hernia sac can be used to close

hese defects. If a large hole in the peritoneum is created,

eral to the inferior epigastrics in line with the umbili-
just lat
everal maneuvers can aid closure. The peritoneal flap dis-


Figure 4 Dissection of peritoneal flap. The flap begins at the medial umbilical fold. Note the length above the inguinal
structures high on the anterior abdominal wall. Care is taken to avoid the epigastric vessels.
Figure 5 The inferior flap is grasped and retracted while the loose filmy attachments of the preperitoneal space are
dissected free. The medial dissection is completed clearly identifying Cooper’s ligament.

Figure 6 The indirect hernia sac is carefully reduced off of the cord structures.

50 M.J. Rosen

Figure 7 The mesh is secured to the anterior abdominal wall with spiral tacks. No tacks are placed below the iliopubic
tract.

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ection should be extended inferiorly to gain laxity for clo-ure, the pneumoperitoneum pressures can be reduced to 8o 10 mmHg to decrease tension, and the patient can be takenut of the Trendelenberg position. For left sided defects, theigmoid colon can be released from its peritoneal attach-ents. The umbilical port is closed with a single figure of

ight resorbable suture and the abdomen is desufflated.

pecial Considerationsn cases of bilateral hernias, we use two separate pieces ofesh that are secured together in the midline. The mesh is
laced in the first hernia but the peritoneum is not closed w
ntil the other side is completed in case the mesh is acciden-ally displaced.

In cases of prior preperitoneal hernia repairs, occasionallyhe peritoneal flap is completely destroyed and in those casesne can consider an onlay technique.

ostoperative Carehe patients are typically discharged home from the recoveryoom. The patients must void before discharge as urinaryetention can be an issue especially in bilateral hernias. Theatients are instructed to avoid heavy lifting for several weeksostoperatively. Patients are followed in the office at 2 and 6
eeks.

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aparoscopic Flank Hernia Repairrchana Ramaswamy, MD, and Bruce Ramshaw, MD

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lank hernias occur between the costal margin and theiliac crest. Primary acquired hernias tend to form in the

nferior lumbar triangle (of Petit) and superior lumbar trian-le (of Grynfeltt). The superior lumbar triangle is bounded byhe 12th rib, paraspinal muscles, and internal oblique musclehereas the inferior lumbar triangle is bounded by the iliac

rest, latissimus dorsi muscle, and external oblique muscle.nnamed hernias can also occur in the flank anywhere

hrough muscular and fascial defects.Flank hernias are uncommon defects without any well-

eported incidence. The acquired defect can be primary orecondary to trauma, infection, or surgery. Primary defectsomprise 50% of flank hernias with secondary and congeni-al comprising the rest. Post surgical hernias can follow flankncisions primarily for kidney or adrenal surgery and lessrequently after iliac bone graft harvesting, retroperitonealascular procedures or abscess drainage. The incidence ofernia after flank incision for urologic surgery has recentlyeen reported as high as 31%. The risk of hernia formationas been associated with age greater than 50, wound infec-ion, abdominal wall hematoma, and hypoproteinemia. Over0% of these hernias were detected within 1 year of surgery.1

Flank hernias usually present as a posterior bulge that maye asymptomatic, or may be associated with mild or severeiscomfort from nerve compression. Acute incarceration,hough infrequent, is more commonly seen with a primarycquired defect. The diagnosis can be difficult and often im-ging studies are helpful to distinguish a hernia from a softissue lesion, hematoma, abscess, renal lesion or muscularaxity. Imaging studies (commonly CT or MRI) are also help-ul in identifying the anatomical boundaries of the hernia.

epartment of Surgery, University of Missouri, Columbia, MO.ddress reprint requests to Bruce Ramshaw, Department of Surgery, Uni-

versity of Missouri, 1 Hospital Dr. MC 414, Columbia, MO, 65212.E-
lmail: [email protected]

his is useful for surgical planning because healthy tissueeeds to be identified for mesh fixation. With intraabdominalressure and presumed muscle atrophy, the natural historyf flank hernias tends to be an increase in size. Because repairf large flank hernias can become very complex with increas-ng size, consideration should be given to early repair inndividuals who do not have medical contraindications tourgery.

Techniques for open repair of flank hernias have rangedrom layered closure with muscular and fascial flaps to these of prosthetic material. Laparoscopic flank hernia repair isased on the principles of laparoscopic repair for ventralernias: adequate overlap of mesh with healthy tissue andppropriate fixation. These two requisites for a durable repairre often challenging in the flank. Posteriorly, the mesh issually fixed to the paraspinal muscles (sacrospinus, serratusosterior inferior, latissimus dorsi) with attention being paid,

n large hernias, to the position of the inferior vena cava.uperiorly, fixation can often be applied just below the costalargin with a flap of mesh extending up to the diaphragm. As

ur experience has increased with these hernias, we haveound that with defects that extend right to the costal marginack fixation can be performed at the level of a superior rib,eing careful to avoid the diaphragm and thus the mediasti-al organs. Inferior fixation can also be difficult with hernialefects extending to the iliac crest. In these situations, fixa-ion can be accomplished through the iliac crest by using

itek anchors or simply by drilling through the bone. Weave chosen to leave power tools to our orthopedic col-

eagues and perform a dissection similar to that for an ingui-al hernia, identifying Cooper’s ligament and the iliopubicract and obtaining solid fixation at Cooper’s ligament, drap-ng a leaf of mesh into the pelvis. Prosthetic material shoulde appropriate for intraperitoneal use: e-PTFE or composite

ightweight polypropylene or polyester.

Laparoscopic flank hernia repair 53

Operative Technique

Figure 1 After intubation, antibiotic administration (usually first generation cephalosporin) and thromboembolicprecautions, bladder catherization is performed. Patient positioning is then undertaken with diligence. We position thepatient in full lateral decubitus, using a bean bag if necessary, being careful to allow easy access to the area of theparaspinal muscles. The kidney rest can be used to open up the space between the costal margin and the iliac crest. Theipsilateral arm needs to be suspended in a similar manner as that used for positioning for adrenalectomy. The surgeonand assistant are positioned on the same side with the tower and monitor being placed just opposite. A monitor on theother side can be useful during suture fixation at the posteromedial border through the paraspinal muscles. The skinis then prepped widely and an adhesive skin barrier is used to keep the drapes in place.

Figure 2 Initial access is usually gained at the infraumbilical position using an open approach to place a 10 mm port.Two 5 mm ports are then usually placed in the midline above and below the camera port. A fourth trocar is sometimes
placed through the paraspinal muscles and will be discussed later.

54 A. Ramaswamy and B. Ramshaw

Figure 3 Initial view of the right flank hernia may demonstrate incarcerated contents including small and large bowel.Also important to note is that the initial view may not provide a realistic estimate of the hernia size because a large
portion of the defect is masked by the overlying colon.
Figure 4 After reduction of any incarcerated contents, the colon then needs to be mobilized. With significant incarcer-ated contents, the peritoneum is often stripped down allowing access into the retroperitoneal space as the contents arereduced. If there aren’t any incarcerated contents, the white line of Toldt can be incised to begin mobilizing the colon.The kidney may also have to be mobilized lateral to medial if the hernia defect extends posteriorly. Adequate dissectionhas been performed when there is at least 4 cm of exposed abdominal wall circumferentially around the hernial defect.
Energy sources are usually avoided during the initial dissection to avoid the risk of transmitted injury to the bowel.


Figure 5 The hernia defect is then sized using spinal needles if needed. The mesh is chosen to provide at least 4 to 5 cmoverlap with healthy tissue. This overlap with healthy tissue can be limited depending on the extent of the defect;hernias which extend to the costal margin or the iliac crest will be addressed later. With large posterior extension of thedefect, it is imperative to assure that there is adequate tissue lateral to the spine for fixation. If this is lacking, there is ahigh expected risk of recurrence since the mesh will pull away from the defect edge. Preoperative CT scan is of valueto identify these situations and to appropriately select patients for surgical management. Once the appropriate sizemesh is chosen, four nonabsorbable sutures are placed, knots tied, and the tails left long. Sites for pulling through thetransfascial sutures are marked on the skin, and the mesh is then marked for orientation, inserted into the abdominalcavity and unrolled. The sutures are then grasped with a suture passer and pulled through the abdominal wall. Theseare not tied down until all four sutures have been pulled through to allow adequate visualization of the entry of thesuture passer and of the suture tails. We begin with the posteromedial suture because there can often be no modifica-
tions made to the site of suture pull through because of limitations in this area secondary to the spine.


Figure 6 The next suture pulled through the abdominal wall can be the inferior or superior one. After fixation with thefirst two sutures, tension should be placed on these to pull the mesh up to the abdominal wall. The mesh should thenbe pulled taut at the unfixed superior or inferior end to see if the site marked externally for suture pull through needsto be modified. This maneuver is similarly performed for the anteromedial suture. The mesh should be stretched taut
so that once the pneumoperitoneum is deflated the mesh will configure to the natural curve of the abdominal wall.
Figure 7 Tacks are then placed circumferentially at 1 cm intervals. Additional transfascial sutures should be placed
when a large mesh is being used, at 4 to 5 cm intervals around the mesh.


Figure 8 (A,B) For large defects, a trocar may need to be placed through the paraspinal muscles to obtain an angle toapply fixation for the anteromedial edge of the mesh. Depending on the posteromedial extent of the mesh fixation, this
5-mm trocar may be medial to the mesh or come through the mesh.


Figure 9 A hernia defect that extends to the level of the iliac crest will require either fixation through the bone, or fixationdown in the pelvis. We choose to identify Cooper’s ligament and place tacks at this level, leaving a skirt of mesh drapedinto the pelvis. The inferior edge of the mesh is also fixed just anterior to the iliopubic tract, both with tacks and sutures.Similar to an inguinal hernia repair, no fixation should be placed below the iliopubic tract to avoid nerve and vascular
injury.


Figure 10 For fixation, with the defect edge bordering on or in close proximity to the costal margin, the mesh is sizedand positioned to provide a 5 cm flap above the costal margin. Transfascial fixation is then performed just subcostallyand tack fixation is performed at the level of a rib. Intercostal vessel injury is a theoretical risk, though unlikely sincethe tacks are only 3.8 mm long and need to first go through at least a 1 mm mesh. Of importance here is to avoid placing
any tacks in the diaphragm to minimize risk of cardiac or lung injury.

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igure 11 Appearance after the final fixation has been completed,
pplicable in a patient with a small hernia.
Falevel of Cooper’s ligament and up to the diaphragm.

igure 12 Appearance after the final fixation has been completed,pplicable for a large hernia when fixation is required both at the
evel of Cooper’s ligament and up to the diaphragm.
igure 13 Appearance after the final fixation has been completed,pplicable for a large hernia when fixation is required both at the

Figure 14 CT scan image of right flank hernia following repair.

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Postoperative care is similar to that for laparoscopic ventralernia repair. Early ambulation is encouraged. The bladderatheter is removed in the immediate postoperative periodor simple cases or on ambulation for large repairs. Adequatenalgesia can be achieved with regular administration of non-teroidal anti-inflammatory agents in addition to narcoticsith a PCA if needed. Epidural analgesia is currently being

valuated for efficacy in patients undergoing laparoscopicentral hernia repair. Oral intake is allowed on the day ofurgery and advanced as tolerated by the patient. Venoushromboembolic prophylaxis should be undertaken untilhere is adequate ambulation. Postoperative seromas are fre-uent and usually resolve spontaneously over 4 to 6 weeks.bdominal binders may be used for patient comfort. We doot routinely drain seromas, and will only consider it after arolonged period in a severely symptomatic patient since theisk of introduction of bacteria into a sterile collection exists.

Short term outcomes have been good in our initial experi-

nce. Of our first 10 cases, nine were incisional hernias, andne was posttrauma. Median hernia diameter was 222 cm2

25-780 cm2) and median size of mesh was 600 cm2 (96-368 cm2). Median operative time was 137 minutes (81-322inutes). There were no intraoperative or postoperative

omplications and median hospital stay was 2.5 days (0-6ays). There were no complications or recurrences at 1onth follow up.In conclusion, laparoscopic repair is well suited for flank

ernias because there is clear visualization, and wide cover-ge and secure fixation can be achieved. Good knowledge ofroin and retroperitoneal anatomy is required and patientositioning is key to accessing this difficult region.

eference. Delgado MS, Urena MAG, Garcia MV, Marquez GP: La Eventracion

Lumbar Como Complicacion de la Lumbotomia Por el Flanco: Revisio
de Nuestra Serie. Actas Urol Esp 26:345-350, 2002

2006, vol.8, no.1, techniques of laparoscopic hernia repair

Health & Medicine

Transcript of 2006, vol.8, no.1, techniques of laparoscopic hernia repair