2006, Vol.8, No.1, Techniques of Laparoscopic Hernia Repair

Volume 8, Number 1
March 2006
Techniques of Laparoscopic Hernia Repair
here are few surgical topics that so perfectly exemplify the general surgeons task, as does the repair of a hernia. All surgeons know the mighty tome rst edited by Nyhus and Condon entitled Hernia that at last count had over 600 pages, a testament to the complexity, variety, and difculty presented by the treatment of this uniquely surgical condition. With the advent and accelerating role of laparoscopy in all surgical conditions, naturally the hernia would be targeted for care. With its intrinsic advantage of minimizing the size of the incision necessary to access the site of the hernia itself, laparoscopy is now considered by some to be the highly preferred method for surgical management. Its role continues to rapidly expand. As evidenced by the topics presented in this issue of Operative Techniques in General Surgery, ever more complex and demanding hernia repairs are now standard material for the laparoscopic technique. Todd Heniford
in his introductory editorial admirably summarizes and highlights the revolution that has taken place in hernia surgery using the laparoscope. All of the authors that he has drawn on to contribute to this issue are leaders in the eld, some having originated and dened the techniques they describe. The reader is thus witness to another advance in that age-old evolution of the surgical care of the venerable hernia. Walter A. Koltun, MD Professor of Surgery, Peter and Marshia Carlino Professor of Inammatory Bowel Disease Chief, Section of Colon and Rectal Surgery, Penn State College of Medicine, Milton S. Hershey Medical Center Editor-in-Chief
1524-153X/06/$-see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.04.002
Volume 8, Number 1
March 2006
Introduction
was particularly pleased to be asked to organize an edition of this journal dedicated to the laparoscopic management of abdominal and inguinal hernias. Hernias and abdominal wall complications have been a problematic mainstay for physicians since the rst recordings of medical history. Indeed, the signicance of abdominal wall defects has dissipated very little. From the belts and trusses that are so elegantly depicted in drawings from the middle ages to the videos of today that demonstrate laparoscopes, dissecting balloons, and preformed meshes, few topics allow one to analyze the origins and evolution of surgical theory and therapy as well as the study of hernias. Despite more than one million hernia operations performed annually in this country, the perfect hernia repair, which should offer no recurrences, little patient discomfort, and normal body function, does not exist. Signicant to this edition, two important points can be made: (1) laparoscopic herniorrhaphy techniques have earned the status of a legitimate means to manage abdominal and groin defects; and (2) surgeon familiarity with these techniques directly impacts their patients outcome. Hence, I consider this journal, as composed by busy, expert surgeons, as particularly timely and important. Changes in the management of hernias have followed our understanding of their origins and, perhaps more importantly, our failures in their repair. Sutured repair continues to play a valuable role in herniorrhaphy, but suturing a defect under tension or using tissues of questionable strength results in a repair that is doomed to fail. Bridging a hernia with a prosthetic mesh has established a valid position in the repair of not only large or recurrent hernias but also in primary repairs of ventral, lateral, and groin defects. The need for a strong prosthetic that is well tolerated by the human body is not a new thought or concept. In 1857, Bilroth stated, If we could articially produce tissue of the density and toughness of fascia and tendon, the secret of the radical cure of the hernia repair would be discovered. Nearly 150 years later we understand the importance of that statement. Industry also recognizes its worth, both in improving patient outcomes and in providing materials to a million-cases-a-year market. Research in the area of prosthetic mesh has soared over the last decade. This is especially true for the laparoscopic arena, given that most laparoscopic hernia repairs take advantage of the concept of a tension-free repair and require mesh placement. Specic biomaterials have been engineered for placement inside the abdomen, in the preperitoneal space, with nonstick surfaces or antimicrobial coatings, preformed for 2
left or right-sided inguinal hernias (in small, medium, or large sizes), lightweight textiles, etc. There is no perfect biomaterial, but outstanding, well-tolerated choices exist. The organization of this text is fairly simple, but it is designed to cover the majority of the hernias that a surgeon might encounter. The authors are notable experts in their elds, and many of them have the largest series in the world literature on their assigned topic. I thank them for taking the time to provide insight into understanding the anatomic basis of the hernias, supplying me with their proven tactics for the laparoscopic approach for repair of their assigned hernia, and working with the artists to give us insightful drawings. In reviewing each section, I see particular points that are not to be missed. Specic technical tips and tricks that have taken these notable authorities time and repeated cases to perfect are abundant. Reading Dr Ramshaws description of the lumbar hernia repair (one of the most difcult hernias to conceptualize, much less x) and his interpretation of using mesh as a sling from the pubis, iliac crest, para-spinal muscles, and ribs is remarkably insightful and is not to be found in any text but this one. He has undoubtedly spoken to or taught more surgeons about abdominal hernias and their repair than any one person on Earth. Each time I hear him or read his work, I benet from the experience. The sections covering the TEPP and TAPP inguinal hernia repairs complement each other nicely; they demonstrate the same anatomy from different perspectives, and separately, but together, assert why many think these repairs offer excellent coverage of the oor of the abdomen. But, these authors also show why a real understanding of the anatomy and a large piece of mesh separate their results from those in some printed reports by less experienced surgeons and resident surgeons. Dr. Sing has the largest documented series in the world of traumatic diaphragmatic hernias repaired laparoscopically. He has utilized his trauma and laparoscopic know-how to provide a description and pictorial demonstration of both mesh and primary closure that makes the work seem easy. Indeed, the depiction of leaving sutures untied and tagged with clips to allow complete visualization of the nal few stitches is simple but brilliant; those having been there will certainly understand. In the laparoscopic ventral hernia section, Dr. Novitsky provides practiced insight to one of the most difcult aspects of the operation. Mastering a straight forward method for sizing the mesh appropriately and making sure that the prosthetic is taut as it is being secured will help prevent surgeons from having the unfortunate experi-
Introduction
ence of an early recurrence because of a mesh that does not adequately cover the defect or a lax mesh that, unfortunately, parachutes into the hernia and forms an expensive hernia sac. Dr. Carbonell has the largest published experience in the darning of supra-pubic hernias, and he very competently demonstrates the anatomy, mesh placement, and xation of the prosthetic in this not-so-easy hernia repair. Having seen him operate live previously, this description matches his steps in the operating room perfectly. If one reads the TAPP manuscript and follows it with this supra-pubic paper, it will be easy to see why we frequently teach our trainees these techniques in tandem. Dr. Rosens and Dr. Carbonells papers complement one another nicely. Consensus regarding the approach to specic hernias will not be found, even among experts, but these surgeons have documented admirable outcomes with their described techniques. I must, however, emphasize that there is more than one way to x a hernia. For the surgeon reviewing this text, a laparoscopic technique that ts his or her strengths and disposition should be appropriately described. However, there
3 is no method in this text that is a quick x. There are few of those in surgery, and almost none in hernia repair. If there was, one should expect that it would have been discovered in the millions of herniorrhaphies that are antecedent to this text. As I was taught early on, there are simple, straightforward, and wrong ways to do things. The techniques presented here have stood the test of time, as short as it is for laparoscopy, and proven to provide excellent outcomes. Again, I hope that the text provides needed insight to those looking for it, and I thank the experts who provided their knowledge and time to put this together. B. Todd Heniford, MD, FACS Chief, Division of Gastrointestinal and Minimally Invasive Surgery, Director, Carolinas Hernia Center Carolinas Medical Center Charlotte, North Carolina Guest Editor
Laparoscopic Ventral Hernia Repair

Yuri W. Novitsky, MD, B. Lauren Paton, MD, and B. Todd Heniford, MD, FACS
entral herniorrhaphies are among the most commonly performed operations by general surgeons throughout the world. Incisional hernias, with a reported incidence of up to 20%, have become an increasing problem because of the increasing number of laparotomies performed. In the United States, approximately 175,000 ventral abdominal hernias are repaired each year. Surgical approaches to ventral herniorrhaphy have been a subject of research and technical modications for many years. Although the routine use of prosthetic reinforcement for the repair of herniations in adults has been contested, existing evidence strongly supports tensionfree hernia repairs in most patients. With the development and popularization of tension-free repairs using prosthetic meshes, the recurrence rates are typically less than 20%. Large abdominal incisions and wide tissue dissection with the creation of large aps needed for open placement of adequately sized mesh; however, this dissection often leads to a high incidence of postoperative morbidity and wound complications. Recently, open ventral herniorrhaphy has been challenged by reports of successful implementation of minimally invasive techniques. The principles of retro-rectus prosthetic reinforcement have been adapted for laparoscopic ventral hernia repair. The mesh is placed as an intraperitoneal onlay with wide coverage of the hernia defect. Avoidance of large incisions has substantially reduced wound complications. Overall, the clinical benets of laparoscopic ventral hernia repair include a faster convalescence, fewer complications and, importantly, a low recurrence rate.
Techniques of Laparoscopic VHR

After general anesthesia is induced, the patient is positioned supine with the arms adducted and tucked at the sides. This allows for adequate space for both primary surgeon and an assistant on the same side of the patient. We use two monitors, placed on each side of the patient (Fig. 1). In most cases, the bladder and stomach are decompressed with catheters. An antibiotic, usually a rst-generation cephalosporin, is given prophylactically before the incision is made and re-
Department of Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC. Address reprint requests to Dr. Yuri W. Novitsky, Department of Surgery, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, 1000 Blythe Blvd, MED 601, Charlotte, NC 28203. E-mail: yuri.novitsky@carolinas.org
peated if the operation lasts longer than 2 hours. We routinely use an Ioban drape to minimize mesh contact with the patient skin. Laparoscopic hernia repair is performed by using a 30-degree angled laparoscope, 5-mm bowel graspers, scissors, and clip appliers. Access to the peritoneal cavity is gained using a cut-down technique (Fig. 2). A window of access is usually present, even in the multiply operated abdomen, below the patients costal margin between the midclavicular or anterior axillary lines. The initial entry site is chosen just inferior to the tip of the eleventh rib, usually on the left side. We often prefer to then use a balloon-tipped trocar to avoid air leakage. A total of three trocars are placed under direct vision laterally along anterior-to-mid-axillary line. Often, a fourth 5-mm port is placed contralaterally to facilitate intra-abdominal mesh introduction and xation. Port placement for less common defects (subxyphoid, suprapubic, parailiac, spigelian, etc.) is adjusted based on the location of the hernia. On entrance to the abdominal cavity, adhesiolysis is performed sharply with limited use of electrosurgery or ultrasonic coagulators. Reduction of the hernia contents is performed using blunt graspers and sharp dissection from the inside and is facilitated by manual compression from the outside. The hernia sac is usually left in situ. Once the adhesiolysis is completed, the hernia defect is measured to determine an appropriate size of a prosthetic mesh. The borders of the abdominal wall defect are delineated with a combination of laparoscopic vision and external palpation. The edges of the defect are marked externally. Often, placement of spinal needles through the abdominal wall at the internally visualized defect edges is needed to accurately determine the size of the hernia (Fig. 3). This maneuver is especially important in obese patients with large defects as externally measured size of a defect can be dramatically overestimated. A ruler is placed through a 5-mm port, and the dimensions of the hernia defect to allow for the direct measurement of the defect. The mesh is than tailored to overlap all margins of the hernia by at least 4 cm. Once the mesh is cut to the desirable size, four size-0 permanent monolament or ePTFE sutures are placed at the mid-point of each side of the mesh. Points of reference on the mesh and corresponding points on the abdominal wall are marked to aid in orienting the mesh after its introduction into the abdomen. The mesh was rolled up and pushed or pulled into the abdomen through a 5- or 10-mm trocar site. The mesh is rolled from both edges to facilitate the unfolding step (Fig. 4). If the defect size dictates a very large prosthetic it is usually introduced in the abdominal cavity by pulling with
Laparoscopic ventral hernia repair
Figure 1 Patient positioning, room set-up, and our trocar strategy.
the grasper passed through the contralateral trocar. It is important to maintain the appropriate orientation of the mesh during the insertion and unfolding of the mesh. Two Maryland graspers are best used to unfold the mesh. After the mesh is oriented intracorporeally, the sutures are pulled through the abdominal wall with a suture passer (Fig. 5). A 4 cm mesh/defect overlap is once again conrmed using spinal needles, as described above. The suture pulled rst is usually closest to the sensitive border (xiphoid, pubis, iliac crest, costal margin, colostomy, etc.). We subsequently pull the suture that is adjacent (not opposite) to the rst one. Once sufcient overlap is conrmed, we tie both sutures with the knots buried in subcutaneous tissues. The other two sutures are then pulled transabdominally and tied ensuring that the overlap is sufcient and that the mesh is taut (Fig. 5). The perimeter of the mesh is then stapled to the posterior fascia with 5-mm spiral tacks at approximately 1 cm intervals to prevent intestinal herniation. Placing the tacks is facilitated by the external manual palpation of the tackers tip (Fig. 6). This is particularly important for tacking the mesh in the lower abdomen to ensure that the tacks are placed superiorly to the inguinal ligament. Additional full-thickness stitches are placed circumferentially every 3 to 6 cm by using the
suture passer (Figs. 7 and 8). This transabdominal xation is crucial to ensure that the mesh will not be displaced over time. The knots are tied in the subcutaneous tissues. The skin is released to avoid dimpling.
Conclusion
Laparoscopic ventral hernia repair has reliably been shown to be superior to the open approach. Overall LVHR is associated with a decreased perioperative pain, reduced hospital stay, and faster recovery. Postoperative complications are also less frequent in the laparoscopic group (23.2% vs. 30.2%) as well as the incidence of wound and mesh infections (Table 1). In addition, the recurrence rate is 4% for the laparoscopic group and 16.5% for the open technique. Overall, numerous studies demonstrate that laparoscopic ventral hernia repair is an effective and safe approach to the abdominal wall hernia. It can be performed in complex surgical patients with a low rate of conversion to open surgery, a short hospital stay, a moderate complication rate, and a low risk of recurrence. With additional long-term follow-up to support the safety and durability of the procedure, LVHR will likely be considered the standard of care in the future.19
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 identication of the 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 xation.
Y.W. Novitsky, B.L. Paton, and B.T. Heniford
Figure 6 Transabdominal suture xation 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.
Figure 8 Final appearance of the hernia repair. Table 1 Comparison studies of laparoscopic and open ventral hernia repairs # Patients Study McGreevy Raftopoulos Wright Robbins DeMaria Chari Carbajo Ramshaw Park Holzman Percent Year 2003 2003 2002 2001 2000 2000 1999 1999 1998 1997 Lap 65 50 90 18 21 14 30 79 56 21 Open 71 22 90 31 18 14 30 174 49 16 Morbidity Lap 5 14 15 13 2 20 15 10 5 23.2 Open 15 10 31 13 2 6 46 18 5 30.2 Mesh infection Lap 2 1 1 1 1 0 0 1 2 0 2.0 Open 0 0 1 4 2 1 3 5 1 1 3.5 Wound infection Lap 0 1 1 1 1 0 6 0 1 2.6 Open 7 1 8 0 4 5 2 2 0 5.8 Recurrence Lap 1 1 1 1 2 6 2 4.0 Open 4 5 0 2 36 17 2 16.5
References
1. 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 2. Novitsky YW, Cobb WS, Kercher KW, Matthews BD, Sing RF, Heniford BT: Laparoscopic ventral hernia repair in obese patients: A new standard of care. Arch. Surg 141:57-61, 2006 3. Rosen M, Brody F, Ponsky J, et al: Recurrence after laparoscopic ventral hernia repair. Surg Endosc 17:123-128, 2003 4. Carbonell AM, Kercher KW, Matthews BD, Sing RF, Cobb WS, Heniford BT: The laparoscopic repair of suprapubic ventral hernias. Surg Endosc 19:174-177, 2005 5. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel 6.
7. 8.
9.
J: Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578-583, 2004 Luijendijk RW, Hop WC, van den Tol MP, et al: A comparison of suture repair 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 polytetrauoroethylene (PTFE) prosthetic patch repair of ventral hernia. Prospective comparison to open prefascial polypropylene mesh repair. Surg Endosc 14:326-329, 2000 Carbajo MA, Martin del Olmo JC, Blanco JI, et al: Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc 13:250-252, 1999
Laparoscopic Repair of Suprapubic Ventral Hernias

Alfredo M. Carbonell, DO
he laparoscopic approach to ventral hernia repair appears to be superior to the traditional open operation. The use of laparoscopy is associated with less pain, a better cosmetic result, a lower incidence of mesh and wound complications, and possibly a lower recurrence rate. As a result of their low prevalence, hernias located in atypical areas may not be seen as frequently by surgeons, leading to a relative inexperience in their repair; and a subsequent higher recurrence rate. The suprapubic incisional hernia is one which is located in close proximity to the pubic bone, arising after urologic or gynecologic procedures. The repair of these hernias can be difcult because of the complexity of dissection and their anatomic proximity to bony, vascular, and nerve structures. This technique article gives the operating surgeon a thorough understanding of the nature of suprapubic hernias and an illustrated step by step approach to the laparoscopic repair of this difcult problem; particularly the transabdominal suture xation to the bony and ligamentous structures of the pelvis. Although technically demanding and time-consuming, the laparoscopic repair of suprapubic hernias yields a durable hernia repair. It is safe, technically feasible, results in a low recurrence rate, and is applicable to large or multiply recurrent hernias. Incisional hernias can develop in up to 20% of patients undergoing laparotomy, and, after a primary repair, these hernias may recur in up to 63% of patients.1 With the development of laparoscopic techniques, the recurrence rate for ventral hernia repair is frequently reported to be below 4%.2-5 Based on the open, retrorectus, Rives-Stoppa6 repair mandating wide coverage of the hernia defect, the laparoscopic approach is associated with few recurrences, rapid hospital discharge, improved cosmesis, a reduced risk of infection, and possibly less postoperative pain.2-5 Certain critical steps are required to ensure a reliable laparoscopic ventral hernia repair, such as a minimum of 4 to 5 cm mesh overlap of the hernia defect, and mesh xation with both full-thickness transabdominal sutures and helical tacks.7,8 Although no randomized, prospective studies have been performed, a strong association has been made in the literature between hernia recurrences and the lack of mesh xation with full-thickness
transabdominal sutures.2,7,8 Additionally, animal studies have demonstrated the superior xation strength of sutures compared with tacks for mesh xation.9,10 The terms suprapubic and parapubic are often used interchangeably. When used to describe hernias, they refer to those located just above the symphysis pubis. They may occur as a result of low mid-line, Pfannenstiel, Maylard, and Cherney incisions used principally for gynecologic, prostatic, or rectal procedures.11 These hernias have also been reported after suprapubic catheterization.12 There is limited experience with the repair of these difcult hernias using both the open11,13-15 and laparoscopic approach.16-18 The abdominal oblique aponeurosis, rectus abdominus musculature, and rectus sheath insert on the symphysis pubis. In the event an incision is placed in proximity to this musculotendinous insertion, a hernia may develop as a result of inadequate tissue purchase inferiorly when re-approximating the fascia. The complexity of dissection and the close proximity of these hernias to bony, vascular, and nerve structures make the repair of suprapubic hernias a formidable operation. We developed a unique technique in the repair of these hernias, and present our 10-year experience, discussing in detail the operative approach.
Preoperative Workup
Patient selection for the laparoscopic approach is up to the individual surgeon. Preoperative workup should include a thorough history of all past surgeries and review of operative reports, particularly if a previous hernia repair with mesh was undertaken. On physical examination the surgeon should palpate the entire incision both in the supine and upright position. Provocative maneuvers should be used to accentuate the hernia bulge and attempt to delineate the inferiormost edge of the defect. For the laparoscopic ventral hernia repair, a minimum 4 cm overlap of mesh past the edge of the hernia defect is recommended; as a result, hernias less than 4 cm from the pubic symphysis are dened as suprapubic and will require this modied approach to repair. Computed tomography (CT) is helpful in determining the exact size of the hernia, its contents, and the relation of the inferior edge to the pubic symphysis. Although we do not typically have the patient undergo CT before hernia repair, we will do so if there is a question regarding proximity of the hernia to the pubic symphysis or if there has been a previous mesh repair. A previous repair with mesh may make the laparoscopic approach difcult, particularly if polypropylene mesh was used
Division of General Surgery, Minimally Invasive Surgery Center, Virginia Commonwealth University Medical Center, Richmond, VA. Address reprint requests to Alfredo M. Carbonell, D.O., Division of General Surgery, Virginia Commonwealth University Medical Center, 1200 East Broad Street, PO Box 980519, Richmond, VA 23298. E-mail: amcarbonell@vcu.edu
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Laparoscopic repair of suprapubic ventral hernias

or a previous laparoscopic repair attempted. This information helps plan out the operative approach.
11 bladder as a tumescent to aid in determination of the bladders location in the preperitoneal space so as to avoid injury to it during the procedure. Should an injury be suspected, methylene blue can be instilled in the irrigant to help identify a cystotomy. The patient is positioned supine with both arms padded and tucked. This allows the surgeon and the assistant to work on the same side of the patient without interference from the patients extended arm. With more obese patients, padding to elevate the tucked arm will ensure there is no undue traction placed on the brachial plexus. The pubic hair is shaven to ensure complete access to the area of the pubic symphysis during the operation. Using a standard iodine skin prep, the abdomen is prepped up to the nipple line, as far lateral as the arms allow, and down onto the thighs. An iodine-impregnated skin drape is used on the abdomen for an added antimicrobial barrier.
Equipment
Instrumentation for the repair is similar to that of the typical laparoscopic ventral hernia repair. We use from three to four trocars for the procedure; at least one being 10 mm in size, the rest may be 5 mm. Because most of the trocars are 5 mm, we use a 5 mm, 30-degree angled laparoscope that will allow the surgeon to change the position of the camera between multiple ports. The angle allows the surgeon to look around corners during difcult portions of the procedure. A Maryland dissector, atraumatic graspers, and laparoscopic shears are required for the lysis of adhesions. We refrain from the use of ultrasonic coagulating shears to take down adhesions because this can result in an unnoticed thermal injury to the intestine. Sharp division of adhesions is advised. Simple monopolar cautery attached to the scissors should sufce if nuisance bleeding arises. The use of a 5 mm clip applier can serve as an added measure for hemostasis. For mesh we use expanded polytetrauoroethylene (ePTFE, DualMesh GoreTex, WL Gore & Associates, Flagstaff, AZ), however, several other tissue-separating mesh products are available that are safe to use in direct contact with the intestine. The four cardinal sutures used to initially hold the mesh in place are CV-0 sutures constructed of ePTFE (Gore-Tex, WL Gore & Associates). The additional xation sutures should be size #0 or #1 polypropylene or polybutester that are both nonabsorbable. Our preferred xation construct device is the ProTack (United States Surgical, Norwalk, CT) that employs titanium spiral tacks. Several other xation construct devices are available as well. For passing and retrieving the transabdominal sutures, a Gore Suture Passer (WL Gore & Associates) is used.
Trocar Placement
The procedure commences with an open cutdown to enter the abdomen safely away from any previous incisions and placement of a 10-mm trocar. The incision can be made in the midline above the umbilicus, distant to the hernia defect. Placing the rst trocar this far above allows a more expanded view of the abdomen and ensures the trocar is out of the way should it be required to place a large piece of mesh. Two additional 5 mm trocars are placed in a horizontal line.
Lysis of Adhesions
The procedure proceeds with a sharp enterolysis, avoiding injury to any hollow viscus. Care should be taken in dissecting the inferior-most aspect of the hernia because it often contains herniated bladder. The herniated contents should be completely reduced, and no effort made to remove the hernia sac. At this point, a metric ruler is placed into the abdomen to determine the proximity of the inferior edge of the hernia defect to the pubic symphysis. If this measures less than 4 cm, plans should be made to proceed with this modied technique.
Patient Set-up
After anesthetic induction, a three-way Foley catheter is placed into the bladder. This is used to instill saline into the
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Operative Technique
Figure 1 After initial access to the abdomen via an open cutdown technique, laparoscopic ports are placed in a horizontal conguration far above the hernia defect to allow manipulation and placement of a large enough piece of mesh without interfering with the ports. This picture demonstrates the surgeon working in the pelvis on a suprapubic hernia associated with a large Pfannenstiel incision. (Color version of gure appears online.)
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Figure 2 With suprapubic hernias the inferior edge of the defect may be intimately associated with the superior edge of the bladder. (A) The intraoperative photo demonstrates the bladder lled with saline and the hernia defect completely abutting the pubic bone. (B) The CT shows a portion of the bladder herniating into the defect. When the hernia edge lies within 4 cm of the superior most aspect of the pubic bone the surgeon must create a peritoneal ap to enter the prevesical space of Retzius so as to identify the proper bony and vascular structures for safe suture mesh xation. (Color version of gure appears online.)
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Figure 3 If the hernia defect edge is less than 4 cm from the pubis, then a peritoneal ap will need to be created to enter the space of Retzius and Bogros to expose the posterior aspect of the pubic bone, Coopers ligaments, and the inferior epigastric vessels bilaterally. Identication of these key structures will allow the surgeon to place the transabdominal sutures and tacks with pinpoint precision, avoiding injury to any of the surrounding neurovascular structures. The peritoneum is grasped in the midline at the median umbilical ligament at a level immediately below the hernia defect edge. The surgeon can avoid injury to the bladder at this point by instilling approximately 200 mL of saline through the three-way Foley catheter, allowing the bladder to become more visible. The peritoneum is sharply incised in a horizontal fashion toward the epigastric vessels (Lateral umbilical ligaments) on either side. The prevesical space of Retzius is entered and blunt dissection similar to that used for the laparoscopic, transabdominal, preperitoneal, inguinal hernia repair is performed. (Color version of gure appears online.)
Figure 4 The ap is raised inferiorly to expose the underlying bony pelvic structures. The dissection proceeds until the posterior aspect of the pubic bone, Coopers ligaments, and the inferior epigastric vessels are identied bilaterally. (Color version of gure appears online.)
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Figure 5 (A) After completely delineating the edges of the hernia, 3.5 long 20 gauge spinal needles are placed at the extreme edges of the hernia defect. These spinal needles mark the edges of the hernia, helping to measure the exact size of the hernia using an intracorporeally placed thin, plastic, metric ruler. Once the maximum vertical and horizontal measurements 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 of the pubic bone plus 1 to 2 cm for overlap below the pubis. (Color version of gure appears online.)
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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 the mesh to serve as the initial transabdominal xation sutures. Because the inferior portion of the mesh will overlap onto the pubic bone, the inferior suture should be placed 2 cm from the actual mesh edge. (Color version of gure appears online.)
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Figure 7 (A) The mesh is rolled from the top and the bottom concomitantly like a scroll. (B) This allows for the mesh to be dragged directly into the abdomen. (C) The mesh is then unrolled without having to reorient the mesh once it is in the abdomen. (Color version of gure appears online.)
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Figure 8 After unrolling the mesh, the inferior transabdominal suture needs to be retrieved rst to ensure adequate overlap inferiorly where it is most important. (A,B) The suture passer is advanced into the abdomen, puncturing the periosteum of the pubic bone and grasping one limb of the inferior suture, a second path through the periosteum grasps the second limb of the suture and brings the inferior portion of the mesh against the pubic bone. (C) Note, the inferior suture is not tied down immediately, rather, the suture limbs are held under tension with a hemostat. (Color version of gure appears online.)
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Figure 8 Continued
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A.M. Carbonell
Figure 9 (A) The superior suture and the two lateral sutures are then retrieved transabdominally ensuring a minimum of 4 cm mesh-defect overlap. When the mesh lies tight against the anterior abdominal wall, then the superior and lateral sutures are tied. (B) The superior and lateral portion of the mesh is then xated to the abdominal wall with spiral tacks every 1 to 2 cm apart and interrupted #1 permanent suture every 4 to 6 cm. (Color version of gure appears online.)
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Figure 10 (AF) 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 lateral to the rst inferior midline suture. The suture must be taken in with the suture passer, advanced through the mesh and a second pass through the mesh retrieves the suture, forming a U-stitch. These sutures are not secured until all of the inferior sutures are placed. This allows the surgeon to hold the mesh loosely upwards with a grasper to allow direct visualization of the suture passer safely traversing the abdominal wall and periosteum. A minimum of three sutures are placed through the periosteum. More may be placed as space allows. After placing all the inferior sutures, they are individually tied. (Color version of gure appears online.)
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A.M. Carbonell
Figure 10 Continued
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Figure 10 Continued
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Figure 11 (A,B) Further mesh xation is achieved with spiral tacks every 1 cm and transabdominal #1 polypropylene suture every 4 to 5 cm circumferentially around the mesh, avoiding placement of sutures or tacks below the iliopubic tract. Although several tacks are placed directly into the posterior pubis and Coopers ligament laterally, care should be taken because of the close proximity to neurovascular structures. It is unnecessary to reconstruct the peritoneal defect. (Color version of gure appears online.)
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Figure 12 At the conclusion of the procedure the 10 mm trocar site is closed with a permanent suture using a suture passer. All sutures are tied, skin is closed in the standard fashion, and sterile dressings are applied. Patients are typically admitted to the hospital and discharged once their pain is controlled and a diet is tolerated. (Color version of gure appears online.)
Procedure Outcomes
We published our outcomes in 36 patients (26 females and 10 males) with a mean age of 55.9 years (range, 33-76) and a mean BMI of 31.0 kg/m2 (range, 22-67) underwent LRSPH.19 Twenty-two (61%) of the repairs were for recurrent hernias, with an average of 2.3 previously failed open repairs each (range, 1-11). The mean hernia size was 191.4 cm2 (range, 20-768), with an average mesh size of 481.4 cm2 (range, 193-1428). All repairs were performed with ePTFE. Mean operating room time was 178.7 minutes (range, 95-290), with a mean blood loss of 40 mL (range, 20-100). One patient undergoing her fth repair required conversion because of adhesions to previously placed polypropylene mesh. Hospital stay averaged 2.4 days (range, 1-7). Mean follow up was 21.1 months (range, 1-70). Complications (16.6%) included: deep venous thrombosis,1 prolonged pain greater than 6 weeks,1 trocar site cellulitis,1 ileus,1 prolonged seroma,1 and Clostridium difcile colitis.1 Hernias recurred in two of our rst nine patients, for an overall recurrence rate of 5.5%. Since initiating the technique of applying multiple sutures directly to the pubis and Coopers ligament (in the subsequent 19 patients), no recurrences have been documented.
Discussion
Hermann Johann Pfannenstiels rst description of his eponymous incision in 51 patients in 1900, reported no incisional
hernias after a 2-year follow up.20 Recent authors cite a 0.04% to 2.1% incisional hernia rate after Pfannenstiel incision.21,22 There is a paucity of literature regarding the technical aspects of the repair of suprapubic ventral hernias. Bendavid11 reported the Shouldice Clinic experience repairing parapubic hernias via an open technique in seven patients. All of his patients presented with a denuded pubis lacking fascia. He approached the defect preperitoneally through the space of Retzius, and placed a polypropylene mesh anchored to the pubis and Coopers ligaments inferiorly, and full-thickness abdominal wall sutures superiorly. Although recurrence was not reported, his results were favorable after a 5 to 48 month follow-up with no infections or seromas. Hirasa17 reported the rst laparoscopic experience with the repair of suprapubic hernias. They employed a composite mesh with a 2 to 3 cm overlap, xated only with spiral tacks and no transabdominal sutures in seven patients. After a 4 to 9 month follow up in six of the patients, one hernia (14.3%) recurred at 8 months as a result of the mesh pulling off of the abdominal wall. There is some evidence to support the use of full-thickness transabdominal sutures to ensure adequate mesh xation.2,7,8 Another important aspect of ventral hernia repair is an adequate overlap of mesh from the edge of the hernia defect.2,7 Obtaining adequate overlap to provide the necessary surface area for mesh-host tissue integration is difcult to achieve in hernias occurring just above the pubic bone. We develop a peritoneal ap inferiorly similar to the dissection plane for
26 laparoscopic, transabdominal, preperitoneal, inguinal hernia repair to identify the critical pelvic structures, and allow for the safe placement of xation constructs directly to Coopers ligaments and the pubic bone. We believe this represents the strongest tissue of the pelvis, holding suture well enough to rely on them almost exclusively for the inferior xation of the mesh. The two recurrences reported in our series occurred in the rst nine patients (5.5% overall recurrence rate).19 The recurrences occurred just above the pubis before we began to employ full-thickness, transabdominal sutures incorporating the periosteum of the pubis. After this modication, no recurrences have been documented. This underscores the importance of adequate mesh xation with sutures to the strong bony or ligamentous structures as opposed to the attenuated muscle at the hernias border. Although technically demanding, the LRSPH is technically feasible, safe, and results in a low recurrence rate. It can be performed with low morbidity in very large and recurrent hernias. Transabdominal suture xation to the bony and ligamentous structures yields a durable hernia repair.
A.M. Carbonell
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 hernia repairs: A personal series and review of the literature. JSLS 3:293-304, 1999 8. LeBlanc KA: The critical technical aspects of laparoscopic repair of ventral and incisional hernias. Am Surg 67:809-812, 2001 9. Joels CS, Matthews BD, Kercher KW, et al: Evaluation of adhesion formation, mesh xation strength, and hydroxyproline content after intraabdominal placement of polytetrauoroethylene mesh secured using titanium spiral tacks, nitinol anchors, and polypropylene suture or polyglactin 910 suture. Surg Endosc 19:780-785, 2005 10. vant Riet M, de Vos van Steenwijk PJ, Kleinrensink GJ, et al: Tensile strength of mesh xation methods in laparoscopic incisional hernia repair. Surg Endosc 16:1713-1716, 2002 11. Bendavid R: Incisional parapubic hernias. Surgery 108:898-901, 1990 12. Lobel RW, Sand PK: Incisional hernia after suprapubic catheterization. Obstet Gynecol 89(Pt 2):844-846, 1997 13. Losanoff JE, Richman BW, Jones JW: Parapubic hernia: Case report and review of the literature. Hernia 6:82-85, 2002 14. Norris JP, Flanigan RC, Pickleman J: Parapubic hernia following radical retropubic prostatectomy. Urology 44:922-923, 1994 15. el Mairy AB: A new procedure for the repair of suprapubic incisional hernia. J Med Liban 27:713-718, 1974 16. Carbonell AM, Kercher KW, Matthews BD, et al: The laparoscopic repair of suprapubic ventral hernias. Surg Endosc 19:174-177, 2005 17. Hirasa T, Pickleman J, Shayani V: Laparoscopic repair of parapubic hernia. Arch Surg 136:1314-1317, 2001 18. Matuszewski M, Stanek A, Maruszak H, Krajka K: Laparoscopic treatment of parapubic postprostatectomy hernia. Eur Urol 36:418-420, 1999 19. Huang CS, Huang CC, Lien HH: Prolene hernia system compared with mesh plug technique: A prospective study of short- to mid-term outcomes in primary groin hernia repair. Hernia 9:167-171, 2005 20. Pfannenstiel H: Ueber die vortheile des suprasymphysaren fascienquerschnitts fur die gynakologischen koliotomien. Samml Klin Vortr 268: 1735-1756, 1900 21. Luijendijk RW, Jeekel J, Storm RK, et al: The low transverse Pfannenstiel incision and the prevalence of incisional hernia and nerve entrapment. Ann Surg 225:365-369, 1997 22. Grifths DA: A reappraisal of the Pfannenstiel incision. Br J Urol 48: 469-474, 1976
References
1. Burger JW, Luijendijk RW, Hop WC, et al: Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578-583, 2004; discussion 583-585 2. 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; discussion 399-400 3. DeMaria EJ, Moss JM, Sugerman HJ: Laparoscopic intraperitoneal polytetrauoroethylene (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 hernia repair: A comparison study. Surgery 124:816-821, 1998; discussion 821-822 5. Ramshaw BJ, Esartia P, Schwab J, et al: Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 65:827-831, 1999; discussion 831-832
Laparoscopic Repair of Traumatic Diaphragmatic Hernia

Marc Zerey, MD, FRCSC, B. Todd Heniford, MD, FACS, and Ronald F. Sing, DO, FACS, FCCP
iaphragmatic injuries are not uncommon with rates as high as 5% for patients hospitalized after motor vehicle accidents, and 15% for patients after penetrating injuries to the lower chest and upper abdomen.1-3 Left-sided rupture is more common than right-sided rupture (68.5% vs. 24.2%, respectively), owing to hepatic protection and increased strength of the right hemidiaphragm.4 During the initial evaluation and hospitalization of the trauma patient, diaphragmatic injuries from either penetrating or blunt thoracoabdominal trauma frequently are missed. Investigative techniques to diagnose traumatic diaphragmatic injuries [chest roentgenogram, diagnostic peritoneal lavage, ultrasound, and computed tomography (CT) scan] are limited by their low sensitivity and high false-negative rates.5,6 Reports have documented the effectiveness of laparoscopy as a means to diagnose intraabdominal injury in penetrating thoracoabdominal trauma. The surgeon may effectively visualize abnormal uid collections as well as injury to the peritoneum or diaphragm with the introduction of a laparoscope. If there are no apparent signs of visceral injury it is mandatory that the surgeon perform a systemic examination of the supra- and infracolic compartment and pelvis. The intestines should be run using as many additional ports as necessary and the lesser sac inspected through a defect in the lesser omentum and gastric traction and elevation. When a diaphragmatic laceration or hernia has been identied, repair is mandatory. Latent repair of missed traumatic diaphragmatic hernias has been associated with a 20% to 36% mortality rate.7,8 Over the past decade, a select group of trauma surgeons and advanced laparoscopic surgeons have applied minimally invasive surgical techniques for the repair of acute diaphragmatic lacerations and chronic traumatic diaphragmatic hernias.9-12 The laparoscopic repair in the acute setting is limited by the frequent presence of concomitant injuries that reect
the severity of the traumatic event. The laparoscopic repair of chronic diaphragmatic hernias is more difcult because of entrapment of organs and presence of adhesions. Symptoms of a chronic diaphragmatic hernia are related to the incarceration of abdominal contents in the defect or to impingement of the lung, heart, or thoracic esophagus by abdominal viscera and include abdominal pain, respiratory distress, and cardiac dysfunction. Nevertheless, with the recent increase in the prociency in laparoscopic technique, the number of patients having this condition dealt with laparoscopically is increasing. Once the diagnosis is made, operative repair is mandated. The decision to proceed laparoscopically depends on the hernia itself, the patient, and the surgeon. A hernia amendable to laparoscopic repair is one that is typically located on the left side, that may or may not communicate with the esophageal hiatus but that is less than 10 cm in diameter. The surgeon must possess advanced laparoscopic skills to perform dissection and intracorporeal knot tying. The presence of multiple injuries is not necessarily a contraindication to laparoscopic repair unless the patient is unstable.
Operative Techniques
Positioning of Patient and Surgeon
The patient is placed in the supine position with legs apart enough to accommodate the operating surgeon (see Fig. 1). The rst assistant is located to the patients left and second assistant (laparoscope operator) to the patients right. We favor entry into the abdominal cavity using the open Hasson technique where a 10-mm port will be placed. Use of a 30degree (and occasionally a 45-degree) laparoscope is required. After CO2 insufation, an exploratory laparoscopy is performed to verify the presence of concomitant injuries or conditions in addition to visualizing the hernia. Four additional 5-mm ports are placed along the subcostal margin at the right midclavicular, subxiphoid, left midclavicular, and left anterior axillary positions.
Department of Trauma, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, Charlotte, NC. Address reprint requests to Ronald F Sing, DO, FACS, FCCP, Department of Trauma, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Medical Center, 1000 Blythe Blvd MEB 601, Charlotte NC 28203. E-mail: Ron.Sing@carolinashealthcare.org
Primary Repair of Diaphragmatic Injury

Following visualization of the hernia defect (see Fig. 2), the decision to repair primarily depends on the ability to approx27
28
M. Zerey, B.T. Heniford, and R.F. Sing
Figure 1 Positioning.
imate the edges without undue tension. The standard repair involves placement of simple, horizontal mattress (Fig. 2B, C) or gure-of-eight zero or number one nonabsorbable braided sutures. After the suture is placed across the defect the needle is cut and the two free ends are kept together using a titanium clip. This process is repeated to avoid blindingly placing a needle across the defect and injuring structures in the chest or mediastinum. Once all the sutures have been placed the clip is removed and sutures are progressively tied intracorporeally. A red rubber catheter may be placed in the pleural cavity and the air suctioned as the nal suture is tied to minimize a postoperative pneumothorax. Alternatively, a chest tube should be placed in the presence of lung injury.
nonabsorbable braided suture, ensuring some overlap beyond the diaphragmatic defect (Fig. 3D).
Results
We recently reported on the feasibility and limitations of a laparoscopic approach for the repair of acute traumatic diaphragmatic lacerations and chronic traumatic diaphragmatic hernias.13 Thirteen traumatic diaphragmatic injuries were repaired laparoscopically with four (two acute and two chronic) requiring conversion. Among the laparoscopically repaired diaphragmatic injuries, three defects (chronic) were repaired using ePTFE and nine were repaired primarily. The mean length of the diaphragmatic defects was 4.6 cm (range, 1.5-12 cm). The mean operative time was 134.7 minutes (range, 55-200 minutes). The mean estimated blood loss was 108.5 mL (range, 30-500 mL), and the postoperative length of stay was 4.4 days (range, 1-12 days). There were no intraoperative complications, but three patients developed pulmonary complications (atelectasis/pneumonia). Follow-up evaluation was available for 11 patients. There were no documented recurrences after a mean follow-up period of 7.9 months (range, 1 week to 24 months). Conversion resulted from a reluctance or inability to perform laparoscopic suture of transverse diaphragmatic lacerations longer than 10 cm anterior to the esophageal hiatus and adjacent to the pericardium (n 2) or communicating with the esophageal hiatus (n 2). The four patients undergoing laparotomy had a
Repair of Diaphragmatic Injury Using Prosthetic Biomaterial

Laparoscopic visualization reveals incarcerated abdominal viscera through diaphragmatic defect (see Fig. 3). Laparoscopic grasper and scissors are used to reduce hernia contents. Use of electrocautery or harmonic instruments is avoided to prevent injury to hernia contents and structures present in thoracic cavity and mediastinum (Fig. 3B). When it has been determined that hernia will be unable to be closed without undue tension, prosthetic biomaterial is required (Fig. 3C). Prosthetic repairs are performed with expanded polytetrauoroethylene (ePTFE) mesh (Soft Tissue Patch, W.L. Gore & Associates, Flagstaff, AZ) secured by 0 or 1
Laparoscopic repair of traumatic diaphragmatic hernia
29
Figure 2 (A) Diaphragmatic hernia seen laparoscopically; (B) placement of Ethibond suture (Ethicon Inc., Somerville, NJ) across defect; (C) intracorporeal knot tying to close defect; (D) repaired diaphragmatic hernia.
mean postoperative discharge date of 8.7 days (range, 6-14 days). The feasibility of repairing acute diaphragmatic lacerations and chronic traumatic diaphragmatic hernias laparoscopically appears to be based mostly on experience but also on location. Hernias directly communicating with the esophageal hiatus or anterior to the esophageal hiatus and adjacent
to the pericardium are extremely difcult to repair using a minimally invasive approach. Anterior to the esophageal hiatus the diaphragm is thin, taut, relatively immobile, and in close proximity to the pericardium. The immobility of the diaphragm anterior to the esophageal hiatus also impedes visualization cephalad into the mediastinum, even with an angled laparoscope. Sutures placed too deep in this location
30
Figure 2 Continued
31
Figure 3 (A) Diaphragmatic hernia with incarcerated abdominal viscera; (B) reduction of hernia contents and mobilization of hernia sac; (C) placement of ePTFE mesh onto diaphragmatic defect; (D) repaired diaphragmatic hernia with ePTFE mesh.
32
Figure 3 Continued

Table 1 Indications and contraindications of laparoscopic repair of diaphragmatic hernia Indications Presence of hernia Contraindications Unstable patient (absolute) Hernia > 10 cm (relative) Hernia communicating with esophageal hiatus (relative)
4. 5. 6.
33
laparoscopy for penetrating abdominal trauma: A multicenter experience. J Trauma 42:825-829, 1997; discussion 829-831 Shah R, Sabanathan S, Mearns AJ, Choudhury AK: Traumatic rupture of diaphragm. Ann Thorac Surg 60:1444-1449, 1995 Aronoff RJ, Reynolds J, Thal ER: Evaluation of diaphragmatic injuries. Am J Surg 144:571-575, 1982 Schneider C, Tamme C, Scheidbach H, et al: Laparoscopic management of traumatic ruptures of the diaphragm. Langenbecks Arch Surg 385: 118-123, 2000 Hegarty MM, Bryer JV, Angorn IB, Baker LW: Delayed presentation of traumatic diaphragmatic hernia. Ann Surg 188:229-233, 1978 Madden MR, Paull DE, Finkelstein JL, et al: Occult diaphragmatic injury from stab wounds to the lower chest and abdomen. J Trauma 29:292-298, 1989 Cougard P, Goudet P, Arnal E, Ferrand F: Treatment of diaphragmatic ruptures by laparoscopic approach in the lateral position. Ann Chir 125:238-241, 2000 Matz A, Landau O, Alis M, et al: The role of laparoscopy in the diagnosis and treatment of missed diaphragmatic rupture. Surg Endosc 14:537539, 2000 Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic injuries: Spectrum of radiographic ndings. Radiographics 18:49-59, 1998 Simpson J, Lobo DN, Shah AB, Rowlands BJ: Traumatic diaphragmatic rupture: Associated injuries and outcome. Ann R Coll Surg Engl 82:97100, 2000 Matthews BD, Bui H, Harold KL, et al: Laparoscopic repair of traumatic diaphragmatic injuries. Surg Endosc 17:254-258, 2003
7. 8.
may violate the pericardium, and sutures placed too supercially risk hernia recurrence. The hemidiaphragm is more mobile laterally and near the central tendon, and greater visualization is provided by retracting the edges of the defect and placing the laparosocope into the hemithorax. Table 1
9.
10.
References
1. Brandt ML, Luks FI, Spigland NA, et al: Diaphragmatic injury in children. J Trauma 32:298-301, 1992 2. Ward RE, Flynn TC, Clark WP: Diaphragmatic disruption secondary to blunt abdominal trauma. J Trauma 21:35-38, 1981 3. Zantut LF, Ivatury RR, Smith RS, et al. Diagnostic and therapeutic
11. 12.
13.
Laparoscopic Total Extraperitoneal Inguinal Hernia Repair

Bruce Ramshaw, MD, FACS
he laparoscopic approach for inguinal hernia repair was rst reported by Ger, who performed a high ligation of the sac without mesh placement.1 In the early 1990s, a variety of trans-abdominal laparoscopic approaches were reported, with the trans-abdominal preperitoneal (TAPP) approach and the intraperitoneal onlay mesh (IPOM) techniques being the most common. Because of reports of high recurrence rates, the IPOM technique quickly fell out of favor. In 1993 the laparoscopic total extraperitoneal (TEP) approach was reported by McKernan.2 The TEP approach allows for mesh placement within the preperitoneal space, without entering the abdominal cavity. Another benet of this approach is the avoidance of the incision and closure of the peritoneum typically required in the TAPP approach. I had the fortune of being a resident in Atlanta in 1993, allowing me to travel only a few miles to watch Barry McKernan perform several laparoscopic TEP hernia repairs. With the help of fellow residents and my attendings, we integrated this technique into all general surgery practices at Georgia Baptist Medical Center that year. Because it is an extremely difcult procedure to learn, it was advantageous to have over 10 surgeons helping each other learn the technique. On completing residency, the laparoscopic TEP approach became my procedure of choice for essentially all inguinal hernia repairs in my practice. Contraindications for performing the TEP technique include age (prepubertal children) and the inability to tolerate general or regional anesthesia. Relative contraindications include large scrotal hernias, previous lower midline abdominal surgery, and previous mesh placement in the preperitoneal space. I currently use a TAPP approach without reperitonealization, using mesh designed for intraabdominal placement, in these patients. The primary barrier to performing a successful laparoscopic TEP inguinal hernia repair is the difculty associated with learning the technique. Once mastered, the repair can be performed faster, with better visualization and wider mesh
Division of General Surgery, University of Missouri Hospital & Clinics, One Hospital Drive, MC414 McHaney Hall, Columbia, MO. Address reprint requests to Bruce Ramshaw, MD FACS, Associate Professor of Surgery, Chief, Division of General Surgery, University of Missouri Hospital & Clinics, One Hospital Drive, MC414 McHaney Hall, Columbia, MO 65212. E-mail: ramshawb@health.missouri.edu
coverage than the commonly performed open tension-free inguinal hernia repairs, especially for bilateral and recurrent hernias. There are several barriers to learning the technique. First, access to the extraperitoneal space through a small infra-umbilical incision is not something a general surgeon has typically done. The extraperitoneal dissection of the lower abdomen, exposing the myopectineal orice bilaterally, can be a daunting task. Balloon dissectors can signicantly help a surgeon perform a safe, consistent extraperitoneal dissection, especially early in the learning curve. However, even with the balloon, accidental placement into the subcutaneous tissue, within the rectus muscle and inside the abdominal cavity has occurred. A laparoscopic view through the balloon helps ensure that it has been placed in the correct space. Usually, the pubis and Coopers ligament are the rst structures visualized when the balloon is placed correctly. However, even when placed in the correct space, ination of the balloon can injure the bowel or bladder, especially in patients with previous lower abdominal surgery. Directing the balloon more laterally toward the side of the defect and inating it less than usual can minimize the likelihood of injury in these patients, including those who have undergone previous open prostatectomy. Another barrier is the variability of the initial presentation of the anatomy. Signicant preperitoneal fat, presence of an unreduced direct hernia, bleeding from the balloon dissection, and previous lower abdominal surgery, can obscure the anatomy. Probably the most dangerous portion of the operation is the lateral dissection, where dissecting too far posteriorly can increase the risk of inadvertent iliac vessel injury. To minimize this dangerous complication, lateral dissection should be done near the anterior extraperitoneal plane, just posterior to the rectus muscle and inferior epigastric vessels. All structures posterior and lateral to the epigastric vessels should be carefully dissected posteriorly and medially to open up the lateral extraperitoneal space. Probably the most difcult dissection, even in experienced hands, is the reduction of a chronic, large indirect sac that is often adherent to the cord and surrounding structures. Reduction of the indirect sac can add several minutes to the procedure in experienced hands, and may necessitate conversion to an open approach for the surgeon early in the learning curve. Another barrier to learning the operation is the mesh manipulation. Manipulating and orienting a large mesh in a relatively small space can be challenging.
34
Laparoscopic total extraperitoneal inguinal hernia repair
35
Operative Technique
Figure 1 (AC) The skin incision is made at the inferior aspect of the umbilicus. Dissection is carried down to the anterior fascia of the rectus muscle just lateral to the midline. If the incision is made away from the hernia, there will be less dissection of that groin by the balloon (more dissection in the ipsilateral groin). However, there will be more room to work because the 10 mm trocar and scope will be farther away from the groin with the hernia defect. If the hernia is bilateral, I usually place the incision on the side away from the larger hernia defect, to allow more room to work there. If, however, there is previous lower abdominal surgery on one side or the other (a previous RLQ appy scar for example), I will direct the balloon to the contralateral side, away from the previous scar to minimize the chance of tearing the peritoneum. (Color version of gure appears online.)
36
B. Ramshaw
Figure 2 (AD) Following the anterior fascia incision, I use my nger to sweep the rectus muscle off the posterior fascia from the midline. This is important to ensure proper balloon dissector placement. If this space cannot be entered, or if the peritoneum is injured, the same dissection may be performed on the contralateral side. There are advantages and disadvantages of placing the balloon dissector on the side of the hernia. The dissection is better; however, the balloon may dissect the inferior epigastrics off the anterior abdominal wall, making the repair more difcult. Also, with the laparoscope closer to the ipsilateral groin, there is a smaller space in which to work. (Color version of gure appears online.)
37
Figure 3 (AC) The balloon dissector is placed in the space between rectus muscle and posterior fascia, and directed down to the pubis. The canula is removed and the zero degree, 10 mm laparoscope is used. The dissector is inated while the space is viewed laparoscopically. The pubis and Coopers ligaments should be identied as well as rectus muscle bers, which are seen anteriorly, not posteriorly, through the balloon. After appropriately dissecting the preperitoneum, the balloon is left in place briey for tamponade and then deated and removed. (Color version of gure appears online.)
Figure 4 A 10 mm balloon tip or other Hassan type trocar is placed, and the extraperitoneal space is insufated to a maximum pressure of 10 to 12 mmHg. Two 5 mm trocars are placed in the low midline between the rectus muscles. I usually place the rst trocar about one nger breadth above the pubis and the nal trocar halfway between the end of the 10 mm trocar and the suprapubic 5 mm trocar. (Color version of gure appears online.)
38
B. Ramshaw
Figure 5 (AD) Medial dissection is usually accomplished by the balloon dissector. However, an unreduced direct hernia will obscure the medial anatomy. Careful reduction of the hernia sac and counter traction of the weakened transversalis fascia with graspers will allow for complete reduction and exposure of the medial anatomy. Hernias may also be reduced from the femoral space, between the iliopubic tract and Coopers ligament, and the obturator space, posterior to Coopers ligament. (Color version of gure appears online.)
39
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 to identify inferior epigastic vessels to guide initial lateral dissection. The vessels should be retracted anteriorly and all cord contents should be carefully dissected off of the anterior and lateral abdominal wall to expose the lateral anatomy. The transversus arch bers join the iliopubic tract to form the lateral border of the indirect space. The iliopubic tract travels laterally, parallel and deep to the inguinal ligament. The cutaneus nerves (lateral femoral cutaneous, femoral branch of the genitofemoral and their branches) usually travel on the psoas muscle and leave the extraperitoneal space at or near the level of the iliopubic tract. For this reason, xation 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 iliopubic tract. Therefore, xation anterior to the iliopubic tract should be approached with caution. (Color version of gure appears online.)
41
Figure 7 (A,B) Once the lateral dissection is complete, the cord is explored for an indirect sac and/or a lipoma of the cord. The indirect hernia sac will usually be located on the anteriomedial portion of the cord and may be more difcult to 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 lipoma of the cord will usually reduce easily from the internal ring, with minimal or no bleeding. (Color version of gure appears online.)
42
B. Ramshaw
Figure 8 The vas deferans lies posteriomedially and the vessels lie on the psoas muscle posteriolaterally. They join at the internal ring and form a triangle (with the peritoneal reection forming its base) called the triangle of doom, where the iliac vessels are found posteriorly. Posteriolaterally, the peritoneal reection should be taken back to the level of the umbilicus 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 fatty tissue 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 gure appears online.)
43
Figure 9 (A,B) With the TEP technique for inguinal hernia repair, there are traditionally two types of mesh preparation: a mesh with a 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 xed, attempting to prevent herniation through the mesh slit. If the mesh is not slit it is very important to make sure that the peritoneum does not protrude under the mesh with the cord. To avoid recurrence, the peritoneum is dissected to the level of the umbilicus, and the posterior edge of the mesh is held down with a grasper during deation of the extraperitoneal space. There are now newer meshes with different shapes and designs, adapted for laparoscopic inguinal hernia repair. I currently use a mesh that is shaped to conform to the preperitoneal inguinal anatomy. It has a posterior ap with a velcro-like patch that is placed behind the cord. Another ap is then placed anterior to the cord and xed to the velcro-like patch to provide xation posteriolaterally where point xation devices cannot be used. This mesh was designed to minimize the chance of herniation through a slit in the mesh, or from under the posterior edge of mesh. Other potential solutions include using an additional piece of mesh to completely cover the slit if a slit mesh is used or using a glue to x the mesh posteriolaterally if a mesh without a slit is used. I continue to use minimal point xation because of the possibility of mesh contraction or migration, and/or folding that may occur with any type of mesh material. Multiple animal studies appear to show that heavyweight polypropylene mesh is more likely to contract than polyester or lightweight polypropylene. I usually use three points of xation in addition to the velcro-like xation posteriolaterally. One is at the superiolateral corner of the mesh. This corner is located at the lateral abdominal wall above the iliac crest at the level of the umbilicus, well away from the nerves at risk for injury. The other two points of xation are medial, to Coopers ligament posteriorly and anteriorly to the lower rectus muscle. For bilateral hernias, the mesh should overlap at the midline and the mesh overlap is xed in two areas, one near the pubis and one at the lower rectus muscles. The mesh should cover all hernia and potential hernia defects and widely cover the myopectineal orice. It is xed well away from the nerves. (Color version of gure appears online.)
44
B. Ramshaw
no treatment is required. Rarely, aspiration may be considered if there are signicant symptoms. In conclusion, the total extraperitoneal approach for laparoscopic inguinal hernia repair can be utilized for almost all adult inguinal hernias. The ability to visualize the entire groin bilaterally, widely cover the myopectoneal orice, and securely x the mesh to healthy abdominal wall tissue away from nerves will result in a highly effective repair.
Summary
The patient is usually able to go home on the day of surgery and is allowed to return to activity as tolerated. A prescription for pain medicine is given to the patient and the patient is usually able to switch to antiinammatories in the rst few days. Bruising and swelling of the groin, penis, and scrotum is not uncommon and ice and/or a jockstrap may be used for comfort. Urinary retention in the rst 24 hours and constipation in the rst few days are also possible and management strategies should be discussed with the patient. Signicant wound and mesh complications are extremely rare with the laparoscopic TEP inguinal hernia repair. Drainage from the 10 mm incision is the most common wound complication and usually only requires a dry dressing. After the repair of large hernias, seromas, and/or hematomas are possible as a result of serous uid and/or blood collection in the space created by the hernia reduction. The patient should be educated and forewarned of this possibility and told that usually
Acknowledgments
The author thanks Bill Winn (Medical Illustrator) and Brandy Stockton (Administrative Assistant).
References
1. Ger R, Monroe K, Duvivier R, Mishrick A: Management of indirect inguinal hernias by laparoscopic closure of the neck of the sac. Am J Surg 159:370-373, 1990 2. McKernan JB, Laws HL: Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 7:26-28, 1993
Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair

Michael J. Rosen, MD
hen considering a laparoscopic approach for repairing inguinal hernias, the surgeon has several options. Initially laparoscopic repairs involved an intraperitoneal onlay mesh. Using this technique, the surgeon placed a large piece of mesh in an intraperitoneal position, similar to a laparoscopic ventral hernia repair. This approach has largely been abandoned secondary to high recurrence rates and the drawbacks of intraperitoneal mesh. The remaining two techniques include a totally extraperitoneal (TEP) and a transabdominal preperitoneal (TAPP) approach. The main difference between these two techniques is the sequence of gaining access to the preperitoneal space. In the TEP approach, the dissection begins in the preperitoneal space with a balloon dissector. In the TAPP approach, the preperitoneal space is accessed after initially entering the peritoneal cavity. Each approach has its own merits. Using the TEP approach, the preperitoneal dissection is quicker, and the potential risks of intraperitoneal visceral damage are minimized. However, the use of dissection balloons can be costly, the working space is more limited, and in the case of prior preperitoneal surgery or mesh the space may be impossible to create. Additionally, if large tears in the peritoneal ap are created during a TEP, the potential working space can become obliterated necessitating conversion to a transabdominal approach. For these reasons, knowledge of a transabdominal technique is essential when performing laparoscopic inguinal hernia repairs. The transabdominal approach allows immediate identication of the groin anatomy before extensive dissection and disruption of natural planes. The larger working space of the peritoneal cavity can make early experience with the laparoscopic approach safer and easier. The TAPP is the preferred approach of the author and will be described herein. There are no absolute contraindications to laparoscopic inguinal hernia repair other than the inability to tolerate general anesthesia. Patients who have had extensive prior lower abdominal surgery can require signicant adhesiolysis and may be best approached anteriorly. In particular patients who have had a radical retropubic prostatectomy with the preperitoneal space previously dissected can make accurate safe dissection challenging.
Preoperative
Routine use of Foley catheterization is not performed. The patients are instructed to empty their bladder before entering the operating room. A single dose of a rst generation cephalosporin is given and sequential compression devices are applied. The patient is placed under general anesthesia, both arms are tucked at the patients side, and the abdomen and groin are sterilely prepped. The surgeon stands on the side opposite the hernia and the rst assistant stands on the ipsilateral side of the hernia along with the scrub nurse. The laparoscopic tower is positioned at the foot of the table (Fig. 1).
Trocar Positioning
The abdomen is accessed via an open Hasson technique through an infraumbilical incision. The abdomen is insufated to 15 mmHg. A 5 mm 30 degree laparoscope is then inserted and a general inspection of the abdominal cavity is performed. The pelvic oor is evaluated and the pathology of the inguinal anatomy is examined (Fig. 2). Two additional 5-mm ports are placed in line with the umbilicus and just lateral to the inferior epigastric vessels. These trocars should remain above the umbilicus to avoid interference with the preperitoneal ap dissection. Additionally, placing these trocars too far laterally can result in difculty navigating instruments across the abdominal viscera (Fig. 3). Using an angled 5-mm laparoscope, the surgeon can stand on the opposite side of the hernia and use the middle trocar as a working port. The camera operator uses the lateral 5-mm port ipsilateral to the defect for visualization.
Peritoneal Flap Dissection

The patient is placed in a slight Trendelenberg position. The dissection begins at the ipsilateral medial umbilical fold. The preperitoneal ap is raised from a medial to lateral direction using the curved scissors with monopolar cautery. It is important to begin this dissection rather cephalad on the abdominal wall to leave enough space for reduction of the hernia and placement of an appropriately sized piece of mesh (Fig. 4). Additionally, as the initial incision is carried laterally, one should avoid the temptation to drift inferiorly toward the inguinal canal, again compromising the eventual space necessary for mesh placement. The proper incision carries transversely across the ab45
Department of Surgery, University Hospitals of Cleveland, Case Western Reserve School of Medicine, Cleveland, OH. Address reprint requests to Michael J. Rosen, Assistant Professor of Surgery, Department of Surgery, University Hospitals of Cleveland, Euclid Ave, Cleveland, OH 44106. E-mail: Michael.rosen@uhhs.com
46
M.J. Rosen
Figure 1 Patient positioning and operating room setup for left inguinal hernia. Surgeon stands on opposite side of hernia using middle and lateral trocar working ports. First assistant stands on ipsilateral side of hernia with camera. Arms are tucked bilaterally at sides, with monitor at foot of bed.
dominal wall toward the anterior superior iliac spine. When traversing across the plane, one must be cautious and avoid the epigastric vessels. Achieving the appropriate dissection plane is critical to the success of the operation. Although the dissection is typically below the arcuate line there tends to be an attenuated
transversalis fascia that is adherent to the rectus muscle. The appropriate plane is just supercial to the peritoneum. By grasping the inferior cut edge of the peritoneum and retracting cephalad the preperitoneal space is created by gently pushing away and dividing the loose lmy attachments (Fig. 5). The rst struc-
Transabdominal preperitoneal inguinal hernia repair
47
Figure 2 Inguinal anatomy of the right side. Location of indirect and direct space in relation to the inferior epigastric vessels.
ture identied is Coopers ligament. By sweeping down the bladder staying high on the anterior abdominal wall one eventually encounters this white rm ligament. Even in unilateral hernias, I routinely sweep the bladder far medially past the midline to provide adequate mesh overlap. Coopers ligament is cleared off laterally until a fairly constant crossing vessel is identied. This so-called aberrant obturator vessel is present in over 75% of patients. Next, the lateral dissection is begun. Unlike the medial dissection plane which typically can be developed bluntly allowing the preperitoneal fatty tissue to divide in its natural plane, the appropriate plane for the lateral dissection is directly on the peritoneum which can typically be quite thin. The lateral dissection is carried medially until the spermatic vessels and then the vas deferens are encountered. One must use extreme caution when using electrocautery in the preperitoneal space, as a loop of intestine can be just below the peritoneal ap with energy easily transmitted through the ap.
and retracted while bluntly sweeping off attachments to the cord structures. Large chronic indirect sacs can be particularly challenging. In cases where the hernia sac cannot be completely reduced, it can be transected and either sutured or closed with an endoloop leaving the distal end open. Any cord lipoma typically located inferior and lateral to the cord structures should be completely reduced to avoid potential confusion as a recurrence. These lipomas do not need to be resected and can be left in the preperitoneal space. Once the hernia sac is completely reduced, the peritoneal ap should be dissected at least 3 cm off the vessels and cord structures to prevent any drag coefcient from allowing peritoneum to sneak under the mesh, predisposing to recurrence. The upper ap of peritoneum is then grasped and retracted cephalad to develop a larger pocket for the mesh.
Placement of Mesh
At least a 12 14 cm piece of polypropylene mesh is utilized. We do not place a slit for wrapping around the cord structures as recurrences have occurred through these defects. The mesh is grasped at the medial aspect. We do not roll the mesh tightly as this just makes unraveling more difcult once inside the patient. The mesh is brought in through the
Dissection of Hernia Sac

At this point the hernia sac should be reduced (Fig. 6). If a direct defect is encountered, the hernia contents are grasped and the attenuated transversalis fascia is gently teased away. If an indirect hernia is identied, the sac is likewise grasped
48
M.J. Rosen
Figure 3 Trocar positioning. Note two lateral ports are just lateral to the inferior epigastrics in line with the umbilicus.
10-mm trocar and tucked medially into the pocket. The superior medial corner of the mesh is grasped and brought anteriorly while the inferior instrument pushes the mesh against the abdominal wall. While some groups advocate no mesh xation, we currently believe some form of mesh xation is important to prevent migration. Once the mesh is situated we place one tack in Coopers ligament. By only placing one tack, the mesh can still be rotated to obtain ideal lateral placement. However, the mesh will not migrate during lateral retraction. We then place a spiral tack at the superior lateral aspect of the mesh. It is critical that the tip of the tacker can be palpated with the nondominant hand of the surgeon through the anterior abdominal wall before deploying any tacks. If the tacker can not be palpated it indicates that it is likely below the iliopubic tract and therefore the lateral femoral cutaneous, genital-femoral, or femoral nerve could be entrapped. We then place one tack just lateral to the inferior
epigastric and one at the superior medial border of the mesh. Finally, another tack is placed in Coopers ligament (Fig. 7). At the conclusion, the peritoneum is re-examined with particular concern over the vessels to ensure it is not encroaching underneath the mesh. No tacks can be placed in the triangle of doom bordered by the vas deferens medially and the spermatic vessels laterally which contains the iliac artery and vein.
Peritoneal Closure
The peritoneal ap is then secured to the anterior abdominal wall. This can be completed with spiral tacks, staples, or suturing. Any defects in the peritoneum should be closed. Occasionally, the reduced hernia sac can be used to close these defects. If a large hole in the peritoneum is created, several maneuvers can aid closure. The peritoneal ap dis-
49
Figure 4 Dissection of peritoneal ap. The ap 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 ap is grasped and retracted while the loose lmy attachments of the preperitoneal space are dissected free. The medial dissection is completed clearly identifying Coopers ligament.
50
M.J. Rosen
Figure 6 The indirect hernia sac is carefully reduced off of the cord structures.
Figure 7 The mesh is secured to the anterior abdominal wall with spiral tacks. No tacks are placed below the iliopubic tract.

section should be extended inferiorly to gain laxity for closure, the pneumoperitoneum pressures can be reduced to 8 to 10 mmHg to decrease tension, and the patient can be taken out of the Trendelenberg position. For left sided defects, the sigmoid colon can be released from its peritoneal attachments. The umbilical port is closed with a single gure of eight resorbable suture and the abdomen is desufated.
51 until the other side is completed in case the mesh is accidentally displaced. In cases of prior preperitoneal hernia repairs, occasionally the peritoneal ap is completely destroyed and in those cases one can consider an onlay technique.
Postoperative Care
The patients are typically discharged home from the recovery room. The patients must void before discharge as urinary retention can be an issue especially in bilateral hernias. The patients are instructed to avoid heavy lifting for several weeks postoperatively. Patients are followed in the ofce at 2 and 6 weeks.
Special Considerations
In cases of bilateral hernias, we use two separate pieces of mesh that are secured together in the midline. The mesh is placed in the rst hernia but the peritoneum is not closed
Laparoscopic Flank Hernia Repair

Archana Ramaswamy, MD, and Bruce Ramshaw, MD
lank hernias occur between the costal margin and the iliac crest. Primary acquired hernias tend to form in the inferior lumbar triangle (of Petit) and superior lumbar triangle (of Grynfeltt). The superior lumbar triangle is bounded by the 12th rib, paraspinal muscles, and internal oblique muscle whereas the inferior lumbar triangle is bounded by the iliac crest, latissimus dorsi muscle, and external oblique muscle. Unnamed hernias can also occur in the ank anywhere through muscular and fascial defects. Flank hernias are uncommon defects without any wellreported incidence. The acquired defect can be primary or secondary to trauma, infection, or surgery. Primary defects comprise 50% of ank hernias with secondary and congenital comprising the rest. Post surgical hernias can follow ank incisions primarily for kidney or adrenal surgery and less frequently after iliac bone graft harvesting, retroperitoneal vascular procedures or abscess drainage. The incidence of hernia after ank incision for urologic surgery has recently been reported as high as 31%. The risk of hernia formation has been associated with age greater than 50, wound infection, abdominal wall hematoma, and hypoproteinemia. Over 80% of these hernias were detected within 1 year of surgery.1 Flank hernias usually present as a posterior bulge that may be asymptomatic, or may be associated with mild or severe discomfort from nerve compression. Acute incarceration, though infrequent, is more commonly seen with a primary acquired defect. The diagnosis can be difcult and often imaging studies are helpful to distinguish a hernia from a soft tissue lesion, hematoma, abscess, renal lesion or muscular laxity. Imaging studies (commonly CT or MRI) are also helpful in identifying the anatomical boundaries of the hernia.
Department of Surgery, University of Missouri, Columbia, MO. Address reprint requests to Bruce Ramshaw, Department of Surgery, University of Missouri, 1 Hospital Dr. MC 414, Columbia, MO, 65212.Email: ramshawb@health.missouri.edu
This is useful for surgical planning because healthy tissue needs to be identied for mesh xation. With intraabdominal pressure and presumed muscle atrophy, the natural history of ank hernias tends to be an increase in size. Because repair of large ank hernias can become very complex with increasing size, consideration should be given to early repair in individuals who do not have medical contraindications to surgery. Techniques for open repair of ank hernias have ranged from layered closure with muscular and fascial aps to the use of prosthetic material. Laparoscopic ank hernia repair is based on the principles of laparoscopic repair for ventral hernias: adequate overlap of mesh with healthy tissue and appropriate xation. These two requisites for a durable repair are often challenging in the ank. Posteriorly, the mesh is usually xed to the paraspinal muscles (sacrospinus, serratus posterior inferior, latissimus dorsi) with attention being paid, in large hernias, to the position of the inferior vena cava. Superiorly, xation can often be applied just below the costal margin with a ap of mesh extending up to the diaphragm. As our experience has increased with these hernias, we have found that with defects that extend right to the costal margin tack xation can be performed at the level of a superior rib, being careful to avoid the diaphragm and thus the mediastinal organs. Inferior xation can also be difcult with hernial defects extending to the iliac crest. In these situations, xation can be accomplished through the iliac crest by using Mitek anchors or simply by drilling through the bone. We have chosen to leave power tools to our orthopedic colleagues and perform a dissection similar to that for an inguinal hernia, identifying Coopers ligament and the iliopubic tract and obtaining solid xation at Coopers ligament, draping a leaf of mesh into the pelvis. Prosthetic material should be appropriate for intraperitoneal use: e-PTFE or composite lightweight polypropylene or polyester.
52
Laparoscopic ank hernia repair
53
Operative Technique
Figure 1 After intubation, antibiotic administration (usually rst generation cephalosporin) and thromboembolic precautions, bladder catherization is performed. Patient positioning is then undertaken with diligence. We position the patient in full lateral decubitus, using a bean bag if necessary, being careful to allow easy access to the area of the paraspinal muscles. The kidney rest can be used to open up the space between the costal margin and the iliac crest. The ipsilateral arm needs to be suspended in a similar manner as that used for positioning for adrenalectomy. The surgeon and assistant are positioned on the same side with the tower and monitor being placed just opposite. A monitor on the other side can be useful during suture xation at the posteromedial border through the paraspinal muscles. The skin is 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 ank 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 signicant incarcerated contents, the peritoneum is often stripped down allowing access into the retroperitoneal space as the contents are reduced. If there arent 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 dissection has 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.
55
Figure 5 The hernia defect is then sized using spinal needles if needed. The mesh is chosen to provide at least 4 to 5 cm overlap 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 the defect, it is imperative to assure that there is adequate tissue lateral to the spine for xation. If this is lacking, there is a high expected risk of recurrence since the mesh will pull away from the defect edge. Preoperative CT scan is of value to identify these situations and to appropriately select patients for surgical management. Once the appropriate size mesh is chosen, four nonabsorbable sutures are placed, knots tied, and the tails left long. Sites for pulling through the transfascial sutures are marked on the skin, and the mesh is then marked for orientation, inserted into the abdominal cavity and unrolled. The sutures are then grasped with a suture passer and pulled through the abdominal wall. These are not tied down until all four sutures have been pulled through to allow adequate visualization of the entry of the suture passer and of the suture tails. We begin with the posteromedial suture because there can often be no modications made to the site of suture pull through because of limitations in this area secondary to the spine.
56
Figure 6 The next suture pulled through the abdominal wall can be the inferior or superior one. After xation with the rst two sutures, tension should be placed on these to pull the mesh up to the abdominal wall. The mesh should then be pulled taut at the unxed superior or inferior end to see if the site marked externally for suture pull through needs to be modied. This maneuver is similarly performed for the anteromedial suture. The mesh should be stretched taut so that once the pneumoperitoneum is deated the mesh will congure 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.
57
Figure 8 (A,B) For large defects, a trocar may need to be placed through the paraspinal muscles to obtain an angle to apply xation for the anteromedial edge of the mesh. Depending on the posteromedial extent of the mesh xation, this 5-mm trocar may be medial to the mesh or come through the mesh.
58
Figure 9 A hernia defect that extends to the level of the iliac crest will require either xation through the bone, or xation down in the pelvis. We choose to identify Coopers ligament and place tacks at this level, leaving a skirt of mesh draped into the pelvis. The inferior edge of the mesh is also xed just anterior to the iliopubic tract, both with tacks and sutures. Similar to an inguinal hernia repair, no xation should be placed below the iliopubic tract to avoid nerve and vascular injury.
59
Figure 10 For xation, with the defect edge bordering on or in close proximity to the costal margin, the mesh is sized and positioned to provide a 5 cm ap above the costal margin. Transfascial xation is then performed just subcostally and tack xation is performed at the level of a rib. Intercostal vessel injury is a theoretical risk, though unlikely since the tacks are only 3.8 mm long and need to rst 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.
60
Figure 11 Appearance after the nal xation has been completed, applicable in a patient with a small hernia.
Figure 13 Appearance after the nal xation has been completed, applicable for a large hernia when xation is required both at the level of Coopers ligament and up to the diaphragm.
Figure 12 Appearance after the nal xation has been completed, applicable for a large hernia when xation is required both at the level of Coopers ligament and up to the diaphragm.
Figure 14 CT scan image of right ank hernia following repair.

Postoperative care is similar to that for laparoscopic ventral hernia repair. Early ambulation is encouraged. The bladder catheter is removed in the immediate postoperative period for simple cases or on ambulation for large repairs. Adequate analgesia can be achieved with regular administration of nonsteroidal anti-inammatory agents in addition to narcotics with a PCA if needed. Epidural analgesia is currently being evaluated for efcacy in patients undergoing laparoscopic ventral hernia repair. Oral intake is allowed on the day of surgery and advanced as tolerated by the patient. Venous thromboembolic prophylaxis should be undertaken until there is adequate ambulation. Postoperative seromas are frequent and usually resolve spontaneously over 4 to 6 weeks. Abdominal binders may be used for patient comfort. We do not routinely drain seromas, and will only consider it after a prolonged period in a severely symptomatic patient since the risk of introduction of bacteria into a sterile collection exists. Short term outcomes have been good in our initial experi-
61 ence. Of our rst 10 cases, nine were incisional hernias, and one was posttrauma. Median hernia diameter was 222 cm2 (25-780 cm2) and median size of mesh was 600 cm2 (962368 cm2). Median operative time was 137 minutes (81-322 minutes). There were no intraoperative or postoperative complications and median hospital stay was 2.5 days (0-6 days). There were no complications or recurrences at 1 month follow up. In conclusion, laparoscopic repair is well suited for ank hernias because there is clear visualization, and wide coverage and secure xation can be achieved. Good knowledge of groin and retroperitoneal anatomy is required and patient positioning is key to accessing this difcult region.
Reference
1. 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

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2006, Vol.8, No.1, Techniques of Laparoscopic Hernia Repair

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Volume 8, Number 1

Techniques of Laparoscopic Hernia Repair

Laparoscopic Ventral Hernia Repair

Techniques of Laparoscopic VHR

Laparoscopic ventral hernia repair

Figure 1 Patient positioning, room set-up, and our trocar strategy.

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

Laparoscopic ventral hernia repair

Figure 5 Initial four-point mesh xation.

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

Figure 6 Transabdominal suture xation of the mesh.

Laparoscopic ventral hernia repair

Laparoscopic Repair of Suprapubic Ventral Hernias

Laparoscopic repair of suprapubic ventral hernias

Laparoscopic repair of suprapubic ventral hernias

Laparoscopic repair of suprapubic ventral hernias

Laparoscopic repair of suprapubic ventral hernias

Laparoscopic repair of suprapubic ventral hernias

Laparoscopic repair of suprapubic ventral hernias

Laparoscopic repair of suprapubic ventral hernias

Laparoscopic repair of suprapubic ventral hernias

Laparoscopic Repair of Traumatic Diaphragmatic Hernia

Primary Repair of Diaphragmatic Injury

M. Zerey, B.T. Heniford, and R.F. Sing

Repair of Diaphragmatic Injury Using Prosthetic Biomaterial

Laparoscopic repair of traumatic diaphragmatic hernia

M. Zerey, B.T. Heniford, and R.F. Sing

Laparoscopic repair of traumatic diaphragmatic hernia

M. Zerey, B.T. Heniford, and R.F. Sing

Laparoscopic repair of traumatic diaphragmatic hernia

Laparoscopic Total Extraperitoneal Inguinal Hernia Repair

Laparoscopic total extraperitoneal inguinal hernia repair

Laparoscopic total extraperitoneal inguinal hernia repair

Laparoscopic total extraperitoneal inguinal hernia repair

Laparoscopic total extraperitoneal inguinal hernia repair

Laparoscopic total extraperitoneal inguinal hernia repair

Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair

Peritoneal Flap Dissection

Transabdominal preperitoneal inguinal hernia repair

Dissection of Hernia Sac

Transabdominal preperitoneal inguinal hernia repair

Transabdominal preperitoneal inguinal hernia repair

Laparoscopic Flank Hernia Repair

Laparoscopic ank hernia repair

A. Ramaswamy and B. Ramshaw

Laparoscopic ank hernia repair

A. Ramaswamy and B. Ramshaw

Laparoscopic ank hernia repair

A. Ramaswamy and B. Ramshaw

Laparoscopic ank hernia repair

A. Ramaswamy and B. Ramshaw

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

Laparoscopic ank hernia repair

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