Laparoscopic Hernia Surgery: An Operative Guide

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Laparoscopic hernia surgery

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Laparoscopic hernia surgery An operative guide Edited by

Karl A. LeBlanc MD MBA FACS Minimally Invasive Surgery Institute, Inc. Baton Rouge, Louisiana, USA Clinical Assistant Professor, Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana, USA Past President of the American Hernia Society

A member of the Hodder Headline Group LONDON

First published in Great Britain in 2003 by Arnold, a member of the Hodder Headline Group 338 Euston Road, London NW1 3BH http://www.arnoldpublishers.com Distributed in the United States of America by Oxford University Press Inc. 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press

© 2003 Arnold All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher or a licence permitting restricted copying. In the United Kingdom such licences are issued by the Copyright Licensing Agency: 90 Tottenham Court Road, London W1T 4LP. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authors nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN 0 340 80940 X 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Joanna Koster Development Editor: Sarah Burrows Project Editor: Anke Ueberberg Production Controller: Deborah Smith Project Managers: Nora Naughton, Samantha Gear Cover Design: Lee-May Lim Typeset in 10/12 Minion by Charon Tec Pvt Ltd., Chennai, India Printed and bound in Italy What do you think about this book? Or any other Arnold title? Please send your comments to [email protected]

I wish to dedicate this book to Zinda, my wife. Please forgive my absence in so many things in our lives so that this textbook could become a reality. Your support and love is never forgotten and always appreciated.


Contents

Contributors Preface

PART 1

xi xiii

Abbreviations

xv

Manufacturers

xvii

OVERVIEW

1

1

Laparoscopic general surgery Roger K.J. Simmermacher

3

2

Technological and instrumentation aspects of laparoscopic hernia surgery Gina L. Adrales and Adrian E. Park

7

3

Prosthetic biomaterials for hernioplasty Karl A. LeBlanc

17

4

Fixation devices for laparoscopic hernioplasty Karl A. LeBlanc

25

LAPAROSCOPIC INGUINAL/FEMORAL HERNIOPLASTY

31

5

History Michael S. Kavic and Stephen M. Kavic

33

6

Anatomy and physiology B. Page and Patrick J. O’Dwyer

41

7

Intraperitoneal onlay mesh approach Morris Franklin

47

8

Transabdominal pre-peritoneal approach Reinhard Bittner, Claus-Georg Schmedt and Bernhard Josef Leibl

53

9

Totally extraperitoneal approach Ed Felix

65

10

Femoral and pelvic herniorrhaphy Christine A. Ely and Maurice E. Arregui

75

11

Results of laparoscopic inguinal/femoral hernia repair Ketan M. Desai and Nathaniel J. Soper

83

12

Complications and their management Ricardo V. Cohen, Carlos A. Schiavon, Sérgio Roll and José C.P. Filho

89

PART 2

viii Contents PART 3

LAPAROSCOPIC INCISIONAL AND VENTRAL HERNIOPLASTY

97

13

History Kristi L. Harold, Brent D. Matthews and B. Todd Heniford

99

14

Anatomy and physiology Karl A. LeBlanc

103

15

Laparoscopic repair in the emergent setting Guy R. Voeller

111

16

Herniorrhaphy with the use of transfascial sutures Karl A. LeBlanc

115

17

Pre-peritoneal herniorrhaphy Sérgio Roll, Wagner C. Marujo and Ricardo V. Cohen

125

18

Hernioplasty with the double-crown technique Salvador Morales-Conde and Salvador Morales-Méndez

133

19

Parastomal hernia repair Karl A. LeBlanc

143

20

Lumbar hernia and ‘denervation’ hernia repair Karl A. LeBlanc

151

21

Results of laparoscopic incisional and ventral hernia repair Rodrigo Gonzalez and Bruce J. Ramshaw

155

22

Complications and their management Samuel K. Miller, Stephen D. Carey, Francisco J. Rodriguez and Roy T. Smoot, Jr

161

PART 4

LAPAROSCOPIC TREATMENT OF DIAPHRAGMATIC HERNIATION

171

23

History Raymond C. Read

173

24

Anatomy and physiology Mark A. Reiner

179

25

Preoperative evaluation Marco G. Patti and Piero M. Fisichella

187

26

Gastroesophageal reflux disease J. Barry McKernan and Charles R. Finley

193

27

Para-esophageal hernias Hugo Bonatti, Beate Neuhauser and Ronald A. Hinder

201

28

Traumatic and unusual herniation Sergio G. Susmallian and Ilan Charuzi

209

29

Etiology of recurrent gastroesophageal reflux disease Ziad T. Awad and Charles J. Filipi

217

30

Reoperation for recurrent gastroesophageal reflux disease Thomas R. Eubanks

227

31

Results of laparoscopic treatment of hiatal hernias Patrick R. Reardon and Stirling E. Craig

235

32

Complications and their management Santiago Horgan and Robert Berger

239

Contents ix PART 5

LAPAROSCOPY IN THE PEDIATRIC HERNIA PATIENT

249

33

History Rajeev Prasad and Thom E. Lobe

251

34

Anatomy and physiology Rajeev Prasad and Thom E. Lobe

255

35

Diaphragmatic herniation Rajeev Prasad and Thom E. Lobe

257

36

Complications and their management Rajeev Prasad and Thom E. Lobe

261

PART 6

FUTURE CONSIDERATIONS

263

37

Robotics and hernia surgery Amit Trivedi and Garth H. Ballantyne

265

38

Socioeconomic issues Karl A. LeBlanc, Andrew N. Kingsnorth and Zinda Z. LeBlanc

273

Index

283


Contributors

Gina L. Adrales MD Clinical Instructor, University of Kentucky Medical Center; and Research Fellow, Center for Minimally Invasive Surgery, University of Kentucky, Lexington, KY, USA Maurice E. Arregui MD FACS Director of Fellowship in Laparoscopy, Endoscopy and Ultrasound, St. Vincent Hospital and Health Care Center, Indianapolis, IN, USA Ziad T. Awad MD FRCSI FICS General Surgery Resident, Omaha, NE, USA Garth H. Ballantyne MD FACS FASCRS Professor of Surgery, Division of Minimally Invasive and Telerobotic Surgery, Hackensack University Medical Center, Hackensack, NJ, USA Robert Berger MD Fellow in Laparoscopic Surgery, Department of Surgery, University of Illinois, Chicago, IL, USA Reinhard Bittner MD FRCS Head of Department of General and Visceral Surgery, Marienhospital Stuttgart, Stuttgart, Germany Hugo Bonatti MD Department of Surgery, Mayo Clinic, Jacksonville, USA Stephen D. Carey MD FACS Nanticoke Surgical Associates, Seaford, DE, USA Ilan Charuzi MD Chairman, Department of Surgery, Wolfson Medical Center, Holon, Israel Ricardo V. Cohen MD FACS Department of Surgical Endoscopy, Sao Camilo Hospital, Sao Paulo, Brazil Stirling E. Craig MD BA Research assistant, Methodist Reflux Center, The Methodist Hospital, Texas Medical Center, Houston, Texas Ketan M. Desai MD Department of Surgery, Washington University School of Medicine, St Louis, MO, USA Christine A. Ely MD Fellow in Laparoscopy and Endoscopy, St Vincent Hospital and Health Care Center, Indianapolis, IN, USA Thomas R. Eubanks MD DO Portland Surgical Specialists, Portland, OR, USA

Ed Felix MD California Institute of Minimally Invasive Surgery, Fresno, CA, USA José Carlos Pinheiro Filho MD Department of Surgical Endoscopy, Sao Camilo Hospital, Sao Paulo, Brazil Charles J. Filipi MD Professor, Department of Surgery, Creighton University, Omaha, NE, USA Charles R. Finley MD FACS Videoscopic General Surgeon, Atlanta, GA, USA Piero M. Fisichella MD Fellow, Swallowing Center, University of California, San Francisco, CA, USA Morris Franklin MD Professor of Surgery, University of Texas Health Science Center, and Director, Texas Endosurgery Institute, San Antonio, TX, USA Rodrigo Gonzalez MD Fellow, Emory Endosurgery Unit, Surgery Department, Emory University School of Medicine, Atlanta, GA, USA Kristi L. Harold MD Laparoscopic Fellow, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, NC, USA B. Todd Heniford MD Chief of Minimal Access Surgery, Co-Director Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, NC, USA Ronald A. Hinder MD PhD Professor and Chairman, Department of Surgery, Mayo Clinic, Jacksonville, FL, USA Santiago Horgan MD Director of Minimally Invasive Surgery and Assistant Professor of Surgery, Department of Surgery, University of Illinois, Chicago, IL, USA Michael S. Kavic MD Professor of Clinical Surgery and Vice Chair, Department of Surgery, Northeastern Ohio Universities College of Medicine, and Director of Education, General Surgery, St Elizabeth Health Center, Youngstown, OH, USA

xii Contributors Stephen M. Kavic MD Department of Surgery, Yale University School of Medicine, New Haven, CT, USA

Marco G. Patti MD Associate Professor of Surgery, Director, Swallowing Center, University of California, San Francisco, CA, USA

Andrew N. Kingsnorth BSc MD MS FRCS FACS Professor of Surgery and Consultant Surgeon, Plymouth Postgraduate Medical School, Derriford Hospital, Plymouth, UK

Rajeev Prasad MD Fellow in Pediatric Surgery, University of Tennessee College of Medicine, and Le Bonheur Children’s Medical Center, Memphis, TN, USA

Karl A. LeBlanc MD MBA FACS Minimally Invasive Surgery Institute, Inc. Baton Rouge, Louisiana, USA. Clinical Assistant Professor, Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana, USA. Past President of the American Hernia Society Zinda Z. LeBlanc RN BSN MD MBA Director of Surgical Services/AICU/PACU/TX Rm., Woman’s Hospital, Baton Rouge, LA, USA Bernhard Josef Leibl MD Department of General and Visceral Surgery Marienhospital Stuttgart, Stuttgart, Germany Thom E. Lobe MD Chairman, Section of Pediatric Surgery, and Chairman, Task Force on Complementary and Alternative Medicine, and Professor of Surgery and Pediatrics, University of Tennessee College of Medicine and Le Bonheur Children’s Medical Center, Memphis, TN, USA Wagner C. Marujo MD Attending Surgeon, Liver Transplantation Unit, Hospital Albert Einstein, Sao Paulo, and Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil

Bruce J. Ramshaw MD FACS Director of Education, Emory Endosurgery Unit, and Assistant Professor, Surgery Department, Emory University School of Medicine, Atlanta, GA, USA Raymond C. Read MD FACS FRCS Professor of Surgery Emeritus, University of Arkansas for Medical Sciences, Rockville, MD, USA Patrick R. Reardon MD Director, Texas Institute for Advanced Minimally Invasive Surgery Training, Texas Medical Center, Houston, Texas and Surgical Director, Methodist Reflux Center, The Methodist Hospital, Texas Medical Center, Houston, Texas Mark A. Reiner MD Assistant Clinical Professor of Surgery, Laparoscopic Surgical Center of New York, Mount Sinai School of Medicine, New York, NY, USA Francisco J. Rodriguez MD FACS Nanticoke Surgical Associates, Seaford, DE, USA

Brent D. Matthews MD Chief of Research, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, NC, USA

Sérgio Roll MD Director of Laparoscopic Surgery, Department of General Surgery, Heliopolis Hospital, University of Santos School of Medicine, Sao Paulo, Brazil

J. Barry McKernan MD PhD FACS Clinical Professor of Surgery, Medical College of Georgia, Augusta, GA, USA

Carlos A. Schiavon MD Department of Surgical Endoscopy, Sao Camilo Hospital, Sao Paulo, Brazil

Samuel K. Miller MD FACS Nanticoke Surgical Associates, Seaford, DE, USA Salvador Morales-Conde MD Laparoscopic Surgery Unit, University Hospital Virgen Macarena, Seville, Spain Salvador Morales-Méndez MD Digestive and General Surgery Unit, University Hospital Virgen Del Rocío, Seville, Spain Beate Neuhauser MD Department of Surgery, Mayo Clinic, Jacksonville, FL, USA Patrick J. O’Dwyer MB BCh MD FRCSI MCh FRCS Professor of Gastrointestinal Surgery, University Department of Surgery, Western Infirmary, Glasgow, UK B. Page BSc MD MBChB MRCS Research Fellow, University Department of Surgery, Western Infirmary, Glasgow, UK Adrian E. Park MD FRCS FACS Department of Surgery, Center for Minimally Invasive Surgery, University of Kentucky Chandler Medical Center, Lexington, KY, USA

Claus-Georg Schmedt MD Department of General and Visceral Surgery Marienhospital Stuttgart, Stuttgart, Germany Roger K.J. Simmermacher MD PhD General Surgeon, University Medical Centre, Utrecht, The Netherlands Roy T. Smoot, Jr MD FACS Nanticoke Surgical Associates, Seaford, DE, USA Nathaniel J. Soper MD Department of Surgery, Washington University School of Medicine, St Louis, MO, USA Sergio G. Susmallian MD Department of Surgery, Wolfson Medical Center, Holon, Israel Amit Trivedi MD Division of Minimally Invasive and Telerobotic Surgery, Hackensack University Medical Center, Hackensack, NJ, USA Guy R. Voeller MD FACS Associate Professor, Surgery, University of Tennessee, Memphis, Memphis, TN, USA

Preface

The laparoscopic repair of inguinal hernias quickly followed the development of the laparoscopic approach to the cholecystectomy. This operation was, and continues to be, a controversial subject. In contrast, the adoption of the laparoscopic methodology for the treatment of the other hernias of the abdominal wall has experienced continued growth. While there are textbooks that have dealt with general laparoscopic surgical techniques and others that are comprehensive texts on the subject of hernias, none have been dedicated solely to the laparoscopic treatment of this malady in all aspects of the abdomen. A review of the authors that have contributed to this work is a testament of my efforts to provide a true “operative guide” to those surgeons-in-training and those who desire more detailed information on this subject matter. An international representation is evident. These are the opinion leaders and the surgeons that have helped to develop this field. I appreciate their efforts to share their knowledge. I have tried to provide the reader with the different techniques that are currently being used to repair the hernias in the inguinal region, the incisional and hiatal locations. I have also relied on different authors to provide the details of the pertinent anatomy, the current results and the various complications and the management. The segregation of these topics should remove any bias that may be seen in the usual textbooks of this type. A section on the use of the laparoscope in the pediatric hernia patient is also included. In many areas of the

world, the availability of the pediatric surgeon is quite uncommon. The information imparted in these chapters should provide guidance to the general laparoscopic surgeon in this setting. The era of robotics is also upon us. It may be surprising to many of us but there is utility in the repair of hernias also. The final chapter on socioeconomics is needed to educate the surgeon as he or she makes the operative choices that are available. Many issues will be regional while others are national and international. We are all continually faced with the economic realities of the practice of surgery. More attention should be given to this subject in the training programs. It is hoped that this book provides a sound basis to begin this process. I wish to thank all of the contributors for their persistence in this work. It is rather difficult and time-consuming to provide a chapter of the detail and with the significant references that I desired. It is the expertise of these authors that will truly make this text a reference source. I would also express my appreciation of all of the staff from Arnold Publishers and Naughton Management that have helped in the production of this text. I hope that the reader will realize the goals that I set forth upon the commencement of this operative guide to laparoscopic hernia surgery. Karl A. LeBlanc

Louisiana July 2003


Abbreviations

CGRP CT DES DPL ECG ECMO EGD ePTFE GER GERD GPRVS HAL IEM IPOM LES LIVH MIS MRI NSEMD PCA PEH PFA PONV PPM PTFE TAPP TEP TLESR

calcitonin gene-related peptide computerized tomography diffuse esophageal spasm diagnostic peritoneal lavage electrocardiogram extracorporeal membrane oxygenation esophagogastroduodenoscopy expanded polytetrafluoroethylene gastroesophageal reflux gastroesophageal reflux disease giant prosthetic reinforcement of the visceral sac hand-assisted laparoscopy ineffective esophageal motility intraperitoneal onlay of mesh lower esophageal sphincter laparoscopic incisional and ventral hernioplasty minimally invasive surgery magnetic resonance imaging non-specific esophageal motility disorder patient-controlled analgesia para-esophageal hernia platelet function assay postoperative nausea and vomiting polypropylene mesh polytetrafluoroethylene transabdominal pre-peritoneal total extraperitoneal transient lower-esophageal sphincter relaxation


Manufacturers

Angiologica, S. Martino Sicc., Italy Applied Medical, Rancho Santa Margarita, CA, USA Atrium Medical Corp., Hudson, NH, USA Autosuture, Norwalk, CT, USA BARD, Loomis, CA, USA Brennen Medical, Inc., St Paul, MN, USA Coalescent, Sunnyvale, CA, USA Cook Surgical, Inc., Bloomington, IN, USA Computer Motion, Inc., Santa Barbara, CA, USA Cousin Biotech, Wervicq-Sud, France C. R. Bard, Inc., Cranston, NJ, USA Curon Medical, Sunnyvale, CA, USA Ethicon, Inc., Somerville, NJ, USA Ethicon Endosurgery, Inc., Cincinnati, OH, USA Genzyme Corp., Cambridge, MA, USA HerniaMesh, S.R.L., Turin, Italy Intuitive Surgical, Mountain View, CA, USA Lifecell, Inc., Branchburg, NJ, USA Louisville Laboratories, Inc., Louisville, KY, USA 3M Healthcare, St Paul, MN, USA Meadox Medical Corp., Oakland, NJ, USA Onux Medical, Inc., Hampton, NJ, USA Organogenesis, Inc., Canton, MA, USA Origin Medsystems, Menlo Park, CA, USA Phillips Petroleum Co., Bartlesville, OK, USA Sanofi Winthrop Pharmaceuticals, New York, NY, USA Sofradim International, Villfranche-sur-Saône, France Storz Endoscopy, Los Angeles, CA, USA Tissue Science Laboratories plc, Covington, GA, USA U.S. Surgical Corp./Tyco International, Inc., Norwalk, CT, USA W. L. Gore & Associates, Inc., Flagstaff, AZ, USA


PART

1

Overview

1 Laparoscopic general surgery 2 Technological and instrumentation aspects of laparoscopic hernia surgery

3 7

3 Prosthetic biomaterials for hernioplasty 4 Fixation devices for laparoscopic hernioplasty

17 25


1 Laparoscopic general surgery ROGER K.J. SIMMERMACHER

References

5

Fortunately the time when many surgeons and their patients thought that laparoscopy should be a purpose rather than a means to an end has passed. Although the ‘scopic’ approach has become the gold standard for some indications, it has not brought completely new ideas on how to handle surgical diseases, but it has changed our certain approach in order to facilitate the postoperative recovery of the patient. Principally, a surgical disease should be managed by a surgeon. Who, in order to treat his or her patient optimally, is not limited by technology (a scalpel for open surgery or the laparoscope for some of us) rather than trying to find the best treatment modality by chance, which might include techniques still to be envisioned.1 For many of us, laparoscopy is, or was, the first expansion of our rather limited armamentarium. As with many things in surgery, Hippocrates is credited as the first physician to have used a tool to obtain a better view of the human interior, in his case the rectum.2 Further development of this idea, however, was hampered for nearly 2000 years due to a lack of progression in technological innovation.3 The evolution of laparoscopic surgery parallels the evolution of two distinct technical factors, which are the basis for all current endoscopic interventions: the invention and development of a lens system that could be connected to a computer-chip television camera and an effective lighting system via fiber-optic delivery were the essential prerequisites for the current possibilities of laparoscopic technology. This allowed other surgeons and their assistants to handle the endoscope while actively participating and assisting in the scopic procedures. It is difficult to state with certainty who should be credited with performing the first human laparoscopy, complete with pneumoperitoneum. However, at the beginning of the twentieth century, three names are mentioned: Kelling,4 Jacobaeus5 and Ott.6 Jacobaeus was the first physician to

mention thoracoscopy, a procedure that he initially felt had a better chance than laparoscopy for further development. In 1927, the first textbook dealing with thoracoscopy and laparoscopy was published by Korbsch in Munich, Germany. After World War II, the development of laparoscopic investigations into the human body was led mainly by European gynecologists. An extensive overview of their contributions into the development of endoscopic surgery is beyond the scope of this chapter, but some of their advancements are interesting and worth consideration.7 Once technical innovations allowed more than one person to view through the laparoscope at the same time, it was only a few years before Phillipe Mouret of Lyon, France performed the first human laparoscopic cholecystectomy in 1987. This event initiated an explosion of experiments that has brought us to the current position of laparoscopy as an important part of the surgical armamentarium. Nowadays, laparoscopic cholecystectomy, by far the most extensively described and most frequently performed laparoscopic procedure, is the gold standard treatment for most diseases that merit removal of the gallbladder,8 irrespective of age and comorbidity.9 Additionally, cholecystectomy is very often the first laparoscopic operation that trainees are taught. It should be emphasized that the principles and indications for cholecystectomy have not changed because of the laparoscopic approach. However, the old controversy of whether intraoperative cholangiography should be a routine part of the procedure returned early in the development of this procedure.10 Additional concerns were exposed, partly because the laparoscopic exploration of the common bile duct was in its infancy.11,12 Even today, these arguments are not resolved.10 Within a short period of time, the scopists turned their interest towards another frequent surgical procedure,

4 Overview

appendectomy.13 Laparoscopic appendectomy had been reported as early as 1977 in a paper from The Netherlands,14 and since then there has been an ongoing discussion about the merits of the laparoscopic approach in the surgical treatment of appendicitis. A recent review by Fingerhut concluded that because many of the surgical aspects of the open appendectomy have improved so greatly, the apparent advantages of a laparoscopic approach are hard to demonstrate.15 It is acknowledged, however, that local cultural factors, as well as operative experience, are important considerations that should dictate the strategic decisions of any individual surgeon and/or hospital.15 Recently, a randomized clinical trial in children, which compared both approaches, demonstrated clearly that laparoscopic appendectomy did not offer advantages over the open method.16 These findings are disputed heavily by others.17 Advantages of laparoscopic appendectomy appear to be limited to obese patients and patients whose preoperative diagnosis is not clear-cut.18 Another organ system that received a lot of attention in the early years of laparoscopy was the upper gastrointestinal tract.19 The initial interest began with the treatment of duodenal ulcers and gastroesophageal reflux disease.20 Since its introduction of laparoscopic surgery of the upper gastrointestinal tract, has become the gold standard for the surgical treatment of gastroesophageal reflux disease (GERD).21 It is frequently performed in daycare situations,22 although there can be persistent complaints years after the operation.23 According to the French literature, gastric ulcers should be approached laparoscopically at the initial operation,24 as both retrospective25 and prospective26 analyses have shown excellent results and low conversion rates.25 Other diseases of the stomach for which laparoscopy is frequently performed in some centers with standardized laparoscopic methods include achalasia,26,27 perforated peptic ulcer,28 and gastric cancer. With respect to bariatric surgery, there appear to be current differences between the use of the gastric bypass (more popular in the USA) and the application of adjustable bands on the stomach (more popular in Europe). The laparoscopic approach for both procedures continues to grow rapidly, but randomized controlled trials comparing the different methods are needed urgently.29 Laparoscopy offers an important advantage in the treatment of many types of intra-abdominal cancers, as it allows staging of the disease prior to any intended resection. However, careful patient selection is necessary to effectively limit the number of unnecessary laparotomies.30,31 Additionally, intraoperative laparoscopic ultrasonography may become mandatory in the future because it allows more accurate pretreatment staging.32 Preoperative staging will allow the correct operation to be chosen from one of the many different types of resections that are feasible.33–36

Introduction of improved techniques for intracorporeal hemostasis, stapling and knot-tying make it possible to treat many colorectal diseases laparoscopically,37 even in the presence of generalized peritonitis.38 Despite initial doubts about the maintenance of oncological resection principles, it has been shown that both types of operations, laparoscopic and open, do not differ greatly in this respect.39 The incidences of anastomotic leakage, morbidity and mortality are not significantly different between the two methodologies, but the laparoscopic approach requires more operative time.39 Laparoscopic resection of cystic and solid liver tumors, curative or palliative, is receiving increasing interest as reports of the different techniques and their pitfalls are accumulating.40–43 Staging, of course, has also been shown to be feasible.44 The spleen has also been the target of the laparoscopist. Currently, open splenic resection is usually reserved for treating a very large spleen with hypersplenism and in the acute trauma setting.45 Retroperitoneal organs, such as the pancreas, adrenal glands and prostate, have also become the domain of laparoscopically trained surgeons.46–49 Admittedly, these more advanced procedures require sufficient training and skills in both laparoscopic and open surgery. Vascular surgeons are now evaluating the newest treatment modalities of endovascular procedures and endoscopic techniques. Veins50 and the aorta51 can be handled via a laparoscope, although this is still experimental in most cases.52 Future developments will probably focus on the improvement of intraoperative imaging techniques, improved tactile feedback through the so-called ‘endohand’,53 navigation,54 and robotic assistance.55 The primary efforts of the developments of laparoscopic surgery focused upon the improvements for the care of the patients, which of course continues today (e.g. the development of gasless pneumoperitoneum by lifting of the abdominal wall).42,53 Current innovative attention seeks to improve the range of motion, precision and control of the surgeon through the development of intracorporeal instruments that are handled via the endo-hand or revolutionary improvements of the tip of the laparoscopic instruments53 as the ‘endo-wrist’ of the da Vinci® robotic system.55 Furthermore, gastroenterologists might be challenged as some surgeons turn their interest into endoorgan laparoscopic management. However, there are only limited anecdotal reports of resections of gastric leiomyomas56 or small neoplasms, which predicts that further investigations will be undertaken in the future.57 In conclusion, it is evident that laparoscopy is currently part of the surgical armamentarium as much as the hand and scalpel have always been. Due to the current availability of rapid communication facilities,58 the development of laparoscopy has been quicker than that of any other innovation within surgery. In fact, this may

Laparoscopic general surgery 5

have pushed some surgeons to use laparoscopy for very many different indications with, in some cases, less than optimal preparation.59 Laparoscopy is well established for cholecystectomy and gastric fundoplication,18 but for many other indications its position still has to be determined, because many reports of successful laparoscopic management for various indications are either from anecdotal or personal experiences. The following chapters of this book indicate the current state of the art concerning hernia surgery. Certainly, there is enough evidence to direct a choice. Thus far, the discussion regarding the value of laparoscopy in trauma has yet to be finalized with respect to its indications60,61 and its potential risks.62 The alleged or partly demonstrated advantages of laparoscopic surgery, such as reductions in postoperative morbidity,63 postoperative intra-abdominal adhesions,64 postoperative analgesia requirements, sleep disturbances,65 blood loss, and moderate immunological responses, and, increasingly, lower costs66 are not proven completely,18 despite the fact that others test endoscopic surgery in rather extreme circumstances.67 Training of our future colleagues should be standardized with well-organized hands-on courses combined with pelvic trainers and animal models. This issue is a matter of concern that still needs attention.68 In order to convince the surgical community of its advantages, randomized clinical trials and thorough analyses of the outcomes from these procedures are mandatory. Nevertheless, one must not forget the real experts’ wisdom and warnings.1

11 12

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21

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REFERENCES 1 2 3 4 5

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Scott-Conner CEH, Arregui M. Visions of things that will come to pass. Surg Laparosc Endosc Percutan Tech 1999; 9: 85–6. Edmondson JM. History of the instruments for gastrointestinal endoscopy. Gastrointest Endosc 1991; 37: S27–57. Gunning JE. The history of laparoscopy. J Reprod Med 1974; 12: 222–6. Kelling G. Über Oesofagoscopie, Gastroscopie und Kölioscopie. Munch Med Wochenschr 1902; 41: 259–71. Jacobaeus HC. Über die Möchligkeit die Zystoscopie bei Untersuchung seröser Höhingen auszuwenden. Munch Med Wochenschr 1910; 57: 2090–92. Ott D. Die direkte Beleuchtung der Bauchhöhle, der Harnblase, des Dickdarms und des Uterus zu diagnostischen und operativen Zwecken. Rev Med Tcheque 1901; 2: 27–9. Taniguchi E, Ohashi S, Takiguchi S, Kanno H, Oriyama T, Ikuma K, et al. Laparoscopic surgery assisted by a transvaginal approach. Surg Laparosc Endosc 1999; 9: 53–6. Zacks SL, Sandler RS, Rutledge R, Brown RS, Jr. A populationbased cohort study comparing laparoscopic cholecystectomy and open cholecystectomy. Am J Gastroenterol 2002; 97: 334–40. Ludwig K, Patel K, Wilhelm L, Bernhardt J. Prospective study on patients outcome following laparoscopic vs. open cholecystectomy. Zentralbl Chir 2002; 127: 41–6. Podnos YD, Gelfand DV, Dulkanchainun TS, et al. Is intraoperative cholangiography during laparoscopic cholecystectomy cost effective? Am J Surg 2001; 182: 663–9.

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Phillips EH, Rosenthal RJ, Caroll BJ, Fallas MJ. Laparoscopic transcystic common bile duct exploration. Surg Endosc 1994; 8: 1389. Berci G, Morgenstern L. Laparoscopic management of common bile duct stones. A multi-institutional SAGES-study. Surg Endosc 1994; 8: 1168. Schreiber JH. Early experience with laparoscopic appendectomy in women. Surg Endosc 1987; 1: 211–16. Kok HJ. A new technique for resecting the non-inflamed not-adhesive appendix through a mini-laparotomy with the aid of the laparoscope. Arch Chir Neerl 1977; 29: 195–8. Fingerhut A, Millat B, Borrie F. Laparoscopic versus open appendectomy: time to decide. World J Surg 1999; 23: 835–45. Little DC, Custer MD, May BH, Blalock SE, Cooney DR. Laparoscopic appendectomy: an unnecessary and expensive procedure in children? J Pediatr Surg 2002; 37: 310–17. Garbutt JM, Soper NJ, Shannon WD, et al. Meta-analysis of randomized controlled trials comparing laparoscopic and open appendectomy. Surg Laparosc Endosc 1999; 9: 17–26. Tittel A, Schumpelick V. Laparoskopische Chirurgie: Erwartungen und Realität. Chirurg 2001: 72: 227–35. Katkhouda N, Moniel J. A new technique of surgical treatment of chronic duodenal ulcer without laparotomy by videocoelioscopy. Am J Surg 1991; 161: 361–4. Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1: 138–43. Booth MI, Joines L, Stratford J, Dehn TCB. Results of laparoscopic Nissen fundoplication at 2–8 years after surgery. Br J Surg 2002; 89: 476–81. Trondsen E, Mjåland O, Raeder J, Buanes T. Day-case laparoscopic fundoplication for gastro-esophageal reflux disease. Br J Surg 2000; 87: 1708–11. Liu JY, Woloshin S, Laycock WS, Schwartz LM. Late outcomes after laparoscopic surgery for gastroesophageal reflux. Arch Surg 2002; 137: 397–401. Yahchouchy E, Debet A, Fingerhut A. Crack cocaine-related prepyloric perforation treated laparoscopically. Surg Endosc 2002; 16: 220. Cougard P, Barrat C, Gayral F, et al. Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery. Ann Chir 2000; 125: 726–31. Alamowitch B, Aouad K, Sellam P, et al. Laparoscopic treatment of perforated duodenal ulcer. Gastroenterol Clin Biol 2000; 24: 1012–17. Spiess A, Kahrilas P. Treating achalasia: from whalebone to laparoscope. JAMA 1998; 280: 638. Sunderland GT, Chisholm EM, Lau WY, et al. Laparoscopic repair of perforated peptic ulcers. Br J Surg 1992; 79: 785. Gentileschi P, Kini S, Catarci M, Gagner M. Evidence-based medicine: open and laparoscopic bariatric surgery. Surg Endosc 2002; 16: 736–44. Lehnert T, Rudek B, Kienle P, et al. Impact of diagnostic laparoscopy on the management of gastric cancer: prospective study of 120 consecutive patients with primary gastric adenocarcinoma. Br J Surg 2002; 80: 471–5. Böhm B, Ablassmaier B, Müller JM. Laparoscopische Chirurgie am oberen Gastrointestinaltrakt. Chirurg 2001; 72: 349–61. Feussner H, Omote K, Fink U, et al. Pretherapeutic laparoscopic staging in advanced gastric carcinoma. Endoscopy 1999; 31: 342–7. Ohgami M, Otani Y, Kumani K, et al. Curative laparoscopic surgery for early gastric cancer: 5 years experience. World J Surg 1999; 23: 187. Zornig C, Emmermann A, Blöchle C, Jackle S. Laparoscopische 2/3-Resektion des Magens mit intracorpaoraler Anastomose nach Roux-Y. Chirurg 1998; 69: 467.

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Uyama I, Sugioka A, Fujita J, et al. Laparoscopic total gastrectomy with distal pancreatosplenectomy and D2 lymphadenectomy for advanced gastric cancer. Gastric Cancer 1999; 2: 230–34. Adachi Y, Suematsu T, Shiraishi N, et al. Quality of life after laparoscopy-assisted Billroth I gastrectomy. Ann Surg 1999; 229: 49. Szinicz G, Riegler M, Müller W, Beller S. Minimally invasive surgery (MIC) in the area of the colon and rectum: technique of minimally invasive colorectal surgery. Chirurg 2001; 72: 362–7. Faranda C, Barrat C, Catheline JM, Champault GG. Two-stage laparoscopic management of generalized peritonitis due to perforated sigmoid diverticula: Eighteen cases. Surg Laparosc Endosc Percutan Tech 2000; 3: 135–8. Milsom JW, Böhm B, Hammerhofer KA, Fazio V. A prospective randomized trial comparing laparoscopic versus conventional techniques. In colorectal cancer surgery: a preliminary report. J Am Coll Surg 1998; 187: 46. Zacherl J, Scheuba C, Imhof M, et al. Long-term results after laparoscopic unroofing of solitary symptomatic congenital liver cysts. Surg Endosc 2000; 14: 59. Katkhouda N, Hurwitz M, Gugenheim J, et al. Laparoscopic management of benign solid and cystic lesions of the liver. Ann Surg 1999; 229: 460. Intra M, Viani MP, Ballarini C, et al. Gasless laparoscopic resection of hepatocellular carcinoma in cirrhosis. J Laparoendosc Surg 1996; 6: 263. Antonetti MC, Killelea B, Orlando R, 3rd. Hand-assisted laparoscopic liver surgery. Arch Surg 2002; 137: 407–11. Montorsi M, Santambrogio R, Bianchi P, et al. Perspectives and drawbacks of minimally invasive surgery for hepatocellular carcinoma. Hepatogastroenterology 2002; 49: 56–61. Klingler PJ, Tsiotos GG, Glaser KS, Hinder RA. Laparoscopic splenectomy: evolution and current status. Surg Laparosc Endosc 1999; 9: 1–8. Arca MJ, Gagner M. Minimal-invasive Verfahren am Pankreas. Chirurg 1998; 69: 621–7. Walz MK. Minimal-invasive Nebennierenchirurgie. Chirurg 1998; 69: 613–20. Turk I, Deger S, Winkelmann B, et al. Radical prostatectomy in clinically localized prostate carcinoma. Pro laparoscopic approach [in German]. Urologe A 2002; 41: 48–54. Sirén J, Haglund C, Huikuri K, et al. Laparoscopic adrenalectomy for primary aldosteronism: clinical experience in 12 patients. Surg Laparosc Endosc 1999; 1: 9–13. Maghraby HA. Laparoscopic varicocelectomy for painful varicoceles: merits and outcomes. J Endourol 2002; 16: 107–10. Silva L, Kolvenbach R, Pinter L. The feasibility of hand-assisted laparoscopic aortic bypass using a low transverse incision. Surg Endosc 2002; 16: 173–6.

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Dion YM, Hartung O, Gracia C, Doillon C. Experimental laparoscopic aortobifemoral bypass with end-to-side aortic anastomosis. Surg Laparosc Endosc 1999; 1: 35–8. Cuschieri A. Neue Technologien in der laparoskopischen Chirurgie. Chirurg 2001; 72: 252–60. Van der Peet DL, Berends FJ, Klinkenberg-Knol EC, Cuesta MA. Endoscopic treatment of benign esophageal tumors. Surg Endosc 2001; 15: 1489. Ruurda JP, Broeders IAMJ, Simmermacher RKJ, et al. Feasibility of robot-assisted laparoscopic surgery. An evaluation of 35 robotassisted laparoscopic cholecystectomies. Surg Laparosc Endosc Percutan Tech 2002; 12: 41–5. Seelig MH, Hinder RA, Floch NR, et al. Endo-organ and laparoscopic management of gastric leiomyomas. Surg Laparosc Endosc 1999; 9: 78–81. Mittal SK, Filipi CJ. Indications for endo-organ gastric excision. Surg Endosc 2000; 14: 318–25. Allen JW, Finch RJ, Coleman MG, et al. The poor quality of information about laparoscopy on the World Wide Web as indexed by popular search engines. Surg Endosc 2002; 16: 170–72. Liberman MA, Greason K. Residency training in advanced laparoscopic surgery: how are we doing? Surg Laparosc Endosc Percutan Tech 1999; 9: 87–90. Cottom D, Gorecki PJ, Curvelo M, Shaftan GW. Laparoscopic repair of traumatic perforation of the urinary bladder. Surg Endosc 2001; 15: 1488–9. McKinley AJ, Mahomed AA. Laparoscopy in a case of pediatric blunt abdominal trauma. Surg Endosc 2002; 16: 358. Howells GA, Uzieblo MR, Bair H, Boyer MD. Tension pneumopericardium during laparoscopy for trauma. Surg Laparosc Endosc Percutan Tech 2000; 10: 44–6. Langebrekke A, Istre O, Hallqvist AC, et al. Comparison of laparoscopy and laparotomy in patients with endometrial cancer. J Am Assoc Gynecol Laparosc 2002; 9: 152–7. De Wilde RL. Goodbye to late bowel obstruction after appendicectomy. Lancet 1991; 338: 1012. Gogenur I, Rosenberg-Adamsen S, Kiil C, et al. Laparoscopic cholecystectomy causes less sleep disturbance than open abdominal surgery. Surg Laparosc 2001; 15: 1452–5. Hawkins J, Dube D, Kaplow M, Tulandi T. Cost analysis of tubal anastomosis by laparoscopy and by laparotomy. J Am Assoc Gynecol Laparosc 2002; 9: 120–24. Campbell MR, Kirkpatrick AW, Billica RD, et al. Endoscopic surgery in weightlessness. Surg Endosc 2001; 15: 1413–18. Shalhav AL, Dabagia MD, Wagner TT, et al. Training postgraduate urologists in laparoscopic surgery: the current challenge. J Urol 2002; 167: 2135–7.

2 Technological and instrumentation aspects of laparoscopic hernia surgery GINA L. ADRALES AND ADRIAN E. PARK

Instrumentation Fixation Videoendoscopic system Other enabling technologies

7 11 12 12

Laparoscopic hernia surgery, like other types of minimally invasive surgery (MIS), has been shaped and impacted by the emergence of new surgical techniques and the assimilation of new and evolving medical technologies. To address the technological and instrumentation aspects of laparoscopic herniorrhaphy comprehensively could extend the discussion from a macro-perspective dealing with issues of operative suite design and integration of technology to a micro-view focusing on, for example, the tines of a dissecting instrument. Such a dissertation is beyond the scope of this chapter. Instead, we will focus upon the instruments, equipment and material used in laparoscopic hernia surgery and the related technological advances that have facilitated a widening adoption of various laparoscopic hernia procedures. Some topics that are dealt with in greater detail in later chapters, such as methods of mesh fixation and surgical energy sources, will receive more cursory mention in this chapter, in the context of specific instrument use and development. Ergonomic considerations in surgical instrument and equipment design, so often overlooked yet so vital to optimal surgical performance, will also be addressed.

Ergonomics Conclusion References

13 13 14

invasive approaches to a variety of surgical therapies. The development of new dissecting tools and the incorporation of various energy sources into laparoscopic procedures have greatly enhanced the physician’s capability for fine dissection and rapid hemostasis. Despite these achievements, the basic design of laparoscopic instruments and the associated ergonomic constraints have evolved little over the past century. Laparoscopic instrument design is still based upon a template consisting of a handle connected to a long, slender shaft, which then engages an endeffector unit. Like all surgical instruments, laparoscopic instruments should be cost-effective, low-maintenance, functional tools that achieve the intended purpose safely, easily and reliably, as Melzer has stipulated.1 Over the past two decades, an abundance of end-effectors with varied functions has been developed. As a result, a wide array of instruments is currently available to the surgeon performing laparoscopic hernia repair. A brief discussion of the various characteristics and distinguishing features of laparoscopic instrumentation relevant to hernia repair follows.

Disposable instruments INSTRUMENTATION The rapid expansion of available laparoscopic instrumentation has fueled the widespread application of minimally Supported in part by an educational grant from Tyco/US Surgical Corporation.

Disposable instruments may increase operative efficiency by eliminating the need for sterilization of reusable instruments perioperatively. This convenience comes at a significant cost in terms of equipment expenditure and environmental impact. In a cost-comparison of procedural equipment, the cost of disposable equipment exceeded that of reusable instrumentation by a factor of

8 Overview

10–20.2 Although reusable instrumentation is subject to the wear and tear of repeated use and sterilization, disposable instruments may be imprecise.3 Reposable instruments, which combine reusable and disposable components, represent a compromise between the two instrument types.

Laparoscopic dissecting and grasping instruments Although laparoscopic dissectors and graspers conform to a basic design, the configurations of the end-effectors vary in terms of size, shape and surface. Different types of dissection (sharp or blunt dissection, micro- or macro-exposure) require instruments with different dissecting tips. Sharp-tipped instruments, including laparoscopic shears and needle-nose dissectors, facilitate fine spreading and micro-dissection. Blunt dissectors, such as the Reddick-Olsen, may reduce the risk of inadvertent injury to adjacent structures, but their utility in fine dissection and micro-exposure is limited. Tapered tips that fall somewhere in the continuum from sharp to blunt end-effectors constitute the majority of commonly used dissectors. Tapered, narrow-tipped dissectors, such as the Maryland/Kelly or DeBakey laparoscopic instruments, have proved useful during laparoscopic hernia repair, from dissection in para-esophageal herniorrhaphy to creation of the peritoneal flaps in transabdominal pre-peritoneal inguinal herniorrhaphy. Additionally, the Maryland/Kelly dissectors have curved jaws, which facilitate dissection around structures. The curved tips of the Maryland/Kelly dissector allow clear visualization of the operative target and the tip of the instrument, unlike the shadowing that may occur about the symmetrically tapered, flat-tipped, duckbill dissector. Effective tissue grasping is made possible by the surface topography of the instrument tips. The fine ridges and grooves provide friction during grasping, limiting slippage and therefore tissue trauma. The delicate serrations of the DeBakey clamp provide atraumatic tissue handling. This curved instrument is thus ideally suited for the fine dissection and the gentle manipulation of the bowel required during adhesiolysis and reduction of hernia contents. In contrast, ratcheted instruments with thick serrations are poorly suited for bowel handling, but they are designed for constant grasping, such as gallbladder retraction. Other dissectors have tines that appose incompletely along the proximal jaws of the instrument, allowing the instrument to hold tissue atraumatically in that space. The laparoscopic handle and the hinge mechanism of the jaws greatly impact the function of grasping and dissecting instruments. Instruments with coaxial or articulating shafts provide the surgeon with greater freedom of movement in restricted working spaces. Locking

or ratcheted instruments may reduce muscular fatigue during grasping, but they are not appropriate for dissection, which requires more dynamic handling. Similarly, single-action jaws, in which one jaw remains fixed, are effective for grasping but less so for dissection. Furthermore, the symmetry of double-action jaws makes these instruments better suited for fine dissection. The diameter of the instrument also affects function and performance. Micro-instruments (2–3 mm diameter) have been applied to a variety of minimally invasive procedures, including laparoscopic hernia repair.4,5 These ‘needlescopic’ dissectors have relatively elastic shafts and short end-effectors with limited spread. Thus, limitations inherent in the design of 2-mm graspers and dissectors have in turn limited the use of such needlescopic instruments in laparoscopic hernia surgery. Unique to laparoscopic totally extraperitoneal inguinal hernia repair is the balloon dissector, commonly used in North America to develop the pre-peritoneal plane. A variety of balloon dissectors are available, most furnished with a guiding trocar and obturator for initial placement beneath the rectus muscle. With inflation of the balloon, a pre-peritoneal working space is created. Although this device provides a simpler and more timely alternative to manual dissection, it is imperative that the surgeon is familiar with the laparoscopic pre-peritoneal anatomy to recognize the appropriate plane of dissection and to avoid associated complications.

Trocars Careful consideration of trocar type and placement is imperative in the successful conduct of laparoscopic hernia repair. Quite simply, trocars are the portals through which the laparoscopic instruments are passed. At the same time, trocars represent potential weapons, and their misplacement can contribute to the morbidity and even mortality of a laparoscopic procedure. The incidence of trocar-related injury is low but significant. The incidence of hollow viscus perforation varies between 0.04 and 0.14 per cent.6–13 Major retroperitoneal vascular injury has been reported in 0.03–0.1 per cent, carrying a substantial mortality rate of nine per cent.9–12,14 Major vascular injury is a very common cause of death in laparoscopy, second only to anesthetic complications.14 In an effort to increase the safety of trocar insertion, a variety of trocar designs has been introduced. The previously stated pros and cons of reusable instrumentation also hold for trocars. Reusable, metal trocars may provide better grip to the skin and abdominal wall compared with plastic, disposable trocars. Several trocar designs have been developed to prevent slippage and leakage of pneumoperitoneum. The Hasson trocar, typically used as an initial trocar after peritoneal

Technological and instrumentation aspects 9

access via an open technique, has threads along the end of its shaft. Much like the configuration of a screw, these threads assist in securing the trocar in the abdominal wall. Balloon trocars utilize an attached, inflatable, intraabdominal balloon after insertion to bolster the trocar against the abdominal wall. While these balloons add security, they are subject to breakage and may decrease the radial mobility often required during ventral hernia repair to visualize and operate on the anterior abdominal wall. Safe peritoneal entry is a particular concern during incisional hernia repair, where there is a considerable risk of injury to adherent loops of bowel. A variety of measures

(a)

(b)

has been implemented in trocar design to reduce insertionassociated injury. The optical view trocar was developed as an alternative to Hasson trocar placement. This single-use, plastic trocar has a clear shaft and conical tip, allowing visualization of the abdominal wall layers as they are traversed while inserting the laparoscope. This trocar design is well suited for insertion after pneumoperitoneum has been established using a Veress needle. While the optical trocar capitalizes on the benefit of direct visualization, other trocar designs are centered on the tip configuration for injury prevention (Figure 2.1). In an effort to circumvent visceral damage, the shielded trocar

(c)

(d)

(e)

Figure 2.1 A variety of trocars is available for use during laparoscopic ventral herniorrhaphy. (a) The Hasson trocar has threads to prevent slippage from the abdominal wall (Ethicon Endosurgery, Inc.). (b) The non-cutting trocar tip is designed to split the musculature in an effort to decrease bleeding and other trocar-related injuries (Ethicon Endosurgery, Inc.). (c) The plastic shield of this trocar retracts during insertion to expose a cutting blade then deploys upon peritoneal entry to protect the viscera from injury (U.S. Surgical Corp., Inc.). (d) The bladed trocar features a blade that retracts upon peritoneal entry (Ethicon Endosurgery, Inc.). (e) The laparoscope is housed in the optical trocar to provide visual guidance during insertion of this non-cutting trocar. This is particularly useful in the reoperative abdomen after insufflation via the Veress needle technique (Ethicon Endosurgery, Inc.).

10 Overview

consists of an exposed blade for abdominal wall entry and a plastic shield that is released upon peritoneal entry to safely cover the cutting blade. Many disposable trocars incorporate this mechanism. Importantly, this feature does not guarantee protection against trocar entry injuries. Pyramidal and conical trocar tips have also been examined for safety and efficacy. When use of a conical, non-cutting reusable trocar was compared with that of a cutting, disposable trocar during transperitoneal inguinal herniorrhaphy, the reusable trocar resulted in a lower complication rate.15 Trocar vascular and visceral injuries are thought to be related to the force required for trocar insertion. However, the size of the abdominal wall defect created by the trocar has been shown to be inversely proportional to the entry force.16 In an animal study, it was demonstrated that conical tips require greater entry force than pyramidal trocars yet subsequently produce smaller abdominal wall defects. To decrease the insertion force and possibly reduce visceral injury, innovative trocar designs have been coupled with various energy sources. However, these new designs have not yet been proven in human application in laparoscopic hernia surgery; studies have been limited almost entirely to animal models. Electrosurgical trocars utilize thermal energy to create the abdominal wall opening for passage of the trocar. This has been found to reduce the force required for entry without detrimental effects on wound healing at the trocar site after laparoscopic cholecystectomy.17 Taking advantage of the decreased thermal spread associated with ultrasonic dissection, an ultrasonically activated trocar has been designed with an associated decrease in insertion time and force as well as a smaller increase in abdominal pressure during insertion compared with conventional conical trocars.18 The applicability of these trocars is yet to be seen in patients with multiple previous surgeries or with ventral hernias, where the proximity of adhered bowel may predispose the patient to thermal visceral injury. Another substantial concern in the treatment of hernia patients is recurrent herniation. In a retrospective review of 320 patients (including two patients with concomitant para-esophageal hernia repair), the overall incidence of trocar site herniation after laparoscopic fundoplication was found to be three per cent.19 As herniation at trocar sites has been reported repeatedly in the literature,19–21 the size of the defect created by trocars is a key factor. The size of the trocar site defect is influenced by the tip shape, trocar size, and mechanism of entry. The radially expanding trocar utilizes a needle puncture followed by insertion of a blunt, radially expanding obturator through the needle tract. This alternative to the traditional cutting trocar has been associated with less postoperative pain, improved postoperative patientrated wound scores, decreased intraoperative and postoperative complications, and smaller fascial defects.22–24

Similarly, other non-bladed trocars have also been demonstrated to cause smaller abdominal wall defects that do not require closure.25 In contrast to cutting trocars, non-bladed trocars split the musculature rather than cut through the abdominal wall, a technique that may also be associated with less minor bleeding.16

Energy sources Advances in the use of energy sources have increased the ease and feasibility of performing MIS. While energy sources are used largely for hemostasis, increasingly they are employed in tissue dissection as well. Available energy sources include both thermal and mechanical energy devices. Electrosurgery Thermal energy sources rely on the passage of electrical current through tissues and the subsequent production of heat. Applying high-radiofrequency alternating current results in the excitation of cellular ions and the conversion of electrical energy to mechanical energy. The degree of the thermal response is directly proportional to the inherent resistance of the tissues, with little heat production in plasma but significant heat production in bone. The electrical current can be applied with a bipolar or monopolar electrode, the most common method in general surgery.26 Bipolar electrosurgery confines the electrical current to the tissue between the forceps and consequently offers the added safety of decreased thermal spread. Electrothermal injury is a substantial concern, with the incidence of laparoscopic electrosurgery-associated complications numbering two to five per 1000 cases.27 Ultrasonic dissection Ultrasonic dissection is a form of mechanical dissection, like scissor or water-jet dissection, that has gained popularity in laparoscopy. Mechanical energy is created by high-frequency sound-wave vibration. The highfrequency vibration produces denatured collagen and effectively vaporizes cells. The ultrasonically activated scalpel, the ultrasonic instrument used most commonly in laparoscopy, has been shown to seal vessels at diameters up to 5 mm. However, it is recommended that its use is limited to vessels 3 mm or less in diameter.28 At 80°C, the ultrasonically activated scalpel operates at a lower temperature than electrosurgery (100°C).3 Ultrasonic dissection is reported to produce decreased lateral thermal spread when compared with traditional electrosurgery.29 However, identification of intestinal or biliary duct injury due to the ultrasonic dissector may be delayed. Anecdotally, the dissector may temporarily seal the


injury site, such as an enterotomy, only to open days later with devastating consequences. In summary, electrosurgical and ultrasonic dissection instruments minimize blood loss and may reduce operative time in a variety of laparoscopic procedures. However, very judicious and limited use of energy sources in ventral and incisional hernia repair is encouraged. A higher tolerance for a small amount of oozing is accepted in exchange for a reduced risk of intestinal, spermatic cord, or nervous thermal injury. The morbidity of intestinal injuries, particularly missed enterotomies, is remarkably high, with a mortality rate of at least 25 per cent.30

thin arm that is then covered by a retractable sheath during insertion. The operation of this device is rather counterintuitive, as retraction of the handle is required during insertion. Proper handling of the device is essential to protect the delicate mechanism responsible for securing the suture. A more cost-effective method of suture introduction has been illustrated elegantly by Park and colleages31 and Rosenthal and Franklin.32 Rather than employing a suture passer, the suture is introduced on a Keith needle and extracted through a large-gauge spinal needle.

Fixation devices FIXATION Needle drivers and suture passers The employment of needle drivers and suture passers during laparoscopic hernia repair will be discussed in more detail in subsequent chapters. A variety of needle drivers and aids to suturing (e.g. Endostitch, Surg-assist) is available for use during laparoscopic hiatal hernia repair. These devices were developed to assist the surgeon with intracorporeal suturing, an advanced laparoscopic technique. Sutured mesh fixation is imperative in laparoscopic ventral hernia repair. This crucial component of ventral herniorrhaphy can be accomplished via various suturepassing devices. These reusable, low-profile, sharp instruments pierce the abdominal wall through small stab incisions and transfer the suture to secure the mesh to the abdominal wall (Figure 2.2). The suture is held in place by a

Figure 2.2 Gore suture passer (W.L. Gore & Associates, Inc.).

In an effort to secure the prosthetic material and to facilitate its incorporation, several fixation methods have been developed. The need for prosthetic fixation by sutures, tacks and/or staples has been well demonstrated for ventral and incisional herniorrhaphy, and it is now considered indispensable to the long-term durability of the repair.33,34 The picture is less clear with regard to inguinal herniorrhaphy, where data regarding the utility of tissue adhesives or even non-fixation continue to emerge. In contrast, primary suture closure is the most significant component of hiatal hernia repair, as prosthetic mesh is seldom used. The development of staples and spiral tacks has increased operative efficiency in ventral and incisional hernia repair. A variety of tacking devices is now available, including a reusable device, the Salute™ (Onux Medical, Inc.). This innovative device delivers a stainlesssteel construct that is not preformed but assumes the final shape of a keyring. Traditional spiral tacks are approximately 3–4 mm in length, limiting the depth of fixation of the prosthetic patch into the abdominal wall. In a study comparing titanium stapling and Prolene suture fixation of mesh, the burst strength of mesh fixed with suture was significantly greater (1461.7 mmHg) than that of staple fixation with two different delivery systems (885.5 mmHg, 665.2 mmHg).35 It is thus recommended that tack or staple fixation of the mesh be combined with nonabsorbable suture fixation in laparoscopic ventral hernia repair. The development of effective bioadhesives and tissue substitutes may facilitate mesh fixation in ventral and inguinal hernia repair and offer an alternative to prosthetic mesh in crural closure for large hiatal hernias. Several adhesives have been studied. Fibrin sealant or fibrin glue, a hemostatic agent derived from human plasma, has been evaluated as an alternative prosthetic fixation tool in ventral and inguinal hernia repair. However, fibrin application has been associated with a greater inflammatory reaction compared with staple fixation.36 In another animal study, the incorporation of fibrin glue in ventral hernia repair resulted in reduced intra-abdominal

12 Overview

adhesions.37 While an inflammatory reaction was also noted in this study, the density of adhesions and the percentage of expanded polytetrafluoroethylene (ePTFE) prosthetic patch coverage by adhesions was decreased in the fibrin glue cohort. The majority of fibrin sealant studies associated with hernia repair have been conducted in animal models. The hemostatic properties of fibrin glue in hernia repair were notable in one of the few published human studies. In patients with coagulopathic disorders, fibrin glue was noted to reduce postoperative bleeding after inguinal herniorrhaphy.38 The cyanoacrylates, a class of tissue adhesives traditionally used in wound management, have been examined for use in laparoscopic hernia repair. Internal use of this tissue adhesive was previously limited due to the potential toxicity associated with early formulations. However, newly designed formulations have been studied for their applicability in hernia repair, although these studies remain limited to animal models. In an examination of octylcyanoacrylate tissue adhesive for fixation of ePTFE in a rabbit incisional hernia model, less force was required for displacement of adhesive-fixed mesh than for suture or spiral tack fixation.39 In addition, the octylcyanoacrylate adhesive stimulated an inflammatory reaction that delayed cellular migration into the ePTFE interstices, so the clinical implications of this finding are unclear.

VIDEOENDOSCOPIC SYSTEM The videoendoscopic system has become the eyes of the laparoscopic surgeon. With the limited tactile feedback inherent in MIS, the quality of the surgical image is crucial. The present limitations of the imaging system include detrimental reductions in resolution, field of view, contrast, and depth perception. These limitations are the result of optical distortion by the camera and monitor systems, and the loss of monocular and stereoscopic visual cues. The current videoendoscopic system begins with a rod-lens laparoscope with coaxial illumination and fiberoptic light bundles. Illumination is provided by a highintensity but ‘cold’ broadband light source. Most systems employ a high-quality solid-state camera equipped with a charged-coupled device and a three-chip array for color separation (red, green, blue). This provides optimal color fidelity. Standard display systems utilize National Television Committee Standard video with a resolution of no less than 640 ⫻ 480 pixels. Improving upon standard composite video systems, which combine luminance and chrominance signals, S-video separates the signals and offers superior color saturation. Most cathode-ray tube monitors in use are curved and are therefore associated with a degree of distortion. Flat-screen monitors eliminate

this distortion, but they remain cost-prohibitive in many institutions and may provide poorer resolution and movement lag. Advances in imaging technology have led to the development of new systems to address current optical and ergonomic limitations. Head-mounted displays reduce the displacement associated with standard video towers positioned at a distance from both the surgeon and the operative field. However, the results of head-mounted displays have been mixed; at least one report notes decreased eyestrain and improved operative efficiency, but another study fails to duplicate these results.40,41 Three-dimensional imaging systems have also been constructed to provide stereoscopic perceptual cues. However, the spacing between the component imaging systems is generally limited and is significantly smaller than the normal interpupillary distance. This restriction limits the depth perception provided by the three-dimensional optical systems. Additionally, the accompanying headmounted display results in degradation in image quality, limiting the widespread incorporation of this innovative system. It is hoped that with the adoption of high-definition television standards and new research in advanced digital signal processing technology, many limitations of videoendoscopic imaging will be eliminated.42 This has important implications for laparoscopic hernia surgery. Real-time reversal of the video display could avoid the mirror-image effect of working against the camera in ventral herniorrhaphy. These new systems could also correct for perceptual distortion, such as the lack of shadowing and other depth cues, and could facilitate the performance of more complex laparoscopic procedures.

OTHER ENABLING TECHNOLOGIES Hand-assisted laparoscopy The technique of hand-assisted laparoscopy (HAL) has been applied to a variety of laparoscopic procedures, in some cases avoiding certain laparotomy. With HAL, the surgeon’s hand is inserted into the peritoneal cavity to assist in dissection and retraction. Various port systems that maintain pneumoperitoneum are used for hand placement. In HAL, the incision size is limited to the surgeon’s hand size, and this incision may be later used for specimen extraction. The application of the hand-assisted technique in laparoscopic hernia repair has been limited. In 2000, Litwin and colleagues reported one repair of a post-traumatic left diaphragmatic hernia in a series of HAL cases.43 The patient was noted to have incarcerated colon, spleen and small intestine. This repair was facilitated by the entry


of the surgeon’s hand via an upper midline incision with a resultant operative time of 206 minutes, estimated blood loss of 50 ml, and a length of stay in hospital of four days. Hand-assisted ventral herniorrhaphy has not been reported. There does not appear to be a clear role for HAL in the repair of ventral or inguinal hernias.

Robotic surgery The feasibility of robotic-assisted surgery has been examined for a variety of laparoscopic procedures. In 2001, Cadiére and colleagues published a robotic-assisted laparoscopic surgery series using the Da Vinci system (Intuitive Surgical), including three inguinal hernia repairs.44 Although the robotic articulating instruments facilitated dissection in a variety of procedures, one system limitation noted by the authors was the narrow field of vision provided by the three-dimensional optical system.

ERGONOMICS Research in the field of surgical ergonomics may have a far greater impact on MIS than will some of the technological advancements addressed previously. In the manufacturing industry, it is well recognized that paying proper attention to postural mechanics and the health impact of instrumentation and machinery can significantly increase the productivity, efficiency and longevity of workers. There are comparatively few available data on the ergonomic risk factors associated with surgery. The performance of surgery can be both mentally and physically demanding, and there is an alarming incidence of musculoskeletal complaints among laparoscopic surgeons.45 Ergonomic risk factors (prolonged static postures, awkward stances, extreme joint angles, pressure points from instrumentation, etc.) are pervasive in MIS as a result of long instrumentation with reduced degrees of freedom and displaced imaging (Figure 2.3). More specifically, there are ergonomic issues that are unique to laparoscopic hernia repair, such as the strain of working against the camera (mirror-image effect) and the complex movements required to repair hernia defects from underneath the anterior abdominal wall during ventral herniorrhaphy. While changes in instrument design and imaging are forthcoming, the incorporation of these changes will take time and the ergonomic hazards will persist until they take effect. In the interim, attention to the current operative environment and the selection of appropriate available instrumentation may improve operative efficiency and protect the health of the surgeon. The etiology of the ergonomic problem in laparoscopy is multifactorial. Consideration should be given to instrumentation, image quality, and the positioning of

Figure 2.3 Minimally invasive surgery often requires awkward positioning.

the patient, the surgical staff, and the equipment. Within the current ergonomic constraints of laparoscopy, changes can and should be made to increase the comfort of the surgeon and reduce muscular fatigue. Instrumentation should be selected not only for function but also for ease of use and proper individual surgical fit. Currently, this selection may not be accomplished easily for surgeons with smaller hands. The operating table should be positioned so that the instrument handles are at the surgeon’s elbow level.46 Similarly, the video monitor should be positioned at or slightly above eye level. Suspended mobile monitors may facilitate this adjustment. The monitor should be in alignment with the operative target and the surgeon. Foot pedals that control energy sources should be placed within a small radius from the surgeon’s feet to avoid stiffening and straining to maintain balance. Patient position is also crucial. The patient should be positioned to allow gravity to assist with operative exposure, reducing the exertion needed from the surgeon and assistants for retraction. For example, the patient is placed in mild reverse Trendelenburg position during para-esophageal hernia repair. Similarly, the patient’s arms should be tucked during ventral herniorrhaphy to provide freedom of movement by the surgeon and assistants about the operating table. Attention to these details in positioning and operative set-up should greatly improve operative efficiency.

CONCLUSION As with other types of MIS, laparoscopic hernia repair evolved through the merger of innovative technology and new surgical techniques. The wide array of available instrumentation for tissue dissection, the development of

14 Overview

new tools for mesh fixation, and the application of novel techniques have all facilitated and expanded the role of laparoscopy in the treatment of a variety of hernia defects. With continuing technological advances and attention to ergonomic factors, the outcome and efficiency of laparoscopic hernia repair are certain to improve.

20

21

22

23

REFERENCES 24 1

2

3 4

5 6

7

8

9 10 11 12

13 14 15

16

17

18

19

Melzer A. Endoscopic instruments: conventional and intelligent. In: Toouli J, Gossot D, Hunter J, eds. Endosurgery. New York: Churchill Livingstone, 1996: 69–95. Fengler TW, Pahlke H, Kraas E. Sterile and economic instrumentation in laparoscopic surgery. Surg Endosc 1998; 12: 1275–9. Park AE, Mastrangelo MJ, Jr, Gandsas A, et al. Laparoscopic dissecting instruments. Semin Laparosc Surg 2001; 8: 42–52. Tagaya N, Aoki H, Mikami H, et al. The use of needlescopic instruments in laparoscopic ventral hernia repair. Surg Today 2001; 31: 945–7. Ferzli G, Sayad P, Nabagiez J. Needlescopic extraperitoneal repair of inguinal hernias. Surg Endosc 1999; 13: 822–3. Zaraca F, Catarci M, Gossetti F, et al. Routine use of open laparoscopy: 1,006 consecutive cases. J Laparoendosc Adv Surg Tech A 1999; 9: 75–80. Catarci M, Carlini M, Gentileschi P, Santoro E. Major and minor injuries during the creation of pneumoperitoneum: a multicenter study on 12,919 patients. Surg Endosc 2001; 15: 566–9. Bonjer HJ, Hazebroek EJ, Kazemier G, et al. Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg 1997; 84: 599–602. McMahon AJ, Baxter JN, O’Dwyer PJ. Preventing complications of laparoscopy. Br J Surg 1993; 80: 1593–4. Saville LE, Woods MS. Laparoscopy and major retroperitoneal vascular injury. Surg Endosc 1995; 9: 1096–100. Loffer FD, Pent D. Indications, contraindications and complications of laparoscopy. Obstet Gynecol Surg 1975; 30: 407–27. Deziel DJ, Millikan KW, Economou SG, et al. Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and analysis of 77,604 cases. Am J Surg 1993; 165: 9–14. Penfield AJ. How to prevent complications of open laparoscopy. J Reprod Med 1985; 30: 660–63. Hashizume M, Sugimachi K. Needle and trocar injury during laparoscopic surgery in Japan. Surg Endosc 1997; 11: 1198–201. Leibl BJ, Schmedt CG, Schwarz J, et al. Laparoscopic surgery complications associated with trocar tip design: review of literature and own results. J Laparoendosc Adv Surg Tech A 1999; 9: 135–40. Bohm B, Knigge M, Kraft M, et al. Influence of different trocar tips on abdominal wall penetration during laparoscopy. Surg Endosc 1998; 12: 1434–8. Waxman K, Birkett DH, Sackier JM, et al. Clinical and laboratory evaluation of an electrosurgical laparoscopic trocar. Surg Endosc 1994; 8: 1076–9. Gossot D, Validire P, Matsumoto S, et al. Development of an ultrasonically activated trocar system. Surg Endosc 2002; 16: 210–14. Bowrey DJ, Blom D, Crookes PF, et al. Risk factors and the prevalence of trocar site herniation after laparoscopic fundoplication. Surg Endosc 2001; 15: 663–6.

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De Giuli M, Festa V, Denoye GC, Morino M. Large postoperative umbilical hernia following laparoscopic cholecystectomy. A case report. Surg Endosc 1994; 8: 904–5. Patterson M, Walters D, Browder W. Postoperative bowel obstruction following laparoscopic surgery. Am Surg 1993; 59: 656–7. Bhoyrul S, Payne J, Steffes B, et al. A randomized prospective study of radially expanding trocars in laparoscopic surgery. J Gastrointest Surg 2000; 4: 392–7. Yim SF, Yuen PM. Randomized double-masked comparison of radially expanding access device and conventional cutting tip trocar in laparoscopy. Obstet Gynecol 2001; 97: 435–8. Lam TY, Lee SW, So HS, Kwok SP. Radially expanding trocar: a less painful alternative for laparoscopic surgery. J Laparoendosc Adv Surg Tech A 2000; 10: 269–73. Liu CD, McFadden DW. Laparoscopic port sites do not require fascial closure when nonbladed trocars are used. Am Surg 2000; 66: 853–4. Tucker RD. Laparoscopic electrosurgical injuries: survey results and their implications. Surg Laparosc Endosc 1995; 5: 311–17. Nduka CC, Super PA, Monson JR, Darzi AW. Cause and prevention of electrosurgical injuries in laparoscopy. J Am Coll Surg 1994; 179: 161–70. Mueller W, Fritzsch G. Medicotechnical basics of surgery using invasive ultrasonic energy. Endosc Surg Allied Technol 1994; 2: 205–10. Birch DW, Park A, Shuhaibar H. Acute thermal injury to the canine jejunal free flap: electrocautery versus ultrasonic dissection. Am Surg 1999; 65: 334–7. El-Banna M, Abdel-Atty M, El-Meteini M, Aly S. Management of laparoscopic-related bowel injuries. Surg Endosc 2000; 14: 779–82. Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional hernias. Surg Laparosc Endosc 1996; 6: 123–8. Rosenthal D, Franklin ME. Use of percutaneous stitches in laparoscopic mesh hernioplasty. Surg Gynecol Obstet 1993; 176: 491–2. LeBlanc KA. The critical technical aspects of laparoscopic repair of ventral and incisional hernias. Am Surg 2001; 67: 809–12. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000; 6: 645–50. Dion YM, Charara J, Guidoin R. Bursting strength evaluation. Comparison of 0-Prolene sutures and endoscopic staples in an experimental prosthetic patch repair of abdominal wall defect. Surg Endosc 1994; 8: 812–16. Katkhouda N, Mavor E, Friedlande MH, et al. Use of fibrin sealant for prosthetic mesh fixation in laparoscopic extraperitoneal inguinal hernia repair. Ann Surg 2001; 1: 18–25. Toosie K, Gallego K, Stabile BE, et al. Fibrin glue reduces intra-abdominal adhesions to synthetic mesh in a rat ventral hernia model. Am Surg 2000; 66: 41–5. Canonico S, Sciaudone G, Pacifico F, Santoriello A. Inguinal hernia repair in patients with coagulation problems: prevention of postoperative bleeding with human fibrin glue. Surgery 1999; 125: 315–17. Birch DW, Park A. Octylcyanoacrylate tissue adhesive as an alternative to mechanical fixation of expanded polytetrafluoroethylene prosthesis. Am Surg 2001; 67: 974–8. Geis WP. Head-mounted video monitor for global visual access in mini-invasive surgery. An initial report. Surg Endosc 1996; 10: 768–70. Herron DM, Lantis JC, 2nd, Maykel J, et al. The 3-D monitor and head-mounted display. A quantitative evaluation of

Technological and instrumentation aspects 15 advanced laparoscopic viewing technologies. Surg Endosc 1999; 13: 751–5. 42 Park A, Charash WF, Shaw M. The future of imaging in minimally invasive surgery. Surg Endosc 2000; 14: 517–19. 43 Litwin DEM, Darzi A, Jakimowicz J, et al. Hand-assisted laparoscopic surgery (HALS) with the HandPort System: initial experience with 68 patients. Ann Surg 2000; 231: 715–23.

44

Cadiére GB, Himpens J, Germay O, et al. Feasibility of robotic laparoscopic surgery: 146 cases. World J Surg 2001; 25: 1467–77. 45 Berguer R, Forkey DL, Smith WD. Ergonomic problems associated with laparoscopic surgery. Surg Endosc 1999; 13: 466–8. 46 Berguer R, Smith WD, Davis S. An ergonomic study of the optimum operating table height for laparoscopic surgery. Surg Endosc 2002; 16: 416–21.


3 Prosthetic biomaterials for hernioplasty KARL A. LEBLANC

Synthetic prosthetic biomaterials: flat, single-component products 17 Synthetic prosthetic biomaterials: preformed products 21 Synthetic prosthetic biomaterials: composite products 21

Almost all hernia repairs that are performed laparoscopically utilize some form of prosthetic biomaterial. One notable exception is the infrequent small hernias found during laparoscopic incisional and ventral hernioplasty, which are merely sutured. The early pioneers in laparoscopic inguinal hernia repair generally used polypropylene mesh (PPM) products, but a few attempted to use expanded polytetrafluoroethylene (ePTFE). Incisional and ventral hernioplasty utilized ePTFE when it was first described. Currently, PPM and ePTFE prostheses are the preferred biomaterials for the laparoscopic repair of inguinal and incisional hernias, respectively. The preferences for each of these operations and the choice of prostheses are described in the following chapters. This chapter will present the currently available materials that are used for the laparoscopic repair of hernias. The biomaterials can be subdivided into many classes. The broadest distinction is between synthetic and nonsynthetic products. These can be subdivided further into products used for inguinal and non-inguinal hernia repair. While any prosthetic biomaterial could be used in the repair of any hernia, the common preferences noted above will be assumed.

SYNTHETIC PROSTHETIC BIOMATERIALS: FLAT, SINGLE-COMPONENT PRODUCTS Most of these products are manufactured from polypropylene. The major differences between the meshes are the size of the monofilaments used in the structure of the mesh and the size of the pores (interstices) of the mesh

Non-synthetic prosthetic biomaterials Conclusion References

22 24 24

Table 3.1 Flat, single-component polypropylene biomaterials and manufacturers Biomaterial

Manufacturer

Angimesh Biomesh P1 Biomesh P3 Biomesh 3D Hertra 1, 2 Hermesh 3, 4, 5 Intramesh NK1, NK2, NK8 Marlex Parietene Prolene Prolene Soft Mesh Prolite Prolite Ultra Surgipro (Monofilament) Surgipro (Multifilament) Trelex

Angiologica Cousin Biotech Cousin Biotech Cousin Biotech HerniaMesh HerniaMesh Cousin Biotech C. R. Bard, Inc. Sofradim International Ethicon Ethicon Atrium Medical Corp. Atrium Medical Corp. U.S. Surgical Corp., Inc./Tyco U.S. Surgical Corp., Inc./Tyco Meadox Medical Corp.

itself (i.e. the weight of the mesh). These two factors influence the thickness, stiffness, shrinkage rates, inflammatory response, potential for development of adhesions to the product, and resulting changes in the elasticity of the abdominal wall. These products are listed in Table 3.1, and the differences in the weave and pore sizes of some of them are noted in Figure 3.1. One of the problems that has been seen in the past with the repair of incisional hernias is fistulization.1 This has also been seen with laparoscopic inguinal repair.2 These real and potential complications of PPM may be

18 Overview

(a)

(d)

(b)

(c)

(e)

(f)

Figure 3.1 Comparison of the weaves of PPM products: (a) Hetra 1, (b) Hetra 2, (c) Prolene, (d) Prolene Soft Mesh, (e) Marlex, and (f) NK Mesh.

related to the weight of the polypropylene within the mesh. Newer, lighter-weight meshes have been developed (Table 3.1) that, theoretically, are designed to overcome many of the adverse effects of the heavier meshes. However, the lighter products are very soft and pliable, and consequently the use of them within the pre-peritoneal space created for the repair of inguinal hernias can be somewhat difficult. Manipulation can be particularly troublesome because of other difficulties, such as obtaining the correct spatial and linear orientation. To overcome this, innovations such as Prolene Soft Mesh have blue lines incorporated within the biomaterial, which provides a degree of ease for laparoscopic inguinal hernia repair. Although not as prevalent or plentiful as PPM, polyester products are used in the repair of inguinal hernia in several countries (Table 3.2). The use of polyester is generally prescribed because of its pliability and conformability to the inguinal floor. However, the use of polyester biomaterial has been associated with fistulas.3 Figure 3.2 shows the differences between the polyester products. The Parietex and Biomesh meshes are woven into a threedimensional weave rather than the two-dimensional weave that is most familiar to flat meshes. This is said to make them even more pliable and to allow a greater degree of tissue penetration. As with other biomaterials, ePTFE products were initially developed many years ago for open repair of inguinal hernias. The use of these single-component

Table 3.2 Polyester prostheses and manufacturers Biomaterial

Manufacturer

Biomesh A1 Biomesh A3 Biomesh 3D Mersilene Parietex® TEC Parietex® TECR Parietex® TET

Cousin Biotech Cousin Biotech Cousin Biotech Ethicon Sofradim International Sofradim International Sofradim International

patches compromises about 85 per cent of the published reports on the repair of incisional and ventral hernias. The prevalence of use of ePTFE is based upon the fact that there has never been a reported case of fistulization subsequent to the intraperitoneal placement of this product. In addition, ePTFE results in very minimal adhesions to itself. The currently available products are listed in Table 3.3 and shown in Figure 3.3. There has been some concern regarding the extent and nature of tissue penetration into ePTFE. However, this was based upon an earlier product that is no longer used in the laparoscopic arena. Recent studies have confirmed that the level of tissue penetration and attachment strength of the newer DualMesh® is superior to that of PPM at only three days post-implant.4 Other postoperative data also support the inhibition of adhesions to ePTFE.5

Prosthetic biomaterials for hernioplasty 19 Table 3.3 ePTFE biomaterials and manufacturers

(a)

(b)

(c)

Figure 3.2 Comparison of polyester biomaterials: (a) Mersilene, (b) Parietex TEC, and (c) Parietex TET.

Biomaterial

Manufacturer

DualMesh DualMesh Emerge DualMesh Plus DualMesh Plus Emerge DualMesh with Holes DualMesh Plus with Holes Dulex Mycromesh Mycromesh Plus Reconix Soft Tissue Patch

W. L. Gore & Associates W. L. Gore & Associates W. L. Gore & Associates W. L. Gore & Associates W. L. Gore & Associates W. L. Gore & Associates C. R. Bard, Inc. W. L. Gore & Associates W. L. Gore & Associates C. R. Bard, Inc. W. L. Gore & Associates

There is a distinctive difference between DualMesh and Dulex products. As can be seen in Figure 3.3, the rough surface of the latter is more like that of sandpaper than the corduroy appearance of the former. Close-up views reveal that these differences in appearance are due to the laminar construction of the Dulex and the transverse interstices of the DualMesh. Collagen penetration will be throughout the entire structure of the latter and will be stopped at the visceral surface of the biomaterial. Another unique feature of the DualMesh is that it is available impregnated with silver and chlorhexidine, antimicrobial agents that are added for the obvious purpose of preventing infection. Long-term data on the benefits of impregnating these substances into the product are difficult to document due to the low rate of infection that is associated with laparoscopic hernioplasty. The brown color of the material does, however, present a significant improvement in the use of the prosthesis, as it results in a reduction in the glare that is apparent with the non-impregnated product; this eases its use during laparoscopy. DualMesh Emerge and DualMesh Plus Emerge comprise DualMesh standard or DualMesh Plus biomaterial that has an attached removable layer of silicone on its surface (Figure 3.4a). This is currently available on the 15 ⫻ 19-cm patch, but other sizes should become available soon. This stiffens the product significantly, such that it cannot be inserted into the abdomen via a 5-mm port site. The purpose of this additional layer is to act as an aid in the manipulation and fixation of the DualMesh during incisional hernia repair. Once the product is secured to the abdominal wall, the silicone layer is peeled off the ePTFE and removed (Figure 3.4b). DualMesh with Holes and DualMesh Plus with Holes are similar to the above products but with perforations at evenly spaced intervals throughout the biomaterial. These products are 1.5-mm thick, compared with the DualMesh products without holes, which are 1-mm thick.

20 Overview

(a)

(b)

(d)

(c)

(a)

Figure 3.3 ePTFE biomaterials: (a) DualMesh, (b) DualMesh Plus, (c) DualMesh Plus with Holes, and (d) Dulex.

(b)

Figure 3.4 Emerge biomaterial (a) with the silicone unpeeled and (b) as it is peeled off the DualMesh.

Prosthetic biomaterials for hernioplasty 21

Figure 3.6 Anatomical Mesh.

Table 3.4 Composite biomaterials and manufacturers

Figure 3.5 3D Max.

Biomaterial

Manufacturer

Composix Composix EX Paritex® Composite Paritene® Composite Sepramesh® Glucamesh Glucatex 3D

C. R. Bard, Inc. C. R. Bard, Inc. Sofradim International Sofradim International Genzyme Corp. Brennen Medical, Inc. Brennen Medical, Inc.

SYNTHETIC PROSTHETIC BIOMATERIALS: PREFORMED PRODUCTS These products have been manufactured to conform, in one way or another, to the inguinal floor. They are placed specifically via the laparoscopic approach, either by a transabdominal or a totally extraperitoneal technique. The most common of these prostheses is the 3D Max (C. R. Bard, Inc.) (Figure 3.5). This polypropylene product is available in two sizes. Because of the curve within the product, left and right prostheses are available for use on the left and right sided inguinal hernia, respectively. The orientation of this biomaterial is critical to ensure adequate coverage of the myopectineal orifice. The larger product may be used without the need for fixation; the intra-abdominal pressure and the stickiness of the PPM are said to allow for this.6 The smaller biomaterial does require fixation because of its potential to migrate within the pre-peritoneal space. Another preformed device is the Anatomical Mesh (Sofradim International) (Figure 3.6). The flat portion of the prosthesis is made of PPM, while the portion that is made to lie over the iliac vessels is made of polyester. The sutures intertwined into the mesh are drawn together to compress the product to ease its introduction through a trocar. This is then cut to deploy the full surface of the biomaterial. At the time of writing, there are no longterm follow-up data on the use of this product.

SYNTHETIC PROSTHETIC BIOMATERIALS: COMPOSITE PRODUCTS The introduction of the laparoscopic approach to incisional hernioplasty has identified the need to protect the intra-abdominal viscera from contact with the mesh materials that are used in the repair. Table 3.4 lists the products that are composed of two different biomaterials. The construction of these biomaterials is designed to allow the in-growth of tissue while protecting the opposite surface from adhesion formation during the healing phase. The concept differs in the individual products. The first of these to be manufactured was that of the Composix mesh (Figure 3.7a). A thin layer of ePTFE is heat-sealed on to two layers of Marlex mesh. This is a very thick product that requires at least a 12-mm trocar site hole in which to introduce it. There have been reports of adhesion formation and postoperative pain with the use of this biomaterial.7 A thinner product, Composix EX (Figure 3.7b), is comprised of one layer of Marlex and a thicker layer of ePTFE. The ePTFE on this prosthesis is sutured on to the PPM to provide secure fixation between the two products. There is an overlap of the ePTFE past the PPM to minimize the risk of exposure of the edges of the PPM to the viscera. Therefore, one should avoid cutting the mesh to conform to a non-standard shape,

22 Overview

(a)

Figure 3.8 Sepramesh.

PPM similar to the other two products above. The manufacturer recommends that the mesh be covered by the omentum at the completion of the laparoscopic incisional hernia repair. There is some dispute as to the success of this biomaterial in the prevention of adhesions.8,9 Glucamesh and Glucatex 3D are, at the time of writing, very new polypropylene and polyester biomaterials that are impregnated with oat beta glucan. Oat beta glucan is a purified complex carbohydrate that is isolated from the cell wall of oats. It is absorbed following introduction of the product. (b)

Figure 3.7 Comparison of (a) Composix and (b) Composix EX.

which could expose the PPM. The products are available in numerous sizes, so cutting will seldom be necessary. The last five products listed in Table 3.4 have absorbable components. Parietex composite consists of a threedimensional polyester mesh (listed in Table 3.3) that has been incorporated by hydrophilic collagen. Paritene composite uses the PPM that is listed in Table 3.1 and has the same collagen layer as Parietex composite. The absorbable collagen is no longer present by the fourteenth postoperative day. At the time of writing, long-term studies using these biomaterials are in progress. Sepramesh (Figure 3.8) is PPM coated on one surface with carboxymethylcellulose and hyaluronate foam. This foam will be absorbed in about seven days to leave the

NON-SYNTHETIC PROSTHETIC BIOMATERIALS Several products based upon biological materials are now available (Table 3.5). The use of a non-synthetic biomaterial for the repair of hernias may be the better approach. However, long-term studies and biocompatibility evaluations will be needed to confirm their usefulness. All have been processed to eliminate the risk of transmission of viral or other diseases. These generally are pure or nearly pure collagen that will be incorporated and/or replaced by the patient’s own collagen over time. The hernia is repaired by the neofascia that subsequently develops. The majority of implantations of these biomaterials have been via open operation, but their use with laparoscopic technique is undergoing evaluation.

Prosthetic biomaterials for hernioplasty 23 Table 3.5 Biological prosthetic biomaterials and manufacturers Biomaterial

Manufacturer

Surgisis ES® and Surgisis Gold® FortaPerm™ FortaGen™ Permacol™ Alloderm®

Cook Surgical, Inc. Organogenesis, Inc. Organogenesis, Inc. Tissue Science Laboratories plc Lifecell, Inc.

(a)

Figure 3.9 Alloderm.

(a)

(b)

Figure 3.11 (a) Fortagen and (b) Fortaperm.

(b)

Figure 3.10 (a) Surgisis ES and (b) Surgisis Gold.

Alloderm (Figure 3.9) is manufactured from cadaveric skin. Its width is limited by the size of the dermatome that is used to harvest the material. Surgisis ES and Surgisis Gold (Figure 3.10) are four- and eight-ply, respectively, porcine small-intestinal submucosa. The manufacturing process causes the nodules that are seen on the Surgisis Gold. Fortagen and Fortaperm are also processed porcine submucosa of the small intestine (Figure 3.11). These latter two products are very similar

Figure 3.12 Permacol.

in appearance. They are five layers thick, the layers being cross-linked together to provide greater strength. Fortagen will be replaced by the native collagen, similar to Surgisis, but Fortaperm becomes a permanent prosthetic similar to that of the synthetic biomaterials described above. Permacol (Figure 3.12) is porcine dermis with indications similar to the other products.

24 Overview

At the time of writing, all of these biomaterials are relatively new and clinical experience is generally limited. There may be particular application in the site of infections that are associated with tissue loss or following hernia repair with synthetic meshes. These cannot be used in the presence of an intestinal fistula because the enteric contents will dissolve the collagen in the product.

REFERENCES 1

2

3

CONCLUSION Laparoscopic hernioplasty is dependent upon the use of prosthetic biomaterial and the in-growth that ensues. A variety of synthetic and non-synthetic biomaterials are available for implant. Surgeons should be aware of all of the available products. The selection of the ideal prosthesis should be based upon experimental, clinical and longterm follow-up data. Newer biomaterials will probably be developed in the future that may enhance the repair of hernias.

4

5

6 7 8 9

Losanoff JE, Richman BW, Jones JW. Entero-colocutaneous fistula: a late consequence of polypropylene mesh abdominal wall repair: case report and review of the literature. Hernia 2002; 6: 144–7. Klein AM, Banever TC. Enterocutaneous fistula as a postoperative complication of laparoscopic inguinal hernia repair. Surg Laparosc Endosc 1999; 9: 60–2. Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998; 133: 378–82. LeBlanc KA, Bellanger DE, Rhynes VK, et al. Tissue attachment strength of prosthetic meshes used in ventral and incisional hernia repair. Surg Endosc 2002; 16: 1542–6. Koehler RH, Begos D, Berger D, et al. Adhesion formation to intraperitoneally-placed mesh: reoperative clinical experience after laparoscopic ventral incisional hernia repair. Am J Surg; in press. Pajotin P. Laparoscopic groin hernia repair using a curved prosthesis without fixation. J Coelio-Chir 1998; 28: 64–8. LeBlanc KA. ‘Tack hernia’ – a new entity. JSLS 2003; in press. Kramer K, Senninger N, Herbst H, Probst W. Effective prevention of adhesions with hyaluronate. Arch Surg 2002; 137: 278–82. Amid P. Hyaluronate does not prevent adhesions. Arch Surg 2002; 137: 1313–14.

4 Fixation devices for laparoscopic hernioplasty KARL A. LEBLANC

Early devices Later devices Latest devices

25 27 27

Laparoscopic hernioplasty requires the use of a prosthetic biomaterial. Consequently, a method of fixation will be necessary for all but the smallest of incisional and some of the inguinal hernia prostheses. The earliest attempts to repair inguinal hernias laparoscopically were performed with the suture fixation of the mesh to the structures of the inguinal floor. This was a very tedious task, which greatly hindered the adoption of this new technology. Manufacturers of instruments responded with the development of different devices that delivered metal fixation to secure the biomaterial to the inguinal floor. The use of these devices is, of course, an integral part of all laparoscopic hernia repairs. There have been a number of these products that have not been successful or even brought to large-scale production. These and the newer instruments are discussed below. The classification of these devices is arbitrary. Regardless of the product that is used by the surgeon, it is critical that each is used properly. Few surgeons are afforded the opportunity to use these instruments for the first time in the laboratory setting. Therefore, it is recommended that the surgeon experiences the mechanism of delivery of each device before using it in the operating room. Proper surgical technique is critical for the correct application of these devices without exposing the patient to untoward consequences.

Conclusion References

a series of 13 patients in whom he closed the peritoneal opening of the sac using Michel clips. All but the last patient in this series were repaired through an open incision. The thirteenth patient was repaired in 1979 under laparoscopic guidance with a special stapling device. The three-year follow-up of this patient revealed him to be free of an identifiable recurrence. Ger and colleagues continued their efforts to repair these hernias laparoscopically. They reported the closure of the neck of the hernia sac using a prototypical instrument called the Herniostat in beagles (Figure 4.1).2 This device was never produced commercially, but it was certainly ahead of its time. Schultz and colleagues published the first patient series of laparoscopic herniorrhaphy in 1990.3 Rolls of polypropylene were stuffed into the hernial orifice, which was then covered by two or three flat sheets of polypropylene mesh (2.5 ⫻ 5 cm) over the defect. These rolls of mesh were not secured to either the fascia or peritoneum. The peritoneum, however, was closed using clips that were commonly used for hemostasis. Corbitt

EARLY DEVICES Ger, in 1982, was the first to report the use of the laparoscope in the repair of an abdominal hernia.1 He reported

28 28

Figure 4.1 Ralph Ger’s ‘Herniostat’. (Photograph used with permission of Ralph Ger, MD.)

26 Overview

Figure 4.2 Ethicon EMS stapler and the staples that it fired.

modified this technique by inverting the hernia sac and performing a high ligation with sutures or with an endoscopic stapling device used for transection of tissues similar to that used for open bowel resection.4 A similar concept was applied in the intraperitoneal onlay patch (IPOM) technique. This repair, originally investigated by Salerno and coworkers, used a polypropylene patch material in a porcine model.5 They placed rectangular pieces of the prosthesis against the abdominal wall covering the internal inguinal ring and secured it with a stapling device. The success of these repairs led them to apply this method in clinical trials. This early stapling device was the EMS stapler (Figure 4.2). It was a reusable instrument that had to be reloaded following the placement of every staple. This placed a box type of staple similar to that which is used commonly for skin closure. This was a 10-mm instrument that greatly improved and decreased the time required for the inguinal hernia repair technique. At about the same time, Toy and Smoot reported on their first ten patients repaired with the IPOM technique.6 They secured an expanded polytetrafluoroethylene (ePTFE) patch to the inguinal floor with staples that were introduced by a prototypical stapling device of their own design, which they called the Nanticoke Hernia Stapler (Figure 4.3). They used this fixation device successfully without adverse results in 20–30 patients. The device did not become available commercially. A subsequent report of their first 75 patients was published in 1992.7 In this later series, the same prosthetic biomaterial was attached with the Endopath EMS® stapler (Ethicon Endosurgery, Inc.) (Figure 4.4). After a follow-up of up to 20 months, the recurrence rate was 2.4 per cent. They noted a significant decrease in postoperative pain and an earlier return to normal activity compared with the open repair of the hernia defect. These early hernia repairs continued to become modified in many different aspects, including approaches to the inguinal area, prosthetic biomaterials, and fixation devices. The devices that followed, such as the EMS, allowed the placement of multiple staples without the need to reload after each use. U.S. Surgical Corporation, Inc. released its stapler, which was similar in concept (Figure 4.5). This device required a 12-mm trocar rather than the 10-mm trocar used by the EMS staplers. The

Figure 4.3 Nanticoke Hernia Stapler and staples. These devices are conformed into a more rounded shape than the EMS staples.

Figure 4.4 Endopath EMS stapler.

Figure 4.5 Endo-universal stapler of USSG.

Figure 4.6 Endopath EAS stapler.

device, however, allowed the articulation of the end of the instrument, giving the surgeon the capability to place the staples more accurately against the abdominal wall and the ligament of Cooper. Ethicon responded with the release of the EAS device, which also has an articulating head (Figure 4.6). Both the U.S. Surgical Corporation stapler and the Ethicon EAS allowed 360-degree rotation of the shaft of the device and articulation of the end of the shaft to place staples. In most cases, these movements in these two different planes allowed exact delivery of the staple to the prosthesis and tissue. At about this time, there was an increasing use of laparoscopic repair of not only inguinal but also incisional hernias subsequent to the first report in 1993.8 The

Fixation devices for laparoscopic hernioplasty 27

Figure 4.8 Origin Tacker. Figure 4.7 Omni-Tack.

delivery of the staples for this operation was not always ideal because of the lack of further rotation of the end of the head of the stapler. Because of this limitation, the staple could not always be placed exactly perpendicular to the edge of prosthesis, which resulted in fixation that was not always flat against the abdominal wall. This problem was solved with the release of the Omni-Tack by Ethicon Endosurgery (Figure 4.7). Despite its innovative design and increased ability of accurate staple placement, this product was never distributed widely.

LATER DEVICES As laparoscopic surgery expanded into the many areas of general surgery, there was an unsatisfactory realization that hernias developed in trocar sites that were larger than 5 mm. Because of this, the trocar sites of the larger ports required fascial closure to prevent these hernias. In an effort to decrease this risk, the use of 5-mm instead of 10-mm trocars, wherever possible, became more frequent. However, all of the instruments mentioned above required access with trocars that were at least 10 mm. Further engineering refinements in all laparoscopic instruments provided the surgeon with 5-mm instruments and laparoscopes. Origin Medsystems introduced the first successful 5-mm fixation device (Figure 4.8). The method of fixation of this new helical coil was a significant departure from the previous staples. Delivery with the 5-mm size was accepted quickly. The apparent disadvantage of the inability to rotate or articulate the device did not prove to be important to the vast majority of surgeons. This method of fixation was quite secure. U.S. Surgical Corporation introduced a similar product, the ProTack, shortly thereafter (Figure 4.9). The ProTack is almost identical, conceptually, to the Origin tacker. Both deliver a 5-mm titanium helical coil that is screwed through the prosthesis and into the tissues. The ProTack, however, allows the surgeon to unscrew the tack after it is introduced if the placement is deemed to be inadequate or inappropriate. Because the ends of these devices cannot be manipulated, it is important to use significant counter-pressure during the implantation of these tacks. If not, poor placement can result and

Figure 4.9 ProTack.

a part of the coil could remain exposed to the intestine. At least one report has documented the development of a colocutaneous fistula that is presumed to be due to a tack.9

LATEST DEVICES Newer products have recently been introduced into the hernia repair market. Like their predecessors, these have unique characteristics. Onux Medical, Inc. has produced the Salute fixation device (Figure 4.10). Unlike all of the products discussed above, which used titanium as the metal for the device, this construct is made of stainless steel. This is the only reusable fixation device that has been available commercially. Unlike the other products, it does not deliver a preformed device into the tissues. A construct is formed into a keyring shape as the trigger is fired (Figure 4.11). This motion also cuts the wire at the same time. While the device does require the use of counter-pressure for placement, its method of delivery makes it appealing for use in the upper abdomen, on the diaphragm or at the esophageal hiatus. Although the device does not seem to have as deep a penetration into the tissues as the tack, experimental evidence has shown that it is an effective method of fixation.10 Two slightly different heads are available with this instrument. Some surgeons find the use of one or the other preferable, in that the depth of penetration (depending upon the particular surgeon’s technique) is affected by the shape of the head. Because of the shape of the head, the thickness of the wire is greater in the newer design. Therefore, there are two different thicknesses of these wires. Consequently, the spools of wire that are used to deliver the coil are not interchangeable between these devices.

28 Overview

Figure 4.10 Salute instrument. Figure 4.13 EndoAnchor with the inner needle shaft exposed by squeezing the trigger of the device.

Figure 4.11 Salute construct.

Figure 4.14 EndoAnchor device.

CONCLUSION

Figure 4.12 EndoAnchor instrument.

The most recently developed product is the EndoAnchor by Ethicon Endosurgery, Inc. (Figure 4.12). This allows the entire device to be loaded into either a 3-mm or a 5-mm shaft. To place this product into the tissues, the trigger is fired first. Unlike all of the other products, this maneuver does not deploy the device. A large needle-like shaft is moved forward from inside the end of the outer shaft (Figure 4.13). The anchor is contained within the end of the needle. The anchor is released into the tissues as the trigger is released. Once this occurs, the nitinol anchor assumes its shape after that movement (Figure 4.14). The upper protrusions of the shaft of the nitinol are the portion of the device that remains in the tissues. The lower, larger hooks are positioned over the prosthesis to hold it in place. Currently, there is only a limited release of this device.

Laparoscopic hernioplasty requires fixation of the biomaterial. The devices described above are almost all in use today. The effectiveness of the newer products will become known with the passage of time. Whichever product is chosen in the laparoscopic repair of hernias, it is critical to use the device properly. Knowledge of the mechanism of delivery and the concept that is applied in the shape of the final delivered device is important. Emerging technologies will continue to deliver newer products for this operation.

REFERENCES 1

Ger R. The management of certain abdominal herniae by intra-abdominal closure of the neck of the sac. Ann R Coll Surg Engl 1982; 64: 342–4. 2 Ger R, Monro K, Duvivier R, et al. Management of inguinal hernias by laparoscopic closure of the neck of the sac. Am J Surg 1990; 159: 370–73. 3 Schultz L, Graber J, Pietrafitta J, et al. Laser laparoscopic herniorrhaphy: a clinical trial, preliminary results. J Laparoendosc Surg 1990; 1: 41–5.

Fixation devices for laparoscopic hernioplasty 29 4

Corbitt J. Laparoscopic herniorrhaphy. Surg Laparosc Endosc 1991; 1: 23–5. 5 Salerno GM, Fitzgibbons RJ, Filipi C. Laparoscopic inguinal hernia repair. In: Zucker KA, ed. Surgical Laparoscopy. St Louis: Quality Medical Publishing, 1991: 281–93. 6 Toy FK, Smoot RT. Toy–Smoot laparoscopic hernioplasty. Surg Laparosc Endosc 1991; 1: 151–5. 7 Toy FK, Smoot RT. Laparoscopic hernioplasty update. J Laparoendosc Surg 1992; 2: 197–205. 8 LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene:

preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. 9 DeMarie EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Surg Endosc 2000; 14: 326–9. 10 LeBlanc KA, Stout RW, Kearney MT, Paulson DB. Comparison of adhesion formation associated with Pro-Tack (US Surgical) versus a new mesh fixation device, Salute (ONUX Medical). Surg Endosc 2003; in press.


PART

2

Laparoscopic inguinal/femoral hernioplasty

5 6 7 8 9

History Anatomy and physiology Intraperitoneal onlay mesh approach Transabdominal pre-peritoneal approach Totally extraperitoneal approach

33 41 47 53 65

10 Femoral and pelvic herniorrhaphy 11 Results of laparoscopic inguinal/femoral hernia repair 12 Complications and their management

75 83 89


5 History MICHAEL S. KAVIC AND STEPHEN M. KAVIC

Hernia paradigm Open hernia repair Genesis of hernias

33 33 36

A hernia has been defined as the protrusion of a loop or knuckle of an organ or tissue through an abnormal opening.1 In their earliest state, hernias of the abdomen and pelvic side wall begin as a protrusion of peritoneum through a fascial defect. They are rarely symptomatic, and typically they are undetectable on physical examination. In order to understand the development of laparoscopic hernia repair, it is necessary to review how the approach to hernias and hernia repair has evolved throughout history.

HERNIA PARADIGM Before recorded or written history, humans are thought to have managed hernia with taxis. From its Greek origin, meaning ‘the drawing up in rank and file’, taxis for hernia involved the use of finger or hand pressure to reduce the displaced organ or tissue. Support after reduction, utilizing a belt or girdle to maintain the herniated content, would have been a logical extension of taxis. Thus the first paradigm for hernia management is most likely to have been one of conservative, nonoperative management. The date of the first operation for hernia and change in the nonoperative paradigm is unknown. However, allusion to an operative procedure for hernia was made in one of the earliest written medical records, an ancient Egyptian medical text known as the Ebers Papyrus. George Moritz Ebers (1837–98), a professor of Egyptology at the University of Berlin, purchased an ancient papyrus while traveling in Egypt in 1873. The papyrus contained a collection of older works dating back to 3000–2500 BC. Ebers prepared a partial translation of

Laparoscopic hernia repair Conclusion References

37 39 39

the papyrus in 1875, which was later completed by Bendix Ebbell, a Norwegian physician. Ebbell’s study of the papyrus suggested that the ancient Egyptians had attained a high level of surgical skill and had developed procedures for hernia and aneurysm management.2 Interestingly, then, in the first preserved written record of medical practice, the paradigm for hernia management included surgical intervention. Surgical intervention for hernia, and almost any other disease, was mercifully rare before the modern era. Without anesthesia, operative pain was real and fearsome. In addition, infection almost inevitably followed a surgical procedure and frequently was life-ending. Because of this, the religious proscriptions against human dissection, and technological immaturity, progress in the surgical sciences stagnated. The discovery of anesthesia and the development of antiseptic methods in the mid-nineteenth century revolutionized the practice of surgery. Operative intervention without the twin specters of agonizing operative pain and postoperative infection became possible, and the abdominal cavity no longer remained terra incognita. Along with that for many other diseases, the paradigm for hernia changed.

OPEN HERNIA REPAIR Henry O. Marcy (1837–1924), a surgeon from the USA and a disciple of the English surgeon Joseph Lister, described two cases of incarcerated hernia that he treated surgically in 1871.3 Marcy, using Listerian antiseptic techniques, performed the standard operation of the day on these two patients: he divided the hernia ring ‘in the

34 Laparoscopic inguinal/femoral hernioplasty

usual way with the hernial knife’ and reduced the incarcerated hernia. However, Marcy went a step further and expanded the hernia technique then in vogue. Rather than open the hernia sac, he reduced it and repaired the defect by closing the ‘constricting ring’ with carbolized catgut suture. Marcy, in his report of these procedures, emphasized the use of Lister’s antiseptic technique and a new form of sterile (carbolized catgut) suture. He stressed that the two patients healed without infection. Almost as an afterthought, he noted that both patients were ‘cured’ of their hernias. In truth, Marcy may have been the first to have closed the internal ring for hernia repair and probably helped initiate the modern age of hernia repair.4 Although Marcy made significant contributions to herniology, it is generally agreed that the Italian surgeon Eduardo Bassini (1844–1924) is the progenitor of modern hernia repair (Figure 5.1). Bassini, in 1884, devised a method of hernia repair that called for a three-layer reconstruction of the inguinal floor.5 After division of the posterior wall of the inguinal canal and herniotomy (high ligation and excision of the sac), Bassini performed a ‘triple layer’ repair of the inguinal floor. He approximated the internal oblique muscle, transversus abdominus muscle, and transversalis fascia to the inguinal ligament. According to Bassini, this herniorrhaphy technique (suture reinforcement of the floor of the inguinal canal) repaired the inguinal defect(s), re-established the obliquity of the inguinal canal, and reconstructed the internal and external inguinal rings, restoring all to competency. The Bassini repair was logical from an anatomic perspective, and it worked in practice. It was also radical, as the patient did not have to wear a truss after the procedure as in other repairs popular at the time. Bassini’s operation was a marked improvement over what had preceded it. Unfortunately, the sound procedure that Bassini devised became corrupted during its dissemination worldwide. Surgeons, particularly in the

Figure 5.1 Eduardo Bassini.

USA, failed to appreciate the importance of dividing the transversalis fascia to expose all layers, and a true triplelayer repair was often not accomplished. Bassini’s operation was modified and simplified by not dividing the transversalis fascia, but it was also diminished. Bassini initially reported a recurrence rate of about three per cent.5 In the USA, experience with the Bassini repair, which was frequently modified, differed from the Italian master, and recurrence rates ranged from five to ten per cent in most hands.6 Although Annandale, in 1876, was the first to enter the pre-peritoneal space for hernia repair,7 Cheatle, in 1920, is generally credited with being the first to introduce a pre-peritoneal (otherwise known as pro-peritoneal, extraperitoneal, or posterior) approach.8 Cheatle described his procedure as follows: ‘an incision is made to one side of the middle line, the rectus abdominus is split longitudinally and the abdominal wall is retracted to the side of the operation’. The hernia sac was ligated ‘as low down as possible’ and the internal ring closed by suturing ‘the muscle fibres and their sheath’. For femoral hernia, Cheatle recommended that a flap of pubic bone periosteum be secured to Poupart’s ligament to secure the femoral orifice. In 1936, Arnold Henry described a similar extraperitoneal approach to hernia repair in which he secured the femoral canal with a flap of pectineus fascia to Poupart’s ligament ‘without tension’.9 The internal ring was repaired ‘from within’. Nyhus and colleagues later adopted and further refined the open pre-peritoneal repair.10 They recommended that the pre-peritoneum be approached via a suprainguinal incision and that suture plasty (herniorrhaphy) be performed to secure the defects of indirect, sliding, and recurrent inguinal hernias. Because of the significant recurrence rate after herniorrhaphy, many surgeons recalled a quote attributed to Theodore Billroth (1829–94): ‘If we could artificially produce tissues of the density and toughness of fascia and tendon, the secret of the radical cure of hernia would be discovered.’11 The earliest use of synthetic material to substitute for living tissues in herniorrhaphy occurred in 1894, and involved the use of silver wire coils placed in the inguinal canal to induce fibrosis and strengthen the hernia repair.12 A few years later, German surgeons Goepel13 and Witzel14 independently utilized handmade silver wire filigrees to serve as a prosthetic ‘mesh’ for difficult or recurrent hernias. Silver wire, however, lacked pliability and caused patient discomfort. It was not inert, and metal fatigue led to disintegration of the silver wires. Infection and sinus tract formation with persistent drainage occurred, and silver wire was eventually abandoned as prosthesis for hernia repairs. Despite a genuine need for fascial substitutes, investigation of prosthetics for hernia repair was unfocused

History 35

until the seminal work of Francis Usher (1908–80). Usher, in the 1950s, became interested in hernia recurrence and attempted to repair hernias with freeze-dried homographs and lyophilized dura mater.15 None of these materials proved satisfactory, so Usher turned his attention to synthetic materials. Various forms of plastic had been tried before, but because of their rigidity, tendency to fragment, and susceptibility to infection, none was found to be satisfactory for hernia repair. Usher persisted in his investigation of plastic materials and learned of a new polyolefin plastic (polypropylene, i.e. Marlex) that could be extruded as a monofilament, did not fragment, and was inert. Usher worked closely with the company that produced Marlex (Phillips Petroleum Co.), and had the material woven into a mesh and tested in animal studies. He found that polypropylene mesh was tolerated well in sterile and infected fields, and he began to use Marlex mesh in humans in 1958.16,17 Usher made many original contributions to the field of hernia repair, which Read lists elegantly in a scholarly retrospective of Usher’s life:15

• • • • • •

•

The development of polypropylene mesh and suture for repair of abdominal-thoracic defects. Improved techniques for mesh placement. A prosthetic bridge was placed deep and under lapped the hernia defect. Anterior, pre-peritoneal placement of the prosthesis for large, primary, direct or recurrent groin herniae without suture closure of the defect. Elimination of tension in hernia repair, which facilitated early ambulation. Demonstrated that infected prosthesis could remain in situ and heal after open drainage. The use of unsplit groin mesh with overlap and interrupted suture lateral to the internal inguinal ring to allow extended pre-peritoneal obliquity of the spermatic cord. This provided a shelf for the cord to rest on and preserved the normal obliquity of the internal ring. The use of bilaminar mesh to bridge a hernia defect and suture of the two lamina and encompassed tissue laterally to prevent the suture from tearing out weakened structures.

These contributions were significant advances in the field of herniology.16–21 However, like so many other pioneers, Usher did not receive the recognition he deserved. It remained for others to build on his work and advance the science of hernia repair. In the 1986 edition of his textbook Hernia Repair Without Disability, Irving L. Lichtenstein stated that he was performing a tension-free repair utilizing synthetic mesh to bridge the hernia defect and that he had discarded older classical techniques of suture repair (herniorrhaphy).22 Tension, as noted by Lichtenstein, was ‘the bête noire of the hernia surgeon’ and could lead to suture or

tissue disruption and hernia recurrence. He reported that tension-free repair with mesh prosthesis had been employed in more than 300 consecutive cases of direct and indirect inguinal hernia without complication or recurrence. Lichtenstein’s genius was not that he introduced polypropylene mesh for inguinal hernia repair; he did not. Nor was his concept of a tension-free repair new; it was not. Usher deserves primacy in both of these matters. Lichtenstein’s insight was in understanding the work that had gone on before and building on it. He helped popularize the concept of ambulatory hernia surgery and advocated a tension-free onlay of polypropylene mesh for all groin hernias, regardless of size or complexity. He stressed the use of local anesthesia and the importance of immediate resumption of normal activity. Lichtenstein and colleagues reported on the technique in 1989.23 They described over 1000 cases of hernias repaired with a ‘tension-free hernioplasty’ technique and followed for one to five years with no recurrences or mesh infections. This paper described hernia repair with elegant simplicity and took the surgical world by storm. Not only were the results excellent, but the operation was easy to perform and patients underwent a rapid recovery. In a study of more than 16 000 tension-free mesh repairs performed by 72 surgeons, the recurrence rate was reported to be less than 0.5 per cent and the incidence of infection was 0.6 per cent.24 For the last quarter of the twentieth century, a mantra for hernia repair might have been ‘tension-free, tension-free, tension-free’. In referring to hernia procedures, Halsted noted that surgical skeptics at the turn of the nineteenth century exclaimed: ‘Why take so much trouble, when such good results, as are published, may be obtained by simpler methods?’25 This at a time when William T. Bull, a prominent New York surgeon, reported recurrence rates of 40 per cent in the first year after hernia repair and almost 100 per cent within four years.26 Indeed, many surgeons at the turn of the twentieth century held a similar view regarding a change of technique for open hernia repair: ‘If it ain’t broke, why fix it?’ Groin hernias originate in the abdomen and traverse a myopectineal orifice between abdomen and thigh to present in the inguinal region (Figure 5.2). The myopectineal opening, as described by Fruchaud (Figure 5.3), is bounded by the rectus sheath medially, internal oblique and transversus abdominus muscles superiorly, the iliopsoas muscle laterally, and pubis inferiorly.27 It is an irrefutable anatomic structure whose entire opening must be addressed before a complete cure of inguinal-femoral hernia can be anticipated. The Lichtenstein operation is an excellent procedure. However, it is not perfect. The Lichtenstein technique of open anterior repair does not allow for the entire myopectineal orifice to be addressed easily. There is


prosthesis that would functionally replace the transversalis fascia.29,30 Stoppa advocated an extensive reinforcement of transversalis fascia without repair of the hernia defect. Whereas the goal of surgical therapy had always been to achieve parietal repair, i.e. closure of the hernia defect, Stoppa’s revolutionary concept was to render the peritoneal envelope inextensible without mandatory repair of the deteriorated abdominal wall and hernia defect. The operation has become known as the giant prosthetic reinforcement of the visceral sac (GPRVS) or Stoppa procedure, and has worked quite well, with low recurrence rates reported for even very large, complex, recurrent hernias.

GENESIS OF HERNIAS

Figure 5.2 Myopectineal orifice.

Figure 5.3 Henri Fruchaud.

limited exposure of the inferior aspect of the myopectineal orifice. Moreover, it should be noted that performance of an anterior repair requires the spermatic cord and its structures to be mobilized circumferentially before the mesh can be positioned. Circumferential cord mobilization and manipulation can lead to spermatic venous thrombosis, ischemia of the testicle, and testicular atrophy.28 Lichtenstein in 1986 reported his incidence of testicular atrophy to be one per cent.22 During the latter third of the twentieth century, René Stoppa and colleagues performed much of the innovative work that ultimately formed the foundation for a successful laparoscopic approach to hernia repair. Stoppa’s contribution to herniology was that he suggested managing hernias of the groin with a very large, permanent

For thousands of years, adult groin hernias were thought to result from a physical rupture or tear of the abdominalwall supporting tissues. In the late 1960s, Read noted that during a pre-peritoneal approach for hernia repair, the rectus sheath above the hernia defect appeared thin and felt greasy, particularly with direct hernia defects.31 He followed up this observation with other studies in which he biopsied and weighed constant-area rectus sheath samples of patients operated on for hernia and compared them with samples from patients operated on for intra-abdominal conditions other than herniation. The weight of the biopsy specimens, especially of chronic smokers, was less per unit area in patients with direct hernia than in controls and did not relate to the patient’s age or muscle mass.32 Read and others have suggested that there is an increased number of circulating white blood cells in the blood and lungs of smokers that discharge free, unbound, active protease and elastase compounds.33 These proteolytic enzymes disturb the normal protease/anti-protease balance and contribute to the damage of elastin and collagen in the fascia transversalis and rectus sheath of smokers, which leads to direct inguinal herniation.34 It has been shown that purified human neutrophil polymorphonuclear leukocyte elastase can induce pulmonary emphysema.35 There are other conditions of systemic illness and stress (pulmonary emphysema, ruptured abdominal aortic aneurysm, burns) that cause an enhanced leukocyte count and the discharge of proteases and oxidants from leukocytes. These conditions may, in part, be responsible for the biochemical changes that lead to damage of the collagenous connective tissues in the groin and cause hernia formation in non-smokers in a manner similar to smokers. Because of these findings and the work of others, it was Cannon and Read’s opinion that: ‘The surgeon’s approach to inguinal herniation should consider more than the anatomic and technical detail. It must now embrace biochemistry, because he is dealing with a local manifestation of a generalized lesion of connective tissue.’36

History 37

LAPAROSCOPIC HERNIA REPAIR With little fanfare and without much notice, Ger reported the first laparoscopic hernia repair in a paper published in 1982.37 This study conducted from August through November 1977 examined the effectiveness of stainless-steel clips to secure the peritoneal opening of known abdominal hernias during laparotomy for other major abdominal procedures. In the thirteenth and final case of the series, an operating laparoscope was used to visualize the peritoneal defect of a right indirect inguinal hernia. The neck of the hernia sac was closed with a specially devised stapling device passed through a port placed in the right iliac fossa. The staple was constructed of tantalum and measured 12.5 mm long in the open position. Ger reported that the first patient to be treated by laparoscopic closure of the neck of the sac was under the care of Dr P. Fletcher of the University of the West Indies, Jamaica.37 Gynecologists have been responsible for many of the innovations in laparoscopy, and hernia repair has been no exception. In 1990, Popp published a report of the coincidental repair of an inguinal hernia during laparoscopic uterine myomectomy.38 In this paper, Popp related that the hernia margins were apposed and secured by endosutures tied extracorporeally. A patch of dehydrated dura mater was applied to the sutured area to further cover the repair site. Early on, several prominent laparoscopic surgeons advocated repair of inguinal hernia by ‘plugging’ the hernia defect. At the annual meeting of the American Association of Gynecological Laparoscopists (AAGL) in 1989, Bogojavlensky showed a video that demonstrated repair of an indirect inguinal hernia with a laparoscopic stuffing technique.39 The hernia canal was filled with a plug of polypropylene mesh, and the internal ring was closed with suture placed laparoscopically. In 1990, Schultz and colleagues reported on a plugand-patch technique for hernia repair that expanded on the initial work described by gynecologists.40 In their technique, the sac of an indirect inguinal hernia was visualized with a laparoscope and grasped on its superior margin with forceps. The peritoneum was incised, and the sac was removed from the musculofascial defect. The hole in the muscle was then filled with rolls of polypropylene mesh tied with dissolvable suture. It was thought that the rolled polypropylene mesh would expand to completely fill the canal once the suture tie was absorbed. After the defect was filled with rolled mesh, one or two pieces of 1 ⫻ 2-inch mesh were laid over the defect, and the cut edges of peritoneum were brought together (over the mesh patch) and secured with endoclips. In 1991, Corbitt independently described a similar technique; however, he further ligated the inverted hernia sac with an endoscopic linear stapler.41

Both Schultz and Corbitt abandoned the technique of plugand-patch repair because of excessive hernia recurrence and changed their technique to one that utilized a large prosthesis of polypropylene mesh in the pre-peritoneal space that covered the entire myopectineal orifice. Toy and Smoot42 in 1991, along with Salerno and colleagues,43 took a somewhat different approach to laparoscopic hernia repair. Both groups reported on an intra-abdominal onlay technique subsequently dubbed the intraperitoneal onlay of mesh (IPOM) procedure.42–44 This technique involved a transabdominal examination of the hernia defect and placement of synthetic mesh directly on the peritoneal surface about the hernia defect. Salerno and colleagues, in an animal model, investigated polypropylene as an onlay prosthesis.43 Toy and Smoot utilized a prosthesis of expanded polytetrafluoroethylene (ePTFE) stapled to the peritoneal surface.42 In the Toy–Smoot modification, no attempt was made to shield the graft from intra-abdominal content for the reason that previous animal studies suggested that adhesions between ePTFE graft and abdominal viscera were thin and inconsequential. The IPOM procedure was satisfactory for small to moderately sized defects. However, because staple bites were shallow (grasping principally peritoneum) and because of difficulties in visualizing substantial pre-peritoneal structures (Cooper’s ligament, iliopubic tract, transversalis fascia, transversus abdominus aponeurosis, etc.), larger hernias repaired with this technique frequently recurred. With increased intra-abdominal pressure, such as with coughing, straining or exercise, the mesh (attached principally to peritoneum) would slide into the hernia defect and the repair would fail. The early 1990s were a time of great intellectual ferment in laparoscopic hernia surgery. While the intraabdominal onlay technique was being developed, several groups, led most notably by Arregui45 and Dion,46 reported on a transabdominal pre-peritoneal patch technique that eventually became adopted widely. In no small measure, this technique relied on the principles of hernia repair established by Stoppa and his GPRVS. After pneumoperitoneum was established, a laparoscope was inserted into the abdominal cavity, typically via an umbilical port, and both groin areas were examined. Two additional ports, each placed lateral to the rectus sheath and on a plane level with the umbilicus, provided access for laparoscopic instrumentation. If an inguinal hernia was identified, then an incision was made into the peritoneum several centimeters above the superior margin of the inguinal hernia defect. The indirect or direct hernia sac was reduced, and wide dissection of the pre-peritoneal space was performed. No attempt was made to obliterate the inguinal canal as in the plug-andpatch technique. Rather, a large portion of mesh, commonly 8 ⫻ 13 or 10 ⫻ 15 cm in size, was used to cover


the myopectineal orifice of Fruchaud. The mesh was fixed to the transverse abdominus aponeurotic arch and Cooper’s ligament and lateral to the internal ring with staples or tacks. The peritoneum was closed over the mesh with suture or staples. The transabdominal pre-peritoneal application of synthetic graft, later dubbed the transabdominal preperitoneal (TAPP) patch procedure, was elegant in concept. The entire opening between abdomen and thigh through which all hernias of the groin originate (the myopectineal orifice of Fruchaud) was bridged in a tension-free manner. Intra-abdominal content was protected from contact with the graft by placing the mesh in a pre-peritoneal position. Several benefits were accrued with this technique, and were summarized in a 1993 paper:47

• • • • • •

Expose and reconstitute the entire myopectineal orifice. Examine both groin areas and repair bilateral inguinal hernias as required. Perform repair with little disturbance of cord structures with a likely reduction in the incidence of ischemic orchitis. Avoid transgression of the scarred tissue of a recurrent hernia and the potential for nerve or spermatic cord injury. Permit a thorough diagnostic abdominal laparoscopic examination. Reduction in the incidence of hernias ‘missed’ on external physical examination.

Repair of an inguinal hernia from a transabdominal approach, however, exposed the patient to theoretical complications, including postoperative adhesions, postoperative ileus, bowel obstruction, and intra-abdominal organ injury.48 To reduce the potential for complications associated with a peritoneal incision or the intra-abdominal application of a synthetic prosthesis, several authors, including McKernan and Laws,49 Dulucq,50 and Phillips,51 discussed a totally extraperitoneal approach to laparoscopic groin hernia repair. This method, which would become known as the total extraperitoneal (TEP) patch procedure, deployed all laparoscopic instrumentation, cannulae, and camera in a working pre-peritoneal space outside of the peritoneal cavity. The entire TEP procedure is performed in an extraperitoneal space, a pneumoextraperitoneum, between the peritoneum and abdominal wall musculature. An initial incision is made at the umbilicus, and the anterior rectus sheath on the side of the hernia defect is incised. A cannula is inserted and passed caudally along the intact posterior rectus sheath, and the extraperitoneal space is developed with blunt dissection or a balloon dissector. Additional cannulae are placed in this pre-peritoneal space under direct laparoscopic vision, and extraperitoneal dissection of the myopectineal orifice is completed. A large piece of

mesh, usually polypropylene, is then positioned to cover the femoral canal and the indirect and direct inguinal spaces with a 3–5 cm overlap. The mesh is secured with suture, staples or tacks, and the pneumoperitoneum is deflated. No incision is made into the peritoneum, and the mesh is completely shielded from intra-abdominal content. Although an additional cost is engendered with the use of the balloon dissector, its employment has simplified the technique and encouraged many more surgeons to perform laparoscopic repair. Additionally, recent longterm outcome studies have suggested that laparoscopic extraperitoneal hernia repair has outcomes similar to open hernia repair.52 One of the major frustrations encountered while performing laparoscopic abdominal wall repair has been manipulation of the mesh prosthesis. A bitter lesson learned early on was that there must be adequate overlap of mesh (usually 3–5 cm) beyond the perimeter of the hernia defect. An adequate overlap demands a large portion of mesh, and the larger the mesh the more difficult it is to manipulate in a laparoscopic environment. Several ‘pearls’ have been developed to ease mesh deployment and assure adequate tension-free repair. Marking the mesh with a sterile pen has been of help in orienting the prosthesis. Rolling up the mesh like a cigarette and securing the rolled mesh with suture has simplified initial mesh placement. Using this technique, an edge of the rolled mesh is first secured with tacks or staples. The remainder of the mesh is then unfurled, finessed into position, and anchored with tacks or staples. An intriguing use of mesh for groin hernioplasty, first proposed by Felix and Michas, was that of a ‘doublebuttress’ repair using two sheets of polypropylene mesh.53 In this variation, the authors suggested using two pieces of mesh, typically 8 ⫻ 13 cm (in a pre-peritoneal position), one overlying the other at an oblique angle, thus creating a ‘double buttress’ of mesh over the mid-portion of the myopectineal orifice. While application of two layers of mesh undoubtedly bolstered the mid-portion of the orifice, this methodology had the additional benefit of increasing the diameter of the area repaired far in excess of 8 ⫻ 13 cm, widely overlapping the entire myopectineal orifice. Laparoscopic access has also been proposed for repair of ventral incisional hernias. In 1993, LeBlanc and Booth described their experience with repair of incisional hernia using ePTFE prosthetic graft.54 Franklin and colleagues reported on the use of open-weave polypropylene mesh for repair of ventral hernias.55 Notably, no fistula formation or significant adhesive bowel complications were found in their study. Kavic commented on the use of dual-mesh ePTFE (Gore-Tex) for abdominal-wall ventral hernia repair.56 Dual-mesh has a rough side and a smooth side. The smooth side of the ePTFE graft is intended to interface with intra-abdominal content and to not excite

History 39

adhesion formation. The rough side is placed in apposition to the abdominal wall, where its rough surface encourages tissue adhesion. The graft is fixed circumferentially with staples or tacks and anchored with transfascial stay sutures placed at the four cardinal points of the graft. Carbajo and colleagues prospectively compared laparoscopic with open prosthetic repair of large incisional hernias.57 Their study suggested that laparoscopic repair reduces complication rates and hernia recurrence compared with open methods.

complex pathophysiological, biochemical, molecular, and perhaps genetic derangements that are, even today, not well understood. Study of the groin by several generations of surgeon-scientists has provided an appreciation of the dynamic mechanisms that protect the myopectineal orifice in the normal state. Current understanding suggests that the entire myopectineal window must be secured if a complete cure of groin hernia is to be accomplished.56 Achievement of the perfect operation may be an unobtainable goal, but pursuit of the perfect operation is neither unreasonable nor undesirable.

CONCLUSION The successful repair of groin hernia can be accomplished in many ways. Conventional anterior herniorrhaphy, as described by Bassini and Shouldice, or anterior hernioplasty, as advocated by Lichtenstein, are effective procedures. These repairs, however, limit their focus to the upper aspect of the myopectineal orifice and neglect the lower aspect. They have been successful in large measure because of the application of sound surgical principles to secure the hernia defect and because the large majority of groin hernias pass through the indirect or direct inguinal ring. Laparoscopic access has advanced the art of hernia repair, as the entire myopectineal orifice with its multiple openings can be approached and exposed. Bilateral groin hernias can be repaired without a large incision or multiple incisions. Hernias that may have been missed during anterior repair (contralateral inguinal, femoral, occult hernias) can be examined and repaired.58 Surgical trauma to skin, subcutaneous tissue, fascia and muscle is reduced. Moreover, the spermatic cord is not manipulated circumferentially, offering the possibility that testicular vein thrombosis and testicular atrophy will be lessened. Hernias that recur after open procedures can be repaired laparoscopically without transgressing scarred tissue of the previous procedure. Over the past two decades, laparoscopic hernioplasty has evolved from an experimental procedure to one of proven efficacy. Groin hernia repair is not a simple exercise, and its practice requires skill and attention to detail. Differing clinical situations demand different anatomic approaches. Anterior open repair should probably be considered for pediatric patients and for patients with severe cardiopulmonary compromise, when repair may be performed under local anesthesia. Bilateral inguinal hernias, recurrent hernias, and unilateral hernias with a suspected contralateral hernia, however, suggest that a laparoscopic approach be considered. The modern herniologist should be proficient in both laparoscopic and open repair techniques. The myth that the least skilled surgeon or resident can perform hernia repair should be laid to rest. Hernia genesis involves

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Dorland’s Illustrated Medical Dictionary, 28th edn. Philadelphia: Saunders, 1994: 756. Ebbell B (transl.). The Ebers Papyrus. The Greatest Egyptian Medical Document. London: H. Milford and Oxford University Press, 1937: 17 and 123. Marcy HO. A new use of carbolized catgut ligatures. Boston Med Surg J 1871; 85: 315. Ponka JL. Significant contributions toward understanding and sound treatment of hernias. In: Ponka JL, ed. Hernias of the Abdominal Wall. Philadelphia: W.B. Saunders Co; 1980: 1–17. Bassini E. Nuovo metodo per la cura radicale dell’ernia inguinale. Arch F Klin Chir 1890; 40: 429–76. Heydorn W. Hernia. In: James EC, Corry RJ, Perry JF, eds. Principles of Basic Surgical Practice. St Louis: Mosby, 1987: 351–2. Annandale T. A case in which a reducible oblique and direct inguinal and femoral hernia existed on the same side and were successfully treated by operation. Edinburgh Med J 1876; 21: 1087–91. Cheatle GL. An operation for the radical cure of inguinal and femoral hernia. Br Med J 1920; 2: 68–9. Henry AK. Operation for femoral hernia by a midline extraperitoneal approach. Lancet 1936; 1: 531–3. Nyhus LM, Stevenson JK, Listerud MB, Harkins HN. Preperitoneal herniorrhaphy. A preliminary report in fifty patients. Western J Surg 1959; 67: 48–53. Billroth T, ed. Czerny V. Beiträge zur Operativen Chirurgie. Stuttgart: F Enke, 1878. Phelps AM. A new operation for hernia. N Y Med J 1894; 60: 291. Goepel R. Ueber die Verschliessung von Bruchpforten durch Einheilung geflochtener, fertiger Silberdrahtnetze (Silberdrahtpelotten). Verh Dtsch Ges Chir 1900; 19: 174. Witzel O. Ueber den Verschluss von Bauchwunden und Bruchpforten durch versenkte Silberdrahtnetze (Einheilung von Filigranpelotten). Centralbl Chir Leipz 1900; 27: 257. Read R, Francis C. Usher, herniologist of the twentieth century. Hernia 1999; 3: 167–71. Usher FC. Hernia repair with knitted polypropylene mesh. Surg Gynecol Obstet 1963; 117: 239. Usher FC, Gannon JP. Marlex mesh: a new plastic mesh for replacing tissue defects: I. Experimental studies. Arch Surg 1959; 78: 131. Usher FC, Cogan JE, Lowry TI. A new technique for the repair of inguinal and incisional hernias. Arch Surg 1960; 81: 847. Usher FC. Hernia repair with Marlex mesh. Arch Surg 1962; 84: 73. Usher FC, Allen Jr, Crosthwait RW, et al. Polypropylene monofilament: a new biologically inert suture for closing contaminated wounds. JAMA 1962; 179: 780.

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Usher FC, Wallace SA. Tissue reaction to plastics; comparison of nylon, Orlon, Dacron, and Teflon. Arch Surg 1958; 76: 997. Lichtenstein IL. Hernia Repair Without Disability, 2nd edn. St Louis: Ishiyaku Euroamaerica, Inc., 1986. Lichtenstein IL, Shulman AG, Amid PK, Montilier MM. The tensionfree hernioplasty. Am J Surg 1989; 157: 188–93. Shulman AG, Amid PK, Lichtenstein IL. A survey of non-expert surgeons using the open tension-free mesh repair for primary inguinal hernia. Int Surg 1995; 80: 35–6. Halsted WS. Bull Johns Hopkins Hosp 1903; 149: 211. Zimmerman LM, Zimmerman JE. The history of hernia treatment. In: Nyhus LM, Condon RE, eds. Hernia, 2nd edn. Philadelphia: JB Lippincott Co., 1978: 3–13. Fruchaud HR. Anatomie chirurgicale des hernies de l’aine. Paris: G. Doin, 1956. Wantz GE. Testicular atrophy as a risk of inguinal hernioplasty. Surg Gynecol Obstet 1982; 154: 570–1. Stoppa RE, Petit J, Henry X. Unsutured Dacron prosthesis in groin hernias. Int Surg 1975; 60: 411–15. Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in the repair of hernias of the groin. Surg Clin N Am 1993; 73: 571–81. Read RC. Preperitoneal exposure of inguinal herniation. Am J Surg 1968; 116: 653–8. Read RC. Attenuation of the rectus sheath in inguinal herniation. Am J Surg 1970; 120: 610–14. Read RC. The metabolic role in the attenuation of transversalis fascia found in patients with groin herniation. Hernia 1998; 2 (suppl 1): 17. Read RC. Blood protease/antiprotease imbalance in patients with acquired herniation. Prob Gen Surg 1995; 12: 41–6. Senior RM, Tegner H, Kuhn C, et al. The induction of pulmonary emphysema with human leukocyte elastase. Am Rev Resp Dis 1977; 116: 469–75. Cannon DJ, Read RC. Metastatic emphysema. A mechanism for acquiring inguinal herniation. Ann Surg 1981; 194: 270–8. Ger R. The management of certain abdominal herniae by intra-abdominal closure of the neck of the sac. Ann R Coll Surg Engl 1982; 64: 342–4. Popp LW. Endoscopic patch repair of inguinal hernia in a female patient. Surg Endosc 1990; 4: 10–12. Bogojavlensky S. Laparoscopic treatment of inguinal and femoral hernia. Video presentation presented at the 18th Annual Meeting of the American Association of Gynecological Laparoscopists, Washington, DC, 1989.

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Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparoscopic herniorrhaphy: a clinical trial preliminary results. J Laparoendosc Surg 1990; 1: 23–5. Corbitt JD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc 1991; 1: 23–5. Toy FK, Smoot RT, Jr. Toy–Smoot laparoscopic hernioplasty. Surg Laparosc Endosc 1991; 1: 151–6. Salerno GM, Fitzgibbons RJ, Filipi C. Laparoscopic inguinal hernia repair. In: Zucker KA, ed. Surgical Laparoscopy. St Louis: Quality Medical Publishing, 1991: 281–93. Fitzgibbons RJ. Laparoscopic inguinal hernia repair. New Frontiers in Endoscopy, Nationwide Satellite Teleconference, May 1991. Arregui ME, Davis CD, Yucel O, et al. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc 1992; 2: 53–8. Dion YM, Morin J. Laparoscopic inguinal herniorrhaphy. Can J Surg 1992; 35: 209–12. Kavic MS. Laparoscopic hernia repair. Surg Endosc 1993; 7: 163–7. MacFayden B, Arregui M, Corbitt J, et al. Complications of laparoscopic hernia. Surg Endosc 1993; 7: 155–8. McKernan BJ, Laws HL. Laparoscopic preperitoneal prosthetic repair of inguinal hernias. Surg Rounds 1992; 7: 579–610. Dulucq JL. Traitement des hernies de l’aine par mise en place d’un patch prothétique sous-péritonéal en rétropéritonéoscopie. Cahiers Chir 1991; 79: 15–16. Phillips EH, Carroll BJ, Fallas MJ. Laparoscopic preperitoneal inguinal hernia repair without peritoneal incision. Surg Endosc 1993; 7: 159–62. Wright D, Paterson C, Scott N, et al. Five-year follow-up of patients undergoing laparoscopic or open groin hernia repair. Ann Surg 2002; 235: 333–7. Felix E, Michas C. The double-buttress laparoscopic herniorrhaphy. J Laparoendosc Surg 1993; 1: 1–8. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. Franklin ME, Heniford BT, Arca MJ, et al. Laparoscopic ventral and incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. Kavic MS. Laparoscopic Hernia Repair. Amsterdam: Harwood Academic Publishers, 1997. 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 1999; 13: 250–2. Crawford DL, Hiatt JR, Phillips EH. Laparoscopy identifies unexpected groin hernias. Arch Surg 1998; 64: 976–8.

6 Anatomy and physiology B. PAGE AND PATRICK J. O’DWYER

View from the peritoneal cavity Pre-peritoneal space Transversalis fascia Oblique muscles Inguinal canal Spermatic cord

41 42 43 44 44 44

A thorough knowledge of the anatomy and function of the pre-peritoneal space and groin region is required by any surgeon with a special interest in treating hernias. Lack of knowledge of the basic pre-peritoneal anatomy has almost certainly led to injuries to vessels and nerves in this region, which otherwise could have been avoided. In addition, failure to recognize the importance of the anatomy by surgical trainees and practicing surgeons has slowed progress in minimal-access approaches to hernia repair via the pre-peritoneal space.

Myopectineal orifice Femoral canal and sheath Nerves Pathophysiology and conclusion References

44 45 45 45 46

VIEW FROM THE PERITONEAL CAVITY A starting point for any surgeon contemplating laparoscopic hernia repair is to view the normal anatomy of the pelvis through the laparoscope (Figure 6.1) of a patient undergoing another laparoscopic procedure, e.g. cholecystectomy. With a head-down tilt of 15–30 degrees, first observe the natural boundaries between the pelvic and abdominal cavity. In the midline, one will see the symphysis pubis, the superior pubic ramii bilaterally, and the iliopubic tract laterally, traversing out as far as the

Median umbilical ligament (urachus)

Lateral fossa Medial fossa

Medial umbilical ligament Lateral umbilical ligament

Supravesical fossa

Deep inguinal ring Ileopubic tract Testicular vessels Vas deferens Bladder

Figure 6.1 View of the pelvic anatomy observed through a laparoscope.


anterior superior iliac spines. The iliopubic tract is a condensation of the fascia transversalis and lies deep to the inguinal ligament. Anterior to this natural division, in the midline, the median umbilical ligament is observed, which represents the obliterated remnant of the urachus and extends from the fundus of the bladder to the umbilicus. On either side and lateral to this are the medial umbilical ligaments, which represent the peritoneal folds around the obliterated embryonic umbilical arteries. Further laterally, one can observe the inferior epigastric vessels, sometimes referred to as the lateral umbilical ligament. The inferior epigastric vessels are important landmarks for the hernia surgeon, as indirect inguinal hernias pass lateral to them on their way through the internal ring to the inguinal canal, while direct hernias pass medially on their way through the transversalis fascia. Posterior to the natural division between the abdomen and pelvis, the bladder is noted in the midline and on either side the venous pulsation of the external iliac vein and the arterial pulsation of the external iliac artery. From this view, it should also be possible, in male patients, to note the vas deferens on its course through the internal ring over the external iliac vessels and down the pelvic side well, where it disappears to join the seminal vesicles on their way into the prostatic urethra. The testicular artery and vein should also be noted coursing lateral to the external iliac artery. If at this stage one is performing laparoscopy under local anesthesia, then it is worth asking the patient to cough. It will be noted that the internal inguinal ring is suddenly pulled upwards and laterally by the fascia transversalis sling, thus shutting the door to the inguinal canal.

PRE-PERITONEAL SPACE The laparoscopic surgeon enters the pre-peritoneal space either transperitoneally or totally extraperitoneally. Getting into the right plane (i.e. immediately posterior to the rectus muscle) is important (Figure 6.2), otherwise the space between the pre-peritoneal fat and the deep layer of fascia transversalis is entered (Figure 6.3). This space contains numerous small blood vessels and is associated with troublesome bleeding, while the space posterior to the rectus muscle is avascular. The deep layer of fascia transversalis lies between the rectus muscle and the peritoneum, with pre-peritoneal fat sandwiched between them. The fascia transversalis extends laterally beyond the inferior epigastric vessels and can be observed surrounding the sac of an indirect hernia. It is particularly strong lateral to the inferior epigastric vessels, and as it is pulled down to open the space lateral to this it can be seen to interdigitate with the fibers of transversus abdominus muscle. Inferiorly, in the midline, the fascia transversalis fuses with the pubis, but it is quite flimsy here and breaks easily with posterior movement of the laparoscope. In

Figure 6.2 The avascular plane immediately posterior to the rectus muscle in a patient undergoing open surgery. Note the transverse fibers pointed out with tissue forceps below the arcuate line.

Figure 6.3 The vascular plane between the pre-peritoneal fat and the deep layer of fascia transversalis. This membranous layer is in continuity with the posterior rectus sheath. The allis forceps nearest the umbilicus marks the level of the arcuate line.

the midline, it is seen to fuse with the linea alba and can be difficult to separate from that structure when moving to the contralateral side in bilateral hernia repair. The pre-peritoneal space is in direct communication with the retropubic space of Rietzius.1 Following the pubic arch around on either side, the pectineal (Cooper’s) ligament comes into view (Figure 6.4). This is usually crossed by the anastomotic pubic artery and vein, tributaries from the inferior epigastric vessels, which course towards the obturator foramen, where they join with their respective pubic branch of the obturator vessels. An abnormal obturator artery arising from the inferior epigastric will be seen in a similar location; observed in about 30 per cent of cases, this is larger than the aforementioned vessels. The pectineal ligament itself fans out over a broad area of the superior pubic ramus, where medially it forms the lacunar ligament and anteriorly it continues as the iliopubic tract. The latter structure goes from the pubic

Anatomy and physiology 43 Medial limb of transversalis sling Aponeurotic arch Hasselbach's triangle Internal ring Femoral branch of genitofemoral nerve

Inferior epigastric vessels

Rectus muscle Transversus abdominus muscle Ileopubic tract Deep circumflex iliac artery and vein Iliacus muscle

Lateral cutaneous nerve of thigh

Transversalis fascia Femoral nerve Lacunar ligament

Genital branch of genitofemoral nerve Femoral canal Anastomotic pubic artery and vein

Psoas mucle Ileopsoas fascia (cut)

Bladder

Pectineal ligament

Testicular vessels Vas deferens Obturator vessels and nerve

Obturator foramen External iliac artery and vein

Figure 6.4 The pre-peritoneal pelvic anatomy with the iliopsoas fascia partially excised to expose the femoral nerve on the right side.

tubercle to the anterior iliac spine and is a condensation of the anterior layer of fascia transversalis. The iliopubic tract thus forms the posterior margin of both direct and indirect hernias while it is anterior to a femoral hernia. The femoral canal is bounded by iliopubic tract anteriorly, the pectineal ligament posteriorly, the lacunar ligament medially, and the iliac vein laterally. Likewise, the triangular area bounded by the deep epigastric vessels laterally, the lateral margin of the rectus muscle medially, and the iliopubic tract posteriorly (Hesselbach’s triangle) is the area through which direct hernias are formed. More precisely, from the pre-peritoneal view, the medial limb of the fascia transversalis U-sling forms the lateral margin of a direct hernia, while the medial margin is formed by the aponeuroses of the transversus abdominus muscle. The former can be seen easily at laparoscopic surgery with a large direct hernia, where the defect extends lateral to the deep epigastric vessels. The fascia transversalis forms a U-shaped sling around the cord, with the two limbs extending anteriorly and laterally to fuse with the posterior aspect of the transversus muscle. This sling is responsible for the shutter mechanism, which, for practical purposes, closes off the inguinal canal with sudden increases in intra-abdominal pressure. The iliopubic tract is an important landmark for the surgeon, for as well as having the femoral canal posterior to it, the external iliac vein and artery pass behind the iliopubic tract and inguinal ligament to become the femoral vessels. Both run on the medial aspect of the psoas muscle and can be seen easily during a totally extraperitoneal laparoscopic hernia repair. It goes without saying for surgeons who continue to use staples or other fixation methods for laparoscopic hernia repairs that placement of these devices in this area should be avoided. As stated already, the vas deferens runs over the iliac vessels on its course from the prostatic urethra to the internal ring. The testicular artery and vein course just lateral to the iliac artery, while the genitofemoral nerve runs a similar course, having split into its genital and

femoral branches at a variable distance along the psoas muscle. The femoral nerve lies deep to the iliopsoas fascia and is again lateral to the iliac artery and runs along the lateral border of the psoas muscle. Further lateral is the lateral cutaneous nerve of thigh, which can be seen crossing the iliacus muscle and which passes below the iliopubic tract just medial to the anterior superior iliac spine. The deep circumflex iliac artery and vein cross over the lateral cutaneous nerve on their course parallel and superior to the iliopubic tract. These vessels can easily be injured at this site and cause some nuisance bleeding during laparoscopic hernia repair.

TRANSVERSALIS FASCIA This fascial layer, which is thought to invest the entire abdominal cavity, is a source of controversy for surgeons and anatomists. Some argue that it is a weak layer with no intrinsic strength, while others regard it as essential both in the origin and repair of groin hernias. It is likely that both of these statements are true and almost certainly represent observations from different groups of patients or cadavers. Some regard it as a bilamellar structure with a strong anterior layer and a membranous deep layer.2 There is little doubt from the laparoscopist’s point of view that a two-layer fascial structure exists. The anterior layer of transversalis fascia can be seen easily when reducing a direct hernia as an attenuated fascial structure that lines the defect. The deep layer is observed when entering the pre-peritoneal space subumbilically and immediately posterior to the rectus muscle (Figure 6.3). Both structures appear strong and difficult to break through in the young patient with an indirect hernia; in older patients, both are flimsy, presumably because of a deficiency of collagen.3 Some regard the deep layer as a distinct structure from the transversalis fascia. However, as it is followed laterally it appears to interdigitate with the abdominal muscles, making it likely that it is attenuated posterior


rectus sheath and will thus contain a fascial contribution from the transversalis fascia.4 It is also likely that the socalled anterior layer of transversalis fascia is merely an attenuation of the aponeuroses of the internal oblique and transversus abdominus muscles. Evidence for this comes from children and young adults, in whom this layer is mainly muscular or musculotendinous.5 The transversus abdominus muscle is the deepest of the three abdominal muscle layers and the one seen by the laparoscopic surgeon. It arises from the costal cartilages of the lower six ribs, the vertebral column and the iliac crest. Its fibers run transversely, except in the lower abdomen, where they arch over the inguinal canal as an aponeurotic arch, which is inserted into the pubic crest and iliopectineal line. The transverse fibers proceed horizontally to their insertion in the rectus sheath and linea alba. Below the aponeurotic arch, the posterior wall of the inguinal canal is closed by transversalis fascia only in adults and is the site through which direct hernias occur. When the aponeuroses of the transversus and the internal oblique muscle are fused lateral to the rectus sheath, the term ‘conjoined tendon’ is used. This is a variable structure, however, and does not exist in all patients.6

OBLIQUE MUSCLES In addition to the transversus abdominus muscle, the abdominal wall is composed of the internal and external oblique muscles. The external oblique arises from the lower eight ribs. From its fleshy origin, the muscle spans widely to an aponeurotic insertion. Superiorly, the aponeurosis is very thin and is attached to the xiphoid process. Inferiorly, it is thick and inserts into the anterior superior iliac spine and pubic tubercle as the taut inguinal ligament. In the midline, the aponeurosis forms the anterior rectus sheath and is inserted into the linea alba. Posteriorly, the external oblique is not attached and forms part of the lumbar triangle. This, on occasion, may be a site for a lumbar hernia. The internal oblique muscle arises from the lumbar fascia, from the anterior two-thirds of the iliac crest, and from the lateral part of the inguinal ligament. The muscle fibers run parallel to the costal cartilages until they reach the ninth rib, where they become aponeurotic. Above the umbilicus, the tendinous aponeurosis of the internal oblique splits to encircle the rectus muscle. At a point 2.5 cm below the umbilicus lies the arcuate line, the posterior layer that was once thought to not exist. It is now recognized that the arcuate line merely marks the point where the posterior rectus sheath goes from a strong fascial structure to a more attenuated membranous structure (Figure 6.3). The lower fibers of the internal oblique originate at the inguinal ligament and arch downward and medially with the fibers of transversus abdominus to insert into the pubic crest anterior to the rectus muscle.

INGUINAL CANAL The inguinal canal is an oblique intermuscular slit about 6 cm long, lying above the medial half of the inguinal ligament. It begins at the deep (internal) ring and ends at the superficial (external) ring. It transmits the spermatic cord and the ilio-inguinal nerve in the male, and the round ligament and the ilio-inguinal nerve in the female. The anterior wall is formed by the external oblique aponeurosis medially and the internal oblique laterally. Its floor is made up of the rolled edge of the inguinal ligament. The lower edges of the internal oblique and the aponeurotic arch of the transversus muscle form the roof of the canal. These muscles arch over from in front of the cord laterally to behind the cord medially. In adults, the posterior wall is thus strong medially and weak laterally, where it is formed by the transversalis fascia only. In children, however, the inguinal canal is short (1–1.5 cm) and the internal and external rings are almost superimposed on each other.

SPERMATIC CORD The spermatic cord leaves the abdominal cavity via the superficial ring. The coverings of the spermatic cord are formed by the local muscles and fascia. The internal spermatic fascia is derived from fascia transversalis, cremaster muscle from internal oblique muscle, and external spermatic fascia from external oblique aponeurosis. The spermatic cord contains the testicular artery and vein, the ductus deferens and its accompanying vessels, the cremasteric artery, lymphatics, and the genital branch of the genitofemoral nerve. Until birth, the processus vaginalis, the portion of the peritoneum that accompanies the testis on its descent into the scrotum in embryonic life, remains opened. In some children, delay in closure may result in the development of a pediatric hernia. Although patent in some adults, the role of the processus vaginalis in the development of an indirect inguinal hernia is not certain. It is likely that failure of the sphincter mechanism of the inguinal region, the transversalis U-sling, combined with contraction and flattening of the transversalis arch and internal oblique muscle, which essentially closes the inguinal canal, is more important.

MYOPECTINEAL ORIFICE Fruchaud emphasized that all groin hernias originate from a single weak area (Figure 6.5).7 This area is formed by the abdominal wall muscles above, the arching fibers of the transversus abdominus, the internal and external oblique muscles, the bony pelvis below, ilium covered by the pectineal ligament, the rectus muscle medially, and the fascia

Anatomy and physiology 45 Ilio-hypogastric nerve

Ilio-inguinal nerve Inferior epigastric vessels Cremasteric vessels Spermatic cord Genital nerve Inguinal ligament

Ileopsoas muscle

Figure 6.6 Position of the nerves in the right inguinal canal. Inguinal ligament

Femoral vessels Spermatic cord Myopectineal orifice

Figure 6.5 The myopectineal orifice.

covering the iliopsoas muscle laterally. The myopectineal orifice is divided into two levels by the inguinal ligament. The superior, inguinal level provides a passage for the spermatic cord or round ligament; the inferior, femoral level provides a passage for the femoral vessels.

FEMORAL CANAL AND SHEATH The femoral canal contains fatty tissue, lymph nodes and lymphatics. The boundaries of the canal include the femoral vein and connective tissue laterally, the aponeurotic insertion of the transversus abdominus and lacunar ligament medially, the iliopubic tract and inguinal ligament anteriorly, and the pectineal ligament posteriorly. The entrance to the canal, the femoral ring, is a little over 1 cm in diameter, while the canal itself is 1–2 cm long with its apex at the fossa ovalis. The femoral sheath is an extension of the transversalis fascia and envelops the femoral artery, vein and canal. The sheath is divided into three compartments by septa of connective tissue between each compartment.

NERVES The nerves of most importance to the laparoscopic surgeon are the genitofemoral nerve, the lateral cutaneous nerve of the thigh, and the femoral nerve. The genitofemoral nerve comes from the first and second lumbar nerves and completes the innervation of the groin

region. It passes obliquely through the substance of the psoas major muscle and emerges from this crossing deep to the peritoneum and the ureter. It splits behind the deep inguinal ring into the genital and femoral branches. The genital branch lies on the floor of the inguinal canal behind the spermatic cord and supplies the cremasteric muscle via its motor branches and the scrotal skin via its sensory branches. The femoral branch contributes to the sensation of the anterior thigh. The lateral cutaneous nerve of the thigh crosses the iliacus muscle after emerging from the lateral border of the psoas muscle. It passes beneath the iliopubic tract just medial to the anterior superior iliac spine and innervates the skin on the anterior and lateral surface of the thigh. The femoral nerve is the largest of the three nerves and lies deep to the iliopsoas fascia. It can be seen emerging between the psoas and iliacus muscle, passing beneath the iliopubic tract, and innervating the muscles in the anterior compartment of the thigh and the skin of the anteriomedial aspect of the lower thigh and leg. Also of importance to the hernia surgeon are the ilioinguinal and ilio-hypogastric nerves (Figure 6.6). The former is usually smaller than the latter and is sometimes absent. These are both sensory nerves that arise from the first lumbar nerve. The ilio-inguinal nerve passes through the inguinal canal and becomes superficial at the external ring to innervate the skin of the scrotum and the medial upper thigh. Damage to the ilio-inguinal nerve in the inguinal canal causes sensory loss as the motor fibers are already given off to the conjoint tendon. The iliohypogastric nerve emerges through the external oblique aponeurosis to innervate the suprapubic skin.

PATHOPHYSIOLOGY AND CONCLUSION A better understanding of the physiology of the inguinal region may lead ultimately to novel methods of preventing and treating inguinal hernias. In children, fusion of the


processus vaginalis is thought to be hormone-related.8 This is supported by the fact that inguinal hernias are associated with an undescended testis and gonadotropin administration results in a significantly higher rate of closure of the processus vaginalis. Since androgen receptors are not present in the processus vaginalis, it has been postulated that their effect is on the genitofemoral nerve. This releases calcitonin gene-related peptide (CGRP), which has been shown to fuse the inner mesothelial layer of the processus vaginalis.9 Hepatocyte growth factor/ scatter factor (HGF/SF) has also been found to induce fusion of the processus, suggesting that local administration of these agents may lead to a non-surgical treatment of an inguinal hernia in neonates.9 While the presence of a patent processus vaginalis is a key element in the development of pediatric hernias, its role in adults is less certain. Autopsy studies reveal that 15–35 per cent of adults have a patent processus vaginalis without ever developing a hernia.10 A more likely cause, given the increasing incidence with age, is a relative reduction in connective tissue in the inguinal region.11 In addition, there is evidence that altered collagen synthesis may weaken the fascia transversalis in patients with an inguinal hernia. In a study by Klinge and colleagues, immunohistochemical and Western blot analysis showed that the ratio of type I to type III collagen was decreased significantly in the fascia transversalis of patients with an inguinal hernia.12 The tensile strength of tissues depends on the proportion of type I and III collagen, and the authors postulated that the relative increase in type III collagen, thin, immature fibers might be responsible for a reduction in mechanical strength of the collagen matrix of the abdominal wall. The lack of strength in the supporting structures is probably only part of the puzzle that leads to failure of the inguinal region in adults. Anatomically, Hessert’s triangle is a weak area that has the internal ring as its apex, the rectus abdominus as its base, and the inguinal ligament and aponeurotic arch of the transversus abdominus and internal oblique as its sides.13 This area is normally closed by the contraction of the transversus and internal oblique muscular arch, which flattens out this arch and causes it to approach the inguinal ligament. This essentially occludes the triangle and is referred to as the inguinal shutter by Keith.14 Recent evidence indicates that in patients with an inguinal hernia, this triangle is larger than usual and thus closure of the shutter may be incomplete.15 The authors of the latter study concluded that the greater area was a cause and not a consequence of inguinal herniation because the reason for the increase in this area was a higher intersection of the internal oblique and transversus abdominus

muscle to its aponeurosis on the rectus sheath. This suggests an inherited anatomical variation that predisposes certain individuals to the development of an inguinal hernia and helps explain why one-third of patients will have or develop a contralateral hernia while a similar number will have a family history of a hernia.16 Although we have made significant progress in the understanding of the anatomy and physiology of the inguinal region, there is still a lot to learn. Advancements in these areas will undoubtedly lead to the prevention of some groin hernias and better treatment of existing symptomatic hernias in the future.

REFERENCES 1

2 3 4

5

6 7 8 9

10

11 12

13

14 15 16

Bouchet Y, Voilin C, Yver R. The peritoneum and its anatomy. In: Bengmark S, ed. The Peritoneum and Peritoneal Access. London: Wright, 1989: 1–13. Cooper A. The Anatomy and Surgical Treatment of Abdominal Hernia. London: Longman, 1804. Wagh PV, Read RC. Collagen deficiency in rectus sheath of patients with inguinal herniation. Proc Soc Exp Biol Med 1971; 37: 382–4. Arregui ME. Surgical anatomy of the preperitoneal fascia and posterior transversalis fascia in the inguinal region. Hernia 1997; 1: 101–10. Bendavid R. The transversalis fascia: new observations in abdominal wall hernias. In: Bendavid R, Abrahamson J, Arregui ME, et al., eds. Abdominal Wall Hernias: Principles and Management. New York: Springer-Verlag, 2001: 97–100. Sorg J, Skandalakis JE, Gray SW. The emperor’s new clothes or the myth of the conjoined tendon. Ann Surg 1979; 45: 588–9. Fruchaud H. Anatomie chirurgicale des hernies de l’aine. Paris: G Doin, 1956. Clarnette TD, Hutson JM. The development and closure of the processus vaginalis. Hernia 1999; 3: 97–102. Sugita Y, Uemura S, Hasthorpe S, Hutson JM. Calcitonin generelated peptide (CGRP) – immunoreactive nerve fibre and receptors in the human processus vaginalis. Hernia 1999; 3: 113–16. Read RC. Historical survey of the treatment of hernia. In: Nyhus LN, Condon RE, eds. Hernia, 3rd edn. Philadelphia: JB Lippincott, 1989: 3–17. Conner WT, Peacock EE. Some studies on the aetiology of inguinal hernia. Am J Surg 1973; 126: 732–5. Klinge U, Zheng H, Si Zy, et al. Altered collagen synthesis in fascia transversalis of patients with an inguinal hernia. Hernia 1999; 4: 181–7. Hessert W. Some observations on the anatomy of the inguinal region, with special reference to absence of the conjoined tendon. Surg Gynecol Obstet 1913; 16: 566–8. Keith A. On the origin and nature of a hernia. Br J Surg 1973; 11: 455–75. Abdalla RZ, Mittlestaedt WE. The importance of the size of Hessart’s triangle in the aetiology of inguinal hernia. Hernia 2001; 5: 110–23. Hair A, Paterson C, Wright D, et al. What effect has the duration of an inguinal hernia on patient symptoms? J Am Coll Surg 2001; 193: 125–9.

7 Intraperitoneal onlay mesh approach MORRIS FRANKLIN

Patient selection Operating room set-up Operative technique

48 48 49

It has been over 100 years since Bassini ushered in a new era of hernia surgery with the introduction of his triplelayer technique to repair the inguinal floor. Since then, surgeons have developed a myriad of new methods of hernia repair in an attempt to improve the results. However, despite a century of advances in hernia surgery, recurrence continues to plague the general surgeon and is the primary reason why no single technique of herniorrhaphy has become universally accepted. The repair of inguinal hernias has probably produced more variety in technique than any other operation performed by the general surgeon today. Complexity of the anatomy, the variety in size and location of the defect, and the multiplicity of the presentations of a hernia have contributed to this uncertainty regarding the optimal repair.1 After minimally invasive surgery proved to be successful in the treatment of biliary, gastric and colon diseases, surgeons attempted to find a method of successfully repairing inguinal hernias laparoscopically. It was felt that the attendant benefits of decreased postoperative pain and disability seen in other minimally invasive procedures could be realized in hernia patients as well. The first report of a laparoscopic technique of inguinal herniorrhaphy was by Ger and colleagues in 1990,2 who advocated simple closure of the neck of the hernia sac. This was soon followed by reports of plugging of the inguinal canal or direct defect with a prosthetic mesh, as described by Schultz and colleagues3 in 1990 and by Corbitt4 in 1991. After unacceptable early recurrence rates, these methods were abandoned in favor of newer techniques that combined the advantages of a tension-free repair utilizing a synthetic mesh with the transabdominal approach of laparoscopy.

Postoperative management Conclusion References

51 51 51

The three most popular procedures to emerge were the transabdominal pre-peritoneal (TAPP) patch, the totally extraperitoneal (TEP) patch, and the intraperitoneal onlay mesh (IPOM) repairs. In the TAPP technique, the peritoneum is incised intra-abdominally and a preperitoneal space is developed. A prosthetic mesh is then introduced into this space, placed over the abdominal wall defect, and stapled into place. The peritoneum is then re-approximated over the mesh so that there is no exposure of synthetic material to the intra-abdominal contents. In the TEP approach, the peritoneal space is never entered. Dissection is carried out in the extraperitoneal space just below the fascia of the abdominal wall. A pre-peritoneal space is created using blunt dissection and carbon dioxide insufflation. Synthetic mesh is then placed over the defect and fixed into place with staples or tacks, as in the TAPP procedure. The potential drawback of both the TAPP and the TEP procedures is that they require considerable dissection to create the pre-peritoneal space, which can result in perioperative discomfort and complications, such as hematoma formation or injury to the vas deferens, vascular structures, or nerves. The TEP technique in particular is technically more demanding, and the pre-peritoneal dissection can be very difficult to perform, particularly in large inguinoscrotal hernias. As a result, a third laparoscopic repair was developed, which involves placing the mesh on the intra-abdominal side of the peritoneum, rather than preperitoneally, thus avoiding the radical dissection of the pre-peritoneal space. This method of repair – the IPOM technique – was concurrently investigated in the Laboratory for Experimental Laparoscopic Surgery at Creighton


University and at the Texas Endosurgery Institute, San Antonio.5 Yorkshire cross-feeder pigs with congenital indirect inguinal hernias underwent intraperitoneal herniorrhaphy with placement of Prolene mesh either laparoscopically or via laparotomy. At six weeks, all pigs were sacrificed and an intra-abdominal exploration was carried out to confirm the success or failure of the repair, to stage the development of any adhesions to the mesh, to examine the prostheses for infection, and to evaluate the erosion of the prosthesis into neighboring structures. All hernia repairs in both groups were successful. In addition, a significant reduction in adhesion formation was noted when the mesh was placed laparoscopically rather than by laparotomy. There was no evidence of intra-abdominal infection or erosion of the prosthesis into adjacent structures in either group. These findings parallel those of Franklin6 and Layman and colleagues,7 who found that the use of intraperitoneal material in swine models resulted in good in-growth of peritoneum over the mesh with minimal adhesion formation. We performed the first IPOM procedure in a human patient at the Texas Endosurgery Institute in 1990. Since then, we have repaired over 550 direct, indirect, and recurrent inguinal hernias using the IPOM technique, with an overall complication rate of 7.5 per cent and a recurrence rate of 0.96 per cent.8 These results are comparable to those of Toy and colleagues,9 who reported 441 IPOM repairs with a complication rate of 8.0 per cent and a recurrence rate of 3.8 per cent, and Fitzgibbons and colleagues,10 who detailed 217 IPOM repairs with a recurrence rate of 5.1 per cent.

PATIENT SELECTION All adult patients with inguinal hernias and who are fit for general anesthesia are considered candidates for a laparoscopic IPOM procedure. Those patients with an obliterated pre-peritoneal space secondary to radiation or previous surgery (radical retropubic prostatectomy, bladder surgery, vascular procedures, cesarean section, etc.) are particularly good candidates in that a laparoscopic TAPP or TEP procedure would be technically difficult or even impossible in this setting. Additionally, those patients with a failed TAPP or TEP are ideal candidates for this approach, which allows for recurrent hernia repair in virgin territory. Relative contraindications include severe intraabdominal adhesions due to prior surgery, ascites, coagulopathy, severe underlying medical illness precluding general anesthesia, and lack of appropriate laparoscopic skills.

OPERATING ROOM SET-UP The operating room set-up for the IPOM procedure on a left-sided inguinal hernia can be seen in Figure 7.1. The operating surgeon stands on the contralateral side of the table from the hernia, while the assistant is positioned on the side ipsilateral to the hernia site. With the patient under general anesthesia, a catheter is placed in the bladder and a nasogastric tube is introduced into the stomach.

Anesthesia Suction irrigation Cautery Camera holder

Laparoscopy table

Assistant surgeon

Surgeon Scrub nurse

Mayo stand

Primary video cart

Secondary video cart

Hot plate sequential compression devices

Figure 7.1 Operating room set-up for left-sided hernia repair.

Intraperitoneal onlay mesh approach 49

After insufflating the peritoneal cavity to 14 mmHg using a Veress needle, a 5-mm trocar is introduced into the abdomen on the side opposite the hernia, just lateral to the rectus sheath at the level of the umbilicus. After a generalized inspection of the abdominal cavity and lysis of adhesions if necessary, a 10/12-mm trocar is placed at the umbilicus and a 5-mm trocar is placed on the ipsilateral side of the hernia, exactly opposite the initial trocar. Trocar placement is outlined in Figure 7.2. For bilateral repairs, the same configuration of trocar placement is utilized.

OPERATIVE TECHNIQUE After inspection of the entire peritoneal cavity and lysis of any remaining adhesions, the hernia site and the contralateral inguinal area are evaluated carefully. For proper orientation, the surgeon should recognize the median, medial and lateral umbilical ligaments. Just below the posterior parietal peritoneum, the external iliac vein and artery, the gonadal vessels, and, in males, the vas deferens should be identified. The hidden course of the genitofemoral nerve and the approximate course of the lateral femoral cutaneous nerve should be recalled and care taken to avoid rough dissection in this area. The exact location of the ureter bilaterally should also be noted. We now routinely remove direct and indirect hernia sacs, since in our experience leaving the sac may perpetuate a bulge in the groin – a bulge that patients and inexperienced surgeons interpret as an operative failure despite repeated assurances that no bowel can enter the sac or

10/12mm port

5 mm port

5 mm port

Hernia

Figure 7.2 Trocar configuration for IPOM inguinal hernia repair.

space. Division of the sac also gives access to the properitoneal area where a ‘lipoma’ of the cord, if present, can be excised. When operating for left-sided hernias, we often find it necessary to divide the embryonic adhesions that the sigmoid colon maintains with the parietal peritoneum adjacent to the hernia defect. We excise the sac using laparoscopic scissors connected to an electrosurgical unit. First, the sac is inverted progressively into the peritoneal cavity using gentle traction. Once the inversion is completed, the sac is incised, starting 1 or 2 cm from its base at the 12 o’clock position and proceeding clockwise to about the 4 o’clock position. The incision is then restarted at the ‘top’ and carried in an anticlockwise fashion until approximately the 8 o’clock position. The inversion of an indirect inguinal hernia sac drags within it the fatty areolar tissue in which the gonadal vessels and the vas may be embedded. This tissue must be bluntly and carefully swept away from the sac anteriorly. Once separated fully from the elements of the cord, the sac can then be safely excised circumferentially and removed through a 10/12-mm port. Small or capillary vessel bleeding during this phase of the operation is controlled easily by pinpoint electrocoagulation. Large inguinoscrotal sacs and sacs in multiple recurrent hernias are ringed at the neck (incision of the peritoneum circumferentially) and are left in place. Bleeding and extensive edema may ensue if these sacs are pursued aggressively. Once the sac is removed, a piece of Polypropylene mesh is prepared. The size of the mesh should be such that it covers the hernia defect and extends 3 cm beyond its rim in all directions at a minimum. We have found that a 12 ⫻ 15-cm portion of mesh covers most defects adequately. The folded mesh is introduced into the abdominal cavity. We have found that if the mesh is folded rather than rolled, it will not have a tendency to curl once opened and it will be much easier to manipulate and hold in place. Once the mesh is unfolded, it is placed over the defect and held there with grasping forceps. The superior border of the mesh at its mid-portion is then held tightly against the anterior abdominal wall. A Keith needle attached to a 2-0 strand of Prolene, Ethicon, Somerville, NJ is pushed through the abdominal wall and through the mesh (Figure 7.3). Pressing gently on the abdominal wall with one’s finger and visualizing the indentation laparoscopically can establish the spot where the 1 mm incision is to be made and where the needle is to pierce the abdominal wall. Through the same incision, a 13-gauge needle is then placed through the abdominal wall and the mesh, parallel to the Keith needle. Once the Keith needle is passed through the abdomen and mesh, it is grasped, turned through 180 degrees, and pushed back through the lumen of the 13-gauge needle, exiting through the small skin incision (Figure 7.4). A clamp is applied to the Prolene suture at skin level, which holds the mesh tightly against the abdominal wall. The same procedure is


Figure 7.3 Keith needle passing through mesh and abdominal wall adjacent to 13-gauge spinal needle.

(a) 13G needle

Skin

Mesh Peritoneum

(b)

Figure 7.4 (a) Keith needle being passed back through abdominal wall via 13-gauge needle. (b) Diagrammatic representation.

repeated at both upper corners of the mesh. This method of percutaneous fixation of mesh for inguinal hernia repair was first described by Rosenthal and Franklin in 1993.11 We do not rely solely on staples, which grasp only mesh and peritoneum, to hold the prosthesis in place.

Figure 7.5 Mesh stapled securely to Cooper’s ligament.

Once placed, these three sutures hold the mesh securely in place, spreading it out evenly and allowing for the rest of the mesh to be precisely and easily stapled in place. The staples are initially placed approximately 1–1.5 cm apart along the lateral edges of the mesh. Around the inferolateral aspect of the mesh, care should be taken to place the staples parallel to the course of the lateral femoral cutaneous nerve or the femoral branch of the genitofemoral nerve to minimize the chance of their entrapment, especially if these are placed lateral to the internal spermatic vessels and inferior to the iliopubic tract.12 Along the lower margin of the mesh, staples should be placed lightly and further apart (2 cm) to avoid damage to the iliac vessels and the vas deferens. A few staples are also used to fix the superior and central portion of the mesh to the anterior abdominal wall. Medially, every effort should be made to secure the mesh to Cooper’s ligament (Figure 7.5). The anteriorly positioned inferior epigastric vessels, immediately beneath the peritoneum, should be avoided in the stapling process. Staples should not be used near the inferior or inferolateral aspect of the internal ring because of the risk of injuring the structures passing through it. The area is irrigated with saline solution and inspected for hemostasis. The subcutaneous fat below the skin incisions through which the Prolene sutures were placed is spread with a fine-tip hemostat, allowing the sutures to be tied over the external oblique aponeurosis. In our opinion, firm anchoring of the mesh by transabdominal stitches and staples in Cooper’s ligament prevents displacement of the mesh when the abdomen is deflated and when the patient assumes the erect position. We firmly believe that recurrent herniation is the result of early migration of the mesh away from its intended position. To repair a contralateral hernia, the same procedure is performed on the opposite side. Initially, we did not combine this type of surgery with operations on the bowel or biliary tree. However, these are no longer contraindications to the simultaneous repair of these hernias with bowel or biliary surgery subsequent to the development

Intraperitoneal onlay mesh approach 51

of biosynthetic mesh materials such as Surgisis™ (Cook Surgical), which have demonstrated high resistance to infection, even in contaminated fields.13 (See Chapter 4.) As the trocars are sequentially removed, the trocar sites are examined to ensure that no bleeding is present. Finally, the umbilical insertion site is observed by slowly withdrawing the camera and its cannula in unison. To prevent potential herniation, all 10-mm trocar sites are closed by repairing the underlying fascia or aponeurosis with the aid of a Carter-Thomason®suture passer (Louisville Laboratories) using 0 Vicryl®(Ethicon) or Polysorb®(U.S. Surgical) sutures. The skin edges are then re-approximated with 3-0 Monocryl®(Ethicon) subcuticular sutures or Steri-strips®(3M Health Care).

anesthesia, higher costs, the potential problems inherent to laparoscopy, and the need for technical expertise in laparoscopic surgery. Potential complications due to the mesh’s direct contact with abdominal viscera have yet to be realized in the laboratory or in clinical practice. The laparoscopic IPOM technique of hernia repair is a safe and relatively easy procedure to perform, with good results and low morbidity. It can be a particularly effective technique for laparoscopic repair of recurrent inguinal hernias or for hernia repair in the setting of an obliterated pre-peritoneal space.

REFERENCES 1

POSTOPERATIVE MANAGEMENT 2

Patients are generally discharged the evening of surgery or after a 23-hour observation period, depending on age, comorbidities, and difficulty of operation. They are scheduled for follow-up office visits one to two weeks following discharge and are instructed to be aware of urinary retention, neuralgia (from damage to the lateral femoral cutaneous nerve), and scrotal swelling in men. We ask that they avoid heavy lifting (⬎9 kg) for five to seven days following surgery. However, after this brief time period, they are allowed to perform activity as tolerated.

3

4 5

6

7 8

CONCLUSION The transabdominal approach to inguinal hernia repair is not a new concept. Advocated by Marcy14 in 1887 and by LaRoque15 in 1932, the transabdominal approach for inguinal herniorrhaphy allows greater ease in identification of groin anatomy, determination of the type of hernia defect, and separation of incarcerated and adherent structures to the sac.16,17 However, the morbidity associated with a laparotomy is far too great for repair of an uncomplicated inguinal hernia. With the advent of laparoscopic surgery, the benefits of the intra-abdominal approach to inguinal herniorrhaphy can be enjoyed without the morbidity of a laparotomy. The IPOM procedure is relatively simple to perform and carries with it all the potential advantages of a minimally invasive procedure with respect to the open inguinal hernia repair, including less postoperative pain, earlier return to normal activities, ability to clearly visualize and repair all hernia defects bilaterally, easier repair of recurrent hernias, and improved cosmesis. Disadvantages of the IPOM technique include the necessity for general

9

10

11

12

13

14 15 16 17

Ramshaw R, Shuler FW, Jones HB, et al. Laparoscopic inguinal hernia repair: lessons learned after 1224 consecutive cases. Surg Endosc 2001; 15: 50–54. Ger R, Monroe K, Duvivier R, Mishriek A. Management of indirect inguinal hernia by laparoscopic closure of the neck of the sac. Am J Surg 1990; 159: 370–73. Schultz L, Graber J, Pietrafitta JJ, Hickok D. Laser laparoscopic herniorrhaphy: a clinical trial preliminary results. J Laparoendosc Surg 1990; 1: 41–5. Corbitt JD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc 1991; 1: 23–5. Fitzgibbons RJ, Salerno GM, Filipi CJ, et al. A laparoscopic intraperitoneal onlay mesh technique for the repair of an indirect inguinal hernia. Ann Surg 1994; 219: 144–56. Franklin ME. Animal studies and rationale for intraperitoneal repair. In: Arregui ME, Nagan RF, eds. Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe Medical Press Ltd, 1994: 241–4. Layman ST, Burns RP, Chandler KE, et al. Laparoscopic inguinal herniorrhaphy in a swine model. Am J Surg 1993; 59: 13–19. Franklin ME, Diaz-Elizondo JA. The intraperitoneal onlay mesh procedure for groin hernias. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s Hernia. Philadelphia: Lippincott Williams & Wilkins, 2002: 269–76. Toy FK, Moskowitz M, Smoot RT, Jr, et al. Results of a prospective multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic inguinal hernioplasty. J Laparoendosc Surg 1996; 6: 375–86. Fitzgibbons RJ, Camps J, Comet DA, et al. Laparoscopic inguinal herniorrhaphy: results of a multicenter trial. Ann Surg 1995; 221: 3–13. Rosenthal D, Franklin ME, Jr. Use of percutaneous stitches in laparoscopic mesh hernioplasty. Surg Gynecol Obstet 1993; 176: 491–2. Eubanks S, Newman L, Goehring LM, et al. Meralgia paresthetica: a complication of laparoscopic herniorrhaphy. Surg Laparosc Endosc 1993; 3: 381–5. Franklin ME, Gonzalez JJ. Preliminary experience with new bio-active prosthetic material for repair of hernias in infected fields. Presented at the American Hernia Society meeting, Tucson, AZ, USA, May 8–12, 2002. Marcy HO. The cure of hernia. JAMA 1887; 8: 589–92. LaRoque GP. The intra-abdominal method of removing inguinal and femoral hernia. Arch Surg 1932; 24: 189–203. Read RC. Preperitoneal herniorrhaphy: a historical review. World J Surg 1989; 13: 532–40. Nyhus LM, Condon RE, Haskins HN. Clinical experiences with preperitoneal hernia repair for all types of hernia of the groin. Am J Surg 1960; 100: 234–44.


8 Transabdominal pre-peritoneal approach REINHARD BITTNER, CLAUS-GEORG SCHMEDT AND BERNHARD JOSEF LEIBL

Principles Preoperative management Instrumentation Operative room set-up Operative technique

53 54 55 55 56

The introduction of laparoscopic operating techniques opened up the possibility of using this method to implant mesh into the pre-peritoneal space to repair an inguinal hernia. By sparing the patient a large abdominal incision in the inguinal region1 or in the midline,2 one can expect a decrease in the number of wound complications, less postoperative pain, and consequently a faster recovery of normal physical activity and return to work. In contrast to pre-peritoneal mesh insertion via a minimized anterior approach,3 the laparoscopic method provides clear visibility when dissecting the inguinal region with safe, wrinkle-free placement of a large mesh.4 Laparoscopic hernioplasty with pre-peritoneal placement of a large mesh (transabdominal pre-peritoneal (TAPP) repair) represents a synthesis between proven conventional operative techniques and the advantages of a minimally invasive approach.

PRINCIPLES Indications The mode of operation of TAPP follows the law of physics according to Pascal.2 As a result of pre-peritoneal placement of the prosthesis, i.e. between abdominal pressure and the weak point in the abdominal wall, the pressure that initially caused the hernia now acts as a stabilizer for reconstruction. If the mesh chosen is

Special remarks Postoperative management Conclusion References

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sufficiently large, then laparoscopic pre-peritoneal hernioplasty can be seen as a completely tension-free method of hernia repair, which dispenses with any and all kinds of fixation. In contrast to this, the success of an anterior mesh implant (Lichtenstein) depends on a strong external oblique aponeurosis and on a row of well-placed fixation sutures. Laparoscopic hernioplasty can be used on any type of hernia, with the exception of huge, non-reducible scrotal hernia (more than double the size of a man’s fist). In our patient pool of more than 1100 hernia repairs yearly, TAPP is used in 99 per cent of repairs.5 Conventional hernia repair operations are carried out only in young patients (⬍20 years of age), in patients at high cardiopulmonary risk where a general anesthetic is refused, and in patients who decline to accept implantation of prosthetic materials. Preferred indications are hernias recurring after conventional operations (with the advantage of avoiding anterior scar areas),6 bilateral hernia (both sides can be treated through the same three trocar incisions), and hernias with extensive destruction of the rear wall of the hernial canal (Nyhus type 3 with a defect diameter of more than 3 cm, pantaloon hernia).7,8 Other accepted indications are inguinal pain in athletes,9 after eliminating other possible causes, and hernias in patients who wish to return to normal physical activity as quickly as possible. Pain in the inguinal area with no clinically or sonographically proven hernia sac or lipoma of the spermatic


cord is not seen as an indication for laparoscopic hernioplasty. Painstaking neurological (inguinal nerve neuralgia?) and orthopedic investigation is necessary. Strong selection for operation is the only way to reduce significantly the frequency of postoperative chronic pain for these patients. However, a clinically proven hernia, even though a hernia sac may not have been identified laparoscopically, does necessitate complete dissection of the inguinal region. As a rule, very often one will find a circumscribed lipoma of the inguinal canal or a fatty mass that has moved into the inguinal canal. The operation is then identical to a hernia repair. Advantages of the TAPP technique over the totally extraperitoneal (TEP) approach include the following:

• • • •

After insertion of the laparoscope, one can assess immediately the hernial situation on both sides and recognize the landmarks that are important for dissection. Intestinal adhesions in the hernial sac (sliding hernia) can be recognized immediately. Control of any bleeding is possible by appropriately aimed electrocoagulation, thereby avoiding injury to the adherent intestinal wall. It is possible to diagnose accompanying pathological conditions as well as to carry out additional surgery in the abdominal space (e.g. cholecystectomy) without conversion to an open procedure.

Contraindications The only absolute contraindication is for patients at high cardiopulmonary risk who cannot be subjected to general anesthesia or a pneumoperitoneum. A relative contraindication is seen in patients after extensive abdominal surgery, especially after a lower abdominal laparotomy through a midline incision as well as after surgery in the space of Retzius (transabdominal prostate resection, bladder resection), after previous laparoscopic or endoscopic hernioplasty with mesh implant, and in patients with large, old, irreducible scrotal hernia. Patients who have undergone the above operations tend to develop extensive adhesions in the abdominal space as well as substantial scarring between the retroperitoneal structures. These patients present a risk not only of increased bleeding but also of injury to the intestinal organs and the bladder, as well as the large abdominal vessels.

Laparoscopic versus open repair According to a meta-analysis of the EU Hernia Trialists Collaboration covering a total of 58 randomized studies, recurrence rates can be reduced by about 50 per cent by implanting prosthetic materials, with no difference noted

between anterior and posterior implant techniques.10 The same meta-analysis confirmed that in comparison with anterior mesh implants, laparoscopic/endoscopic techniques provide a clearly higher patient comfort and a significantly faster resumption of normal physical activity. It was observed, however, that the risk of severe complications is higher when using the laparoscopic technique (4.7/1000 v. 1.1/1000). Furthermore, the laparoscopic technique means longer operating times and significantly higher costs. There is no doubt that the laparoscopic technique is more difficult to learn. This is, to some extent, related to the fact that many clinics do not routinely perform videoendoscopic operations, and therefore there is no structured training curriculum available. In the authors’ hospital, with the experience that comes from more than 8000 hernia repairs, a median operating time of 40 minutes is sufficient for experienced surgeons, while trainees need 55 minutes. These times are completely in the range of those for open repair.5 A decisive factor concerning the costs is whether disposable or non-disposable instruments are used, and whether, or how, the mesh is fixed in place. A high potential cost-saving is possible here. The experience of our clinic is that the costs for the operating theatre alone (personnel and instruments) are only about $75 higher than those of the Lichtenstein operation, assuming that an anesthetist is required for the local anesthesia. Furthermore, the total costs for employees are lower with the laparoscopic technique when the costs of lost work days are factored into overall expense.11 All in all, the literature and our own results show that a well-trained surgeon can perform a cost-effective laparoscopic hernioplasty in a period of time that is well within the range of that for conventional open surgery.

PREOPERATIVE MANAGEMENT Anatomy/pathology Clinical examination of the patient is indispensable. An experienced examiner can diagnose correctly inguinal hernia with a total accuracy rate of 0.93. An additional sonographic examination can increase this figure to 0.94.12 Classification of the hernia into medial or lateral, or in respect to the size of the defect, can be estimated only approximately, both clinically and sonographically, achieving a total accuracy rate of correct diagnosis of only 0.62 and 0.53, respectively. Exact classification of the hernia is therefore only possible intraoperatively. Precise knowledge of anatomy is indispensable for a successful laparoscopic hernia operation, especially concerning the course of the epigastric vessels, the large pelvic vessels, the corona mortis, and the inguinal nerves (Figure 8.1).

Transabdominal pre-peritoneal approach 55

with a blunt, conical tip and a radially expanding effect. Endo-Overholt and endo-scissors have a connection for monopolar electrocoagulation. In the case of large hernia sac, dissection is carried out using two Endo-Overholts. A 30-degree angled laparoscope is used. We recommend using Reddick–Olsen atraumatic forceps to push an umbrella-like mesh through the 12-mm trocar. The handles of the instruments mentioned above should not be lockable; the dissection forceps (Kelly) is the only exception, where a lockable handle is useful. The peritoneum is closed with a running stitch (Lahodny-Suture, Ethicon, PDS 3/0) with clip fixation. An endoscopic needle-holder and a clip-application forceps are necessary for this suture.

Figure 8.1 Complete dissection of the pelvic floor. All important anatomical structures are visible.

Preoperative testing In patients who are old (⬎60 years) or who have an increased cardiopulmonary risk, an electrocardiogram (ECG) and thoracic X-ray are essential. Additionally, if necessary, blood and clotting tests should be run. Patients should be asked whether they have taken aspirin and, if necessary, platelet function assay (PFA) values should be determined. Some authors recommend evaluation of the colon for pathology to eliminate a symptomatic hernia, especially in older patients. If the patient’s history is uneventful, however, this is not considered a routine examination. A preoperative urethral catheter is not necessary. It is usually sufficient to request that the patient empties their bladder before being transported to the operating theater. Should a full bladder be found during laparoscopy, however, a suprapubic urinary catheter can be laid via percutaneous puncture.

OPERATIVE ROOM SET-UP The patient is supine and flat on the operating table. After setting up the pneumoperitoneum, the patient is placed into the Trendelenburg position and turned at an angle of about 15 degrees towards the surgeon, so that the surgeon can approach the inguinal region without being hindered by intestinal loops. The patient’s arms are at his or her side, so that the operator can change sides easily in cases of a bilateral hernia. The surgeon stands on the side opposite the hernia; the camera operator is positioned on the ipsilateral side of the hernia. The monitor is placed at the foot of the patient. The assisting nurse with the instruments is always to the left of the patient, between the surgeon and the camera operator. The anesthetist looks after the patient as usual, from the head of the operating table, so that each member of the team can follow the progress of the operation on the monitor at any time (Figures 8.2–8.4). MCL

MCL

INSTRUMENTATION The following instruments are needed for a laparoscopic hernioplasty:

• • • •

Veress needle for creating a pneumoperitoneum; 10-mm trocar at the navel for insertion of the optics; 5-mm trocar in the left mid-abdomen for insertion of the Endo-grasper (Overholt); 12-mm trocar in the right mid-abdomen for the hernia stapler, the mesh and the Metzenbaum endo-scissors. A dissection swab (forceps according to Kelly) and/or a gauze for hemostasis can also be inserted.

All the trocars and operating instruments are reusable instruments. It is important that the trocars do not cut through the tissues; our preference is to use trocars

Assistant (camera)

Surgeon 10 mm

5 mm

12 mm Scrub nurse

Monitor

Figure 8.2 Localization of ports for TAPP repair of left-sided inguinal hernia. MCL, medioclavicular line.


MCL

MCL

Assistant (camera)

Surgeon 12 mm

10 mm 5 mm Scrub nurse

Monitor

Figure 8.3 Localization of ports for TAPP repair of right-sided inguinal hernia. MCL, medioclavicular line.

MCL

MCL

Assistant changes position for repair of contralateral side

Surgeon changes position for repair of contralateral side

Assistant (camera)

Surgeon 12 mm

10 mm 5 mm Scrub nurse

Monitor

Figure 8.4 Localization of ports for TAPP repair of bilateral inguinal hernias. MCL, medioclavicular line.

OPERATIVE TECHNIQUE The operation begins with the creation of the pneumoperitoneum and insertion of the camera trocar. The pneumoperitoneum can be installed with the help of the Veress needle or after open insertion of the optical trocar (Hasson technique). If a patient has had no previous

abdominal surgery, then we prefer the Veress needle technique. Initially, a longitudinal skin incision about 1 cm long is made along the upper border of the umbilicus. The abdominal layers are held under maximum tension (the umbilical area is lifted with two Backhaus clamps in the corners of the incision), and the Veress needle is inserted into the abdominal space under careful monitoring, as described by Semm.13 At the beginning of insufflation, the intra-abdominal pressure and the rate of gas flow must be monitored carefully. Pressure must initially be 0 mmHg and the gas flow must be 2–3 liters CO2/min. If the pressure is initially too high or the gas flow too low, then the position of the needle must be checked and/or an open approach into the abdominal space should be chosen. If the patient has an umbilical hernia, we make a 2–3-cm-long horizontal incision at the upper border of the umbilicus, dissect the hernial sac, and then use the Veress needle or the optical trocar to gain entry to the abdominal space through the hernial gap (fascial closure in these patients follows at the end of the operation in the same way as for umbilical hernias). If intra-abdominal pressure reaches 12 mmHg and the aspiration test is regular, then the optical trocar is inserted. The abdominal wall should again be held under maximum tension. The optical trocar is then inserted into the abdominal cavity in the direction of the center of the navel with slightly rotating movements, the most effective way to avoid slipping on the fascia. By using this technique, the danger of inadvertent injury to the small or large intestines or large vessels is kept at a negligible minimum. If intra-abdominal adhesions are expected, especially after prior median laparotomy, then the open technique according to Hasson should be chosen to insert the optical trocar. After the somewhat larger skin incision has been made, the linea alba is dissected and opened up far enough between two Kocher clamps to allow insertion of a finger. After opening the peritoneum, the finger is inserted into the abdominal space to check for and/or eliminate possible adhesions. The optical trocar can then be inserted and the pneumoperitoneum created. Now the further steps of the operation are under direct view. In cases of a bilateral hernia, both the working trocars, 5 mm left, 12 mm right, are introduced into the midclavicular line at the level of the umbilicus. If the hernia is unilateral, then we recommend inserting the ipsilateral working trocar about 1–2 cm above the navel area and/or the contralateral working trocar about 1–3 cm below the navel region (Figures 8.2–8.4). In this way, collisions with the optical trocar can be avoided. In order to dissect the inguinal region, the surgeon uses the right hand to operate the Metzenbaum Endo-scissors, which are connected to monopolar electrocautery. The left hand operates the Endo-Overholt. The transabdominal technique allows immediate assessment of the hernia situation. The operative procedure is


Figure 8.5 Generous arcuate incision of the peritoneum about 3–4 cm above the transverse arcade and the inner inguinal ring, beginning at the anterior superior iliac spine and leading to the medial umbilical fold.

initially not dependent on the type of hernia because the aim is to completely dissect the inguinal region and all possible hernial orifices. Adhesions between the omentum or intestine within the inguinal region or the hernial sac (e.g. sliding sigmoid hernia) are not detached but removed en bloc with the peritoneum from the abdominal wall or from the hernial orifices. The operation then begins by determining the site of the anterior superior iliac spine using the bimanual method – the palpating finger of the left hand on the outside, the tip of the scissors on the inside. Regardless of the type and size of the hernial orifice, starting at this point a generous curving incision of the peritoneum is performed, well above the internal inguinal ring and above the rear wall of the inguinal canal as far as the median umbilical ligament (Figure 8.5). It is usually not necessary to divide this ligament, even in the case of a prominent ligament, i.e. when this structure projects far into the abdominal space or has a large component of adipose tissue, nor if the hernial sac is found to be located very medially. Division of this ligament can lead to unnecessary bleeding from umbilical vessels that remain patent. If the peritoneal incision needs to be extended, then this is carried out parallel to the ligament in the cranial direction. The peritoneal and/or subperitoneal small blood vessels are coagulated immediately with monopolar current, so that the site is always absolutely free of blood and has a yellowish-pink color. Dissection continues strictly in the mostly avascular, cobweb-like zone, whereby the procedure is mainly blunt, and the peritoneum with its surrounding pre-peritoneal fatty tissue can be pushed away from the fascia transversalis and the rectus muscle (Figure 8.6). The few blood vessels that may be encountered are coagulated.

Figure 8.6 Partly blunt, partly sharp dissection in the mostly avascular, cobweb-like tissue layer between the peritoneum and the abdominal wall.

Figure 8.7 In very obese patients, early preparation of the anatomical landmarks (e.g. epigastric blood vessels, symphysis) is very important. Dissection then follows these landmarks strictly, which have to be prepared absolutely free of fatty tissue.

During this phase, early identification of some anatomical structures (landmarks), including the epigastric vessels, symphysis and Cooper ligament, and iliopubic tract, is important, especially in obese patients or in unclear hernia situations (Figure 8.7). Only when these structures have been identified properly can dissection continue, following the structures in the direction of the hernial orifice/ hernial sac. Special attention must be paid to dissection underneath the iliopubic tract, in order to avoid injury to nerves (N. cutaneus femoris lateralis, N. genitofemoralis) or vessels (Figure 8.8). Clumsy and obscure use of electrocoagulation and placement of clips are strictly prohibited. Any bleeding that occurs must be controlled immediately to keep the site clearly visible and to avoid increased light absorption, which would cause insufficient lighting


Figure 8.8 Avoiding rough dissection in the lateral caudal compartment, below the iliopubic tract and lateral to the testicular blood vessels, endangering the inguinal nerves, which may have a very variable course.

Figure 8.9 Dissection of a direct hernia in a case of bilateral hernias, where the opposite mesh is already in place. In order to avoid the formation of seroma, generous use of electrocoagulation in hemostasis is recommended.

of the operative field. Control of any bleeding can be carried out with the aid of a dissection swab in the right hand or with a small gauze that is inserted easily via the 12-mm trocar. The electrocoagulator is then connected to the Endo-Overholt in the left hand, allowing accurate coagulation. In most cases of direct herniation, the lipomatous hernial content will be dissected from the extended transversalis fascia and removed from the hernial orifice during dissection of the Hesselbach triangle, i.e. the level between epigastric vessels, the transversus arcade, and the ligamentum inguinale/tractus iliopubicus (Figure 8.9). This dissection is almost completely blunt. Careful hemostasis is important to ensure that the part of the fascia transversalis that forms the hernial sac is totally free of even the

Figure 8.10 Dissection of the medial compartment has to be carried beyond the middle of the symphysis so that a suprasymphytic defect, especially in recurrent hernias, is not missed.

slightest points of bleeding. In this way, the formation of extensive postoperative sero-hematoma can be largely avoided. Furthermore, two basic principles are to be taken into account when dissecting the medial compartment: 1 Dissection has to reach past the middle of the symphysis to the opposite side in order to identify a suprasymphytic hernial orifice (Figure 8.10), not uncommon in recurrent hernias, and also to create a large enough space for wrinkle-free placement of the mesh. Usually, this preparation is simple and carries no risk of injury to the bladder wall. Problems may be expected, however, in cases of previous operations in this area (e.g. prostate resection). Due to the significant risk of bladder injury, operations on such patients should be performed only by very experienced laparoscopic surgeons, otherwise a conventional anterior approach should be selected from the start. 2 In a lateral direction, the medial compartment should be dissected as far as the iliac vessels, in order to eliminate the possibility of a femoral hernia. Preparation should be carried out very carefully to avoid injury not only to the iliac vessels but also to the corona mortis, which is found in about 20–30 per cent of patients (Figure 8.11). Dissection of the lateral compartment is significantly more difficult, especially in patients with a large amount of adipose tissues with a large indirect hernial sac and in patients with severe scar contractions between hernial sac and cremaster muscle. These problems are not uncommon, especially in recurrent hernias after previous conventional operation. A basic consideration in an indirect hernia is that the hernia sac should be located cranially and laterally to the spermatic cord, whereas the vas deferens should be most caudal, stretching over the iliac vessels in a medial direction, while the testicular vessels can


Figure 8.11 During medial dissection, the iliac vein has to be prepared in order to recognize femoral defects. Care: corona mortis! Figure 8.13 In case of a tangled situation around the inner inguinal ring because of fatty tissue, we first prepare the testicular blood vessels, caudal and lateral, and then dissect in a cranial and medial direction.

Figure 8.12 Tip of the hernia sac clearly visible in front of the left Endo-Overholt. Strong adhesions to the cremasteric bundle (in front of the right Endo-Overholt) can be removed after careful electrocoagulation.

be followed in a lateral direction. Detachment of the hernial sac from the internal inguinal ring in the region of its upper circumference can therefore be carried out relatively quickly, as there is usually no danger of injury to the spermatic cord (Figure 8.12). If an accompanying lipoma of the spermatic cord is present, this can usually be mobilized out of the inguinal canal relatively easily; sometimes, only then is it possible to make an approach to the hernial sac. Dissection is mainly blunt, adhering strictly to the hernial sac with careful hemostasis. If there are irremovable adhesions between the hernial sac and the cremaster tube or spermatic cords, then these are electrodissected

carefully and pushed aside easily. If the hernial sac is very long, it may need a strong tug with the left hand holding the Endo-Overholt to remove the hernial sac from its bed in the inguinal canal. To prevent the hernial sac from slipping back into the inguinal canal, e.g. when adjusting the Endo-Overholt, we recommend dissection with two Endo-Overholts following the rope-ladder principle. It is important to identify the testicular vessels as early as possible during dissection. This is usually done easily in the region of the base of the hernial sac as far as possible laterally and dorsal-caudally (Figure 8.13). Further dissection is carried out parallel to the testicular vessels in a medial-ventral direction to the angle between iliopubic tract and epigastric vessels. It can sometimes be helpful to create a dorsocaudal window between hernial sac and spermatic cord, especially in the case of a scrotal hernia. If complete removal of a hernial sac may seem too difficult regarding risk of injury to the spermatic cord, then the hernial sac can be severed. If the hernial sac stays in situ, however, the risk of postoperative hydrocele may be higher. Our experience in more than 450 scrotal hernias shows that the hernial sac can almost always be removed completely without risk of injury to the testicular vessels or extensive postoperative hematoma, as long as the following principles are observed:14 early identification of the testicular vessels laterally and caudally of the hernial sac, dissecting from caudal-lateral to ventral-medial, careful hemostasis, strict dissection while the hernial sac is held under tension, and severing stronger adhesions with the aid of electrocoagulation. Once the point of the top of


Figure 8.14 Partly blunt, partly sharp removal of the hernia sac towards the abdomen while performing meticulous hemostasis of the spermatic structures (parietalization).

the hernial sac has been reached, the rest of the procedure is simple (Figure 8.14). Partly blunt, partly sharp (electrocoagulation) dissection is now carried out in the direction of the abdominal cavity, and the hernial sac is detached completely from the spermatic cords. This procedure is known as parietalization. Parietalization (i.e. detachment of the hernial/peritoneal sac from the retroperitoneum and/or from the spermatic fascia covering the retroperitoneum and the spermatic cord) is performed in the direction of the head, as far as the mid-psoas muscle, so that there is no longer any contact between the peritoneum and the vas deferens medially and between the testicular vessels and the peritoneum laterally. Manipulation of the peritoneum should no longer lead to changes in the position of the spermatic cords. Extensive parietalization is especially important when an unslitted mesh is to be inserted. This is the only way to ensure that when the peritoneum is closed, any adhesions that may be left behind do not displace the mesh into a position that could lead to a recurrence. If extensive parietalization is not possible, which does happen very rarely (sometimes in a patient with a recurrence after TAPP), then a slitted mesh can be introduced, causing the dorsal portion of the mesh to take up a position behind the spermatic cords. After this dissection, the entire myopectineal orifice is free of peritoneum and fatty tissue, thereby allowing complete identification of the epigastric vessels, the internal inguinal ring, Hesselbach’s triangle, Cooper’s ligament, the iliopubic tracts, the testicular vessel bundle, and the vas deferens (Figure 8.15). A 10 ⫻ 15-cm polypropylene mesh can now be inserted. The mesh is folded like an umbrella over the Reddick–Olson Endo-forceps and pushed through the 12-mm working trocar into the inguinal region, where, due to the memory effect, it can be spread out easily. The mesh should be positioned with-

Figure 8.15 End of dissection: the peritoneal sac is removed beyond the middle of the psoas muscle. All anatomic structures are recognizable and freed of fatty tissue.

Figure 8.16 A 10 ⫻15-cm polypropylene mesh is placed without folds. All potential hernia openings are overlapped by at least 3 cm.

out wrinkles, overlapping all possible hernial orifices by at least 3 cm (Figure 8.16). Using such a large mesh means that fixation is necessary only to facilitate positioning (e.g. in very shallow curved inguinal areas or to avoid mesh dislocation in the immediate perioperative phase). Fixation is carried out with a few clips or staples. We recommend using two clips in both the areas of the symphysis and/or Cooper’s ligament, two clips to fix the upper border of the mesh to the rectus muscle medial to the epigastric vessels, and two clips lateral to the epigastric vessels into the fascia transversalis (Figure 8.17). Before the clips are fixed at the ligament of Cooper, a possible corona mortis and/or the iliac vessels should be identified. After the iliopubic tract is identified, the lateral


Clip position in TAPP technique ⫽ Clip position ⫽ Forbidden area

Figure 8.17 Presentation of clip positions and the endangered regions: triangle of pain and triangle of doom. (a) Medial defect; (b) lateral defect; (c) femoral defect.

clips are placed, keeping a minimum cranial distance of about 2–3 cm. If these basic guidelines are followed strictly, injury to the large vessels or the inguinal nerves can be avoided completely. We almost always use an unslitted mesh for the following two reasons:

• •

The slit can cause a recurrence because it weakens the stability of the mesh. In contrast to the keyhole technique, there is no need for circular dissection of the spermatic cord with the risk of damaging some small vessels, and there is also no close contact between the spermatic cord and the mesh, thus eliminating the possibility of it becoming involved in scar tissue.

Before the peritoneum is closed, it is lifted and the extent of parietalization is checked. The covering peritoneal fold should be at least 1–2 cm above the upper end of the mesh (Figure 8.18). Finally, the peritoneal incision is closed carefully with resorbable sutures (PDS, Lahodny). To facilitate tension-free closure, the intraabdominal pressure should be reduced to 6–8 mmHg. When using this technique, a tight and secure seal is possible even with scarred peritoneum, a task that is occasionally difficult when clips are used. The suture closure is technically more difficult, however, and needs practice. After carrying out five to ten operations, however, even a relative beginner should be able to perform it efficiently. Finally, the working trocars are removed under direct visualization. Even though blunt trocars are used, bleeding from the epigastric vessels does occur on occasion and must be recognized and controlled. In such cases, hemostasis is simple to carry out with electrocoagulation and can be performed with an Endo-Overholt introduced via the contralateral trocar.

Figure 8.18 The peritoneal fold should be 1–2 cm proximal to the caudal edge of the mesh.

Suturing of the lateral fascial openings is not necessary when blunt, radially expanding trocars are used, because the rectus muscle covers these openings. The fascial opening for the camera trocar should always be closed with suture to avoid the occurrence of a late postoperative trocar hernia.

SPECIAL REMARKS A drain is generally not necessary, but in the case of large scrotal hernias, a retroperitoneal closed suction drain ought to be used, placed between the mesh and the abdominal wall.


Bilateral hernia The identical standard technique is used separately for each side, with implantation of a 10 ⫻ 15-cm polypropylene mesh on each side.15

Recurrent hernia after conventional operation An essential advantage of the laparoscopic technique in recurrent hernias after anterior conventional repair is that dissection can be shifted into the pre-peritoneal space, which is mostly free of scar tissue, allowing the use of an almost standard primary hernia technique. The results (operating time, morbidity, return-to-work times, recurrence rate) are consequently not significantly different to those of a primary hernia operation (Table 8.1). The only exception is the situation after previous hernioplasty according to Lotheisen. In this case, significant scarring can be expected at Cooper’s ligament, and it is difficult to operate laparoscopically in this area. This situation can be overcome by choosing a peritoneal incision caudal to the Cooper ligament. After the usual dissection of the peritoneum, which has been described above, in an area somewhat medial to the Cooper ligament a whetstone-like incision is made around the ligament itself at the peritoneal level. This method allows renewed access to the scar-free pre-peritoneal space caudally, where further dissection can now take place undisturbed. Although this leaves a small, scarred peritoneal section on the Cooper’s ligament, the polypropylene mesh can nevertheless be anchored safely. In the area of the internal inguinal ring, it is not uncommon to find scar formation 1–2 mm thick surrounding both the hernia sac and the spermatic cord. Once this cuff-like scarred ring of tissue is cut with electrocautery in the neighborhood of the epigastric vessels (which may involve the cremasteric muscle), standard dissection can continue. It must be taken into consideration that the previous operation may have resulted in an atypical localization of the spermatic cord. The recurrent hernia can occasionally develop between the vas deferens and the testicular

vessels, so that the former is displaced medially and the latter are displaced in a very lateral direction. Very rarely, the testicular vessels may be looped around the spermatic cord in a medial and ventral direction. Whereas these problems occur mostly in indirect recurrent hernias, operation of a direct recurrent hernia is much easier because, as a rule, there are no structures nearby that may be injured. It must be taken into account, however, that the tranversalis fascia should not be perforated during dissection, as one would then enter into the inguinal canal and possibly damage the testicular vessels.

Recurrent hernia after pre-peritoneal patch hernioplasty Laparoscopic operation of a recurrent hernia after pre-peritoneal hernioplasty is technically possible, but operation time will be significantly longer, and there will be a risk of higher morbidity.16 However, the time needed to regain physical activity is the same as for the standard technique in primary hernias. Operation of a recurrent hernia after pre-peritoneal hernioplasty is extremely difficult and should be carried out only by very experienced laparoscopic hernia surgeons. As a rule, extensive scarring can be found between the abdominal layer and mesh, and/or mesh and peritoneum, and can only be dissected sharply. Dissection begins in the scar-free areas, with early identification of the landmarks (epigastric vessels, symphysis, Cooper’s ligament). Medial dissection should adhere strictly to the rectus muscle and/or the fascia transversalis in order to avoid damage to the bladder. In 80 per cent of cases, we found a dissection layer between abdominal wall and mesh, and in about 20 per cent of cases between peritoneum and mesh. As noted earlier, reoperation upon a direct hernia is significantly easier than on an indirect hernia. Operation of an indirect hernia is extremely complicated, but once the scar areas have been overcome and direct access gained to the hernial sac, the rest of the operation is not too different to that of a primary hernia. The mesh is usually left in place; parietalization, however, is possible in only the rarest of cases. As a rule, a slitted mesh

Table 8.1 Operative results in 8050 consecutive laparoscopic hernia repairs

Unilateral primary hernia (n ⫽ 4222) Bilateral primary hernia repair (n ⫽ 1341)* Recurrent hernia (n ⫽ 1146) Scrotal hernia (n ⫽ 440) *Results related to 2682 repaired hernias.

Median operation time (min)

Morbidity rate (%)

Reoperation rate (%)

Recurrence rate (%)

Median return to work (days)

47 35 45 65

3.0 2.2 4.5 4.8

0.4 0.5 1.0 1.1

0.8 0.6 1.1 2.7

14 15 21 19


will have to be inserted. In such cases, we do, however, secure the slit with a second, smaller mesh using the so-called double-buttress technique. In case of a direct hernia and stable conditions in the area of the lateral compartment, lateral dissection is not necessary. It suffices to implant a piece of mesh that is appropriately sized so that it overlaps the hernial defect by at least 3 cm and can be anchored to the original mesh, which is located laterally.

simple. Sometimes external pressure may be required. The hernial content can now be reliably assessed for viability. The further procedure again correlates to the standard technique. If the intestine shows signs of gangrene, then a primary mesh implant is not recommended due to the risk of infection. Thorough rinsing of the inguinal region and the insertion of a drain is recommended. Defect reconstruction, however, should not be performed; an option here is open repair with sutures.

Scrotal hernia POSTOPERATIVE MANAGEMENT In comparison to the TEP technique, the advantage of the TAPP technique on scrotal hernia is the immediate identification of adhesions of the intestinal loops within the hernial sac, so that trauma to the wall of the bowel (e.g. by electrocoagulation on the hernia sac) can be avoided completely. The operation is performed strictly according to the standard technique, as mentioned above, almost exclusively using the two Endo-Overholt technique and the rope-ladder principle. Especially important in this kind of hernia is the fat-free dissection of the internal inguinal ring, the detachment of all lipomatous masses from the inguinal canal, the spermatic cord and the hernial sac, early preparation of testicular vessels, and carefully controlled hemostasis.14 In the case of a very large internal inguinal ring, a 10 ⫻ 15-cm standard mesh may be too small because it is not possible to overlap the upper border of the hernial ring by the required minimum 3 cm. Therefore, in these patients we prefer to use a 15 ⫻ 15-cm mesh.

Irreducible/incarcerated inguinal hernia Irreducible and especially acute incarcerated hernias present a good indication for the laparoscopic technique.17 An exception, however, is the very large, chronically irreducible scrotal hernia, as the relationship between operative effort and result are out of proportion. Although an open approach is also difficult in such patients, the few cases that do come into question should opt for this technique. In contrast, the laparoscopic technique offers advantages in acute incarcerated hernias. It may be possible to avoid resection of the intestine, as there is more time available to observe how the damaged intestinal wall recovers. If a resection does prove necessary, then the required laparotomy can be kept small, or it may even be possible for the whole operation to be carried out via laparoscopy. The operation begins in the standard way, with the aim of completely exposing the hernial ring in the preperitoneal space. Reduction of the hernial contents via traction should be avoided. If the exposed hernial ring is split in a ventral-cranial direction, then reduction is

On the evening after the operation, the patient is allowed to get up and use the toilet. The patient may drink freely and may have a light meal if desired. A diclofenac 100 mg suppository is provided as needed. A one-night stay in the hospital is obligatory for insurance reasons in Germany, where the authors of this chapter work. On the following morning, we recommend that the patient moves around freely and begins light stretching exercises for the inguinal region. The patient should decide when to be discharged. As a rule, patients leave the hospital between the second and fourth postoperative day. Before discharge, sonography of both inguinal regions and scrotum is performed routinely. Sutures are removed (as an outpatient) on the sixth postoperative day. From the eighth to the tenth postoperative day, we recommend return to work and resumption of normal physical activity. All patients are included in a follow-up program and requested to attend a specific hernia consultation four weeks and one, three and five years postoperatively.

CONCLUSION Laparoscopic hernia repair is a well-standardized repair technique, suitable for all types of inguinal and femoral hernias. The procedure combines highest patient comfort with low morbidity and recurrence rates. However, fundamental training in laparoscopic surgery is an important prerequisite for good results. When laparoscopic procedures are established in a surgical department, this technique can be performed on a routine basis, even as a teaching operation.

REFERENCES 1

Rives J, Nicaise H, Lardennois B. A propos du traitment chirurgical des hernies de l’aine. Orientation nouvelle et perspectives thérapeutiques. Ann Med Reims 1965; 2: 193–200.

64 Laparoscopic inguinal/femoral hernioplasty 2 3

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6 7 8 9 10

Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in repairs of hernias of the groin. Surg Clin N Am 1984; 64: 269–85. Ugahary F, Simmermacher RKJ. Groin hernia repair via a gridiron incision: an alternative technique for preperitoneal mesh insertion. Hernia 1998; 2: 123–5. Arregui MD, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair of inguinal hernia using a preperitoneal approach: a preliminary report. Surg Laparosc Endosc 1992; 2: 53–8. Bittner R, Leibl BJ, Kraft K, et al. Laparoscopic transperitoneal procedure for routine repair of groin hernia. Br J Surg 2002; 89: 1062–6. Felix EL, Michas C, McKnight RL. Laparoscopic repair of recurrent groin hernia. Surg Laparosc Endosc 1994; 4: 200–4. Nyhus LM. Individualization of hernia repair: a new era. Surgery 1993; 114: 1–2. Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in adults. Lancet 1994; 344: 375–9. Ingoldby CJH. Laparoscopic and conventional repair of groin disruption in sportsmen. Br J Surg 1997; 84: 213–15. EU Hernia Trialists Collaboration. Repair of groin hernia with synthetic mesh – meta-analysis of randomized controlled trials. Ann Surg 2002; 235: 322–32.

11

12

13

14 15

16

17

Heikkinen TJ, Haukipuro K, Hulkko A. A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in day-case unit. A randomized prospective study. Surg Endosc 1998; 12: 1199–203. Bittner R, Kraft B, Kuckuk B, et al. Ultrasound examination in laparoscopic/endoscopic hernia surgery. In: Fitzgibbons RJ, Jr, Greenburg AG, eds. Nyhus and Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2002: 95–102. Semm K. Operative Manual for Endoscopic Abdominal Surgery – Operative Pelviscopy – Operative Laparoscopy. Chicago: Year Book Medical Publishers, 1985. Leibl BJ, Bittner R, Schmedt CG. Scrotal hernias: a contraindication for an endoscopic procedure? Surg Endosc 2000; 14: 289–92. Schmedt CG, Däubler P, Leibl BJ, et al. Simultaneous bilateral laparoscopic inguinal hernia repair: an analysis of 1336 consecutive cases at a single center. Surg Endosc 2002; 16: 240–4. Leibl BJ, Schmedt CG, Kraft K, et al. Recurrence after endoscopic transperitoneal hernia repair (TAPP): causes, reparative techniques and results of the reoperation. J Am Coll Surg 2000; 190: 651–5. Leibl BJ, Schmedt CG, Kraft K, Bittner R. Laparoscopic transperitoneal hernia repair of incarcerated hernias: is it feasible? Surg Endosc 2001; 15: 1179–83.

9 Totally extraperitoneal approach ED FELIX

Principles Preoperative management

65 66

The surgical approach to inguinal hernia repair has undergone a slow evolution since Bassini introduced the first true anatomical repair over 100 years ago.1 Initially, surgeons were fixated on tissue to tissue repairs. Then, Lichtenstein and coworkers2 and Stoppa and colleagues3 demonstrated that tension-free reinforcement of the abdominal wall with mesh eliminates one of the major causes of recurrence, the intrinsic or acquired weakness of the groin; the emphasis of hernia repair then switched dramatically. Ten years later, laparoscopic surgeons took the tension-free repair one step further by introducing a repair that reinforced the groin, avoided missed hernias, and reduced postoperative recovery. Many early attempts at a laparoscopic approach, however, fell quite short of this lofty target. There seemed to be a wide variability in the results reported by surgeons. Many complications as well as early failures were reported. It quickly became apparent, however, that success with this approach was dependent upon the level of laparoscopic expertise of the surgeon and the ability of the surgeon to apply proper techniques to appropriate patients.4 At first, the majority of surgeons were limited to a single laparoscopic approach, the transabdominal pre-peritoneal (TAPP) approach, but soon the totally extraperitoneal (TEP) approach became a viable alternative. Arguments between laparoscopic surgeons on which approach was better were common, but now most surgeons realize that each approach works well when applied appropriately in the hands of an experienced laparoscopic surgeon.5 The purpose of this chapter is to describe an approach to the laparoscopic TEP repair of inguinal hernias that has resulted in a recurrence rate of less than one per cent in over 2000 repairs in our center. The indications and contraindications to the use of the approach, the operative

Postoperative management References

73 74

method, and the potential complications and their management will be described.

PRINCIPLES A surgeon must be experienced in conventional anterior approaches as well as both laparoscopic approaches (TAPP and TEP) in order to make a rational decision on which hernioplasty best fits an individual patient and hernia. The laparoscopic approach that is chosen depends upon the surgeon’s level of experience, the type of hernia present, and the patient’s past history. For most patients, I favor the TEP approach because it avoids entering the peritoneal cavity, it requires less operative time, and it has less potential for complications than the TAPP approach. There are, however, a few exceptions. The TAPP approach is preferred if the patient has an incarcerated hernia, because this approach allows for an accurate analysis of what is incarcerated and its viability, as well as safe and usually easy reduction of the contents of the hernia. When the hernia is incarcerated, balloon dissection of the extraperitoneal space may lead to a large tear in the peritoneum or injury to incarcerated omentum, bowel or bladder. The extraperitoneal approach and especially the use of a balloon dissector should be avoided if the hernia cannot be reduced after the induction of anesthesia. In female patients with abdominal pain, the etiology of the pain may be in question. When a surgeon needs to differentiate between pain secondary to a groin hernia and other possible causes, such as endometriosis, one should perform a diagnostic laparoscopy followed by a TAPP repair when indicated. For female patients where


the diagnosis is certain, a TEP technique is preferred. The presence of a Pfannenstiel incision is common in many female patients because of a previous cesarean section or pelvic surgery, but this should not interfere with the TEP dissection because a Pfannenstiel incision is really a midline fascial incision. Some previous operations, abdominal incisions, or treatments may preclude adequate or safe dissection of the extraperitoneal space. Previous pelvic irradiation or radical prostatectomy can prevent separation of the peritoneum from the abdominal wall. Balloon dissection of the extraperitoneal space may result in injury to the bladder or a large rent in the peritoneum. A lower-abdominal incision crossing the rectus sheath can obstruct the safe passage of the dissector. If the dissector is forced through the obstruction, the peritoneum will tear and an intraabdominal visceral injury may result. A transverse incision is not a contraindication to the use of the extraperitoneal approach, but if resistance is experienced when passing the dissector, then the procedure should be converted to a TAPP approach. A midline incision is usually not a problem when using the TEP approach. The dissector slides toward the pubis parallel to the incision. The peritoneum along the midline will separate from the abdominal wall when the balloon is inflated, or it can be dissected manually after the trocars are placed. If bilateral repairs are planned, however, then there is a small chance that a previous midline incision will prevent dissection of the opposite side. In this case, the surgeon may initiate the procedure as a TEP approach and convert to the TAPP approach when, or if, this becomes necessary. The laparoscopic approach is ideally suited for recurrent hernias. The surgeon’s view of the posterior wall is unobstructed and allows for complete identification of the site of recurrence and repair of the entire posterior floor. The decision of whether a TAPP or TEP approach should be employed is dependent upon the expertise of the surgeon. The dissection of the recurrent indirect sac can be difficult using the extraperitoneal technique and requires more skill than that of a primary repair. With experience, however, this difference in degree of difficulty disappears, and the surgeon should base the hernioplasty choice on other factors. The extraperitoneal dissection of large scrotal hernias is similar to that of recurrent hernias, in that the separation of the indirect sac can be quite difficult.6 To avoid problems, the surgeon should use the TAPP approach until he or she has adequate mastery of some of the special maneuvers required to deal with a long scrotal sac. The age of the patient may influence the type of hernioplasty chosen. In general, laparoscopic hernioplasty should be reserved for adults. In a few cases, the patient that is a minor by chronological age may be fully mature and have an adult-type hernia or even a recurrent hernia. Only then should the laparoscopic approach be

elected in children. At the other extreme are patients over 70 years of age. Some have suggested that laparoscopic repair should be limited to working younger adults. It is our experience, however, that patients of all ages benefit from the laparoscopic approach, especially regarding the rapid recovery and return to normal activity. We recommend that patients who are not candidates for general anesthesia should have an open hernioplasty under a local anesthetic. Although several centers have reported success using local and regional anesthesia for extraperitoneal repairs,7 it has been our experience that some patients will become anxious if carbon dioxide enters the peritoneal cavity, necessitating conversion to a general anesthetic. We would reserve laparoscopic repair for patients who are candidates for general anesthesia, even if the case is to be performed using a local or regional technique. An absolute contraindication to laparoscopic hernioplasty is the presence of infection. Neither the TAPP nor the TEP approach should be used in the face of local or systemic infection because of the risk of infecting the mesh.

PREOPERATIVE MANAGEMENT Anatomy and pathology Understanding the anatomy of the groin has never been easy, but it has always been important to the performance of a successful inguinal hernia repair. Because the posterior anatomy of the groin is being viewed in an unfamiliar way, it can be even more difficult to understand it. Consequently, without a complete knowledge of the normal and pathological anatomical structures of the posterior groin, any laparoscopic posterior repair will be doomed to failure. (See Chapter 6 for an overview of the anatomy/physiology of the inguinal region.) The easiest way to learn the normal anatomy of the posterior wall is to first view it through a transabdominal route (Figure 9.1). Once the surgeon understands the normal and pathological aspects of the posterior anatomy via a TAPP approach, then dissection of the extraperitoneal space and exposing the anatomy of the posterior space via a TEP approach can be undertaken. Because the anatomical structures are not obvious until the dissection is completed, it is key that the surgeon understands what is being dissected in order to prevent becoming lost or confused. Serious complications to major vessels and nerves can occur, especially when there is a large indirect or femoral hernia. To proceed without injuring normal structures, the surgeon must identify certain landmarks. Once the extraperitoneal space is developed, identification of the pubis will allow proper orientation of the other structures. The next landmark is the inferior epigastric vessels,

Totally extraperitoneal approach 67

(a) (a)

(b) (b)

Figure 9.1 (a) Indirect hernia viewed via the intraperitoneal approach. (b) Peritoneum opened. IND, indirect hernia; INF, inferior epigastric vessels; IPT, iliopubic tract; TV, testicular vessels; VAS, vas deferens.

(c)

Figure 9.3 Femoral hernia.

Figure 9.2 Extraperitoneal view of the groin. C, cord; DIR, direct hernia; IL, iliac vessels; IND, indirect hernia; INF, inferior epigastric vessels.

which separate the indirect from the direct hernia and lead the surgeon to the major vessels of the pelvis (Figure 9.2). Sometimes, a large femoral hernia can obscure the major vessels, but the surgeon can become reoriented by locating the inferior epigastric vessels (Figure 9.3). Additionally, these vertical structures mark the location of where the lateral dissection of the indirect hernia begins. The final important landmark is the iliopubic tract (Figure 9.4). The identification of this is essential to avoid injury to several cutaneous nerves and dissection of any cord lipoma that may be present.


Figure 9.5 Balloon dissector and Hasson trocar. Figure 9.4 Recognizing the iliopubic tract. CL, Cooper’s ligament; DIR, direct hernia; INF, inferior epigastric vessels; IPT, iliopubic tract.

Preoperative testing Inguinal hernia repair does not require extensive preoperative testing, but it does require determination of whether the patient is a candidate for general anesthesia. If general anesthesia is thought to be safe, then the surgeon’s next step is to make sure that there are no other contraindications to laparoscopic hernia repair. If there are none, then the most appropriate laparoscopic approach can be selected, as outlined earlier. Before proceeding to the operating room, however, a complete examination of both groins by the operating surgeon is essential. If the surgeon actively looks for a possible hernia on the contralateral side, then we have shown in a prospective study that very few contralateral hernias will be missed.8 It is not necessary to expose the opposite side to look for a second hernia during a TEP repair if the surgeon has performed a proper preoperative examination. In addition, the surgeon should determine whether the hernia is reducible. If it is incarcerated, then a TAPP approach should be chosen. This avoids complications caused by the blind dissection of the incarcerated hernia sac. The TAPP approach also allows the surgeon’s ability to evaluate the viability of the incarcerated contents.

Instrumentation TEP hernioplasty does not require many specialized instruments. A balloon dissector and balloon Hasson trocar (Figure 9.5) make the extraperitoneal dissection easier and simpler for most surgeons, but they are not mandatory. We use a straight 10-mm endoscope, but some surgeons prefer an angled scope. Unipolar scissors for dissection and a bipolar coagulator to control bleeding are useful. At least two atraumatic graspers are needed to perform the dissection, and endoloop sutures

to ligate an indirect sac or a peritoneal tear are suggested. Rarely, a suction irrigator will be needed to clear blood from the extraperitoneal space and decrease groin and perineal ecchymosis postoperatively. A full laparotomy set-up is not required, but a Mayo or 6–8 inch curved clamp is needed to dissect the fat and muscle at the umbilicus. A number 11 scalpel blade is used to incise the fascia, and two ‘S’ retractors facilitate the dissection and retraction of the fascia and muscle. Two 5-mm trocars are used for the placement of the instruments that are used in the dissection of the pre-peritoneal space. Polypropylene mesh is the mainstay of the laparoscopic repair. Usually, a 15 ⫻ 15-cm mesh is used and trimmed to fit the posterior wall. The mesh is anchored to the abdominal wall with 5-mm tacks supplied in a multifire gun. Recently, however, we have used a preformed mesh that does not require fixation of any kind. The recurrence rate remains the same, but the risk of nerve injury is lowered. In a small number of cases in which we feel fixation is required, such as multi-recurrent hernias or where the mesh will not lay flat against the wall, we use a regular mesh and cut it to fit the space.

Operative room set-up The room set-up is simple, requiring one surgeon, a nurse and a video monitor. The patient is positioned with both arms tucked at his or her side and with a slight head-down position. The surgeon stands on the side of the patient opposite the hernia and the scrub nurse/assistant stands on the opposite side. The monitor is placed at the foot of the operative table and the Mayo stand is over the legs. The insufflator should also be in plain view of the surgeon. A single light is positioned directly over the periumbilical incision to help with the initial exposure of the fascial layers. Very few instruments are required for extraperitoneal dissection and hernia repair. They should be set up on the


Mayo stand so that either the surgeon or the nurse can reach them readily. If a preformed mesh is used, then both left- and right-sided meshes must be kept in the room.

the procedure should be converted to a TAPP approach. When the pubis is palpated with the dissector, the balloon is inflated. The operator views the progress of the dissection directly via the laparoscope in the dissector. After completing the balloon dissection, the balloon is removed and replaced with a specialized Hasson trocar that seals the extraperitoneal space. The dissected space is then insufflated with carbon dioxide up to 12 mmHg. We use lower pressures (8–10 mmHg) if the patient is thin or elderly. The anterior and posterior rectus sheaths create a tunnel that opens into the dissected extraperitoneal space. When the tunnel is short, it does not interfere with exposure or placement of the other midline trocars; if it is very long, the available space will be limited and the exposure will be poor. In this case, the sheath should be cut back with laparoscopic scissors. This maneuver will open up the exposure, greatly facilitating the rest of the repair. Three trocars are placed in the midline: a 10-mm Hasson just below the umbilicus for the camera, a 5-mm trocar just above the pubis, and a second 5-mm trocar between these two trocars in the midline. The second trocar is positioned as close as possible to the subumbilical camera trocar in order to leave space between the lowest trocar and the pubis. The inferior trocar is positioned approximately three fingers below the middle trocar to prevent ‘sword fighting’ of the instruments and still allowing the lowest trocar to be above the level of the mesh. The surgeon must watch the entry of each trocar into the extraperitoneal space in order to prevent the laceration of a small branch of the inferior epigastric vessels or penetration into the peritoneal cavity. We anchor each trocar to the skin with a specialized adhesive strip to prevent them from slipping in and out of the abdominal wall during instrument manipulation. The exposure of Cooper’s ligament begins with the dissection of the posterior aspect of the abdominal wall by the gentle sweeping off of any tissue remaining on the pubis. If a direct hernia is present (Figure 9.6), it is completely reduced at this point. This can be accomplished

Operative technique We begin the procedure with a small transverse skin incision 2.5 cm lateral to and just below the umbilicus on the side of the hernia (or the dominant hernia if bilateral hernias are present). By avoiding the midline of the fascia, we avoid entering the peritoneal cavity where the anterior and posterior rectus sheaths merge. We choose the side of the dominant hernia because we use a balloon dissector that will dissect more completely on the side that it is placed. This makes the rest of the dissection simpler. We identify the anterior rectus sheath by carefully spreading the subcutaneous fat with a Mayo clamp. The small vessels in the fat should not be torn at this point, because bleeding in the tiny hole will make identification of the anterior rectus sheath difficult. Two ‘S’ retractors are placed in the wound and used to expose the white fibers of the fascia. An 11 blade is used to incise the fascia exposing the rectus muscle. One of the ‘S’ retractors is placed under the muscle like a shoehorn; the muscle is elevated, thereby allowing visualization of the posterior sheath. A finger is used to dilate the space in preparation for the placement of a balloon dissector. Because the posterior rectus sheath usually ends at the line of Douglas, an instrument such as the balloon dissector can be passed on top of the sheath, allowing it to automatically fall into the extraperitoneal space. The dissector is placed behind the rectus muscle with its tip on the posterior rectus sheath. Aiming it slightly upward, we gently slide on top of the sheath toward the pubis until the pubic bone is palpated. If resistance is encountered, then the dissector must not be forced into the space because it will tear the peritoneum. A second attempt to pass the instrument can be tried after dilating the space with a finger, but if that fails

(a)

(b)

Figure 9.6 Reducing the direct hernia. INF, inferior epigastric vessels.


Figure 9.7 Lipoma of the cord.

with gentle traction on the peritoneal attachments to the defect. The peritoneum usually peels away from the transversalis fascia, allowing it to balloon into the direct defect. When the direct hernia is not reduced by these maneuvers, we incise the fascial defect on the superior aspect to release the incarcerated hernia contents. The direct sac should not be ligated because the bladder may make up the medial aspect of the sac. In this situation, ligation of this sac could result in an injury to the bladder. After dissection of the direct floor, the femoral area must be examined. The iliac vein will be visible just lateral to Cooper’s ligament. If it is not visible, then an incarcerated femoral hernia is probably covering the vein. The surgeon must reduce the hernia carefully so that the small vessels in the femoral canal are not avulsed. If the hernia is stuck in the canal, then an incision in the medial and superior edge of the femoral ring will release the hernia. The dissection of the lateral floor is initiated with identification of the inferior epigastric vessels. The fat and loose connective tissues are dissected off the posterior abdominal wall just lateral to these vessels until the peritoneum is identified. If there is a lipoma of the cord, then it will be lateral to the peritoneal sac and cord (Figure 9.7). It is pulled out of the internal ring and left in the retroperitoneum, out of the operative field. Sometimes, only a slip of fat will be covering the iliopubic tract, but it may lead to a very large lipoma in the scrotum. The fibers of the iliopubic tract must be identified to prevent leaving behind a lipoma. Cautery should be avoided in this part of the dissection because the lateral femoral cutaneous nerve and femoral branch of the genitofemoral nerve are directly under the lipoma. Dissection of the cord and possible indirect hernia is now started. If there is no indirect hernia, then the peritoneal edge will be set back from the internal ring. The edge of the peritoneum is lifted off the testicular vessels with atraumatic graspers and dissected cephalad as far

as possible. This maneuver allows the mesh repair to be covered by the peritoneum and not be lifted by it when the carbon dioxide is evacuated. To prevent the peritoneum from lifting the mesh on the medial aspect, the peritoneum must also be dissected off the vas deferens, as originally described by Stoppa in the open posterior repair. When an indirect hernia is present, the sac will be found anterior and lateral to the cord structures (Figure 9.8). If the sac is broad-based, it may extend medially to involve the vas deferens. We use a hand-over-hand technique to dissect the sac off the cord structures. The peritoneum must be dissected cephalad so that it does not contact the inferior edge of the mesh. If the peritoneum or any of its filamentous attachments to the canal are left under the mesh, they will elevate the mesh and lead to an early recurrence. A short or small sac is easily delivered out of the internal ring, but it may be difficult and traumatic to completely dissect off the cord a very long sac that descends into the scrotum. In the latter case, the sac should be transected. The superior lateral edge of the peritoneum is incised first because the testicular vessels and the vas deferens may be quite adherent to the undersurface of the sac. The vas deferens will be on the medial side and the testicular vessels on the lateral side. To avoid injury to these cord structures, they must be identified before the inferior peritoneal surface is cut. A mass ligation of the sac should be avoided because the spermatic cord could be inadvertently incorporated into the ligated tissue. After the proximal sac is completely separated from the distal sac, it is dissected off the cord structures and ligated with an endoloop. If the intraperitoneal carbon dioxide causes the peritoneum to balloon outward into the operative field, the surgeon can usually dissect the peritoneum further cephalad in order to hold it out of the field of vision. Before ligating the indirect sac, it is probably better to wait until the mesh is in place because this will allow the peritoneal pressure to be in equilibrium with the extraperitoneal space and exposure will not be compromised. At the end of the procedure, the indirect sac and any other tears in the peritoneum are closed to prevent the development of internal hernias or adhesions to the mesh. If carbon dioxide is trapped in the peritoneal cavity, it is vented with a Veress needle to prevent postoperative shoulder discomfort at this point. At the onset of a TEP repair, one cannot tell whether there is an indirect component to the hernia until the lateral dissection is completed. This is in contrast to the TAPP approach, in which an indirect hernia is almost always obvious on the initial inspection of the pelvic floor. Because of this, it is mandatory that the entire posterior floor be dissected in every TEP repair, even if a direct or femoral hernia is not immediately apparent. This is critically important because up to 30 per cent of patients will have an indirect hernia in addition to the obvious direct or femoral hernia defect.9 Historically,


(a)

(b)

(c)

(d)

Figure 9.8 Reducing the indirect sac. IND SAC, indirect sac.

14 per cent of recurrent hernias after open repairs are due to missed hernias, and the laparoscopic approach potentially eliminates this cause of failure. The mesh repair is begun after dissection of all potential hernias. A 15 ⫻ 15-cm sheet of polypropylene flat mesh is cut to fit the pelvic floor and anchored to the wall. Conversely, a preformed mesh can be used without anchors. Because the pelvic floor is wider from top to bottom medial to the iliac vessels, the medial half of the mesh is wider than the lateral side. The mesh drapes over Cooper’s ligament when it is placed into the pelvis. We place a colored absorbable stitch at the bottom of the medial side of the mesh as a marker. We do this with both our flat tailor-cut mesh and our preformed mesh to make orientation of the mesh much simpler and quicker. We place the polypropylene mesh into the extraperitoneal space by removing the laparoscope, grasping the mesh on one end with a 5-mm instrument, and dragging it into the extraperitoneal space via the 10-mm port. We do not find it necessary to roll up the mesh tightly before placing it, as some have described. The laparoscope is replaced and the mesh pushed gently through the 10-mm port the rest of the way into the pelvis with the scope. Once the mesh is fully in the extraperitoneal compartment, it is rotated using two graspers until the tagged corner is in place below Cooper’s ligament or pubis. The

Figure 9.9 Mesh placement.

mesh is large enough to cover all three potential hernia sites in every patient. The total size of the mesh must be tailored to the size of the patient’s pelvis. When the mesh is smoothed out, it overlaps the pubic bone and crosses the midline (Figure 9.9). Folds or wrinkles in the mesh should be avoided because they lead to increased scar or adhesion formation and can be the cause of chronic pain in the future.


The peritoneum and any lipomas of the cord must be well behind the inferior edge of the mesh before the mesh is fixed in place and/or the carbon dioxide is evacuated. As noted above, if tissue attachments of the sac to the distal cord remain under the mesh after the mesh is positioned, then the mesh may be lifted laterally in the postoperative period. The creation of a window between the vas deferens and the testicular vessels will allow the surgeon to be certain that a tail of sac has not been left behind. To accomplish this, the peritoneum on the vas deferens must be dissected completely from underneath the mesh. A large sac or lipoma should be placed on top of the mesh after the mesh is anchored and before the carbon dioxide is evacuated. These maneuvers prevent the mesh from being lifted up by the peritoneal edge when the carbon dioxide is released. If the testicular vessels do not lie flat against the pelvic floor, as happens most often in very thin patients and patients with recurrent hernias, a double-buttress repair, as originally described for the TAPP hernioplasty, can be utilized.10 In this technique, a polypropylene mesh with a slit in the lower third is used to secure the indirect defect. The slit is placed around the cord and loosely re-approximated over Cooper’s ligament (Figure 9.10). A second mesh, like that described for conventional TEP repair, is placed over the mesh with the slit. Both meshes are cut from 15 ⫻ 15-cm sheets of polypropylene and each measures approximately 14 ⫻ 10 cm. The second mesh is placed to prevent a recurrence through the slit and completes the repair of the direct and femoral areas. If fixation of the mesh is to be used, this is the next step. The number of points of fixation has decreased since our technique was first described.11 It is important to recognize that the iliopubic tract is essential in the placement of these anchors. This tract is a white fibrous band running transversely along the lower edge of the internal ring. In some patients it is quite prominent and obvious, while in others it is subtle and barely visible (Figure 9.11). We confirm the location of the tract by placing one hand externally on the abdominal wall while the other hand presses the stapler internally against the wall. If the tip cannot be felt with the opposite hand, then it is unsafe to place a staple or tack at that site. The instrument is below the iliopubic tract and in an area where the nerves (femoral, genital branch of the genitofemoral, lateral femoral cutaneous) are at high risk of injury. No anchor should be inserted into the mesh and the posterior wall unless the anchoring device can be felt with the opposite hand. It is important not to press so hard as to force the staples (or other fixation device) deep into the muscle layers because this can result in an injury to a more superficial nerve, such as the ilio-inguinal. The first tacks or staples are placed through the mesh into Cooper’s ligament to stabilize the mesh, which allows the surgeon to fan out the mesh in a lateral direction so

(a)

(b)

Figure 9.10 TAPP double-buttress mesh approach.

Figure 9.11 Mesh anchored with tacks.

that any wrinkles or folds are removed. If aberrant obturator vessels are present coursing over the pubis, they must be avoided otherwise serious bleeding can result. Other anchors are placed into the mesh and transversalis fascia medial to the inferior epigastric vessels, whereupon the mesh is smoothed out in a lateral direction, making


Mesh

Mesh placement

Spermatic cord Iliac vessels

Vas deferens

Figure 9.12 Preformed mesh (3D Max, BARD).

sure that the peritoneum and lipoma of the cord are well cephalad to the posterior edge of the mesh. Lateral anchors are inserted using the bimanual technique described above, so that damage to the neural structures below the iliopubic tract is prevented. The purpose of the fixation is not to strengthen the repair but rather to keep the mesh in place until natural in-growth occurs. The number of fixation points has therefore decreased as our understanding of this repair has grown. More recently we have begun using a preformed mesh that does not require fixation (Figure 9.12) (see Chapter 3). The results over the last two years equaled our earlier results with anchors. In the newer technique, the mesh, which has a molded contour, fits into the pelvis and is not fixed with anchors. Care must be taken to use a mesh that is large enough to be held in place once the carbon dioxide is removed. The final phase of the procedure is evacuation of the carbon dioxide. It is released slowly through one of the 5-mm ports while the lateral inferior corner of the mesh is held against the wall with a grasper in the other 5-mm port. This procedure ensures that the peritoneum will cover the mesh rather than lift the inferior edge. The peritoneum will rest on top of the mesh, holding it in place. If the peritoneum lifts the mesh, the mesh must be manipulated or trimmed until it is covered properly by peritoneum. If there are bilateral hernias, we release the gas very slowly while watching both meshes and holding the corners of each mesh with a grasper as needed. The small trocars are removed, and the rest of the extraperitoneal gas is evacuated through the umbilical port. If carbon dioxide is trapped within the peritoneal cavity, it is evacuated from the peritoneal cavity with a Veress needle. The fascia of the 10-mm port is re-approximated with absorbable suture. Gas trapped in the scrotum can also be eliminated with a small needle at the end of the procedure, if deemed necessary.

POSTOPERATIVE MANAGEMENT Postoperative management for patients undergoing laparoscopic inguinal hernioplasty is fairly standardized. The surgery is usually performed under general anesthesia and patients are observed for approximately two to three hours before discharge. They are allowed to resume normal activities as soon as they feel that they are capable. No restrictions are placed upon the patients. We allow patients to return to work and physical activity as soon as their pain tolerance allows them to do so. On average, patients are back to 80 per cent of full activity in less than a week and are able to perform fairly physical activity, such as riding a bicycle, by the second week. Some patients develop a seroma at the site of the hernia. This, in fact, may mimic a recurrence, but it will reabsorb in 90 per cent of patients by six weeks. If it is not uncomfortable for the patient, it is observed and then aspirated only if it is present after six weeks and if it appears that it is not resolving. We have not found it necessary to use ultrasonography to diagnosis a seroma, but rather have been able to rely on physical exam alone. On only one occasion did we misinterpret the findings as a recurrent hernia when it was actually a contained fluid collection.12 Using our extraperitoneal technique with and, more recently, without anchors, we have maintained a recurrence rate of less than 0.5 per cent over the last ten years. Short- and long-term morbidity, convalescence and satisfaction of all patients have been excellent. Because the procedure can be performed rapidly and in an outpatient setting, the overall cost has remained comparable to other methods of hernia repair. The keys to a successful laparoscopic technique are an understanding of the posterior anatomy, perfection of the laparoscopic skills required to perform advanced laparoscopic surgery, and knowledge of the limitations of the laparoscopic approach to inguinal hernia repair.


REFERENCES 1 2 3 4

5 6

Bassini E. Nuovo me todo cura radicale dell’ernia inguinale. Arch Soc Ital Chir 1887; 4: 380. Lichtenstein IL, Shulman AL, Amid PK, et al. The tension-free hernioplasty. Am J Surg 1989; 157: 188–93. Stoppa R, Rives JL, Walamount C. The use of Dacron in the repair of hernias of the groin. Surg Clin N Am 1984; 64: 269–85. Felix E, Scott S, Crafton B, et al. Causes of recurrence after laparoscopic hernioplasty – a multicenter study. Surg Endosc 1998; 12: 226–31. Felix E, Michas C, Gonzalez H. Laparoscopic hernioplasty. Tapp vs. Tep. Surg Endosc 1995; 9: 984–9. Felix E, Michas C, Gonzalez H. Laparoscopic repair of recurrent hernia. Am J Surg 1996; 172: 580–4.

7

Ferzli G, Sayad P, Huie F, et al. Endoscopic extraperitoneal herniorrhaphy. A 5 year experience. Surg Endosc 1998; 12: 1311–13. 8 Felix E. Laparoscopic approach to bilateral hernias. Sages abstracts 1999. 9 Felix E, Michas C, Gonzalez H. Laparoscopic hernioplasty: why it works. Surg Endosc 1997; 11: 36–41. 10 Felix EL, Michas C. Double-buttress laparoscopic herniorrhaphy. J Laparoendosc Surg 1993; 3: 1–8. 11 Felix E, Michas C, Mcknight R. Laparoscopic herniorrhaphy. Transabdominal preperitoneal floor repair. Surg Endosc 1994; 8: 100–3. 12 Felix E. A unified approach to recurrent laparoscopic hernia repairs. Surg Endosc 2001; 15: 969–71.

10 Femoral and pelvic herniorrhaphy CHRISTINE A. ELY AND MAURICE E. ARREGUI

Demographics History of repair Techniques Postoperative care

75 76 76 77

Femoral and pelvic hernias are much less common than inguinal hernias. If these hernias are diagnosed preoperatively, they are certainly amenable to laparoscopic repair. However, if they are not diagnosed preoperatively, these cases are the perfect situation for the application of diagnostic laparoscopy followed by laparoscopic repair. Inguinal ligament Less common Femoral hernia (anatomically less weak) Most common Inguinal hernia (Anatomically weakest)

Pectineus muscle Rare Obturator hernia (Anatomically least weak)

Figure 10.1 Surgical anatomy of the obturator and inguinal region. Lateral view of the right side of the pelvis, showing the sites of inguinal, femoral and obturator hernias. From Carter JE. Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic Pain: Diagnosis and Management. Philadelphia: Lippincott Williams & Wilkins, 2000: 385–413, with permission.

Rare and unusual hernias Conclusion References

77 81 82

In this chapter, we will focus on our technique of repair of femoral and obturator hernias, since the obturator hernia is by far the most common of the pelvic hernias (Figure 10.1). Our technique and postoperative care will be reviewed. In addition, we will comment on some other unusual hernias that may be encountered, such as sciatic, supravesicular and perineal hernias, as well as prevascular hernias, lipomas of the cord, and low Spigelian hernias.

DEMOGRAPHICS Femoral hernias are much less common than inguinal hernias, with an incidence of two to four per cent of all groin hernias.1 They are more common in women, with reported male/female ratios of 1 : 1.6 to 1 : 3.1,2 The incidence and rate of repair increase with age.1 The femoral hernia is located most frequently on the right.1 Obturator hernias, although extremely rare, are the most common of the pelvic hernias. Their incidence is reported to be 0.05–0.07 per cent of all groin hernias. They typically occur in an emaciated, dehydrated, multiparous female patient. The patients may have a positive Howship– Romberg sign or a palpable upper-thigh mass. The Howship–Romberg sign is positive when medial thigh and hip pain is created or exacerbated by adduction and medial rotation of the thigh and relieved by thigh flexion.3 More often, however, symptoms are vague, and patients frequently present with small-bowel obstruction with either intermittently incarcerating or strangulated small bowel. One’s level of suspicion, therefore, needs to be high.


These vague symptoms and small-bowel obstructions can occur with both femoral and obturator hernias. d

b

HISTORY OF REPAIR Femoral hernias have been repaired anteriorly with and without mesh, or with a mesh plug, as well as via the suprainguinal ligament approach or the infrainguinal approach. They have been repaired posteriorly via open pre-peritoneal approaches and, most recently, laparoscopically using the transabdominal pre-peritoneal (TAPP) or totally extraperitoneal (TEP) approach. Reports have varied with regards to complications, with the rate of recurrences varying from poor to good.4–8 Reports are now emerging regarding the success of the laparoscopic repair of these hernias.8 A variety of approaches for repair of the obturator hernia has been used. The abdominal, inguinal (extraperitoneal or retroperitoneal), retropubic, and obturator approaches have been described, as well as different combinations of these incisions. The abdominal approach has seemed to be the best approach because it provides simultaneous diagnosis and repair and allows the resection of compromised bowel if necessary. The obturator defect has been closed with sutures or mesh, or with tissue, such as a flap of adductor longus, the round ligament, or a portion of the bladder wall.9,10 Most recently, the laparoscopic approach has been applied to these hernias (Figures 10.2 and 10.3). The reports are few but the results are favorable, and this approach also affords the above-mentioned benefits of the open abdominal approach.

e

a c

Figure 10.2 Transperitoneal view of (a) indirect inguinal hernia, (b) direct inguinal hernia, (c) femoral hernia, (d) inferior epigastric vessels, and (e) median umbilical ligament.

b a c d

TECHNIQUES If the hernia is discovered preoperatively, our approach of choice is the extraperitoneal approach. If the hernia is discovered during diagnostic laparoscopy, either it may be repaired via the TAPP approach or the pre-peritoneal space may be insufflated and an extraperitoneal approach may be used, as described below. We perform extraperitoneal repair of indirect and direct inguinal hernias. Femoral hernias and obturator hernias are repaired in a similar fashion. As we will point out, the most important concept is wide coverage of all hernia orifices with mesh to prevent recurrence. General endotracheal anesthesia is used. After infiltrating with 0.5 per cent bupivacaine with epinephrine (adrenaline), a 5-mm incision is made in a skin fold in the inferior portion of the umbilicus. A Veress needle is introduced for insufflation of carbon dioxide to a pressure of 15 mmHg. A 5-mm trocar is then inserted, followed by a general inspection of the peritoneal cavity

Figure 10.3 Intraoperative view of obturator foramen. (a) Plug of fat in obturator foramen, (b) Cooper’s ligament, (c) obturator nerve, and (d) obturator artery.

with a 5-mm, 30-degree viewing laparoscope. Using the transperitoneal view, an additional 5-mm trocar is placed on the ipsilateral side about one finger’s breadth below the level of the umbilicus over the lateral aspect of the rectus muscle just above the arcuate line of the posterior rectus sheath. The trocar is introduced carefully into the posterior rectus space to avoid perforation of the peritoneum. Dissection of this space is then carried out with a long, blunt grasper inserted through the trocar. For unilateral repair, a second 5-mm trocar is inserted in the midline at the midpoint between the symphysis pubis and umbilicus. For bilateral repair, the second trocar is placed on the opposite side, in the lateral rectus space, again just above the arcuate line.

Femoral and pelvic herniorrhaphy 77

After dissection with the blunt grasper, an additional 5-mm incision is made below the umbilicus, through which a 5-mm trocar is placed. The 5-mm, zero- or 30degree viewing laparoscopes are then used. The dissection of the pre-peritoneal space is carried beyond Cooper’s ligament into the space of Retzius below the obturator foramen. Once dissection is complete, the symphysis pubis, the rectus muscle medially, the anatomic landmarks surrounding Hesselbach’s triangle (including Cooper’s ligament and the medial iliopubic tract), the transversus abdominus musculo-aponeurotic arch, and the inferior epigastric vessels will be identified. Laterally, the dissection will have exposed the cord structures, the underlying femoral vessels, and the lateral iliopubic tract. The direct, indirect and femoral hernial orifices should be identified easily. The obturator orifice should be seen inferior to Cooper’s ligament. Subsequent to the reduction of the herniated contents and sac, the femoral hernia defect and the entire myopectineal orifice of Fruchaud will be covered with Mersilene mesh. A 15 ⫻ 15-cm mesh is trimmed to 13 ⫻ 15 cm. It is introduced by rolling it, grabbing one end with grasping forceps, and pushing it through the 5-mm trocar. The mesh is unrolled and positioned over the entire area, thereby covering the hernia defect and all other potential sites of herniation. The mesh is not sutured or tacked into place. In the case of an obturator hernia, the mesh can be smaller and limited to a wide coverage of the obturator foramen with or without fixation. We would choose to fashion the size of the mesh so that it overlaps the defect by 3–4 cm. Others have fixated the mesh, which can be done with either sutures or tacks. Based on the above principles, however, we would not fixate the mesh. After making sure that the prosthesis is lying flat and in the correct space, the pre-peritoneal trocars are removed and the pre-peritoneal space is desufflated. The laparoscope is then placed in the peritoneal cavity and the mesh is observed as the peritoneum lies on top of it, making sure that there is no buckling of the mesh. Then, while still under direct vision, the peritoneal cavity is desufflated and the final trocar is removed. The positive intra-abdominal pressure that took part in creating the hernia itself is now used to secure the mesh in place, obviating the need for fixation of the prosthetic biomaterial. The subcutaneous tissue at all trocar sites is closed with 3-0 Vicryl (Ethicon). Collodian is applied to the skin for dressing.11

POSTOPERATIVE CARE The patient is observed in the recovery room for one to two hours. The majority of electively repaired patients are then discharged home on the same day. Most patients

are given a prescription for propoxyphene for pain control. The patient is restricted only from driving for two to three days, or until they are pain-free and not requiring narcotic analgesics. Patients may bathe the same day and may return to work or full activity without restrictions when they feel ready.11

RARE AND UNUSUAL HERNIAS In this section, we will mention some unusual hernias that may be encountered and the principles and techniques for their management and repair.

Sciatic hernia Sciatic hernias are very rare. A literature search on Medline from 1966 to 1996 generated only 57 reported cases of sciatic hernias.12 A sciatic hernia is a protrusion of a peritoneal sac and its contents through the greater or lesser sciatic foramen. They may be congenital or, more commonly, acquired. The defect usually results from weakness of the piriformis muscle from a chronic increase in the intra-abdominal pressure, such as in pregnancy, severe constipation, surgery or trauma. It can also occur because of atrophy of the muscle caused by neuromuscular or hip disease.13 The hernia sac can protrude through one of three openings: the greater sciatic foramen above the piriformis muscle, the greater sciatic foramen below the piriformis muscle, or the lesser sciatic foramen (Figure 10.4). Typical symptoms include intermittent pain radiating to the buttocks and/or posterior thigh, with or without a palpable mass deep to the gluteus maximus muscle. The most common contents of a sciatic hernia are small bowel, ovary (with or without the adjacent fallopian tube), and ureter.13 The sciatic hernia has traditionally been approached transabdominally, with reduction of the hernia, excision of the sac, and either suture closure or mesh coverage of the defect. Alternatively, if it is diagnosed preoperatively and it is easily reducible, the hernia could be repaired from a transgluteal approach. The largest series of patients who underwent laparoscopic repair of a sciatic hernia consisted of 20 women who underwent diagnostic laparoscopy for pelvic pain and were found to have a sciatic hernia, which was then repaired via laparoscopic approach.14 When a sciatic hernia was identified, the contents were reduced. The peritoneum was elevated and transected transversely with endoscopic scissors. The obturator internus and coccygeus muscles were identified with the use of blunt dissection. A 6.0 ⫻ 12.5-cm piece of Surgipro mesh (U.S. Surgical) was then folded and placed into the space that had been created by the atrophic piriformis muscle.


The authors do not describe it exactly as a ‘plug’; this is the only description that they gave. A second, smaller piece of mesh, trimmed to the size of the peritoneal defect, was placed over the folded mesh. The second piece of mesh was secured to the obturator internus fascia laterally and the coccygeus medially with a stapler. The peritoneum was then closed over the mesh.12 If the peritoneum is not closed, then an inert mesh, such as DualMesh® (W. L. Gore & Associates) could be used to prevent morbidity due to adhesions.15 The repair was very successful, with 14 patients reporting complete pain relief, and the other six individuals noting continuing improvement over a median follow-up of 13 months. Laparoscopy is a great adjunct in the diagnosis of this hernia because of the excellent view of the pelvis that it affords. In this series of patients, all of the hernias

contained an ovary and/or the fallopian tube, which left little room for the distention of the peritoneum contained within the hernia sac by the intra-abdominal carbon dioxide. However, the authors felt that in other cases the increased intra-abdominal pressure could be helpful in the detection of sciatic hernias because of the actual stretching of the peritoneum to its limit of support, such as the bone or muscle.12

Supravesical hernia Supravesical hernias are rare hernias that herniate through the supravesical fossa of the anterior abdominal wall. They are classified as either external (those that pass downward through the supravesical fossa to become

Anterior sacroiliac ligament

Piriformis muscle a Sacrospinous ligament b

Sacrotuberous ligament c Ischial tuberosity and spine

(a)

Posterior sacroiliac ligament

Posterior inferior iliac spine

Greater sciatic foramen

Piriformis muscle

Sacrospinous ligament

Capsule of hip joint

Sacrotuberous ligament Greater trochanter Lesser sciatic foramen

Ischial tuberosity Sciatic nerve (b)

Quadratus femoris muscle

Figure 10.4 Sites of potential hernias through the sciatic foramina: (a) suprapiriformis sciatic hernia, (b) infrapiriformis sciatic hernia, and (c) subspinous sciatic hernia through the lesser sciatic foramen. From Carter JE. Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic Pain: Diagnosis and Management. Philadelphia: Lippincott Williams & Wilkins, 2000: 385–413, with permission.


direct inguinal or femoral hernias) or internal (those that pass downward to enter the space of Retzius) (Figure 10.5). While the external hernias may be much easier to diagnose, an internal hernia may present with non-specific clinical findings, such as pelvic pain or bladder symptoms, or, as in other hernias, it may present as small-bowel obstruction with its attendant symptoms. Open repair has been described for these hernias, either with or without mesh, particularly for the external hernias. Laparoscopic repair, however, is again applicable to such hernias, using the same technique as described above for sciatic hernias. The internal supravesical hernia

e d a c b

Figure 10.5 External supravesical hernia: (a) external supravesical hernia orifice, (b) Hesselbach’s triangle, (c) transversus abdominus aponeurotic arch, (d) rectus muscle, and (e) inferior epigastric vessels.

may be especially well suited for the laparoscopic approach because of the better visualization of the entire pelvis.16

Perineal hernia Perineal hernias are very rare true hernias, which are usually found in women. These defects are characterized by a peritoneal sac that has herniated between the muscles and fascia of the perineal floor.16 They can be categorized as either anterior or posterior to the superficial transverse perineus muscle. Anterior perineal hernias pass through the pelvic and urogenital diaphragms, lateral to the urinary bladder and vagina and anterior to the urethra (Figure 10.6). They have also been referred to as pudendal, labial, lateral and vaginal-labial hernias. These hernias are unique to women and may contain intestine or bladder. Posterior perineal hernias pass directly through the components of the pelvic diaphragm. Their content is usually omentum or small bowel, which lie between the rectum and uterus. The hernia usually remains lateral to the uterosacral ligament and posterior to the broad ligament. There are two possible locations, an upper posterior hernia between the pubococcygeus and iliococcygeus muscles, and a lower posterior hernia between the iliococcygeus and coccygeus muscles, below the lower margin of the gluteus maximus muscle. Posterior perineal hernias may occur in men or women, but they are more common in men.13,17 Laparoscopic repair of these hernias has been described as an approach for maximum visualization of

Ischiocavernous muscle Bulbocavernosus muscle Superficial transverse perineal muscle a

External anal sphincter

b

Levator ani muscle

c

Coccygeus muscle

d

Gluteus maximus muscle

Figure 10.6 The female perineum, showing possible sites of perineal hernias. A primary perineal hernia may occur anterior or posterior to the superficial transversus perineal muscle. An anterior hernia protrudes through the urogenital diaphragm, lateral to the urinary bladder and vagina (a, b). Anterior hernias occur only in women. A posterior perineal hernia may merge between bundles of levator ani muscle (c), or between that muscle and the coccygeus muscle, midway between the rectum and the ischial tuberosity (d). From Carter JE. Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic Pain: Diagnosis and Management. Philadelphia: Lippincott Williams & Wilkins, 2000: 385–413, with permission.


the pelvic cavity. The hernia is identified, the hernia contents are reduced, and a pre-peritoneal dissection is performed to define the boundaries of the hernia ring. Permanent prosthetic mesh is used to cover and overlap the defect. The mesh is tacked or stapled in place, and reperitonealization is performed.16

Prevascular hernia Prevascular hernias are a variation of the femoral hernia in which the sac is situated in the femoral sheath, but anterior to the femoral vessels rather than medial to them as in the ‘usual’ fashion.18 This hernia was originally described by Teale in 1846. Other related hernias have been described that protrude through the femoral sheath in strict continuity with the femoral vessels but in various locations and are separated from the vessels only by adventitia (Figure 10.7). There is one report of a patient who simultaneously had two bilateral femoral hernias (total of four femoral hernias).18 This group of hernias is rare, with a reported incidence of 1.7–2.5 per cent of all femoral hernias.19 However, recent reports suggest that these hernias may be more common than originally recognized. In a retrospective study in which 105 femoral hernias were identified in an

eight-year period, ten (9.5 per cent) of the hernias were of the prevascular type.20 Repair of these hernias can be difficult because, if repaired anteriorly, the iliopubic tract must be sutured to the vascular adventitia, which obviously holds inherent danger. The pre-peritoneal approach has therefore been recommended as the safest and preferred approach.20 In the previously mentioned study, all ten of the prevascular hernias were repaired using the TEP laparoscopic technique, with good results, no complications, and no recurrences to date.

Lipoma of the cord A lipoma of the spermatic cord or the round ligament is an isolated discrete collection of fatty tissue arising from the retroperitoneal tissue, which protrudes through the internal ring and is easily separated from the cord structures (Figure 10.8). These tissues can cause symptoms similar to a true hernia. Lipomas can occur with or without a coexisting peritoneal defect. In a retrospective review of 280 hernia repairs, the incidence of lipoma of the cord was found to be 22.5 per cent (63/280).21 Eighteen of these lipomas were found in groins without hernias. Fourteen of the patients with lipomas presented with groin pain, and four were asymptomatic. The authors believe that a lipoma can be the cause of a patient’s groin pain, and also can be a predisposing factor to formation or recurrence of a hernia, possibly by insinuating itself into the internal ring and dilating it over time. They recommend removal of all lipomas, with or without a hernia, in symptomatic patients and documenting in detail those found incidentally in asymptomatic patients because of the possibility of future symptoms.21

Hesselbach (lateral femoral)

Teale (prevascular)

Serafini (retrovascular) Femoral Callisen-- Cloquet Laugier

Figure 10.7 The various paravascular hernias. From Bocchi P. Paravascular hernias. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernias. Austin, TX: RG Landes Co., 1994: 415–16, with permission.

Figure 10.8 Laparoscopic view of lipoma of the cord. Cord structures can be seen medially.


Contrary to the advantage that laparoscopy adds in all of the above-mentioned hernia surgeries, lipomas of the cord or round ligament are more difficult to visualize with the laparoscope. A maneuver that is useful to help visualize the lipoma is external compression with the hand at the inguinal canal, thus pushing back the lipoma through the internal ring. This should be done in any patient who is undergoing laparoscopic evaluation for groin pain when a hernia is not found.21 Herniated preperitoneal fat can also be found in the femoral canal, Hasselbach’s triangle, or obturator foramen, or alongside the pre-peritoneal nerves. We have seen small herniations along the lateral femoral cutaneous nerve, which, when reduced, relieved the patient of the preoperative pain over the distribution of that nerve. When a lipoma is discovered and requires removal, it is not always easy to pull it through a 5-mm or 10-mm trocar. The available options are piecemeal removal of the lipoma (which can be tedious), allowing it to remain attached at the base and placing it between the mesh and the peritoneum, or separation of the lipoma from the cord, leaving the lipoma in situ. The latter option is not recommended as the lipoma may re-herniate into the inguinal canal.21

aponeurosis. This aponeurosis, or fascia, is defined as the region between the semilunar or Spigelian line (the transition from muscle to aponeurosis in the transversus abdominus muscle) and the lateral border of the rectus muscle. The usual Spigelian hernia refers to a hernia located above the inferior epigastric vessels. Hernias that penetrate the Spigelian fascia inferior to the inferior epigastric vessels are called low Spigelian hernias (Figure 10.9). These hernias are actually traversing through Hesselbach’s triangle, which includes part of the Spigelian aponeurosis caudal and medial to the inferior epigastric vessels. One can easily appreciate that these hernias are very easily confused with direct inguinal hernias and most likely are underreported because of misrepresentation as direct inguinal hernias. Low Spigelian hernias, if diagnosed properly, are usually diagnosed intraoperatively. The hernial orifice is usually small and has rigid, sharply defined edges. These hernias may also be repaired laparoscopically, which can be done in a preperitoneal fashion, as described for repair of a direct inguinal hernia.22,23

CONCLUSION

Low Spigelian hernia A Spigelian hernia is a rare hernia that protrudes through a congenital or acquired defect in the Spigelian (c)

(a) (d)

(f)

We have described in detail our approach for laparoscopic repair of femoral and obturator hernias. The repair is no different in principle to that of direct or indirect inguinal hernias. The most important step to remember is that wide coverage of all of the possible hernia orifices is necessary to prevent recurrence. In addition, we have stressed the usefulness of the laparoscopic approach because it gives a better total visualization of the entire inguinal and pelvic regions than the open technique. This is especially helpful when one encounters some of the more unusual hernias that have been mentioned in this chapter. Finally, we have described some of the unusual inguinal and pelvic hernias that may be encountered and the basic principles of management of them.

REFERENCES

(b) (e)

1

2

Figure 10.9 Anatomy of the low Spigelian hernia. Shaded area: Spigelian aponeurosis. (a) Region of Spigelian hernia; (b) region of low Spigelian hernia; (c) Spigelian line; (d) lateral border of rectus abdominus muscle; (e) inferior epigastric vessels; and (f) transversus abdominus muscle. Modified from Bennett D. Spigelian hernias. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus & Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2002: 405–13, with permission.

3 4 5 6 7

Rutkow I. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin N Am 1998; 78: 941–51. Sandblom G, Haapaniemi S, Nilsson E. Femoral hernias: a register analysis of 588 repairs. Hernia 1999; 3: 131–4. Haith LR, Simeone MR, Reilly KJ, et al. Obturator hernia: laparoscopic diagnosis and repair. JSLS 1998; 2: 191–3. Koontz AR. Femoral hernia. Arch Surg 1952; 64: 298–308. Glassow F. Femoral hernia: review of 2,105 repairs in a 17 year period. Am J Surg 1985; 150: 353–6. Bendavid R. A femoral ‘umbrella’ for femoral hernia repair. Surg Gynecol Obstet 1987; 165: 153–6. Lichtenstein IL, Shore JM. Simplified repair of femoral and inguinal hernia by a ‘plug’ technique. Am J Surg 1974; 128: 439–44.

82 Laparoscopic inguinal/femoral hernioplasty 8

9 10

11

12 13

14 15

Hernandez-Richter T, Schardey HM, Rau HG, et al. The femoral hernia: an ideal approach for the transabdominal preperitoneal technique (TAPP). Surg Endosc 2000; 14: 736–40. Marchal F, Parent S, Tortuyaux JM, et al. Obturator hernias – report of seven cases. Hernia 1997; 1: 23–6. Skandalakis LJ, Skandalakis PN, Colborn GL, Skandalakis JE. Obturator hernia: embryology, anatomy, surgery. Hernia 2000; 4: 121–8. Arregui ME, Navarrete J, Davis CJ, et al. Laparoscopic inguinal herniorrhaphy – techniques and controversies. Surg Clin N A 1993; 73: 513–27. Miklos JR, O’Reilly MJ, Saye WB. Sciatic hernia as a cause of chronic pelvic pain in women. Obstet Gynecol 1998; 91: 998–1001. Carter JE. Sciatic, obturator, and perineal hernias: a view from the gynecologist. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2002: 539–49. Kavic MS. Chronic pelvic pain in females and obscure hernias. Hernia 2000; 4: 250–4. Chaudhuri A, Chye KK, March SK. Sciatic hernias: choice of optimal prosthetic repair material in preventing long-term morbidity. Hernia 1999; 4: 229–31.

16

17

18 19

20

21 22 23

Kavic MS. Chronic pelvic pain in women. In: Bendavid R, Abrahamson J, Arregui ME, et al., eds. Abdominal Wall Hernias Principle and Management. New York: Springer-Verlag, 2001: 636–8. Skandalakis JE. Perineal hernia. In: Skandalakis JE, Gray SW, Mansberger AR, et al., eds. Hernia Surgical Anatomy and Technique. New York: McGraw-Hill, 1989: 185–206. Harkins HN. In: Nyhus LM, Condon RE, eds. Hernia, 3rd edn. Philadelphia: JB Lippincott, 1989: 302–3. Bocci P. Paravascular hernias. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernias. Austin, TX: RG Landes Co., 1994: 415–16. Spurbeck WW, Voeller GR. Prevascular and retropsoas hernias: incidence of rare abdominal wall hernias. Abstract presented at American Hernia Society Hernia Conference, Tucson, AZ, May 2002. Lilly MC, Arregui ME. Lipomas of the cord and round ligament. Ann Surg 2002; 235: 586–90. Spangen L. Spigelian hernia. Surg Clin North Am 1984; 64: 351–66. Bennett D. Spigelian hernia. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2002: 405–13.

11 Results of laparoscopic inguinal/femoral hernia repair KETAN M. DESAI AND NATHANIEL J. SOPER

TEP versus TAPP repair Laparoscopic versus open tissue repair Laparoscopic versus open mesh repair Summary

83 84 85 86

Over 750 000 inguinal hernia repairs are performed in the USA annually. Historically, many techniques for the tissue repair of groin hernias have been used, including the Bassini, McVay, Cooper and Shouldice repairs. Currently, the tension-free repair of Lichtenstein and the mesh-plug procedure dominate the majority of surgical practices. Since the introduction of laparoscopic cholecystectomy in the late 1980s, advancements in minimally invasive surgery have led surgeons to investigate laparoscopic techniques for treating inguinal hernia while still providing a durable repair. Accepted indications for laparoscopic hernia repair are recurrent and bilateral inguinal hernias in a patient at low anesthetic risk. However, considerable debate over laparoscopic inguinal hernia repair, not seen with other laparoscopic procedures, has diminished the enthusiasm for adopting this technique for unilateral, primary inguinal hernias. The emergence of laparoscopic groin hernia surgery is multifactorial. Following open repair, high rates of postoperative patient discomfort, pain, and increased time away from work, coupled with recurrence rates that ranged from one to ten per cent, influenced surgeons to explore alternative repair methods. Early attempts at laparoscopic inguinal hernia repair included intraperitoneal onlay mesh (IPOM) techniques, simple inguinal ring closure, and plug-and-patch repair. However, these early laparoscopic approaches were abandoned secondary to an unacceptable rate of recurrence and the formation of intra-abdominal adhesions, except at a few centers (see Chapter 7). Today, the two predominant laparoscopic

Laparoscopic femoral hernia repair References Further reading

86 86 87

approaches for the repair of inguinal hernia include the transabdominal pre-peritoneal (TAPP) and the totally extraperitoneal (TEP) approaches. These two laparoscopic procedures, based upon the open Stoppa repair, provide pre-peritoneal mesh reinforcement of the iliopubic tract.

TEP VERSUS TAPP REPAIR TAPP repair requires entry into the peritoneal cavity. Following placement of trocars, the peritoneum is divided transversely anterior to the internal ring, wide peritoneal flaps are raised, and the hernia sac is reduced. A large prosthetic mesh is stapled into place, widely overlapping the defect and buttressing the iliopubic tract. Similarly, TEP repair requires advanced knowledge of the anatomy of the inguinal floor. However, access to the pre-peritoneal space is achieved without incision of the peritoneal membrane. Following balloon or blunt dissection of the preperitoneal space, the cord structures are dissected, and indirect or direct hernias are reduced. The inguinal floor is covered with a large prosthetic mesh and secured with staples or another fixation device. Potential early postoperative complications include bowel injury from trocar insertion (TAPP), bowel obstruction from adhesion formation (TAPP), nerve entrapment from staple placement (TAPP and TEP), and mesh infection (TAPP and TEP). The extraperitoneal approach avoids a number of these

84 Laparoscopic inguinal/femoral hernioplasty Table 11.1 Recurrence rates of laparoscopic repairs Study

Procedure

Number

Follow-up (months)

Recurrence rate (%)

Aeberhard et al. (1999)3 Katkhouda et al. (1999)4 Farinas and Griffen (2000)5 Knook et al. (1999)6 Ferzli et al. (1999)7 Frankum et al. (1999)8 Halkic et al. (1999)9 Lucas and Arregui (1999)10 O’Riordain et al. (1999)11 Juul et al. (1999)1 Knook et al. (1999)12 Smith et al. (1999)13 Johansson et al. (1999)14

TEP TEP TEP TEP TEP TEP TEP TEP TEP TAPP TAPP TAPP TAPP

1605 99 96 256 100 779 118 199 71 138 34 536 204

12 24 12 40 8 30 22 36 12 12 35 17 12

1.3 0 0 5 0 0.2 0 0 0 2.9 0 0.6 2

pitfalls that are unique to entry into the peritoneal cavity. However, early problems with nerve entrapment and hernia recurrence secondary to inadequate mesh size following either procedure have resulted in significant morbidity. Outcome measures following groin hernia repair include postoperative pain, complications, return to work, patient satisfaction, and cost, as well as long-term hernia recurrence rates. Comparisons of laparoscopic approaches have revealed lower rates of postoperative pain following TEP repair; however, operating times and return to normal activity were generally similar. Recurrence rates following either laparoscopic repair were variable (Table 11.1). Non-randomized (usually sequential) trials comparing TEP versus TAPP approaches have reported lower recurrence rates following the TEP technique. However, in a number of these trials the differences were not statistically significant, with subsequent randomized studies reporting similar recurrence rates irrespective of laparoscopic procedure. Evaluations of these two laparoscopic techniques have demonstrated a slightly lower complication rate following TEP repair. Reports of bowel injury and small-bowel obstruction secondary to intra-abdominal adhesions were more common following the TAPP approach than the TEP approach. The difference in complication rates between the two accepted laparoscopic approaches may result from remaining completely extraperitoneal during TEP dissection and repair. However, initial experience with TAPP may have provided surgeons with the additional skills and knowledge to perform a superior TEP repair. In general, due to the small number of comparative studies, firm conclusions on the relative merits of the different techniques are difficult to obtain. However, TEP repair may have some advantages regarding complications and postoperative pain. Despite these potential differences, surgeons should be skilled in both minimally

invasive repairs, due to conversions and recurrences requiring the alternative procedure.

LAPAROSCOPIC VERSUS OPEN TISSUE REPAIR Although we currently use the Lichtenstein (tension-free) repair for open inguinal herniorrhaphy, the Shouldice technique appears to have similar advantages in terms of short recovery time and low recurrence rates. Laparoscopic repair has been compared with a number of open repair methods, with varying results. A number of early, small trials failed to demonstrate a clear benefit following laparoscopic repair. More recent randomized trials comparing laparoscopic and open suture repair have reported superior outcomes following the laparoscopic approach in terms of less postoperative pain and a faster return to normal activity. Although operative times of the laparoscopic approaches have been reported to be significantly longer than with open suture methods in a number of studies, wound complications and overall recurrence rates were similar (Table 11.2). In addition, general anesthesia was used in the vast majority of laparoscopic cases as opposed to local, epidural or spinal anesthesia in the open group. Despite this, several trials have shown earlier hospital discharge and less postoperative pain (early and late) in patients undergoing laparoscopic repair. A randomized comparison of extraperitoneal laparoscopic repair with various open approaches by Liem and colleagues revealed longer procedure times for the laparoscopic repair.13 However, the laparoscopy group had lower analgesia requirements, less postoperative pain, and an earlier return to work. The recurrence rate was slightly lower in the laparoscopy group, as were wound infections and chronic postoperative pain.

Results of laparoscopic inguinal/femoral hernia repair 85 Table 11.2

Comparison of open versus laparoscopic repair Recurrence (%)

Study

No. randomized

Open

Laparoscopic

Open

Laparoscopic

Liem et al. (1997)15 Juul and Christensen (1999)1 Fleming et al. (2001)2 Paganini et al. (1998)16 Zieren et al. (1998)17 Koninger et al. (1998)18 Payne et al. (1994)19 Heikkinen et al. (1997)20 Beets et al. (1999)21 Filipi et al. (1996)22 Johansson et al. (1999)14 Aitola et al. (1998)23 Wellwood et al. (1998)24 Champault et al. (1997)25 Khoury (1998)26

994 268 200 108 240 280 100 38 79 53 613 60 403 100 292

Various Shouldice Shouldice Mesh Mesh Mesh Mesh Mesh Mesh Mesh Mesh Mesh Mesh Mesh Mesh

TEP TAPP TEP TAPP TAPP TAPP TAPP TAPP TAPP TAPP TAPP TAPP TAPP TEP TEP

6 2 5 0 0 1 0 0 3 7 5 8 0 2 3

3 3 2 4 0 1 0 0 14 0 2 13 0 6 2

Laparoscopic repair of groin hernias is generally reserved for bilateral and recurrent hernias. However, the benefits of laparoscopic repair for primary, unilateral hernias have been demonstrated. Patients with primary, unilateral hernias may recover more rapidly after TAPP repair than after an open approach, as assessed by analgesia requirement and functional status. In a randomized clinical trial by Juul and coworkers of laparoscopic (TAPP) versus open (Shouldice) inguinal hernia repair, complication rates were similar, whereas the laparoscopic repair resulted in less postoperative pain, shorter analgesia requirement, and an earlier return to work.1 At postoperative followup, there were similar rates of recurrences. Comparison of Shouldice and TEP repairs by Fleming and colleagues also demonstrated the potential benefits of the laparoscopic approach. TEP repair led to a more rapid return to work, with fewer complications at one-year follow-up, when compared with the open group.2

LAPAROSCOPIC VERSUS OPEN MESH REPAIR The practice of tension-free groin hernia repair using prosthetic mesh materials has become increasingly popular over the last decade. Laparoscopic inguinal hernia surgery should be comparable to the standard Lichtenstein repair, which has a reported recurrence rate of 0.1–1 per cent. Multiple small studies with relatively short-term follow-up have reported that laparoscopic repair can be performed safely with results that equal or surpass open hernia repair. Although the laparoscopic approach may offer shorter recovery time owing to less pain, only a few large studies have investigated overall differences in complication and recurrence rates.

A number of prospective non-randomized studies have compared laparoscopic and open mesh repair. Objective pain scoring, analgesia use, and complication rates were similar. Laparoscopic repair was shown to be superior to open mesh repairs in terms of faster return to normal activity and return to work. Although recurrence rates did not differ significantly, a short duration of follow-up and small cohort numbers were potential limiting factors to a number of these studies. Laparoscopic repair required longer operating times and, in general, was more expensive; however, more rapid return to work may result in lower overall societal costs following the laparoscopic approach. Randomized clinical trials of open versus laparoscopic repair of primary, unilateral inguinal hernias have shown comparable results with respect to overall complications and recurrences (Table 11.2). Major intraoperative and postoperative complications were uncommon in both groups. However, severe visceral and vascular injuries were more frequent following the laparoscopic approach. Postoperative pain was shown to be less among the laparoscopic groups, possibly contributing to the earlier return to regular activity in patients undergoing laparoscopic hernia repair. However, length of hospital stay was similar in patients undergoing open mesh and laparoscopic repair, with no difference in recurrence rates between open mesh and laparoscopic repair at short- to medium-term follow-up (Table 11.2). Outcomes of randomized trials comparing laparoscopic and open herniorrhaphies have shown less pain and faster recovery following laparoscopic approaches, but at increased cost and slightly greater risk. However, prospective, randomized data comparing laparoscopic versus open bilateral hernia repair are lacking. It would be expected that bilateral open repairs would result in a


doubling of operative time and postoperative pain when compared with laparoscopic repair. The laparoscopic approach for repair of unilateral or bilateral hernias utilizes the same ports, thereby limiting additional time requirements for bilateral herniorrhaphy. In addition, pre-peritoneal repair (TEP/TAPP) avoids the scarring of the anterior groin that follows failed open repair, and it should be expected to be less time-consuming and fraught with fewer complications than open herniorrhaphy for recurrent hernias.

SUMMARY Recurrence rates following various open hernia repair techniques have ranged from less than one per cent to more than ten per cent at long-term follow-up. Laparoscopic techniques that were introduced in the early 1990s show promise in treating unilateral, bilateral and recurrent hernias with respect to less postoperative pain, earlier recovery, and improved cosmesis (Table 11.3). Recurrences that do occur following laparoscopic repair are usually the result of inadequate lateral pre-peritoneal dissection or an inadequate size of the prosthesis. In addition, the skill and experience of the operating surgeon greatly affect the rate of recurrence, such that results during the initial learning curve are worse than later in a surgeon’s operative series. In addition, the lack of an inguinal incision, avoidance of extensive dissection, creation of a tension-free repair, and low complication rates all contribute to more rapid return to normal activity following laparoscopic inguinal hernia repair. Comparing laparoscopic and open inguinal herniorrhaphy, differences in outcomes regarding postoperative pain, return to work, and analgesia requirements have generally favored the laparoscopic approach. However, potential limitations to the laparoscopic approach include increased cost, the requirement for general anesthesia, and a steep learning curve. Disadvantages to laparoscopic hernia repair include the widespread use of general anesthesia and the potential for visceral and vascular complications, unique to the laparoscopic approach (Table 11.4).

Table 11.4 Perceived disadvantages of laparoscopic inguinal hernia repair Requirement for general anesthesia Complications unique to laparoscopic approach Steep learning curve Increased cost

LAPAROSCOPIC FEMORAL HERNIA REPAIR The published literature on femoral hernia repair is inadequate to make firm conclusions regarding the relative safety and efficacy of different surgical approaches. Although a few prospective studies comparing different methods of open femoral hernia repair exist, small study sizes hinder definitive conclusions regarding differences in outcomes. Laparoscopic femoral hernia repair is performed in the same fashion as that for inguinal herniorrhaphy. Reports of laparoscopic femoral hernia repair are, in general, limited to case reports, with no randomized trials comparing open and laparoscopic repair.

REFERENCES 1 2

3

4

5

6

7

8

Table 11.3 Potential advantages of laparoscopic inguinal hernia repair 9

Less difficulty in repairing a recurrent hernia Ability to treat bilateral hernia via same incisions Performance of simultaneous diagnostic laparoscopy (TAPP) Less postoperative pain Reduced recovery time Improved cosmesis

10 11

Juul P, Christensen K. Randomized clinical trial of laparoscopic versus open inguinal hernia repair. Br J Surg 1999; 86: 316–19. Fleming WR, Elliott TB, Jones RM, Hardy KJ. Randomized clinical trial comparing totally extraperitoneal inguinal hernia repair with the Shouldice technique. Br J Surg 2001; 88: 1183–8. Aeberhard P, Klaiber C, Meyenberg A, et al. Prospective audit of laparoscopic totally extraperitoneal inguinal hernia repair: a multicenter study of the Swiss Association for Laparoscopic and Thoracoscopic Surgery (SALTC). Surg Endosc 1999; 13: 1115–20. Katkhouda N, Campos GM, Mavor E, et al. Laparoscopic extraperitoneal inguinal hernia repair. A safe approach based on the understanding of rectus sheath anatomy. Surg Endosc 1999; 13: 1243–6. Farinas LP, Griffen FD. Cost containment and totally extraperitoneal laparoscopic herniorrhaphy. Surg Endosc 2000; 14: 37–40. Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Endoscopic total extraperitoneal repair of primary and recurrent inguinal hernias. Surg Endosc 1999; 13: 507–11. Ferzli GS, Frezza EE, Pecoraro AM, Jr, Ahern KD. Prospective randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair. J Am Coll Surg 1999; 188: 461–5. Frankum CE, Ramshaw BJ, White J, et al. Laparoscopic repair of bilateral and recurrent hernias. Am Surg 1999; 65: 839–42, 842–3. Halkic N, Ksontini R, Corpataux JM, Bekavac-Beslin M. Laparoscopic inguinal hernia repair with extraperitoneal doublemesh technique. J Laparoendosc Adv Surg Tech A 1999; 9: 491–4. Lucas SW, Arregui ME. Minimally invasive surgery for inguinal hernia. World J Surg 1999; 23: 350–5. O’Riordain DS, Kelly P, Horgan PG, et al. Laparoscopic extraperitoneal inguinal hernia repair in the day-care setting. Surg Endosc 1999; 13: 914–17.

Results of laparoscopic inguinal/femoral hernia repair 87 12

13

14

15

16

17

18 19

20

21

22

23

24

Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy. Surg Endosc 1999; 13: 1145–7. Smith AI, Royston CM, Sedman PC. Stapled and nonstapled laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. A prospective randomized trial. Surg Endosc 1999; 13: 804–6. Johansson B, Hallerbäck Glise H, Anesten B, et al. Laparoscopic mesh versus open preperitoneal mesh versus conventional technique for inguinal hernia repair: a randomized multicenter trial (SCUR Hernia Repair Study). Ann Surg 1999; 230: 225–31. Liem MSL, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997; 336: 1541–7. Paganini AM, Lezoche E, Carle F, et al. A randomized, controlled, clinical study of laparoscopic vs open tension-free hernia repair. Surg Endosc 1998; 12: 979–86. Zieren J, Zieren HU, Jacobi CA, et al. Prospective randomized study comparing laparoscopic and open tension-free inguinal hernia repair with Shouldice’s operation. Am J Surg 1998; 175: 330–3. Koninger JS, Oster M, Butters M. Management of inguinal hernia: a comparison of current methods. Chirurg 1998; 69: 1340–4. Payne JH, Jr, Grininger LM, Izawa MT, et al. Laparoscopic or open inguinal herniorrhaphy? A randomized prospective trial. Arch Surg 1994; 129: 973–9, 979–81. Heikkinen T, Haukipuro K, Leppala J, Hulkko A. Total costs of laparoscopic and Lichtenstein inguinal hernia repairs: a randomized prospective study. Surg Laparosc Endosc 1997; 7: 1–5. Beets GL, Dirksen CD, Go PM, et al. Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia? A randomized controlled trial. Surg Endosc 1999; 13: 323–7. Filipi CJ, Gaston-Johansson F, McBride PJ, et al. An assessment of pain and return to normal activity. Laparoscopic herniorrhaphy vs open tension-free Lichtenstein repair. Surg Endosc 1996; 10: 983–6. Aitola P, Airo I, Matikainen M. Laparoscopic versus open preperitoneal inguinal hernia repair: a prospective randomised trial. Ann Chir Gynaecol 1998; 87: 22–5. Wellwood J, Sculpher MJ, Stoker D, et al. Randomised controlled trial of laparoscopic versus open mesh repair for inguinal hernia: outcome and cost. Br Med J 1998; 317: 103–10.

25

26

Champault GG, Rizk N, Catheline J-M, et al. Inguinal hernia repair; totally preperitoneal laparoscopic approach versus Stoppa operation: randomized trial of 100 cases. Surg Laparosc Endosc 1997; 7: 445–50. Khoury N. A randomized prospective controlled trial of laparoscopic extraperitoneal hernia repair and mesh-plug hernioplasty: a study of 315 cases. J Laparoendosc Adv Surg Tech A 1998; 8: 367–72.

FURTHER READING Barkun JS, Wexler MJ, Hinchey EJ, et al. Laparoscopic versus open inguinal herniorrhaphy: preliminary results of a randomized controlled trial. Surgery 1995; 118: 703–10. Champault G, Benoit J, Lauroy J, et al. Inguinal hernia in adults. Laparoscopic surgery versus the Shouldice method. Controlled randomized study in 181 patients. Preliminary results. Ann Chir 1994; 48: 1003–8. Cheek CM, Black NA, Devlin HB, et al. Groin hernia surgery: a systematic review. Ann R Coll Surg Engl 1998; 80 (suppl 1): S1–80. Collaboration EH. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000; 87: 860–67. EU Hernia Trialists Collaboration. Mesh compared with non-mesh methods of open groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000; 87: 854–9. Kozol R, Lange PM, Kosir M, et al. A prospective, randomized study of open vs laparoscopic inguinal hernia repair. An assessment of postoperative pain. Arch Surg 1997; 132: 292–5. Maddern GJ, Rudkin G, Bessell JR, et al. A comparison of laparoscopic and open hernia repair as a day surgical procedure. Surg Endosc 1994; 8:1404–8. Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus open inguinal hernia repair: randomised prospective trial. Lancet 1994; 343: 1243–5. Vogt DM, Curet MJ, Pitcher DE, et al. Preliminary results of a prospective randomized trial of laparoscopic onlay versus conventional inguinal herniorrhaphy. Am J Surg 1995; 169: 84–90.


12 Complications and their management RICARDO V. COHEN, CARLOS A. SCHIAVON, SÉRGIO ROLL AND JOSÉ C.P. FILHO

Anesthesia Events related to laparoscopic access Organ involvement Hydrocele Seroma Vascular injury

89 89 90 90 90 91

The modern era of the treatment of inguinal/femoral hernias has evolved over the past 155 years. From truss support to elective outpatient procedures, the surgical techniques to treat these patients have progressed, such that now surgeons are able to employ the use of laparoscopy to approach these hernias. Laparoscopic approaches allow the inspection of the inguinal and femoral areas bilaterally, thereby avoiding unexpected non-diagnosed contralateral hernias. This method of hernioplasty has been shown to reduce postoperative pain and disability and allows the treatment of bilateral defects in one sitting. But, as in all operative procedures, complications exist. Nothing is more effective in the prevention of the occurrence of complications as one’s awareness and fear of them. In this chapter, complications and their management will be focused on the two most commonly performed laparoscopic inguinal hernia repairs, the transabdominal pre-peritoneal (TAPP) approach and the totally extraperitoneal (TEP) technique.

ANESTHESIA It has been suggested that the general anesthesia needed for laparoscopic herniorrhaphy is a major drawback, and open procedures are preferred because they can be performed under local anesthesia. However, numerous reports have revealed the relative absence of anesthesiarelated complications, probably associated with proper patient selection.4,5 If a medical contraindication, other

Neuropathy Visceral complications Mesh-related problems Recurrence Conclusion References

91 92 93 93 94 94

than age, to general anesthesia exists, then hernias must be repaired through an anterior approach under local anesthesia. No controlled trial has been published that has shown definitely that a local anesthetic is truly superior to carefully administered general anesthesia. Consequently, this does not represent a strong reason to avoid TAPP or TEP.

EVENTS RELATED TO LAPAROSCOPIC ACCESS Inherent to laparoscopy are the insufflation of carbon dioxide and the possibility of systemic alterations following pneumoperitoneum, documented very well in the literature. Additionally, trocar access may carry some intra-abdominal complications, such as major vascular or visceral injuries.3 Blind insertion of the Veress needle or trocars may cause intra-abdominal and abdominal wall complications. In a retrospective study of 103 852 laparoscopic operations (nine per cent inguinal hernias), which involved the insertion of 390 000 trocars, the incidence of serious complications was 3.2/1000 interventions (0.032 per cent).4 Bleeding from the trocar site was the most common complication, accounting for two-thirds of the accidents; this resulted in conversion to an open procedure in 11.3 per cent. Visceral injuries occurred in 0.6/1000 interventions, and the conversion rate was 65 per cent. The incidence of vascular injuries was 0.5/1000, and resulted in six deaths (17 per cent); the

90


conversion rate to laparotomy was 85 per cent. The two most important risk factors were inexperienced surgeons and the introduction of the first trocar, which was responsible for 83 per cent of vascular injuries, 75 per cent of bowel injuries, and 50 per cent of local hemorrhage. Complications are theoretically different depending upon the laparoscopic technique (TAPP or TEP). In TEP, because there is no invasion of the abdominal cavity, major intracavity injuries are very rare. However, there have been reports of enterotomies resulting from the tearing of adhesions during extraperitoneal balloon dissection.5 Another complication related to the laparoscopic approach is trocar site incisional hernia. Although quite uncommon, this is associated particularly with TAPP repair. Because the incidence varies from five to 15 per cent, it is recommended that all port sites over 5 mm should be closed in order to avoid this postoperative complication.

ORGAN INVOLVEMENT Almost all organ complications that follow the laparoscopic treatment of inguinal/femoral hernias are similar to those that follow open techniques. The morbidity rate in open operations is approximately ten per cent.6 Tetik and colleagues in 1994,7 Phillips and colleagues in 1995,8 and Crawford and Phillips in 19989 reported complication rates in the order of 11 per cent. Roll and coworkers, in a large Brazilian multicenter trial of 4000 operated patients, found that the rate of complications was seven per cent.10 Felix and colleagues in 1999 reported an incidence of complications of 6.1 per cent.11 All authors demonstrated that the incidence of the complications were significantly higher in the period of the learning curve and could be reduced to less than one per cent with greater experience.

Testicular complications The two pertinent complications concerning the testicle are ischemic orchitis and testicular atrophy. Postoperative inflammation of the testicle occurs within 24–72 hours following the procedure. The associated pain is severe, usually requiring aggressive and effective analgesia. Ischemic orchitis may progress, resulting in testicular atrophy, a process that may be observed over several months. The mechanism of this complication originates from an intense venous congestion within the testicle, secondary to thrombosis of the veins within the spermatic cord. The initiating trauma is seen during dissection of the spermatic cord from the hernia sac, whether for direct, indirect or femoral hernias, or the TAPP or TEP procedure. The incidence of testicular complications is lower with laparoscopy than

with the conventional techniques, ranging from 0.3 to 5 per cent.12

Vas deferens complications The incidence of vas deferens injuries is about the same (about 0.04 per cent) regardless of whether the hernia repair is performed open or laparoscopically. Trauma to the vas deferens can be one of immediate transection or ultimate obstruction. Transection is a very rare mishap following TAPP or TEP repair. If this does occur, then repair must be attempted unless fertility is not a consideration. Obstruction can result from the vigorous handling of the vas deferens with instruments/graspers, yielding a fibrosis of variable intensity through the muscular wall of the vas deferens. Sometimes, the vas deferens may become adherent to the posterior inguinal floor following the operation and form kinks that may represent an outflow obstruction and hence account for dysejaculation.

HYDROCELE This is an uncommon complication following either laparoscopic approach. It may be secondary to overzealous skeletonization of the spermatic cord or tissue dissection from the sac and at the internal ring. Some authors, in retrospective studies, found a low incidence of hydrocele. When a TEP repair was employed, the incidence reported varied from 0.5 to 1.5 per cent.13,14 Felix and coworkers, in a paper devoted to significant complications following laparoscopic hernia repair, pointed out that the incidence of hydrocele was higher in patients with the use of a mesh that was modified to place a ‘keyhole’ to accommodate the spermatic cord.11 Earlier, in a large, multicenter trial, Phillips and colleagues reported an incidence of 0.2 per cent, regardless of the method of laparoscopic technique.8 In a study of open repairs by Obney and Chan, the incidence of hydrocele formation was 0.9 per cent.15

SEROMA Seromas represent an exudate, normally resulting from the trauma of electrocautery, balloon dissection of the preperitoneal space in the TEP approach, scissors dissection, or foreign bodies, such as sutures and mesh. They are infrequently clinically evident and usually they can be allowed to reabsorb spontaneously. Size may vary, and ultrasound follow-up may be important to determine whether needle aspiration and/or drainage is necessary. Several publications have discussed whether the incidence

Complications and their management 91

of seromas is more common in the TEP or the TAPP approach. Studies by Felix and colleagues,11 Ramshaw and colleagues,16 D’Allemagne and colleagues,17 Kald and colleagues,18 and Cohen and colleagues19 revealed different results regarding the higher incidence of seroma in the TEP approach. It seems plausible that the use of balloon dissection in TEP repair can be more aggressive to the preperitoneal space than the TAPP technique. Consequently, it appears that seromas following TAPP are often smaller and easier to manage than those that follow TEP. Additionally, it is quite rare for a seroma to become encapsulated with such a strong fibrotic capsule that resection is required.

The aggressiveness of the dissection and complete parietalization of the cord structures is the probable cause. Injuries of the aorta were described during TAPP, either secondary to the first blind trocar or during dissection in the inappropriate location and resultant injury to the terminal aorta.20 The introduction of prosthetic materials originally raised some concerns with regard to their proximity to arteries and veins. Flat sheets of prosthetic materials have not been associated with vascular erosions and thrombosis.21

VASCULAR INJURY

Residual neuralgia following laparoscopic hernia repair represents the most vexing complication of the inguinal region. The absence of convincing objective tests and the subjective nature of the complaints do not favor an easy resolution of the problem. The femoral branch of the genitofemoral nerve, the lateral cutaneous nerve of the thigh, and the intermediate cutaneous branch of the femoral nerve are at risk of damage during laparoscopic inguinal hernioplasty because of:

Bleeding from arteries or veins can occur at all anatomic levels during an inguinal hernia repair. Superficially, subcutaneous hematomas or severe ecchymoses can result from injuries to superficial vessels, such as the epigastric artery or vein. The dissection in the space of Bogros during TAPP, if careless, may incur bleeding that is usually insidious and may result in large hematomas that can extend from the anterior abdominal wall to the scrotum. During TEP, it is recommended after balloon insertion and insufflation to keep the balloon full of air for five to seven minutes to allow for better hemostasis. Injuries below the iliopubic tract to the major vessels, such as the iliac and femoral artery and vein, can occur and obviously must be controlled swiftly. All control of bleeding must be done under direct vision. Blind clamping and the use of deep suture ligatures must be avoided. Careful postoperative observation must be instituted, and early detection of vascular complications is important. Injury to the inferior epigastric vessels is not infrequent during the learning curve. As this injury is diagnosed, the vessels should be clamped; posterior clip ligation is the desirable treatment. No adverse sequelae have been reported when the inferior epigastric vessels have been ligated. The presence of an aberrant obturator artery originating from the deep inferior epigastric artery can be the source of bleeding when tacks or staples are anchored to the ligament of Cooper. Care must be taken, and acknowledgment of its existence underneath the mesh is very important. If this bleeding is managed poorly, the result can be a bloody operative field that can be an obstacle to the completion of the procedure. This dangerous injury must be avoided. This complication has earned the artery the unenviable designation of the ‘artery of death’. Injuries to the spermatic vessels are more common during the learning curve for both TAPP and TEP procedures.

NEUROPATHY

• • • • •

a failure to appreciate the anatomy from the posterior aspect; difficulty in visualizing the nerves pre-peritoneally; the variable course of the nerves in this region; improper staple placement; extensive pre-peritoneal dissection.

The incidence of neurological complications varies with the technique (TAPP, 1.2–2.2 per cent; TEP, 0–0.5 per cent).22,23 The main clinical features of genitofemoral nerve injury consist of intermittent or constant pain and burning sensations in the inguinal region, with radiation of pain to the genitalia and upper medial thigh. As the mechanism of injury is defined poorly, its diagnosis may be imprecise and available treatment options are varied. The best way to minimize this kind of complication is to avoid any extensive dissection of the posterior pelvis and to avoid placement of staples or tacks below the iliopubic tract, thereby keeping far away from the triangle of doom and the trapezoid of disaster (Figure 12.1).24 A study in 50 cadaveric inguinal regions by Rosen and Halevy demonstrated that the mean safe distance to avoid any possible contact with the genitofemoral nerve or the lateral femorocutaneous nerve during fixation is 3.95 cm lateral to the internal inguinal ring.25 To take all anatomic variations into account, Rosen and Halevy recommended placement of staples no further than 1.5 cm lateral to the lateral border of the internal inguinal ring. This location of fixation, in addition to the non-extensive dissections and the avoidance of manipulation or stapling below the

92


(a)

of the pain. Electromyography may also be helpful. The management is controversial and multimodal. Initial efforts at clinical control with non-steroidal antiinflammatory drugs, rest, and eventually infiltration with local anesthetics are frequently helpful. If inguinodynia persists, and sensory/motor deficit is present on examination, then immediate exploration and staple removal should be considered. If there is mild pain relief, then local infiltration may be a good step, but if local-ized tenderness persists with positive Tinel’s sign, then removal of the staple/tack or mesh or neurectomy may be required. If re-exploration is undertaken, care must be exercised during the removal of the staples/tacks and/or mesh. The removal of the mesh or staples may disrupt the structural integrity of the hernia repair. It should also be realized that removal of the prosthesis could be a very difficult procedure that could pose a threat of injury to contiguous structural injuries, such as the iliac vessels.

VISCERAL COMPLICATIONS Urinary bladder complications

(b)

Laparoscopic hernia repair is associated with urinary complications with an incidence of 1.5–5 per cent, including retention, infection and hematuria.26 Bladder injury with closed peritoneal access is rare but possible. It may be adherent or it may ‘slide’ into a direct or femoral hernia. The most common offender is the Veress needle, followed by the first blind trocar. There is an increased risk in patients with previous dissection in the preperitoneal space or space of Retzius, such as a prior laparoscopic hernia repair or prostatectomy.

Intestinal complications

(c)

Figure 12.1 (a) TAPP – anatomical view: (1) Cooper’s ligament; (2) vas deferens; (3) spermatic cord; (4) nerve area below the iliopubic tract; (5) iliopubic tract; (6) internal ring. (b) Black area, triangle of doom; red area, trapezoid of disaster. (c) Recurrence Mesh invagination in the defect.

iliopubic tract, are the most effective tools to avoid neuralgia paresthetica that may follow the laparoscopic approach to groin hernias. The ilio-inguinal nerve and the ilio-hypogastric nerve are more superficial structures, making them easier to injure in open repair than in the laparoscopic method. Diagnosis can be made after careful anatomical localization

Bowel obstruction is almost unheard of with conventional repair, but it can be associated with the laparoscopic approach, particularly TAPP. However, its incidence in the literature is low, ranging from 0.06 to 0.2 per cent.27 The complication was frequent in the developmental stages secondary to inadequate peritoneal closure over the prosthesis, allowing bowel to migrate into the preperitoneal space, which could result in intestinal obstruction. The major advantage of the TEP procedure is the theoretical avoidance of this problem, as the peritoneal sheath is kept untouched. Another situation, related almost solely to TAPP repair, is the lack of appreciation of the need to close trocar sites. If one considers any hernia as a part of a systemic abdominal wall disease, then it is mandatory to close all fascial defects, avoiding potential port site hernias. The incidence of delayed bowel obstruction related


to adhesions because of the intra-abdominal nature of TAPP has yet to be determined but would appear to be extremely low. Intraoperative laceration of incarcerated or sliding (large bowel) hernias must be avoided and currently are reported rarely. Following general principles of gentle surgical technique, this kind of problem should seldom be found.

Bone complications Bone-related complications were very rare before the laparoscopic era. Today, osteitis pubis after the learning curve is an avoidable complication. The usual mechanism of injury is tacking/stapling the mesh while anchoring it over the periosteum. Oral analgesia and eventually local infiltration may be a good way to initiate treatment of this complication. If unsuccessful, re-exploration with tack/staple removal is the best alternative to treat such a painful complication. It is a personal observation that pubic pain is more frequent when employing tacks rather than the regular hernia staples, probably due to their penetration into the bone.

Skin complications In major series, ecchymoses and subcutaneous emphysema were reported, but these are self-limiting and without major consequences. Skin infections are very rare following laparoscopic repair, and there are no situations that impose a higher risk in either TAPP or TEP.

required, due to their pore diameter, the inability of drainage through them, and impaired macrophage migration and activity. When systemic conditions are unstable and sepsis is present, an aggressive surgical approach is the rule. One should never forget, however, that removal of an infected mesh could be perilous, as firm adhesions to local structures such as major vessels may be found. Fortunately, the incidence of infections in the laparoscopic era varies from 0 to 0.6 per cent.6,28 Rarely, delayed infections may be seen months or years later. The mechanism in this delay is not understood. Conservative management is the choice, and mesh removal is required rarely, subject to the above discussion.

Mesh and infertility Although infertility is not usually reported after hernia repair, a few reports from fertility clinics have shown an association of infertility and previous hernia repair, without accounting for vas deferens injuries or ‘overmanipulation’. The placement of large meshes in the preperitoneal space in TAPP or TEP repair may lead to fibrosis in the proximity of the vas deferens and may predispose to an unknown effect on its function, without any clear vas luminal obstruction. Further studies are needed. It should be noted that it is important to avoid extensive manipulation of the cord structures and vas deferens in men of reproductive age to avoid affecting fertility.

RECURRENCE MESH-RELATED PROBLEMS The introduction of prosthetic mesh in an inguinal hernioplasty is a standard procedure today. Mesh placement allows tension-free repair, leading to significantly lower recurrence rates, but its main complication – infection – poses a series of special management problems. The use of monofilament biomaterials carries a theoretic advantage over the braided biomaterials. Pores in braided yarns and expanded polytetrafluoroethylene (ePTFE) are smaller than macrophages, which implies that an infection associated with these types of mesh affects its management. The presence of infection does not necessarily mandate removal of a polypropylene or polyester mesh, unless the mesh is sequestered or is bathing in a purulent exudate. The infection is predominantly in the surrounding tissue, and abscess drainage and aggressive clinical management with broad-spectrum antibiotics are required. However, when a braided mesh or ePTFE prosthesis is employed, their removal is almost always

As stated by Rutkow in 1995, recurrences are not a parameter of success in the surgical repair of groin hernias;29 rates higher than three per cent are unacceptable, and if any technique reports recurrences higher than that number, then it should be abandoned. However, despite Rutkow’s reasonable ideas on recurrence, and the increasing popularity of the comparison of outcomes by measurement of postoperative pain, return to work, patient satisfaction, and cost, the standard by which any repair is measured is its recurrence rate. That rate in laparoscopic techniques has fallen gradually as experience and knowledge of the anatomy and mesh sizes have improved. Recurrence may be due to a variety of mechanisms, including:

• •

incomplete dissection, with missed hernias, inadequate identification of anatomical landmarks, and the prosthesis being allowed to roll up instead of lying flat; mesh being too small, therefore not covering all potential defects;

94


Table 12.1 Recurrences in large multicenter trials No. hernias

Recurrence (%)

REFERENCES Mean follow-up (months)

1

2

Reference

Repair

Tetik et al. (1994)7

TAPP TEP

553 457

0.7 0.4

13

Fitzgibbons et al. (1995)27

TAPP TEP

562 87

5 0

23

Phillips et al. (1995)8

TAPP TEP

1944 578

1 0

22

• • • •

3

migration of the mesh; mesh slit (the slit is the site of the recurrence); folding or invagination of the mesh into the defect; displacement of the mesh by hematoma.

The first reports with the abandoned laparoscopic plug or plug-and-patch reported recurrence rates of 25 per cent.30 As experience and knowledge of the anatomy and mesh size have grown, so recurrence rates have decreased. Evaluation of large multicenter trial results reveals the low recurrence rates for TEP (Table 12.1). Tetik and coworkers reported a 0.4 per cent incidence of recurrence in TEP,7 whereas no recurrences were reported in 578 patients by Phillips and colleagues8 or in 87 repairs by Fitzgibbons and colleagues.27 It is important to stress that the vast majority of surgeons throughout the world began their experience and learned the TAPP procedure first; TEP came later, bringing more comfort with the anatomy and handling the mesh better. Adoption of the TEP technique by many of these surgeons occurred later, thereby providing a higher level of comfort with the anatomy, and better handling and sizing of the mesh for the laparoscopic procedure. This may explain the relatively lower recurrence rates with TEP than with TAPP in these large trials.

CONCLUSION Over the past 15 years, laparoscopic hernioplasty has made the transition from an experimental to a proven procedure. With increasing laparoscopic skills, many surgeons are now faced with the question of when to recommend a laparoscopic approach to their patients. Complication and recurrence rates, although initially higher than traditional repairs, have now fallen to equal or lower levels at centers experienced in laparoscopic techniques. Prospective randomized trials prove that when patients are selected properly and surgeons are trained, TAPP or TEP repairs may be performed with reasonable rates of complications and recurrence.

4

5 6 7

8 9 10

11 12

13 14

15 16

17

18

19 20

21

22

Arvidsson D, Smedberg S. Laparoscopic compared with open hernia surgery: complications, recurrences and current trends. Eur J Surg 2000; 585: 40–47. Moreno-Egea A, Aguayo JL, Canteras M. Intraoperative and postoperative complications of totally extraperitoneal laparoscopic inguinal hernioplasty. Surg Laparosc Endosc 2000; 10: 30–33. Baadsgard SE, Egelblad K. Major vascular injury during gynecologic laparoscopy: report of a case and review of published cases. Acta Obstet Gynecol Scand 1989; 68: 283–5. Champault G, Cazacu F, Taffinder N. Serious trocar accidents in laparoscopic surgery: a French survey of 103,852 operations. Surg Laparosc Endosc 1996; 6: 367–70. Topal B, Hourlay P. Totally preperitoneal endoscopic inguinal hernia repair. Br J Surg 1997; 84: 61–3. Bendavid R. Complications of groin hernia surgery. Surg Clin N Am 1998; 78: 1089–2000. Tetik C, Arregui M, Castro D. Complications and recurrences associated with laparoscopic repair of groin hernias: a multiinstitutional retrospective analysis. In: Arregui M, Nagan RF, eds. Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe Medical Press, 1994: 494–500. Phillips EH, Arregui M, Caroll BJ, et al. Incidence of complications following laparoscopic hernioplasty. Surg Endosc 1995; 9: 16–21. Crawford DL, Phillips EH. Laparoscopic repair and groin hernia surgery. Surg Clin N Am 1998; 78: 1047–62. Roll S, Cohen R, Miguel P, et al. Laparoscopic transabdominal inguinal hernia repair with preperitoneal mesh. Surg Endosc 1994; 8: 485. Felix EL, Harbetson N, Vartanian S. Laparoscopic hernioplasty. Significant complications. Surg Endosc 1999; 13: 328–31. Cohen RV. Laparoscopic transabdominal preperitoneal hernia repair. Doctoral thesis presented to the Department of Surgery, University of Sao Paulo, Brazil. Sao Paulo, Brazil: University of Sao Paulo Press, 1996: 43–57. Ferzli G, Massad A, Albert P. Extraperitoneal endoscopic inguinal hernia repair. J Laparoendosc Surg 1992; 2: 281–5. McKernan B, Laws HL. Laparoscopic repair of inguinal hernias using a totally extraperitoneal prosthetic approach. Surg Endosc 1993; 7: 26–8. Obney N, Chan CK. Hydrocoeles of the testicle complicating inguinal hernias. Can Med Assoc J 1956; 75:733–6. Ramshaw B, Tucker JG, Conner T, et al. A comparison of the approaches to laparoscopic herniorrhaphy. Surg Endosc 1996; 10:29–32. D’Allemagne B, Markiewicz S, Iehaes C. Extraperitoneal laparoscopic inguinal hernia repair: technique and results. Surg Endosc 1996; 10: 228–34. Kald A, Anderberg B, Smedh K. Transperitoneal or totally extraperitoneal approach in laparoscopic hernia repair. Surg Laparosc Endosc 1997; 7: 86–9. Cohen RV, Alvarez G, Roll S, et al. Transabdominal or totally extraperitoneal hernia repair? Surg Laparosc Endosc 1998; 8: 264–8. Oshinsky GS, Smith AD. Laparoscopic needles and trocars: an overview of designs and complications. J Laparoendosc Surg 1992; 2: 117–25. Kathkouda N. Avoiding complications of laparoscopic hernia repair. In: Arregui M, Fitzgibbons R, Kathkouda N, eds. Principles of Laparoscopic Surgery: Basic and Advanced Techniques. New York: Springer-Verlag, 1995: 435–8. Starling JM. Genitofemoral neuralgia. In: Arregui M, Nagan RF, eds. Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe Medical Press, 1994: 213–17.

Complications and their management 95 23

Eubanks S, Newman L, Goehring L, et al. Meralgia paresthetica: a complication of laparoscopic herniorrhaphy. Surg Laparosc Endosc 1993; 3: 381–5. 24 Seid AS, Amos E. Entrapment neuropathy in laparoscopic herniorrhaphy. Surg Endosc 1994; 8: 1050–53. 25 Rosen A, Halevy A. Anatomical basis for nerve injury during laparoscopic hernia repair. Surg Laparosc Endosc 1997; 7: 469–71. 26 Payne JH. Complications of laparoscopic herniorrhaphy. Semin Laparosc Surg 1997; 4: 166–81. 27 Fitzgibbons RJ, Camps J, Cornet DA, Annibali R. Laparoscopic inguinal herniorrhaphy: results of a multicenter trial. Ann Surg 1995; 221: 3–13.

28

MacFadyen BV. Laparoscopic inguinal herniorrhaphy: Complications. In: Arregui M, Nagan RF, eds. Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe Medical Press, 1994: 284–96. 29 Rutkow I. The recurrence rate in hernia surgery. How important is it? Arch Surg 1995; 130: 575–8. 30 Schultz L, Graber J, Pietrafitta J. Laparoscopic laser herniorrhaphy: a clinical trial preliminary study. J Laparoendosc Surg 1990; 1: 41–5.


PART

3

Laparoscopic incisional and ventral hernioplasty

13 14 15 16 17 18

History Anatomy and physiology Laparoscopic repair in the emergent setting Herniorrhaphy with the use of transfascial sutures Pre-peritoneal herniorrhaphy Hernioplasty with the double-crown technique

99 103 111 115 125 133

19 Parastomal hernia repair 20 Lumbar hernia and ‘denervation’ hernia repair 21 Results of laparoscopic incisional and ventral hernia repair 22 Complications and their management

143 151 155 161


13 History KRISTI L. HAROLD, BRENT D. MATTHEWS AND B. TODD HENIFORD

Laparoscopic ventral herniorrhaphy Adoption of procedure

99 100

Ventral hernias present a challenging surgical problem. Approximately 3–11 per cent of all laparotomy incisions develop a fascial defect, resulting in 90 000 ventral hernias repairs each year.1 Due to the high rate of recurrence with simple suture closure, the techniques of hernia repair have evolved from primary repair to those employing biomaterials. More recently, surgeons’ options have expanded to include repairs using minimally invasive approaches. Primary repairs involve suturing of the aponeurotic layers of the abdominal wall to close defects, along with unique variations such as the ‘vest-over-pants’ technique developed by William J. Mayo in 1895. To repair large defects, in the 1920s Gibson introduced the concept of relaxing incisions, which allowed closure of the abdominal wall in the midline with reduced tension.2 Despite the various and inventive techniques for primary repair, the recurrence rate after primary repair remained unacceptably high, spurring the development of biomaterials to repair abdominal wall defects in the first half of the twentieth century. The first biomaterials employed for hernia repair were metallic. Silver wire mesh, tantalum mesh, and stainlesssteel mesh were all used in an attempt to create stronger hernia repairs. The metallic prostheses, however, led to problems such as erosion, fragmentation, fistulas, and patient intolerability. Hence, a variety of synthetic polymeric meshes were developed, leading to a revolution in hernia repair. Francis Usher introduced monofilament polypropylene mesh in 1958, and today this is the most commonly used mesh. Polyester mesh, which is very popular in Europe, was also introduced in the 1950s. Expanded polytetrafluoroethylene (ePTFE) was added


100 100

to the armamentarium of biomaterials in the 1970s and has become a popular prosthetic for ventral/incisional hernia repair.3 The introduction of tension-free repair with biomaterials has drastically reduced the recurrence rate of abdominal wall hernias. In several studies, the addition of prosthetic mesh has reduced hernia repair failure by more than 50 per cent.4 Nevertheless, the techniques developed by Stoppa and others to employ meshes for repair involve large areas of tissue-flap dissection and create significant patient morbidity, including wound complications, infection, a need for drains, and pain.5 Advances in minimally invasive surgery prompted the first attempts at laparoscopic ventral hernia repair in the early 1990s.6 These techniques eliminated the need for wide soft-tissue dissection and large incisions, and it was hoped that there would be a corresponding decrease in morbidity, such as was seen in the transition from conventional to laparoscopic cholecystectomy.

LAPAROSCOPIC VENTRAL HERNIORRHAPHY Initial laparoscopic ventral hernia repairs were usually performed by placing a large intraperitoneal prosthesis and securing it to the anterior abdominal wall with hernia staples or spiral tacks.6–8 Recurrences secondary to the mesh pulling free from the abdominal wall or migration with the peritoneum into the hernia prompted most surgeons to adopt a fixation technique that employs

100 Laparoscopic incisional and ventral hernioplasty

transfascial non-absorbable sutures in addition to staples or tacks to secure the mesh.7,9 Surgeons also recognized that the lack of overlap of the defect by the prosthesis contributed to recurrent hernia formation.10 This has led to the recommendation that at least a 3-cm overlap be provided circumferentially. Many surgeons advocate a 4–6-cm circumferential overlap if the mesh can be placed without undue technical difficulty. We and others often underlay the entire previous incision, even if it is not involved with the hernia, to prevent the development of another hernia above or below the repaired defect. The choice of prosthetic material for laparoscopic ventral hernia repair is varied and often debated. By far, however, the most frequently used mesh has been expanded polytetrafluoroethylene (ePTFE). While some authors have reported the use of polypropylene or polyester materials for laparoscopic ventral herniorrhaphy without complication,8 these biomaterials lead to adhesion formation and have been associated with intestinal erosion and fistula formation in up to five per cent of patients when placed intraperitoneally.11 Accordingly, the trend has been toward the use of PTFE in most hospitals.

ADOPTION OF PROCEDURE While laparoscopic inguinal herniorrhaphy enjoyed a rather quick acceptance after its introduction, the popularity of laparoscopic ventral hernia repair has arrived somewhat more slowly. This can probably be attributed to the inherent difficulty of the adhesiolysis in the previously operated abdomen and the need for surgeons with limited laparoscopic experience to apply large pieces of mesh. A search of Medline and Embase demonstrated only three articles concerning the procedure published in 1992, the year that laparoscopic ventral herniorrhaphy was introduced. However, interest in the technique increased, and by 1994, 13 publications were posted. There has been a steady or increasing number since that time, and now more than 100 peer-reviewed articles concerning laparoscopic ventral hernia have been published (Table 13.1). Additionally, the number of patients included in single and multi-institutional studies has continued to grow. Currently, well over 1000 patient outcomes have been reported in peer-reviewed articles, and one manuscript details the outcomes of more than 400 patients.9 Use of the technique for laparoscopic ventral herniorrhaphy has also been reported in cases of unusual defects, such as lumbar hernias, parastomal hernias, and diaphragmatic hernias.12–14 While the number of patients in these series is small, the outcomes have been positive, and the laparoscopic approach seems uniquely suited for defects located in challenging anatomical locations.

Table 13.1 Number of articles published concerning laparoscopic ventral hernia repair by year (Medline and Embase search) Publication year

Number of articles published

2001 2000 1999 1998 1997 1996 1995 1994 1993 1992

18 19 11 13 9 12 8 13 3 3

CONCLUSION The future of laparoscopic ventral and incisional hernia repair is promising. Many studies now document a low recurrence rate with this technique, as well as minimal patient morbidity afforded by the laparoscopic approach. While advances in biomaterials and mesh-fixation devices may lead to future modifications in this technique, the ability to perform tension-free repair by a minimally invasive approach is a positive milestone in the history of hernia surgery.

REFERENCES 1 2

3 4

5

6

7

8 9

Mudge M, Hughes LE. Incisional hernias: a 10-year prospective study of incidence and attitudes. Br J Surg 1985; 72: 70–71. Flament JB, Palot J, Burde A, et al. Treatment of major incisional hernias. In: Bendavid R, Abrahamson J, Arregui M, et al., eds. Abdominal Wall Hernias: Principles and Management. New York: Springer-Verlag, 2001: 508–16. DeBord JR. The historical development of prosthetics in hernia surgery. Surg Clin North Am 1998; 78: 973–1006. 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 2000; 343: 392–8. White TJ, Santos MC, Thompson JS. Factors affecting wound complications associated with prosthetic repair of ventral hernias. Am Surg 1998; 64: 276–80. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy: our initial 100 patients. Hernia 2001; 5: 41–5. Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and incisional hernioplasty. Surg Endosc 1997; 11: 32–5. Heniford BT, Park A, Ramshaw B, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000; 190: 645–50.

History 101 10

11

LeBlanc KA. The critical technical aspects of laparoscopic repair of ventral and incisional hernias. Am Surg 2001; 67: 809–12. Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998; 133: 378–82.

12

Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of lumbar hernias. J Am Coll Surg 1998; 187: 147–52. 13 LeBlanc KA, Bellanger DE. Laparoscopic repair of paraostomy hernias: early results. J Am Coll Surg 2002; 194: 232–9. 14 Matthews BD, Bui H, Harold KL, et al. Laparoscopic repair of traumatic diaphragmatic hernias. Surg Endosc 2003; in press.


14 Anatomy and physiology KARL A. LEBLANC

Anatomy and function Anatomy of a hernia Anatomical considerations in the repair of abdominal wall defects Effects of biomaterial placement in laparoscopic herniorrhaphy

103 105 106

Maturation of the hernia repair Cosmetic result Functional result Conclusion References

108 109 109 110 110

107

The abdominal wall is a complex structure with a multitude of components, including skin, muscles, aponeuroses, fat and mesothelium. This musculo-aponeurotic structure is attached to the vertebral column posteriorly, the pelvic bones inferiorly, and the ribs superiorly. The integrity of the abdominal wall is essential for protecting the underlying organs, allowing for movement of the trunk of the body, providing assistance in respiration, and preventing herniation of the intra-abdominal contents. Breaches in this integrity can occur with incisions, drainage tubes, and postoperative complications. Furthermore, the closure of the incisions is affected by the method of closure, the type of suture used, and the development of wound sepsis. Recent studies have even identified that the suture technique, the suture length to wound length ratio, and the suture tension have an effect on the ultrastructural composition of the regenerating tissue and collagen composition.1 Despite the importance of this portion of the body, many surgeons have little knowledge of the anatomical details as they relate to the function of the structure. All physicians know of the need for the disruption of its structural integrity during the course of an operation that requires access to the abdomen and sometimes the retroperitoneum. The factors that influence both the prevention and development of hernias are frequently overlooked during the closure of wounds. The result can be predisposition to a fascial defect that will allow extraabdominal migration of the contents of the abdomen.

This hernia, in turn, can result in complications such as incarceration, strangulation, loss of domain, and significant cosmetic deformities. Therefore, the approximation of the abdominal wall as the final act of laparotomy should be considered to be as important as the intraabdominal procedure that necessitated the incision. This represents the optimum opportunity to avert the development of herniation in the future. Once a hernia has developed and a surgeon is to repair the fascial defect, many considerations influence the herniorrhaphy or hernioplasty chosen, whether open or laparoscopic. The aim of this chapter is to familiarize the laparoscopic hernia surgeon with a working knowledge of the anterior abdominal wall. This understanding is important because the anatomical basis of the repair of incisional and ventral hernias is necessary to assure an optimal result, structurally, functionally and cosmetically.

ANATOMY AND FUNCTION The functional anatomy of the abdominal wall centers upon the flat muscles that provide protection and retention of the abdominal viscera. These muscles also provide assistance in respiration and allow movement of the mid-portion of the body. These components include the rectus abdominus, external oblique, internal oblique, and transversus abdominus muscles.


Rectus abdominus muscle This muscle extends from the xiphoid process and the lower rib margins to the pubis. The entire length of this muscle inserts into the linea alba in the midline of the abdomen. Because the linea alba is the site of the most frequent point of entry into the abdomen for open surgical procedures, this is the site that most commonly becomes the site of herniation. We have found that approximately 80 per cent of the incisional hernias that we repair laparoscopically are located in the midline of the abdomen.2 The rectus muscle, when contracted, will bring the xiphoid and ribs closer to the pubis. It also acts to contain the viscera in concert with the other flat muscles of the abdominal wall. The function of the rectus will be compromised after the development of a hernia at the site of the linea alba. The laparoscopic repair of midline hernias does not re-approximate the linea alba. A few centers make an effort to close this defect when possible, but the vast majority of surgeons make no effort to do so. Therefore, in most cases the normal function of the rectus is not restored to its native state. The placement of the prosthetic biomaterial will reconstruct the containment function of the muscle, but it will improve its motor functions only minimally, if at all. However, the contraction of the scar of the hernia itself will result in a mild to moderate reduction in the size of the gap of the linea alba in many patients. Some laparoscopic surgeons use the posterior rectus sheath of the rectus within which to perform the operative procedure and to place the prosthetic material. This posterior rectus sheath is entered, the hernia is reduced, and the repair is performed within that space. This provides for an extraperitoneal operation similar to that of the laparoscopic inguinal herniorrhaphy and the Rives–Stoppa repair. The space limitations of this operative field make the approach impractical for very large and/or incarcerated hernias that do not reside within the rectus sheath, such as Spigelian or lumbar hernias. It has also not been proven that this method of repair improves the functionality of the muscles to a greater extent than that provided by intraperitoneal placement of prosthetic biomaterial. The extraperitoneal repair that is described in Chapter 17 does not afford any differences as to the function of the linea alba because it is not re-approximated in this repair.

External oblique muscle This outermost layer of the flat muscles of the wall of the abdomen arises from the lowest seven or eight ribs and courses obliquely downward and towards the midline. There, it interdigitates with the fibers of the contralateral external oblique. The fleshy muscle fibers insert on the

anterior iliac spine and the iliac crest. This muscle, in concert with the internal oblique and the transversus abdominus muscles, functions to contain the abdominal viscera. Bilateral contraction of the external oblique lowers the ribs, thereby bringing the thorax closer to the pelvic brim. In this manner, it functions as an accessory muscle of expiration. Unilateral contraction of this muscle causes the opposite hemithorax to depress and rotate toward the side of muscle contraction. The function of this muscle can be compromised by the development of the hernias that are located away from the midline of the abdomen. Such hernias include subcostal incisional, post-appendectomy, post-colostomy and Spigelian hernias. Because of the lack of re-approximation of the edges of the fascial defect during laparoscopic repair, expiratory function will not resume the efficiency that was present before the herniation. The extent of this effect will be dependent upon the size of the fascial defect and the tone of the other muscles of the abdomen.

Internal oblique muscle These fibers course beneath those of the external oblique muscle in an opposite direction. The muscle runs from the pelvic brim upward and medially to the thoracic cage and the linea alba. The function of the internal oblique muscle is similar to that of the external oblique muscle, but its unilateral contraction results in rotation and lowering of the thorax on the ipsilateral side of the contraction. Consequently, laparoscopic hernioplasty has an effect on the internal oblique muscle that is similar to that seen in the external oblique muscle.

Transversus abdominus muscle This innermost muscle layer of the abdominal wall inserts posteriorly on to the lower six ribs, the lumbodorsal fascia, the iliac crest, and the iliopsoas fascia. It also inserts on the medial surface of the costal portion of the lower seven or eight ribs and interdigitates with the insertions of the diaphragm. It is a very important component of respiration as it is the main antagonist of the diaphragm. As such, it could be considered a key muscle of expiratory function. It acts in this role by displacing the visceral contents under the diaphragm at the end of the initial stage of diaphragmatic inspiration. Because of its position within the layers of the abdominal wall, the transversus abdominus muscle is also the major component of the containment function of these muscles. Because of its structure, it has a powerful action that results in traction on the abdominal wall. It is this action that results in the tendency of the margins of the laparotomy incision to separate. This act, of rapid retraction, explains the dehiscence that can occur acutely

Anatomy and physiology 105

with a vertical midline laparotomy incision. It also accounts for the difficulty encountered during attempts to provide closure of the midline following dehiscence or after development of midline incisional hernias. One of the advantages of laparoscopic hernioplasty and the use of a prosthetic biomaterial is that the forces of traction by this muscle are diminished. Therefore, the function of the transversus abdominus that would weaken or destroy a tissue re-approximating type of repair is averted. Conversely, the use of prosthetic material to bridge the gap that is created by the hernia does little to correct the respiratory function that is lost after such an occurrence. Much is known about the function of the muscles of the abdominal wall before the occurrence of a hernia, but few studies have examined the effects of the muscle function after incisions through them or after the development and subsequent repair of the hernias. These studies are needed to assess the ability of these operations to restore the function of these muscles other than that of the retention of the viscera within the abdomen (see below).

ANATOMY OF A HERNIA Approximately 90 per cent of non-inguinal hernias of the abdominal wall result from an incision through the aponeurotic layer. The loss of integrity of the transversalis fascia predates its development. Additionally, poor nutritional status, infection, pulmonary disease, steroid usage, and morbid obesity can potentiate the weakening effects of such an incision. Initially, one may not recognize that a hernia has developed as it could take several months for this to become apparent. Sometimes, however, a postoperative incisional infection will be of such severity so as to delineate the fascial defect before discharge of the patient from hospital. There is a five-fold increase in the occurrence of incisional hernias following an infection in the wound. The edges of the fascial defect may be difficult to demarcate preoperatively by the surgeon because of obesity and/or incarceration. The muscle layers will be forced aside from the herniation of the pre-peritoneal tissues or intra-abdominal contents. The herniated structures can be pre-peritoneal fat, omental fat, or small or large intestine. Rarely, other organs can herniate. Frequently, these organs will be fixed to one another due to adhesions that have developed after the initial operation. Generally, as the number of the intra-abdominal operations increases, so does the probability of encountering more numerous and denser adhesions. Each additional operative procedure increases these odds, especially if the patient has had a previous hernia repair using a polypropylene mesh.

Most incisional and ventral hernias will be single defects within the fascia. The layers of muscle and fascia will be displaced from the normal position into all directions from the hernia. This results from the traction effects of the flat muscles of the abdomen. Approximately 22 per cent will be of the multiple defect (‘Swiss-cheese’) variety.1 In these cases, the muscle will be displaced laterally from the defect, but the fascia will be intact between the hernias. This will create one or many ‘fascial bridges’ separating the various hernias. In either of these hernia anatomic variations, the peritoneal surface of the hernia will then be covered with preperitoneal fat (if any exists), subcutaneous fat, and the skin of the abdominal wall. In some patients, there may be a lack of any tissue between the hernia sac and the skin. If this is encountered, good judgment will dictate that no energy source, such as electrocautery or ultrasonic dissection, should be utilized in that area during the dissection of adhesions. This will avoid the application of heat in the area, which might otherwise cause necrosis of the compromised skin surface and exposure of the underlying prosthetic biomaterial. Numerous types of incisions are used to enter the abdomen, obviously influenced by the intra-abdominal procedure to be performed. Because of this, some patients may have separate and distinct hernias in more than one location. This is not infrequent in patients who have temporary colostomies placed after diverticular perforation of the colon. These are particularly well suited for the laparoscopic approach as both hernias can be repaired simultaneously without the requirement of two separate incisions. A similar situation is seen in patients who present with both incisional and inguinal hernias. The tissue disruption that can be seen following the flank incisions for anterior lumbar interbody fusions and nephrectomies are not usually hernias. This problem is not a true defect in the fascia but is the result of denervation of the musculature caused by the incision itself. The flat layer of muscles becomes paralytic. This loss of tissue support results in a broad area of weakness that is unsightly and frequently symptomatic. While there is no true fascial defect in the usual case, occasionally one will note intestinal contents in a fascial defect within the area of muscle paralysis (see Chapter 20). Finally, hernias that occur without a premorbid event are known as primary hernias. These include epigastric and umbilical hernias. These can represent 10–20 per cent of abdominal-wall hernias in most series (excluding inguinal hernias). These patients, however, will incur a weakness in the transversalis fascia that results in herniation of pre-peritoneal fat and/or the intra-abdominal contents (Figure 14.1). Predisposing factors include low birth weight, steroid usage, pulmonary disease, urological disorders, trauma and obesity. Despite the origin, the


Figure 14.1 Attenuated epigastric fascia (arrows) in a patient with an umbilical hernia.

concepts of the laparoscopic repair of these hernias are not changed. There is only limited information regarding the function of the abdominal wall once herniation develops. Of course, the development of a hernia mandates a loss of the retention function of the muscles of the abdominal wall. It is felt that there is also a decrease in the respiratory function of the flat muscles as they have now been compromised. With chronic incisional herniation, the affected muscles are no longer inserted into the midline and are initially hypertonic. Over time, these muscles undergo ultrastructural changes that result in hypotonicity. The resultant musculofascial changes increase the risk of recurrence with the sutured repair. For this reason, the use of a prosthesis is preferred. Large hernias can result in a paradoxical motion of the abdominal wall with respiration. As the diaphragm is moved inferiorly to inspire, this action increases the intraabdominal pressure, which then forces the hernia outward. In this case, the respirations are shallower than normal, which can be revealed as exertional dyspnea. This will worsen as the hernia enlarges, but compensatory mechanisms will normalize the respiratory exchanges at the expense of increased respiratory work.3

ANATOMICAL CONSIDERATIONS IN THE REPAIR OF ABDOMINAL WALL DEFECTS The goal of abdominal-wall hernioplasty is the restoration of the integrity of the covering of the abdominal contents. The oldest method by which to do this is the sutured technique of herniorrhaphy. This method will approximate the linea alba and attempt to restore the normal architecture of the abdominal wall. It is felt that this will provide the best long-term functional and

cosmetic results for the patient. Unfortunately, this method of repair is fraught with a recurrence rate of 25–51 per cent in most centers.4,5 In many patients, reapproximation of the midline is impossible due to the distraction of the abdominal wall musculature. In such cases, some form of prosthesis is absolutely required if the hernia is to be repaired. The use of a prosthetic biomaterial in the open repair of incisional hernias has reduced the rate of recurrence to 10–25 per cent.2,6 The manner of placement of this biomaterial can vary widely, however.7 The biomaterial can be placed intraperitoneally, extraperitoneally, below the rectus muscle, above the rectus muscle, or above the fascia. Additionally, there are several methods by which to handle the fascial defect itself during the insertion of the prosthesis. Some surgeons will place the mesh at the edge of the fascial defect; others will close the fascial defect before or after the insertion of the mesh.8 Additionally, methods of fixation of biomaterial vary greatly across the world. Indeed, it is very common for the method of fixation to vary between staff of a single institution. Thus, a comparison of the method of prosthetic repair of open incisional hernias can be difficult and inaccurate. Proponents of the laparoscopic repair of incisional and ventral hernias share the common belief that an effective repair of the defect requires the insertion of a prosthetic biomaterial. Only the very smallest of hernias (⬍1–1.5 cm) are closed with sutures alone, although most series have not mentioned this.9 The method of fixation and the location of the prosthetic can vary, as with open repair. The biomaterial can be placed intraperitoneally, extraperitoneally, or behind the rectus muscle but within the rectus sheath. Most commonly, however, it is placed in the intraperitoneal position. The method of fixation is usually with tacks alone or with tacks and transfascial sutures. Other fixation devices are also available (see Chapter 4). It appears that in only one published series has there been a concerted effort to close the fascial defect;10 it has not been the practice in other published reports to close this defect. In fact, little attention has been paid to the necessity of the closure of the linea alba in the laparoscopic hernioplasty of incisional and ventral hernias. It is believed that the repair of the fascial defect will place tension on the repair and offer no improvement in outcome. The anatomical considerations of the closure of the fascial defect and, in most cases, the linea alba will be the reconstitution of the normal anatomy and function of the anterior abdominal wall. It has not been proven that any long-term benefits will be seen if this is done. Many proponents of open repair will insist on the approximation of the linea alba, as it is felt that this will restore the respiratory function of the abdominal wall.


This can be done in many but certainly not all cases of herniation within the abdominal wall (other than inguinal and femoral defects). Hernia defects that are larger than 5 cm2 are unlikely to be repaired, primarily because re-approximation of the fascial edges is usually not possible. Should one accomplish this closure, then the repair of most of these hernias will result in a considerable amount of tension. The success of both open and laparoscopic hernia repair depends on the elimination of tension on the tissues. This can be accomplished, in the majority of patients, only with the use of a prosthetic biomaterial. The question of the anatomical modification of the laparoscopic approach becomes moot if acknowledgment of the concept of tension-free hernioplasty is applied to every hernia repair.

EFFECTS OF BIOMATERIAL PLACEMENT IN LAPAROSCOPIC HERNIORRHAPHY During the repair of incisional and ventral hernias, the prosthesis will usually be placed in the intraperitoneal position. In some areas and in some patients this may not be the case, but in the majority of published series the location is within the abdomen. While there is a theoretical risk of patch migration, such as has been seen in open repair, to date none have been reported with laparoscopic repair. In only one series has the defect within the fascia been closed.10 The usual operation will simply place the prosthesis under the defect with a minimum fascial overlap of 3 cm. The biomaterial is then fixed into position and the operation terminates without regard to the reapproximation of the linea alba. Certainly, in hernias that are located in sites not in the midline, the linea alba is not involved in the repair of the hernia. These typically are not large and are not considered to be significant in the overall function of the wall of the abdomen. Laparoscopic repair does not provide for the resection of the peritoneal sac. Because this sac is not resected, seromas occur very frequently. Some authors have used electrocauterization of the peritoneal surface of the sac to diminish the occurrence of seromas.11 Others have used argon-beam coagulation for the same purpose.12 When seromas do occur, some may require additional procedures to treat them; fortunately, this is infrequent. The prosthesis acts as a barrier to the protrusion of the intra-abdominal contents. It does not assume any functional role in the abdominal wall. The muscles of the abdomen will not have any significant change in their own function after the operation. Repair of the hernia, especially larger ones, will probably improve the function of the flat muscles of the abdomen. There are no supportive data to prove this, but one would assume that elimination of the hernia eliminates the paradoxical

motion of the hernia and its contents in relation to the normal movements of the abdominal wall. This may be enhanced over time as the healing process results in the contraction of the original fascial defect. The method of fixation could potentially impact the function of the abdominal-wall musculature, although this has never been studied. The use of tacks, coils or other fixation devices alone in the fixation of biomaterial may not allow the prosthesis to act in tandem with the muscles, as would the use of transfascial sutures. These devices will penetrate only 3–4 mm, thereby attaching the biomaterial to the posterior layers of the transversus abdominus and possibly the internal oblique muscles. It could be postulated that only the movement of the transversus abdominus muscle will affect the patch attached in this manner. Similarly, one could postulate that the use of transfascial sutures increases the likelihood that the flat muscles that are attached to the prosthesis in that manner will function more normally. Fixation of the biomaterial with transfascial sutures will more likely ensure that the movement of each of the three layers of muscle of the abdominal wall will impact the prosthesis in some manner. The prosthesis becomes a significant portion of the abdominal-wall function once it has been fixed in this manner. I believe that the patch will respond to movement of these muscles and have a greater impact in the function of the wall of the abdomen. However, the sutures will also transfix all of the layers of the flat muscles together. This could diminish the independence of each of their functions at those points of fixation. If the biomaterial is placed in the retrorectal position, then the effects of this will also be felt. Usually, however, hernias are smaller and only in the midline if this method is utilized. The same functional result should be seen. More experimental data are needed to evaluate the impact of these issues. During adhesiolysis and particularly at the time of fixation of the biomaterial, there is a risk of injury to the vessels of the abdominal wall. The significant vessels of the abdominal wall are the inferior epigastric arteries and veins. These are usually out of harm’s way during more traditional repairs of hernias of the abdomen. Generally, any injury to these vessels will be recognized and controlled on the operating table. The most common method of control is the transfascial placement of sutures, similar to the manner used to fix the patch. This will easily and effectively control the hemorrhage. Late hematomas have been described in several series in the literature. One could assume that these represented late development of hemorrhage from these vessels, due to either partial tamponade or delayed necrosis of the vessel wall secondary to electrocautery or other smaller vessels that experience the same process. The sutures may also impinge the small nerves of the subcutaneous space. This is unavoidable, but it has


MATURATION OF THE HERNIA REPAIR

Figure 14.2 CT appearance of the repaired midline incisional hernia with DualMesh six months postoperatively.

not proven to be a significant complaint following the operation. Most of the pain is probably related to neuroma formation, but there are patients who seem to have prolonged pain (one to two per cent) that may be due to suture constriction. I have had two patients who were relieved of symptoms after laparoscopic incisional hernia repair by the incision of the offending sutures. Local anesthetic injection can also be used. The type of biomaterial that is used in laparoscopic incisional and ventral hernioplasty (LIVH) will also impact the functionality of the abdomen. The polypropylene meshes (PPM) are usually quite stiff and result in a significant amount of cicatrization during the healing process. The contraction of the scar that occurs will result in a firm area of the abdomen at the site of the previous hernia sac and defect. This site will not be pliable in the manner of the normal anatomy. It is not an area that acts in unison with the muscles of the abdomen but instead it is an independent site in which the muscles of the abdomen act around rather than with the biomaterial. The thicker, two-layered Composix®mesh has an even greater effect of solidifying the site of implantation than does the single layer of PPM. In the few patients I have seen who have had this implanted, the abdominal wall was more board-like than flexible. Expanded polytetrafluoroethylene (ePTFE) products result in an organized healing process that resembles more closely that of the normal progression. As a result, the abdominal wall is more likely to act with rather than against the patch in the function of the muscles. While this prosthesis is not stretchable, the softness of the product and the characteristics of the collagen infiltration into the biomaterial allow it to conform more naturally to the abdominal wall. Follow-up computerized tomography (CT) of the abdomen after this procedure will verify the conformability of the prosthetic biomaterial (Figure 14.2).

Once LIVH is completed, the healing processes will begin immediately. Scar contraction, which has the effect of shrinking the biomaterials, will generally be completed within 90 days. Following this time period, the effects of the biomaterial choice will become apparent. PPM products can contract as much as 20–60 per cent, although this process may take place over the ensuing one or two years. In so doing, the original defect will correspondingly contract, which results in a closer re-approximation of the abdominal wall muscles. This could improve the function of these muscles, but the dense scar may actually be more of a detriment to this fact; no studies are available to verify this statement. ePTFE biomaterials will contract 20–50 per cent but with more flexibility than polypropylene biomaterials. There is rapid infiltration of cellular elements into the interstices of the product. This may effect more rapid healing and result in the function of the abdominal wall being more ‘matured’ at the completion of the LIVH if ePTFE rather than other materials is used in the repair. This is especially true with the newest products that have a ‘corduroy’ surface.13 During the healing phase following the operation, many clinical changes will be seen that may be new to surgeons who have just started using this technique. Initially, many patients will not have any noticeable protrusion at the site of the original hernia, particularly if a pressure dressing or abdominal binder is used following the procedure. Many, if not all, patients, however, will develop a seroma at the site of the hernia sac.14 The size and significance of this varies greatly. This can be worrisome and unsightly, but it usually resolves without intervention. Following its resolution, the patient will generally have an abdominal wall that is very similar in appearance to the premorbid condition before the development of the hernia. The cosmetic result in the vast majority of patients will be acceptable to both the surgeon and the patient because of the resumption of a normal contour as perceived by the patient. Most patients, particularly obese individuals, will have a lax abdomen due to lack of tone in the muscles of the abdominal wall. In these individuals, the larger patches will actually result in a flattened appearance compared with other areas of the abdomen. This is probably related to the improved support of the abdominal wall by the prosthetic. In some patients, the lateral aspects of the abdomen (outside the prosthetic biomaterial) will seem to protrude disproportionately compared with the mid-portion where the repair was done. These effects are more pronounced with PPM biomaterials than with ePTFE products. A few patients will need reassurance of this phenomenon. In patients that have a particularly


lax abdomen, I prefer to make a note of this to the patient preoperatively so that this can be anticipated.

COSMETIC RESULT Many surgeons are concerned with the skin that overlies the hernia protrusion. In many cases, this represents a fairly sizable amount of tissue that is much larger than the defect of the fascia itself. Patients with a large amount of redundant skin after the hernia repair may need to wear the binder for a longer period of time. This will help to eliminate the dead space that is created by the repair of the hernia. Despite this effort, however, many patients will have changes that will take a few months to resolve. Initially, this area will be soft owing to the presence of a seroma in many cases. After a few weeks or months, this will become firmer as a result of the healing process. The seroma fluid will be absorbed, and scar tissue will replace this fluid. The scar will then contract within several weeks or months. The timeframe of these events will be dictated by the size of the hernia at the original operation. The larger eventrations will, of course, take a longer period of time to complete the healing process. Generally, however, this will be completed within 90–120 days (Figures 14.3 and 14.4). The redundant skin will contract as these events are taking place. Once this is complete, the skin will almost always resume the appearance that it had before the development of the hernia. The pre-peritoneal fat that was scarce preoperatively overlying the hernia sac will sometimes be replaced by new fat. The patch will not be felt underneath the skin, and a more normal curve of the abdomen will be seen, regardless of the size of the hernia that was repaired. In essence, the cosmetic result will be excellent. In no patient, in either my personal work or any known published series, has any mention been made of the need for reconstruction or revision of the skin and subcutaneous tissues overlying the hernia defect after this period of time has transpired. However, some surgeons believe that the cosmetic result is unacceptable to themselves and their patients. For this reason, open repair may be preferred so that a paniculectomy can be performed at the same time. This is particularly apparent with large hernias, such as those that have loss of domain. One may be advised to proceed with the open repair from the outset.

FUNCTIONAL RESULT There is a paucity of information regarding the functional result following LIVH. The compliance of the abdominal wall has been noted to change after the repair of incisional

Figure 14.3 Preoperative photograph of a patient with a post-appendectomy hernia.

Figure 14.4 Postoperative photograph of the patient shown in Figure 14.3 after five months. Note the resumption of the contour of the abdomen. The cosmetic result was symmetrical bilaterally.

and ventral hernias. This seems to be dependent on the type of biomaterial that has been used in the repair of the fascial defect. The elasticity (tensile strength) of the abdominal wall has been evaluated in the laboratory. The mean distention of the abdominal wall at 16 N ranged from 11 to 32 per cent. The textile analysis of PPM, polyester and other meshes revealed the range of elasticity from four to 16 per cent.15 This would indicate that the flexibility might be affected by the implantation of these meshes. These measurements, however, were taken in cadavers, which may have affected the results. Nevertheless, there has been a move to decrease the


amount of PPM material that is used in the open repair of incisional hernias when repaired with PPM. The effect of this can be shown in the laboratory, but the actual clinical significance has not been shown conclusively. There are even fewer data relating to ePTFE products, and no data are available regarding the laparoscopic approach to this implantation. It can certainly be said that there is no re-approximation of the fascia or the muscles of the abdominal wall with LIVH. The long-term effects of this remaining defect in the fascia of these muscles have not been studied. The follow-up of our patients over a period of time that exceeds ten years has not revealed a single problem related to this remaining functional defect. I believe that these patients have lost the benefit of a normal anatomical functioning abdominal wall because of lax musculature and/or the hernia itself. The repair of the single defect does not impact the innate laxity of the normal muscles. Additionally, the development of the hernia itself signifies that the patient has weakened fascia.

2

3

4

5

6

7

8

9

10

CONCLUSION 11

Laparoscopic repair of incisional and ventral hernias requires the use of a prosthetic biomaterial. In all but the smallest of hernias, no tension is placed on the repair. This may explain the decrease in the length of hospitalization of patients because of diminished levels of pain and ileus. This does not provide for the reconstitution of the normal anatomy of the abdominal wall. In so doing, expiratory function may be compromised. In no cases, however, has this been proven to be a clinical problem. More experimental and clinical studies are needed to assess accurately the functionality of the wall of the abdomen following laparoscopic ventral and incisional hernioplasty.

REFERENCES 1

Höer JJ, Junge K, Schachtrupp A, et al. Influence of laparotomy closure technique on collagen synthesis in the incisional region. Hernia 2002; 6: 93–8.

12

13

14

15

LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK. Laparoscopic incisional and ventral hernioplasty: lessons learned from 200 patients. Hernia 2003; in press. Trivellini G, Danelli P. Respiratory pathophysiology and giant incisional hernias. In: Bendavid R, ed. Abdominal Wall Hernias. New York: Springer-Verlag, 2001: 166–72. Hesselink VJ, Luijendijk RW, deWilt JHW, et al. An evaluation of risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993; 176: 228–34. Luijendijk RW, Hop WCJ, Tol van den P, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000; 343: 392–8. Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998; 133: 378–82. Flament JB, Avisse C, Palot JP, Delattre JF. Biomaterials. Principles of implantation. In: Schumpelick V, Kingsnorth AN, eds. Incisional Hernia. Berlin: Springer-Verlag, 1999: 217–30. Flament JP, Palot JP, et al. Treatment of major incisional hernias. In: Bendavid R, ed. Abdominal Wall Hernias. Berlin: SpringerVerlag, 2000: 508–16. LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg 2000; 180: 193–7. Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. Tsimoyiannis EC, Siakas P, Glantzounis K, et al. Seroma in laparoscopic ventral hernioplasty. Surg Laparosc Endosc Percutan Tech 2001; 11: 317–21. Lehr SC, Schuricht AL. A minimally invasive approach for treating postoperative seromas after incisional hernia repair. J Soc Laparoendosc Surg 2001; 5: 267–71. LeBlanc KA, Bellanger DE, Rhynes VK, et al. Tissue attachment strength of prosthetic meshes used in ventral and incisional hernia repair. Surg Endosc 2002; 16: 1542–6. Susmallian S, Gerwurtz G, Ezri T, Charuzi. Seroma after laparoscopic repair of hernia with ePTFE patch: is it really a complication? Hernia 2001; 5: 139–41. Junge K, Klinge U, Prescher A, et al. Elasticity of the anterior abdominal wall and impact for reparation of incisional hernias using mesh implants. Hernia 2001; 5: 113–18.

15 Laparoscopic repair in the emergent setting GUY R. VOELLER

References

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Laparoscopic repair of ventral/incisional hernias is usually an elective surgical procedure. While these hernias may incarcerate, it is usually over a long period of time and they become what should be called chronically incarcerated. The bowel comes to reside in the subcutaneous tissues and can cause cosmetic problems and/or discomfort, but only infrequently does it acutely obstruct. When discussing laparoscopic repair of ventral/incisional hernias in the truly emergent setting, we are talking about the few cases where the bowel is acutely obstructed and/or strangulated. While not common, there is a role for the laparoscopic approach in select cases. Basic preoperative preparation is fairly standard and well known to most surgeons. Fluid and electrolyte correction is most important, along with nasogastric decompression and Foley catheter placement to monitor fluid replacement. Appropriate antibiotic therapy should be administered before making the first incision. If there is evidence of a septic situation, then pulmonary artery catheters, arterial lines and ventilators must be available. A review of our technique is published elsewhere,1 but important points will be described here. The abdominal wall is shaved and prepped in its entirety. The one wellestablished advantage of the laparoscopic repair of ventral/ incisional hernias when compared with open techniques is fewer wound problems. In addition, the mesh becomes infected less frequently. We treat the mesh like a vascular graft and avoid any contact with the skin, etc. An Ioban® (3M Healthcare) protective drape is used to cover all the skin. Using this approach, we have never encountered a patient who has developed a postoperative infection of the prosthesis when placed laparoscopically. Safe access to the peritoneal cavity is of utmost importance, especially when dealing with distended loops of bowel. As we first described, our procedure of choice is the use of a balloon-tipped Hasson-type trocar lateral at the

Figure 15.1 Hasson cannula at left costal margin.

costal margin (Figure 15.1). This is carried out through a 10-mm incision using the S-shaped Hasson retractors. Each layer is incised under direct vision and the muscle layers are spread with a tonsil-type clamp. The retractors hold the muscle aside while a number 11 blade is used to incise each layer of fascia. Again, in several hundred repairs we have never injured any viscera with this method and we have never been unable to gain access. An angled laparoscope (30 or 45 degrees) is very beneficial since it allows viewing of almost any area, depending upon how the angle is directed. A good 5-mm laparoscope allows use of 5-mm working ports, which keeps 10-mm holes to a minimum. The amount of bowel distention in the case of an acutely obstructed ventral/incisional hernia will dictate the ease with which adhesiolysis and visualization can be accomplished. There have been, and continue to be, deaths due to bowel injuries during lysis of adhesions that are not detected at the time of surgery. In almost every case reviewed by the author, harmonic-type scalpels and


Figure 15.2 Incarcerated small bowel.

electrocautery have been used in these cases. We do not recommend the use of these devices unless the surgeon knows that he or she is far removed from the bowel. It is very important to have special graspers for bowel that are atraumatic in every respect. The best grasper we have found is made by Applied Medical and utilizes a reusable instrument with disposable padded cushions that are placed at the tips of the grasper. If adhesiolysis can be done safely and totally laparoscopically, such that the incarcerated bowel can be seen, then the next decision involves reduction of the bowel from the defect(s) (Figure 15.2). Gentle traction on the bowel will either allow or not allow reduction. One must be very careful with this movement; if the bowel is reduced easily, then one can proceed with a standard laparoscopic repair. If the surgeon fears the bowel might be torn, then there are two options. The first option is to take a well-insulated J-type or L-type hook and use it to enlarge the hernia defect to aid in reduction. It is critical that this is done away from the bowel; if the bowel is at risk, it should not be done, since this involves use of energy close to the bowel. We have used this maneuver several times, with good success. If the incarcerated bowel cannot be reduced laparoscopically, then there is a second option that involves a small incision directly over the acutely incarcerated bowel. One should maintain the pneumoperitoneum as the skin incision is made and monitor progress with the laparoscope until pneumoperitoneum is lost. The incision does not have to be large, and usually the bowel can be reduced under direct vision. In several cases, we have even performed a small-bowel resection through this small counter-incision, replaced the bowel back into the abdomen, closed the skin, and finished the procedure laparoscopically. In no instance has this resulted in infected mesh or wound infection. The details of our repair technique are described elsewhere. Once the obstructed/incarcerated bowel is

Figure 15.3 Dual-sided mesh.

Figure 15.4 Suture fixation of mesh.

reduced, the borders of the defect are determined and the correct size of mesh is brought to the field (Figure 15.3). We taught the first organized course in the world on laparoscopic ventral/incisional hernia repair in 1996 and based our technique on an open repair, the Rives–Stoppa repair, which we teach our residents and has been shown worldwide to have the lowest recurrence rates for ventral/ incisional hernia repair.2,3 This open repair relies on retrorectus suture fixation of the mesh (behind the defect) to the fascia of the abdominal wall for long-term success. The same holds true for the laparoscopic approach. To believe that in-growth of various meshes is important for long-term success fails to recognize that any significant in-growth is to peritoneum, not muscular fascia, and if the hernia is of any size then the mesh simply migrates over time with the peritoneal sac into the fascial defect. The sutures are placed every 5–7 cm or more frequently, based on the size of the defect. The mesh is tacked between the suture fixation points to prevent internal hernia formation. The tacks add nothing to the long-term strength of the repair (Figure 15.4). The types of mesh available have significantly increased surgeons’ options in the face of emergent repair of

Laparoscopic repair in the emergent setting 113

Figure 15.5 Final repair.

ventral/incisional hernias laparoscopically. A detailed description of meshes is beyond the scope of this chapter, but a few things need to be mentioned. When we, and others, first developed the technique, expanded polytetrafluoroethylene (ePTFE) became the prosthetic of choice since it could be placed safely in an intraperitoneal position without the worry of in-growth to the viscera. While Franklin has shown that polypropylene mesh (PPM) can be placed laparoscopically against the bowel, we know that in-growth will occur, and long-term problems are well described when this has been done in an open fashion.3 Fistulas and extrusion have been reported with PPM. Various coatings of both PPM (Sepramesh® ) and polyester mesh (Parietex Composite® ) are being investigated to prohibit visceral in-growth. Animal studies show some effectiveness with these coatings. Strangulated bowel presents a different situation. First, it should be said that bowel that appears dead often returns to normal appearance if given time. The incarcerated hernia shown in Figure 15.2 had 20 cm of darkblack-appearing small bowel incarcerated in the defect once it was reduced. The patient was a physician who presented with signs and symptoms of acute small-bowel obstruction. Once the bowel was reduced, the color returned to normal after several minutes and the procedure was completed (Figure 15.5). However, if the bowel is truly gangrenous, then two options now exist. Another big advantage of the laparoscopic approach is that the hernia does not have to be fixed at the time of finding truly necrotic intestine. One can simply resect the bowel laparoscopically or laparoscopically assisted as above, wash out the abdomen, and come back later for definitive hernia repair. If the large bowel is involved in an unprepped colon, then a colostomy can easily be carried out laparoscopically. This is not the case through a large formal

incision, where one is now faced with repairing a large defect in the face of contamination and/or gangrenous intestine. This becomes a very complicated and problematic situation, usually with open wounds, nutritional problems, and prolonged hospitalization. The second option, in the face of strangulated bowel, is to place the mesh if contamination is judged to be minimal and the chance of mesh infection is low (see below). None of this addresses the ability of the various meshes to resist infection when placed in a contaminated or potentially contaminated situation, which is what we are faced with in the emergent setting. Mandala and colleagues have shown that PPM can usually be placed safely in clean contaminated situations but they are not as in favor in contaminated cases (Altemeier classification of wound contamination 3).4 Studies need to be carried out with respect to this. More recently, pig submucosa-based mesh (Surgisis® ) has been promoted for use in the contaminated situation. We have used this on several occasions, without infection of the mesh. Lastly, W. L. Gore has incorporated an antimicrobial coating into its DualMesh Plus that lasts for five to seven days. Intuitively, this makes us feel that there is an element of protection. We have used this mesh in many cases of minimal contamination during laparoscopic ventral/incisional hernia repair, and we have never had to remove it once due to mesh infection. Additionally, in animals, Stone has shown that ePTFE can be used to patch full-thickness defects in bowel without it becoming infected.5 He believes this is due to the type of bacteria that reside in the bowel. In conclusion, laparoscopic ventral/incisional hernia can be done safely in the emergent setting but should be limited to surgeons experienced in the technique in the elective setting. Much work needs to be done with respect to meshes and their abilities to resist infections in the emergent setting laparoscopically.

REFERENCES 1

Voeller GR, Mangiante EC. Laparoscopic repair of ventral/incisional hernias. In: Fitzgibbons ER, Greenburg A, eds. Nyhus and Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2001: 373–9. 2 Rives J, Pire JC, Palot JP, Flament JB. Surgery of the abdominal wall. Major incisional hernias. In: Chevrel JP, ed. Surgery of the Abdominal Wall. Berlin: Springer-Verlag, 1987. 3 Flament JB, Rives J, Palot JP, et al. Major incisional hernia. In: Chevrel JP, ed. Hernia and Surgery of the Abdominal Wall, 2nd edn. New York: Springer-Verlag, 1997: 128–58. 4 Mandala V, Bilardo G, Darca F, et al. Some considerations on the use of heterologous prostheses in incisional hernias at risk of infection. Hernia 2000; 4: 268–71. 5 Stone H. Abdominal compartment syndrome. Presented at the American Hernia Society Meeting, Tucson, AZ, USA, May 2002.


16 Herniorrhaphy with the use of transfascial sutures KARL A. LEBLANC

Indications Contraindications Preoperative evaluation Prosthetic biomaterials

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Laparoscopic incisional and ventral hernioplasty (LIVH) was first described in 1993.1 The concepts of this technique are equivalent to the tension-free repair of inguinal hernias, which has become popular in the past two decades. The open tissue repair of incisional hernias has a recurrence rate of 25–52 per cent. The use of a prosthetic biomaterial to repair these fascial defects lowers the recurrence rate to 11–23 per cent. The rate of recurrence with the laparoscopic approach has been reported to be from 1 to 9 per cent.2–6 It is important to note that in most of these reports, the results included the early experiences of the authors as well as the repairs that occurred with the knowledge gained from that experience (see Chapter 21). The repair of incisional and ventral hernias by this approach should be considered an advanced laparoscopic technique. It is best to have the assistance of a surgeon experienced in performing this particular procedure for at least the first ten to 15 patients if possible. Of course, to optimize outcome, conversion from the laparoscopic technique to the open method should be done at the earliest sign of difficulty. In our experience, this will be necessary in 3.5 per cent of patients. Approximately one-third of these will be due to an injury to the bowel.5 Others have reported that conversion to the open procedure was necessary in seven per cent of patients, with a bowel injury rate of four per cent.6 Once past the learning curve, the participation of an assistant surgeon who is knowledgeable in advanced laparoscopic techniques is generally considered optimum for the repair of all but the smallest defects. Finally, there are a

Intraoperative considerations Postoperative considerations Conclusion References

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few different methods that are used to perform this procedure; these are described in Chapters 17 and 18.

INDICATIONS Any patient that could undergo an open prosthetic repair can be considered for the laparoscopic approach. The size of the fascial defect will play a significant role in many circumstances. The size of the defect is not a limiting factor, although I frequently restrict my use of the laparoscopic procedure to hernias that are larger than 2–3 cm in their greatest dimension. The size of the incision required for the open repair of a small defect is similar to the combined size of the incisions required for insertion of the laparoscopic trocars. Because we use only 5-mm trocars to perform this operation, these hernias will approximate the size of the combined incisions. Additionally, such small defects can often be repaired without the use of a prosthetic material. This recommendation would be universally applicable only to thin patients. Obese patients will have an unacceptably high rate of recurrence without the use of a prosthesis because of the increased intra-abdominal pressure.7 Therefore, I routinely repair these hernias in obese and morbidly obese patients with the laparoscopic technique (even primary umbilical hernias). Patients with recurrent hernias should be repaired with this technique even if the size is less than 3 cm, because they have demonstrated the need for prosthetic placement. LIVH is the easiest method by


which to repair such hernias and also allows the surgeon to inspect the entire length of the abdominal wall to identify any unsuspected fascial defects that were not apparent clinically. This can be seen in 22 per cent of patients who undergo LIVH.5 Some patients will have areas of fascial weakness that are apparent with the laparoscopic approach (Figure 14.1). These areas of potential herniation should be repaired when identified.

CONTRAINDICATIONS As with any operative procedure, the surgeon must evaluate the overall status of the patient before proceeding with a laparoscopic incisional hernia repair. In general, if the patient is a medically appropriate candidate for the open hernioplasty, then they could be considered a candidate for the laparoscopic approach. Patients with severe cardiomyopathy or pulmonary disease may not tolerate the insufflation pressures that are necessary for any laparoscopic procedure. Therefore, these individuals must be evaluated carefully preoperatively. Portal hypertension is nearly always a contraindication. If there is a suspicion of an intra-abdominal infection or an acute surgical abdomen, then the use of prosthetic biomaterial is generally prohibited. In this situation, the laparoscopic approach is contraindicated because of the risk of infecting the prosthesis. One may elect to initiate this operation if incarcerated bowel is suspected. Release of the obstruction will allow the surgeon to inspect the viability of the intestine. If there is no strangulation or perforation, then the operation can proceed. A few centers will perform a bowel resection and repair the hernia laparoscopically and concomitantly (see Chapters 15 and 18). A relative contraindication may be the number of intra-abdominal procedures that the patient may have undergone prior to the anticipated LIVH. This decision should be made based upon the surgeon’s skill level and the type of the procedures that were performed previously. Frequently, the patient may not have significant adhesions despite many previous intestinal procedures. However, one should be very cautious if the patient has had a previous repair of an incisional hernia that included the placement of a polypropylene biomaterial in direct contact with the contents of the abdomen. There is nearly always a significant amount of very dense and extensive adhesions. The risk of intestinal injury is particularly high in these patients.

PREOPERATIVE EVALUATION Once the patient has been identified as an acceptable surgical risk, the surgeon should evaluate the condition of the patient’s abdomen and the hernia(s) that will be repaired. A very large fascial defect may sometimes cause

reconsideration of a laparoscopic approach. The operating time required to repair a defect that approximates the entire surface of the abdominal wall could negate the benefits of the laparoscopic method. These patients are prone to having significant postoperative ileus, regardless of the repair employed. The surgeon may think that the increase in operative time and risk will not justify use of a laparoscopic repair. However, there are currently no hard and fast rules about this issue. In those patients with very large defects, I generally prefer to begin the operation laparoscopically and convert to an open repair if that appears to be the best alternative. More often than not, this proves to be unnecessary. If there is a significant loss of domain, it may be impossible to actually enter the abdomen because the entire musculature of the abdominal wall is absent. In these cases, conversion to the open method is certainly an option. If the patient requires preoperative pneumoperitoneum because of the size of the hernia, then it is not recommended to attempt the repair laparoscopically. Morbid obesity can occasionally become a limiting factor. In such patients, the available trocars may be of insufficient length to maintain adequate access to the abdominal cavity. It could become necessary to convert to the open repair because a working channel through the abdominal wall cannot be maintained. The open ends of the trocars will be withdrawn continually into the excessive fatty tissue, which eliminates the working channel and results in insufflation of the subcutaneous tissues. One may actually sew the trocars to the skin to ensure the position, but the newer, longer trocars that are now available will usually solve this dilemma. In our series of patients, 90 per cent of the hernias that are repaired with this method are incisional. Because the most common incision of the abdomen is placed in the midline, approximately 90 per cent of those hernias are located in the midline of the abdomen.5 These hernias are generally easier to approach with this method than hernias located outside of the midline. However, as more experience is achieved, the presence of a nonmidline defect or multiple defects that are not adjacent to each other should not preclude the use of laparoscopy. Appropriate positioning of the patient and accurate placement of the trocars will permit an approach to the entire abdominal cavity in most cases. The use of angled laparoscopes also facilitates these repairs. In addition to the site of the hernia, the number and type of previous open abdominal operations will influence the choice of patient position, the method of abdominal entry, trocar placement, and the position of the monitors. Decisions regarding these factors should be made preoperatively and then finalized when the patient is on the operating table and under general anesthesia. There will be a greater likelihood of significant adhesions that will require lysis during the initial phases of the operation if the patient has had many separate intra-abdominal procedures. Patients in whom a previous repair included the

Herniorrhaphy with the use of transfascial sutures 117

insertion of a polypropylene prosthesis can be expected to have dense scarring in all areas in which the material was not covered by omentum; however, this should not deter experienced surgeons from attempting a laparoscopic approach. It is important to note that the difficulty of the procedure will be magnified greatly because of the dissection of the tenacious scarring that will have occurred to the bowel and/or omentum. Because the risk of enterotomy is increased significantly in such cases, occasionally it will be necessary to leave remnants of the mesh attached to the bowel to avoid injury to the intestine (Figure 16.1). Laparoscopic incisional hernioplasty should be individualized in patients with known ascites because it is impossible to close the trocar sites in a consistently watertight manner that averts ascitic leaks. Moreover, these patients usually have a metabolic problem (e.g. cardiac, renal or hepatic disease), which can cause poor healing and predispose to development of multiple hernias at the trocar sites. However, it is these metabolic problems that make the laparoscopic approach particularly appealing in these types of patients. If a medical comorbidity does not preclude the laparoscopic method from these patients, then one should use 5-mm noncutting or self-dilating trocars to diminish the risk of prolonged leakage from one of the trocar sites. A Z-path of entry will help in closure of these puncture sites. It is preferable to close the trocar site defects even with the use of these trocars to further decrease the risk of ascitic fluid leakage. Several types of instruments that allow the passage of sutures transfascially are used in this procedure that will also close these defects. LIVH patients are admitted to hospital day-surgery units because they can usually be considered for discharge on the day of surgery. Twenty-six per cent of our patients are discharged on the day of surgery, and 85 per cent of our patients remain in hospital for 23 hours or less.5 The type of hernia and the amount of

dissection required will dictate whether a patient remains in hospital overnight or for longer. Minimal preoperative preparation is required, but appropriate laboratory testing should be obtained before the day of surgery. Patients are routinely given an antibiotic (usually a first-generation cephalosporin) preoperatively. However, if the biomaterial that will be implanted contains antimicrobial agents (e.g. DualMesh Plus® ), antibiotic prophylaxis is not felt to be mandatory.

Figure 16.1 Laparoscopic view of small intestine with remnant of polypropylene mesh. The white arrows outline the mesh.

Figure 16.3 Laparoscopic view of the ‘visceral’ surface color of DualMesh Plus.

PROSTHETIC BIOMATERIALS Many products are available for the repair of incisional hernias. The most commonly used product for this operation is the 1-mm thick expanded polytetrafluoroethylene (ePTFE) prosthesis, DualMesh®or DualMesh Plus (see Chapter 3). My choice of biomaterial for this operation is DualMesh Plus. This contains antimicrobial agents that impart a brown color to the biomaterial (Figures 16.2 and 16.3). This color inhibits the glare of

Figure 16.2 DualMesh Plus.


the white surface of the standard product and identifies the surface that should lie in contact with the intraabdominal organs (‘brown is down’). If one chooses to use the standard DualMesh, it is recommended that the parietal surface of the prosthesis is marked with a skinmarking pencil before its insertion to avoid the inadvertent reversal of the orientation of the patch. The corduroy appearance of the parietal surface also helps distinguish the two different surfaces of the biomaterial.

(a)

(b)

INTRAOPERATIVE CONSIDERATIONS (c)

Patient preparation and positioning LIVH repair requires the use of general anesthesia to achieve the necessary degree of relaxation and sedation. In most cases, it is not necessary to use a gastric tube or urinary catheter unless the operative sites are in close proximity to the stomach or bladder or if the procedure will be prolonged. Typically, when used, both the gastric tube and urinary catheter are removed at completion of the procedure. Most patients will be placed in the supine position. Operations upon lateral defects of the abdominal wall, such as those in a subcostal or flank incision, will be facilitated by the use of a semi-decubitus or full decubitus position that is maintained with the use of a beanbag. The additional use of the tilt capabilities of the operating table (i.e. Trendelenburg or lateral rotation) will assist in the manipulation of the bowel during dissection by moving these into the dependent portion of the abdomen. The patient’s arms should be tucked in close to the body, unless the size of the patient is prohibitive, to allow sufficient room to move around the patient. This is especially important if the hernia is in the lower abdomen.

Instrumentation There are several choices of laparoscopes (0-, 30- or 45degree) for incisional hernia repair. Because thin patients with good muscle tone do not accommodate as much distention as obese patients with poor muscle tone, a 30-degree laparoscope may provide a better view in thin patients. The 45-degree laparoscope is used rarely, if ever. Most surgeons prefer to use the 30-degree laparoscope but I generally use the 0-degree instrument. The angle or size of the laparoscope itself is not important as long as the view is the best available. Smaller laparoscopes permit the use of smaller trocars, which decreases postoperative pain and minimizes the risk of herniation at the site of the trocar. Because I prefer the exclusive use of 5-mm port sites, all of the instruments used will be of that size. However, the size of the instrument is not important. The critical

Figure 16.4 Instrument jaws for organ and prosthetic biomaterial manipulation: (a) aggressive, (b) self-retaining, and (c) smooth.

choice of these instruments will be the shape of the jaws. For grasping the bowel, omentum and the prosthesis, aggressive, thick jaws are preferred (Figure 16.4a). These allow for the firm grasp that is usually required during adhesiolysis and placement of the prosthetic biomaterial. To pull in the biomaterial from the trocar site (see below), a strong-jawed, self-retaining grasper is necessary (Figure 16.4b). This will be required to maintain a firm grasp of the prosthesis so that it can be pulled into the abdomen through the 5-mm port site. The placement of the transfascial sutures should be done with the aid of fine-toothed instruments (Figure 16.4c). These hold the sutures better than instruments with aggressive jaws because the suture will slip between the large spaces of the teeth of the latter (see Chapter 2). The most difficult and tedious portion of the hernioplasty is the dissection of adhesions within the abdomen and/or the hernia itself. The method of dissection is critically important in order to prevent injury to the intestine. If the adhesions encountered are few and rather filmy, then one may use scissors with or without the additional application of electrocautery. The use of this and all energy sources for hemostasis should be judicious and carried out only if there is absolute certainty that there is no bowel adjacent to the area that will be affected by the lateral extension of the heat of the energy source. The upper abdomen and falciform ligament are the most common locations for such a situation. In most cases, however, some dissection of omentum and bowel will be required to allow the identification of the fascial edges and the placement of the prosthetic biomaterial. One may choose to use the Harmonic®scalpel (Ethicon Endosurgery, Inc.). This device has scissor-like jaws that dissect using ultrasonic energy. There is very minimal lateral spread of heat


with this energy source, which enhances the safety in the dissection near the intestine. It cannot be overstated, however, that improper use of any energy source can result in an injury to the intestine. Sometimes, a burn may occur that will not become apparent until the intestinal wall undergoes necrosis several days postoperatively. If intestine is encountered that is densely adherent to the abdominal wall or to a polypropylene biomaterial from a previous repair, then it is recommended that scissors (without electrocautery) are utilized for the required dissection. Some surgeons never use any energy to dissect the tissues. Occasionally, the hernia contents cannot be reduced with dissection and traction because of incarceration. In such cases, the surgical enlargement of the fascial defect will permit the reduction of the involved organs. This can be done with the use of electrocautery scissors or the Harmonic scalpel. Generally, a 1–3-cm incision into the fascia will suffice. The size of this incision is not critical so long as the intestinal contents can be reduced safely because the resulting defect will be covered by the prosthesis that repairs the hernia. A variety of fixation devices is currently available (see Chapter 4). These devices are used to secure the prosthetic biomaterial to the abdominal wall between the transfascial sutures and to prevent the migration of any portion of the omentum or intestine between the patch and the abdominal wall. My preference is the Salute™ device (Onux Medical, Inc.). This allows the accurate placement of the constructs while ensuring that the periphery of the biomaterial is flat against the abdominal wall. Its function is equivalent to that of the helical coil in other respects, however.8 Additionally, a removal instrument is available if one decides that the placement of a construct is not ideal. Devices to place the transfascial sutures are an integral part of this operation. Two such devices are the Endoclose (U.S. Surgical Corp./Tyco International, Inc.) and the Gore-Tex®suture-passer (W. L. Gore & Associates). This author prefers the latter because it is reusable and has a consistently sharp tip (Figure 16.5).

Trocar selection It is understood that the method of access into the abdomen should always be the safest possible approach. In patients with a primary ventral hernia or a single incisional hernia defect, a Veress needle could be considered for insufflation before introduction of the first trocar. In the repair of incisional hernias, a safe area for needle insertion is usually in the right or left upper quadrants because this area is generally free of adhesions of bowel and omentum, particularly for lower-abdominal hernias. An entry point in the midline could be used if it can be placed far enough away from the hernia so that it does

Figure 16.5 Gore-Tex suture-passer holding a suture as it is withdrawn from the abdomen.

not interfere with the placement of the prosthetic biomaterial, in that the overlap may cover the trocar itself. Many surgeons will choose to use either an optical trocar for abdominal entry or an open entry (Hassan technique) if the Veress needle method is not chosen. My preference is the non-bladed trocar (Ethicon Endosurgery, Inc.) but other devices are available, such as the Visiport®(U.S. Surgical/Tyco International, Inc.). These trocars are designed to provide visualization of each layer of the abdominal wall as the trocar passes through them. The former is available in 5-, 10- and 12-mm sizes, whereas the latter is available only in the 12-mm size. While the exact method in which this is accomplished differs between these two devices, both of them are used with the laparoscope inserted into the trocar to view the musculofascial layers as the trocar is passed through them. The non-bladed variety can also be used for the additional trocars that are necessary.

Trocar site selection The location of the trocars will be influenced by the location of the hernia defect(s). Typical sites for these are shown in Figures 16.6 and 16.7. As can be seen easily, the effort is to achieve triangulation of the site of the hernia to allow for its repair. This is typical of most other laparoscopic procedures. While I prefer to place the laparoscope in the midline and have two surgeons work from opposite sides of the operating table, others place all trocars on


the same side of the patient. The placement of the monitors will be dictated by the location of the hernia to be repaired. Generally, upper abdominal hernias will need the monitors to be at the head of the table while lower hernias will have them at the foot of the table.

Operative technique In nearly every patient with an incisional hernia, a complete view of the abdomen is obscured by adhesions. Following the introduction of the initial trocar, the next effort of the surgeon is the placement of additional trocars so that the operation can be performed. Because of these frequent adhesions, the surgeon may be forced to use the laparoscope itself to dissect them before the insertion of any other trocars because there is no working space in which to allow these trocars to be placed under direct vision. After each new trocar is introduced, the laparoscope should be placed through it to visualize the abdomen from that new vantage point to identify the optimal placement of the other trocar sites. Additionally, the collection of views provided by visualization of the abdomen through these multiple trocar sites will help to minimize the risk to the bowel by the necessary surgical maneuvers. In other words, the two-dimensional view that is recorded by the laparoscope may not permit the recognition of any intestinal structures that may be in harm’s way during the dissection of the adhesions. These views will help to avoid an enterotomy. It is frequently necessary to place and manipulate instruments from the side of the patient in direct opposition to the viewing laparoscope. This produces a mirror image of any manipulation that is viewed from that port. In this case, a move of the laparoscopic instrument to the left will be seen as a move to the right, and vice versa. Placement of the laparoscope in the midline, when possible, will prevent this viewing difficulty. Another option would be to insert an additional trocar(s) on the opposite side of the patient from where the surgeon is standing so that the laparoscope is always on the side where the surgeon (or the assistant) is standing. With experience, even this technical problem can be overcome without the use of additional trocars. However, additional trocars should be used when this problem cannot be corrected easily to ensure the accurate assessment of the intra-abdominal contents and the proper performance of the operation. Those surgeons who prefer to place all trocars only on one side of the abdomen will avoid mirror-imaging, but such site selection will not allow viewing of the adhesions from the opposite side of the abdomen. Additionally, this trocar location on only one side can make fixation awkward because the use of the fixation devices can be difficult on the ipsilateral side of the patch biomaterial (Figures 16.6 and 16.7) (see Chapter 4).

Figure 16.6 Typical trocar site locations for a lower midline hernia. Blue, trocar locations; green, umbilicus; black, hernia.

Figure 16.7 Typical trocar site locations for an upper midline hernia. Blue, trocar locations; green, umbilicus; black, hernia.

Adhesiolysis and identification of fascial defect(s) Before insertion of the prosthesis, the entire fascial defect(s) must be uncovered. This usually requires lysis of all of the adhesions within the abdomen unless these are far away from the operative field, such as in the pelvis when the hernia is in the upper abdomen (Figure 16.8). It is important to dissect away from the abdominal wall any adhesions that may interfere with the subsequent placement of the prosthetic material. The prosthesis must contact the fascia without the interposition of any significant amount of adipose tissue so that tissue in-growth into the biomaterial will not be impaired. In the


Figure 16.9 Skin marks demarcating the edges of the defect of a lower midline incisional hernia. Figure 16.8 Small intestinal adhesions to the anterior abdominal wall.

areas low in the abdomen, such as in the parapubic sites, it will be necessary to create a pre-peritoneal flap similar to that done for the transabdominal pre-peritoneal inguinal hernia repair so that the biomaterial can be fixed to Cooper’s ligament. Only this will ensure strong fixation and adequate overlap of the prosthesis. It is not necessary to excise the hernia sac or close the fascia defect. The defect is measured most accurately with the insufflation pressure reduced from the working amount of 12–14 mmHg to near-zero. Reducing the pressure prevents the inflation artifact because the distention of the abdominal wall can substantially increase the apparent size of the defect. This occurs because the measurement is typically taken on the external surface of the abdominal wall rather than on the interior surface of the fascial defect. This measurement would be artifactually larger than the actual measurement. After desufflation, the defect is outlined on the skin over the abdomen with a skin-marking pencil (Figure 16.9). The entire circumference of the defect should be identified to ascertain its maximum dimensions. To ensure adequate coverage of the hernia defect, many authors have stated that a minimum of a 3-cm overlap (in all directions) of the prosthetic biomaterial is mandatory.3–5,9 In general, I strive to cover the entire length of the original incision even though an actual hernia defect may be located only at one site along the incision. This will provide coverage and prevent the future development of a hernia at the uncovered portions of the incision and, therefore, avoid a recurrence of the hernia.5 In this situation, the patient develops a new hernia that is above or below the original one that was repaired. In obese patients and/or patients with very large defects, an overlap that exceeds this minimum, such as 5 cm, is recommended.

Figure 16.10 DualMesh Plus with marks and initial two ePTFE sutures.

There are many variations of the technique used to fixate the patch material once it is inserted into the abdominal cavity. Most surgeons will use transfascial sutures in addition to a metal fixation device, such as a titanium staple or helical tack, a construct of stainless steel, or a nitinol anchor (see Chapters 4 and 17–22). The number of sutures that are applied to the biomaterial before insertion into the abdomen will be dictated by the preference of the surgeon. One method that I choose places two ePTFE sutures (CV-0) at either side of the midpoint of the long axis of the patch. Two marks are placed on both sides of the midpoint of its short axis with a marking pencil before its insertion into the abdominal cavity (Figure 16.10). It is important to mark both the visceral and parietal surface midpoints because once fixation is initiated, the view of the patch will be only that of the visceral surface. These initial two sutures and the marks


Figure 16.11 Folded and twisted DualMesh Plus patch as it is pulled into the abdomen at the site of a 5-mm trocar.

Figure 16.12 Laparoscopic view of the twisted patch as it is drawn into the abdomen.

will help to ensure the correct axial orientation and the degree of overlap on all sides of the hernia defect. Other surgeons place four or more sutures into the patch before insertion. I find that this creates a tangle of suture material that is cumbersome to work with in the limited space available. The placement of only these two initial sutures assures that the center of the fascial defect is placed at the middle of the prosthetic biomaterial. This is particularly evident if the trocars are placed as in Figures 16.6 and 16.7. The DualMesh Plus patch, with its attached sutures placed on the inside of the folds, is folded into sequential halves for introduction into the abdomen.10 These biomaterials are 50 per cent air by volume, which allows them to be twisted into a tight roll that substantially reduces their size (Figure 16.11). In those cases in which the larger patches are used, the skin incision at the site of patch introduction should be made larger than that necessary for placement of the trocar itself (typically 6–8 mm). A strong grasping instrument (Figure 16.4b) is passed through a trocar and advanced through another trocar. The trocar through which the instrument is exited is then removed, whereupon the instrument will grasp the biomaterial and pull it into the abdominal cavity (Figure 16.12). The assistant surgeon can assist this maneuver by maintaining the twist of the patch as it is introduced. This method of folding and introduction into the abdomen and the pliability of the abdominal wall musculature will allow even the largest DualMesh Plus patch (26 ⫻ 34 cm) to be inserted into the abdomen with the exclusive use of 5-mm trocars. Just before the complete introduction of the patch, the tight twist must be undone to make the patch as flat as possible, which facilitates its fixation to the abdominal wall. This is another important step because it is very tedious to try to untwist and unfold the patch once it is introduced into the abdomen.

Placement of the prosthesis Once the insertion of the prosthetic is complete, the patch must be unfolded. The surgeon and the assistant will assist each other in the manipulation of the biomaterial to unfold the patch completely until it is as flat as possible. The two initially placed sutures are now pulled through the entire abdominal wall with the use of a sharp suture-passing instrument inserted through a small skin incision (Figure 16.5). By pulling the initial two sutures through the abdominal wall and viewing the hernia with the laparoscope, one can confirm that the patch is centered over the defect and that there is a minimum of a 3-cm overlap in all directions. It may be necessary to move the laparoscope to another port to do this effectively. If there is insufficient tautness of the prosthesis or if the patch is not properly centered over the hernia defect, then the suture(s) must be repositioned. Once the optimal position is achieved, the sutures are tied. It is important to make sure that these (and all of the subsequent sutures) are tied sufficiently tightly to pull the knots to the fascial level without any laxity. The next step will be to confirm that the orientation along the short axis of the patch is correct (e.g. the lateral aspects of the midline hernia). The biomaterial is grasped by both surgeons at the previously marked midpoints on either side of the biomaterial to position it over the desired final location. Either the assistant or the surgeon then uses a fixation device to deliver the metal construct to fix the midpoint of one side by placing only one or two devices at that location. The fixation instrument is then handed to the other surgeon and the unattached opposite midpoint is secured similarly. The use of only a few constructs at this time will permit the removal of these devices if it is determined that the prosthesis must be repositioned. After four-point fixation is achieved, the


Figure 16.13 Correct spacing of the constructs along the periphery of the patch.

position of the biomaterial is verified again with the laparoscope. After this inspection, the devices are placed in a staggered fashion along the periphery of the prosthesis 1–1.5 cm apart (Figure 16.13). This initial fixation not only positions the patch at its correct location but also ensures that bowel cannot migrate between the prosthesis and the abdominal wall once the repair is completed. The most important component of fixation, however, is the use of transfascial non-absorbable sutures (e.g. ePTFE size CV-0). These sutures will be placed through all layers of the abdominal wall and are tied above the fascia in a manner similar to that of the initial two sutures. A small (2–3-mm) skin incision is made. Through this incision the suture-passer, with a suture in its jaws, is passed through all layers of the abdominal wall. The assistant surgeon then grasps the suture with a laparoscopic instrument (Figure 16.4c). The suture-passer is then removed and re-inserted through the same skin incision. The assistant hands back the suture to the passer, whereupon the suture is retrieved. During the insertion of all sutures, it is critical to avoid the application of any instrument or clamp on any portion of the suture material that will remain within the patient because this will permanently weaken the suture at that site. It may later fracture at that site, leading to a possible failure of fixation and recurrence of the hernia.5 These additional sutures are placed at intervals that are no more than 4–5 cm apart. Once fixation is completed, the patch should now obliterate the fascial defect. A final examination of the prosthetic is performed to ensure that all sutures are tight and that all edges of the patch are secured (Figure 16.14). When any of these sutures are tied, a dimple of the skin may develop at the site of the incision where the suture has been passed because the subcutaneous tissue may have been drawn down when the suture was tied. This dimple can be removed by the placement of a fine-pointed hemostat into the incision to lift the skin, which releases the tissue from the suture knot. After this is done, one should view the sutures

Figure 16.14 Completed repair of the hernia. The proper placement of the sutures and Onux constructs are seen on the DualMesh Plus.

laparoscopically to confirm that this action did not result in a loosening of the suture. If this has occurred, the suture must be cut to prevent migration of any intraabdominal contents into the loop and another suture must be placed. The repair is now complete. At this point, a reasonable precaution may be to scan the intestine to identify any possible injury that may have gone undetected. The trocar cannulas are removed, but before their removal the suture-passer should be used to pass an absorbable suture to close any port sites larger than 5 mm. The skin incisions can then be closed with or without a subcutaneous suture and the use of Steri-Strips®(3M Healthcare) or Dermabond®(Ethicon, Inc.) adhesive. Band-Aid-type dressings or small gauze sponges should be placed over the wounds. The use of an abdominal binder that will be left in place for at least 72 hours will aid in the prevention of a postoperative seroma at the site of the hernia and eases postoperative pain. The use of this binder for as long as 7–14 days is preferred, especially for very large hernias.

POSTOPERATIVE CONSIDERATIONS Patients are sent to the postanesthesia care unit, where they are usually given a single dose of ketorolac intravenously. Once recovered from anesthesia, they are transferred to the day-surgery unit. Most (85 per cent) patients are discharged within 24 hours. In our practice, the average length of stay is slightly over one day. Patients can consume their diet of choice on the day of surgery and can resume any regular medications immediately. Oral or parenteral sedatives are given as needed. Pain may be used as the guide to determine when patients can resume their normal activities. They are allowed to shower the next day. Patients may return to their daily activities, including work, as soon as they can


do so without marked pain. Most are able to drive within a week and resume job-related activities in 7–14 days. We do not restrict their activities but allow their pain to be their own guide.

2 3

4

CONCLUSION LIVH continues to gain popularity. There are several modifications of this technique that can be adopted according to one’s preferences. Surgeons who perform this advanced operation must have a thorough understanding of the specific factors that ensure that the procedure will be associated with an acceptable outcome. Continued research and experience will result in continued modifications to this operation. Technical refinements will undoubtedly occur that will enhance the fixation methods that are currently available. The laparoscopic repair of incisional and ventral hernias may become the standard of care in the future. As the population of general surgeons adopts this methodology, the recurrence rates associated with this difficult malady will, hopefully, decline.

REFERENCES 1

LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41.

5

6

7

8

9

10

Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000; 190: 645–50. LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg 2000; 180: 193–7. LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes KV. Laparoscopic incisional ventral hernioplasty: lessons learned from 200 patients. Hernia 2003; in press. Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia. Surg Endosc 2002; 16: 785–8. Arroyo A, Garcia P, Perez F, et al. Randomized clinical trail comparing suture and mesh repair of umbilical hernia in adults. Br J Surg 2001; 88: 1321–3. LeBlanc KA, Stout RW, Kearney MT, Paulsen DB. Comparison of adhesion formation associated with Pro-Tack (US Surgical) versus a new mesh fixation device, Salute (ONUX Medical). Surg Endosc 2003; in press. Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: a personal series and review of the literature. J Soc Laparoendosc Surg 1999; 3: 293–304. LeBlanc KA. A new method to insert the DualMesh prosthesis for laparoscopic ventral herniorrhaphy. JSLS 2002; 6: 349–52.

17 Pre-peritoneal herniorrhaphy SÉRGIO ROLL, WAGNER C. MARUJO AND RICARDO V. COHEN

Incisional hernias Principles of treatment Indications for laparoscopic repair Laparoscopic transabdominal pre-peritoneal repair Personal series results

125 125 127 127 129

INCISIONAL HERNIAS Incidence Incisional hernias represent one of the more common complications of abdominal surgical procedures. The true incidence of incisional hernias has not been well defined, although a number of reports suggest that 3–13 per cent of patients undergoing laparotomy will develop a fascial defect in their abdominal scar.1 The majority of incisional hernias occur within the first postoperative year. However, the limited follow-up of most series may underestimate late hernia occurrence.

Diagnosis Most patients with small, uncomplicated incisional hernias are asymptomatic or have only minor or intermittent complaints. However, these postoperative hernias may be a significant source of morbidity. Patients with incisional hernias alter their lifestyles so as not to exacerbate their abdominal wall hernia and often complain of their esthetic appearance or suffer from discomfort, pain or, occasionally, intestinal obstruction.

Predisposing factors Predisposing factors for the development of incisional hernias include advanced age, male gender, and systemic

Comparative studies of open versus laparoscopic repair Advantages and disadvantages of different laparoscopic techniques Conclusion References

129 130 130 131

diseases such as obesity, cancer, chronic hepatic and cardiopulmonary failures, severe anemia, and malnutrition.2,3 The underlying pathological process, such as prostatism, radiotherapy, steroid therapy, and operative technical issues are also fundamental factors. Although clinical experience seems to suggest that vertical celiotomy and certain types of suture (e.g. continuous suture and mass tissue closure) may increase the risk of incisional hernias, randomized studies have failed to show that any of these factors significantly alters the incidence of postoperative incisional hernia. Wound infection is associated with a five-fold increase in the risk of developing a hernia.1,4

PRINCIPLES OF TREATMENT The classical principles of ventral hernia repair are wound closure without excessive tension, suture placement into healthy tissue, and the use of strong material to support the wound through the critical period of healing. In many cases of incisional hernia with small defects, fascial closure can be achieved by apposing the fascial edges, which closes the defect. When the fascial defect is large, a number of techniques have been proposed, including relaxing incisions, internal retention sutures, muscle or fascial flaps, fascial grafts, and mesh repair.5 However, the results have often been disappointing. Primary repair with suture only has been associated with 25–52 per cent failure rates.6 The use of a prosthetic material to cover the


hernia defect has reduced substantially the incidence of recurrence. In a multicenter randomized trial that enrolled 100 patients in each arm, Luijendijk and coworkers compared the results of suture alone with those of open mesh repair for incisional hernias.7 After a follow-up of 36 months, the three-year cumulative rates of recurrence among patients who had suture only and those who had mesh repair of a primary hernia were 43 and 24 per cent, respectively. The recurrence rates were 58 and 20 per cent, respectively, for repair of the first recurrence. The risk factors for recurrence were suture repair, infection, prostatism, and previous surgery for abdominal aortic aneurysm. The size of the hernia did not affect the rate of recurrence. The majority of the recurrences were in the first two years following the repair of the hernia. The same factors involved in the genesis of these incisional hernias may contribute to these results.

Prosthesis materials The use of prosthetic materials to assist in incisional hernioplasty usually demands a more extensive dissection and may increase the risk of wound complications slightly.5,8 The synthetic material should be physically unmodified by tissue fluid, chemically inert, and noncarcinogenic. It should also induce no inflammatory or foreign-body reaction, allergy or hypersensitivity.9,10 Finally, it should resist mechanical stresses, be able to be tailored into the form required, and be easily and fully sterilizable. The most popular prosthesis materials are made of polypropylene, polyester, and expanded polytetrafluoroethylene (ePTFE). These are all nonabsorbable, and there is no clear evidence from the literature that supports a preference for the clinical use of any one of the three main materials.11 Polypropylene shows a relatively small inflammatory response with a far lesser degree of foreign-body reaction than does polyester mesh. ePTFE elicits less chronic inflammatory cell reaction but greater foreign-body reaction. Mesh infection rates in selected laparoscopic series for repair of ventral and incisional hernias vary from 0.5 to 12 per cent.12 Despite different characteristics regarding fibroblastic reaction and the time required for incorporation, polypropylene and polyester prosthetic materials are associated with a high incidence of dense adhesions. Their biological behavior increases the risk of adhesions and fistula formation when the mesh is placed in contact with the peritoneum.13 There is strong evidence that adhesions are more common with polypropylene and polyester than with ePTFE. It is acceptable to place the latter in contact with the bowel, as lower complication rates were reported when using ePTFE. Polypropylene and polyester require reperitonization to avoid mesh contact with intra-abdominal structures. The use of

these materials should be balanced in some situations (e.g. the feasibility of closing the peritoneum over the mesh, and the issues of cost) when selecting all prosthetic biomaterials.

Repair strategies Although the modern era of hernia repair began more than a century ago, controversies continue to exist regarding the optimal surgical technique to repair incisional hernias. Open techniques involve a large incision and extensive subcutaneous and intra-abdominal dissection, and often necessitate the placement of drains. Complication rates range from 8 to 19 per cent after open ventral repair.14,15 Fistula rates after elective open hernia mesh repair vary from 2 to 5 per cent.6 Moreover, the infected prosthesis should be excised, demanding another, more complicated repair. Transabdominal approaches carry the risk of injury to the viscera adherent to the undersurface of the scar. The basic strategy of the open repair is based upon the Stoppa technique: the peritoneal cavity should not be entered and the mesh is secured to the fascial edges in the pre-peritoneal space.16 However, the risk of re-entering the site of a previous incision is an inadvertent enterotomy. The open repair does allow the concomitant excision of a usually wide, irregular and unesthetic scar. If this is the case, it is not unusual to enter the abdominal cavity. Surgical laparoscopy has become an increasingly popular method of treatment for many diseases because it potentially offers cost-savings as a result of shorter hospital stays, less postoperative pain, and a more rapid return to work.17 Laparoscopic hernioplasty has been reported to be a safe and feasible technique, with low morbidity and low rates of early recurrence. LeBlanc and Booth first reported the laparoscopic approach to repair incisional hernias in 1993,18 and several series have now demonstrated the efficacy of minimally invasive surgery in incisional hernia repair. Laparoscopic repair involves no long incision, no wide fascial dissection or flap creation, and usually no drains. It also minimizes the manipulation of a potentially contaminated site because the trocars are placed far from the original wound.19 Additionally, the pneumoperitoneum facilitates the necessary adhesiolysis in order to identify the edges of the defect and the hernia sac. Enterotomy rates in selected laparoscopic series of ventral hernia repair, including incisional hernias and many with previous open mesh repair, vary from 0 to 14 per cent (Table 17.1). Mesh infection rates vary from 0.5 to 12 per cent.12 One of the drawbacks of the laparoscopic approach is that it does not allow an esthetic reconstruction of the abdominal wall since the old scar that covers the hernia defect is left untouched. The need for an overall esthetic result

Pre-peritoneal herniorrhaphy 127 Table 17.1 Results of laparoscopic ventral/incisional hernioplasty Complications Reference

Patients (n)

Intraoperative (n)

Postoperative (n)

Constanza et al. (1998)14 Franklin et al. (1998)34 Toy et al. (1998)24 Sanders et al. (1999)35 Scott-Roth et al. (1999)20 Heniford et al. (2000)6 Roll et al. (2000)25

31 176 193 12 73 415 28

0 0 4 0 2 5 1

2 9 28 3 14 48 3

should not be underestimated because the patient frequently demands this outcome.

INDICATIONS FOR LAPAROSCOPIC REPAIR The size of the defect and the characteristics of the patient should dictate the best technical strategy. Patient selection for laparoscopic incisional hernioplasty is usually based upon a demonstrable fascial defect under a previous abdominal incision or a highly suspect abdominal wall defect in a very obese patient, such as in Spigelian hernia. The patient must be able to tolerate general anesthesia and abdominal insufflation.20 Patient size is not a prohibiting factor; nor is a history of previous abdominal explorations or previous attempted repairs with or without placement of prosthetic material. A massive incisional hernia with the protrusion of a substantial portion of the abdominal viscera may be a contraindication for a laparoscopic approach. Significant loss of the abdominal domain by the intestine might preclude the placement of the functional trocars because of insufficient lateral space. A densely scarred abdomen, an inability to establish safely a pneumoperitoneum, and the presence of infected material in the abdomen may also contraindicate the laparoscopic approach. It should be noted that the intensity and extent of adhesion formation is unpredictable. Because of this, multiple previous abdominal operations do not preclude laparoscopy, since an entry port for the first trocar can be obtained. The so-called ‘Swiss cheese’ hernia is a good indication for the laparoscopic approach since it allows a very clear delineation of the wall defects and a more precise repair. Hernias very close to the costal margin may be difficult to treat through an open approach since they usually lack a good rim of strong tissue to secure the mesh. In this situation, the laparoscopic approach is more appropriate, because the mesh can be easily tacked and/or sutured to the internal surface of the abdominal cavity. Moreover, full-thickness stitches around this area are usually followed by pain.

Hospital stay (days) 2.0 2.2 2.0 3.5 2.9 1.8 1.2

Follow-up (months)

Recurrence (n)

18 30 22 12 17 23 36

1 2 9 1 7 14 0

LAPAROSCOPIC TRANSABDOMINAL PRE-PERITONEAL REPAIR Patient preparation and room set-up A thorough preoperative evaluation is performed. The patient is informed fully of the risks of recurrence and the chance of conversion into an open procedure. Educational handouts are given in order to aid the patient during the period of convalescence with a particular emphasis on pain management. Factors that might increase the recurrence rate are corrected, if at all possible, in the preoperative period. Special attention is given to respiratory care before admitting the patient to the hospital. In-hospital standard guidelines to prepare patients for abdominal surgery are followed. Mechanical bowel preparation is not usually necessary, and the patient is asked to void just before leaving the ward. The patient is placed on the operating table in a dorsal recumbent position with the arms padded alongside the body. It is important that the patient is strapped securely to the operating table in order to permit the extremes of table positioning, which is occasionally necessary for visceral displacement or retraction. General anesthesia is instituted, and an orogastric tube is inserted for gastric decompression. Patients are given antibiotic prophylaxis, usually with a first-generation cephalosporin. For most midline hernias, the surgeon stands on either the patient’s left or right side. The video monitor is positioned on the opposite side of the patient so the surgeon’s view on the screen is parallel and in line with the laparoscopic repair of the hernia within the abdomen. The assistant stands opposite the surgeon, and a second monitor is placed in a suitable position.

Operative technique Good laparoscopic skills are mandatory, since each anatomical situation may be unique. The surgeon must always keep a low threshold for conversion to an open


repair. Access to the abdominal cavity is obtained in an area away from the hernia using the Veress needle or, more frequently, by the open technique. Pneumoperitoneum is established by insufflating the abdomen to 12 mmHg with carbon dioxide. A 30-degree laparoscope is introduced through the initial trocar, and the abdomen is explored. The hernia defect and any associated adhesions are identified. Usually two or three additional trocars are inserted under direct vision. The ultimate number and the exact site of the trocars depend on each individual case. For an optimal view and exposure, it is better to place the working ports as far away as possible from the hernia defect. Since the mesh must overlap the defect by about 3 cm, a very lateral or inferior position of the trocar sites maximizes the view and the efficiency of the instruments. The repair technique is based on the Stoppa technique utilized in the open surgical procedure, in which the prosthetic material is placed posteriorly to the anterior fascia.21 Adhesiolysis is performed to free the bowel from the abdominal wall, and the margins of the hernia defect are defined clearly. External manual pressure on the abdominal wall helps to delineate the edges of the hernia defect; it also changes the angles of vision and usually facilitates the dissection. Once the entire abdominal wall is cleared up and any incarcerated omentum or bowel reduced, the hernia defect is measured by introducing a sterile ruler into the peritoneal cavity. The surgeon must be very cautious when dissecting the bowel wall or omentum off the hernia sac, which typically encompasses attenuated fascia and peritoneum. The adhesiolysis is almost always the most challenging part of this procedure, especially if a previous mesh repair has already been attempted. Any energy source is capable of causing a full-thickness injury to the bowel wall. The harmonic scalpel may obviate the risk of an inadvertent injury. The standard approach in the advent of an enterotomy is immediate closure of the site with simple suturing. If this injury is complicated by a significant spillage of luminal fluids, then an open primary repair might be performed or a staged laparoscopic mesh placement should be advised. The hernia sac contents are reduced and the peritoneal sac is now opened, followed by the precise delineation of the fascial defect, with at least 4 cm of healthy tissue surrounding it. When possible, small fascial defects may be closed simply by suturing the edges of the defect without tension. The suture closure is then covered by a mesh to reinforce the herniorrhaphy. This procedure may prevent the annoying sensation of the mesh just underlying the skin. Dissection within the pre-peritoneal plane, in an effort to develop an intact layer of peritoneum to separate the mesh from the abdominal contents, might be extremely difficult in some patients. If unsuccessful, this might result in a large peritoneal defect, leaving the mesh exposed internally. This is especially true in patients with only a thin layer of subcutaneous fat and skin overlying the hernia. In this

Figure 17.1 The hernia sac is opened and the healthy fascia along the defect rim is defined clearly.

case, some authors recommend interfacing the omentum between the mesh and the bowel. However, we make a vigorous effort to interface the sac layer between the mesh and the abdominal contents (Figure 17.1). It is easier to dissect out the healthy fascial edges within the pre-peritoneal space of certain hernias, including incisional hernias secondary to extraperitoneal surgical incisions, such as lumbar discectomies or Pfannenstiel incisions, and defects away from the midline. If the pre-peritoneal technique is deemed impossible, then the hernia sac is not reduced, resected or opened, and the mesh is positioned intraperitoneally according to the onlay technique.22 Prosthetic materials have been used with increasing confidence in direct contact with the abdominal contents. Complications have been few, but this may reflect selective reporting of good results. We always attempt to perform a transabdominal pre-peritoneal repair that uses a mesh prosthesis to cover and close the hernia defect. Three trocars are usually employed, and it is ideal to triangulate them around the hernia defect. As the abdomen is explored, care must be taken to identify and dissect the hernia defect. Gentle grasping and separation of the peritoneal sac are important steps. At this point, tears in the peritoneum must be recognized and managed. Generally, it is not easy to dissect and actually have a good peritoneal flap prepared in order to have it closed over the anchored prosthesis. If a tear occurs, it should be carefully dissected and more peritoneum preserved. If this is impossible due to firm adhesions to the abdominal wall, then in order to cover the mesh safely an omental flap may be created and used to cover the tear. The mesh, under some tension, should be secured to the abdominal wall using a hernia stapler or a tacking device, or sutured into position with full-thickness transabdominal stitches buried in the subcutaneous tissues. The stitches along the outer border of the mesh should leave a 3-cm margin

Pre-peritoneal herniorrhaphy 129

Defect Mesh

Hernia sac Healthy fascia

Figure 17.2 The mesh is positioned into the pre-peritoneal space and secured to the abdominal wall. The stitches along the outer border of the mesh must overlap the rim of the hernia defect by at least 3 cm.

lateral to the edges of the fascial defect (Figure 17.2). Drains are not used. The trocar sites are then closed in the usual fashion.23

Immediate postoperative care Postoperatively, patients are given narcotics for appropriate analgesia. A liquid diet is started on the same day, and patients are encouraged to ambulate as soon as possible. Bowel function usually resumes early in the postoperative period.24 Some patients go home on the day of the operation, but 85 per cent are discharged on the first postoperative day. Most patients develop an area of induration at the previous hernia site, but this resolves without complications or treatment within four to six weeks. In general, patients are allowed to return to work at their convenience and may resume heavy physical activities two to four weeks later. The most common early complications after laparoscopic repair are suture-site pain (when using transabdominal stitches) and seroma. The former is probably related to some muscular ischemia and nerve entrapment. The development of seroma is secondary to the creation of a dead space and a secretory reaction to the prosthetic material. Only large, symptomatic collections should be aspirated.

PERSONAL SERIES RESULTS From January 1997 to January 2002, 52 (21 female, 31 male) patients underwent attempted laparoscopic incisional hernia repair.25 We excluded from this series Spigelian hernias and incisional hernias that required the intraperitoneal onlay technique. There was a total of 53 hernia repairs (one patient with two incisional hernias).

One patient required conversion to an open repair because of dense adhesions and inadvertent intestinal injury. The defect sizes ranged from 64 to 230 cm2. The original surgical procedures were hysterectomy (11), appendectomy (12), prostatectomy (10), gastrectomy (two), nephrectomy (eight), laparotomy (three), epigastric herniorrhaphy (four), and umbilical herniorrhaphy (three). In all cases except one (two incisional hernias), the defect was covered with a single large piece of mesh. In all but three patients (in whom polyester mesh was placed), we used a polypropylene mesh for the repair. The average operating time was 60 minutes (range 30–240 minutes), varying directly with the degree of adhesiolysis that was required. All patients were discharged in the first 24 hours, with the exception of one patient, who had an enterotomy recognized during the procedure. The mean length of hospital stay was 1.2 days (range 1–4 days). Patients required minimal post-surgical analgesia. Bowel function returned quickly in most patients. There were no deaths. Seven complications were recorded (13.4 per cent of patients), most of which were minor (four seromas, two hematomas, one accidental small bowel enterotomy). Patients were followed closely postoperatively for three to 60 months (mean 41 months). Two (3.8 per cent) patients were found to have evidence of hernia recurrence. They were among the very first cases, and they had large defects. Recurrences were diagnosed within the first 12 months after the operation. Lack of experience and large defects may be related to the reason for recurrence. Most patients developed an area of induration at the hernia site, but this resolved without any treatment within four to six weeks. Apart from this transient induration, we have encountered no complications as a result of excising the hernia sac.

COMPARATIVE STUDIES OF OPEN VERSUS LAPAROSCOPIC REPAIR Two retrospective studies and one prospective study have compared the results of open surgery techniques versus the laparoscopic approach for the repair of ventral hernias. These studies consisted of a majority of incisional defects (Table 17.2). In 1997, Holzman and colleagues compared 21 patients with ventral/incisional hernias repaired laparoscopically with a group of 16 patients who had undergone conventional open mesh repair.26 The mean follow-up period was similar, and two recurrences occurred in each group. The investigators concluded that the advantages of the laparoscopic approach seem to be a reduced rate of postoperative complications, fewer wound healing problems, and more rapid recovery after surgery. In 1998, Park and coworkers compared 56 laparoscopic prosthetic repairs of large incisional hernias with 49 open surgical procedures.27 The

130 Laparoscopic incisional and ventral hernioplasty Table 17.2 Comparison studies of laparoscopic versus open repair of ventral/incisional hernia Complications

Reference Holzman et al. (1997)26 Park et al. (1998)27 Carbajo et al. (1999)28*

IntraPostReopera- Hospital Cost Repair Patients Size Time operative operative tions stay Follow-up Recurrence (US$) type (n) (cm2) (min) (n) (n) (n) (days) (months) (n) 7299 4395

Open Lap Open Lap Open Lap

16 21 49 56 30 30

148 105 105 99 141 139

98 128 78 95 111 87

0 1 1 0 0 0

5 4 17 10 35 5

2 0 0 2 1 1

4.9 1.6 6.5 3.4 9 2

18 20 53 24 27 27

2 2 17 6 2 0

*Prospective study.

mean follow-ups were 24 months for the laparoscopic group and 53 months for the open procedure. The hernia recurred in six (11 per cent) patients in the laparoscopic group and in 17 (34 per cent) patients in the open repair group, but the investigators could not make a meaningful comparison of the recurrence rates because of the large difference in the follow-up periods. They found that the laparoscopic procedure took longer to perform, but it was associated with fewer complications and shorter postoperative hospital stays. In the only prospective randomized study of laparoscopic repair versus open repair, Carbajo and colleagues randomized 60 patients over a three-year period into two homogeneous groups to be operated on for major ventral hernias using mesh.28 With an average follow-up of 27 months, they noted that two hernias in the open repair group and none in the laparoscopic group recurred. They concluded that laparoscopic repair offers several advantages over the classic surgical repair of abdominal wall defects, including a reduction in the rate of complications and recurrence.

ADVANTAGES AND DISADVANTAGES OF DIFFERENT LAPAROSCOPIC TECHNIQUES Critical assessment of the reported results is difficult and potentially misleading due to the significant variations in terminology, patient selection, and operative techniques.29 No data are available to support unequivocally an overt advantage of any particular technique to repair incisional hernias. Clinical judgment, previous experience, and team surgical skills should guide the technical choice that is applied to a particular patient. Despite the pitfalls of the available data (mainly from retrospective studies of selected patients), recurrence rates are slightly lower and complications less frequent in the laparoscopic group, regardless of the technique employed. The most popular laparoscopic technique of incisional hernia repair proposes a transperitoneal approach using either an ePTFE

or a composite mesh prosthesis in the intraperitoneal location.30,31 Biomaterials have become an important tool because they can permanently replace the defective transversalis fascia and permit the creation of a truly tension-free hernioplasty. However, utilization of biomaterials is associated with four major concerns: rejection, infection, early adhesion formation and host tissue incorporation. It is well known that a peritoneal defect or the presence of a foreign body in the abdominal cavity creates adhesions.13 This in turn may result in major complications, including intestinal obstruction, migration of the foreign body and erosion into the bowel, fistula, and infection. In general, complications resulting from intraperitoneal adhesions account for a significant number of emergency surgical admissions and abdominal operations.7 These concerns have prompted the development of a further refinement in the transabdominal laparoscopic approach: the pre-peritoneal laparoscopic mesh repair. Dissecting within the pre-peritoneal plane in order to create an anatomical room for the mesh may sometimes be extremely difficult. However, our own experience shows that this approach is technically feasible in many circumstances and, indeed, this procedure is an extension of our current laparoscopic techniques for repairing inguinal hernias.32 However, we should also underscore the fact that even pre-peritoneal repairs of inguinal hernias have not been free of adhesions and associated bowel complications. Only a longer follow-up period of our patients will allow us to determine whether the theoretical advantages of positioning the mesh in the pre-peritoneal location will overcome the possible disadvantages of a more tedious procedure that usually demands a longer operative time.33

CONCLUSION The laparoscopic route has made possible the introduction of new surgical techniques for the repair of major abdominal wall defects. The laparoscopic surgeon is able to minimize the great degree of tissue trauma involved in

Pre-peritoneal herniorrhaphy 131

classic open surgery, typically associated with large fascial dissection, tense sutures, and postoperative drains. Laparoscopic repair of incisional hernias is a promising but still new technique that may be seen as a further refinement of the current surgical armamentarium to treat this common problem in general surgery. As with any new operation, we should initially be more careful about patient selection before embarking on a broader application of this technique. Adequate training and judicious indication can certainly ensure good surgical outcomes. Until now, patients in several series have tolerated the procedure well and had shorter postoperative hospitalizations in comparison to open procedures. Accordingly, given the potentially lower morbidity due to the smaller abdominal wall incisions, the overall hospital cost may be reduced, making this a more attractive approach to incisional hernias. Moreover, laparoscopy allows comprehensive exploration of the abdominal cavity, adequate assessment of the adhesions in the hernia process, and a clear delineation of the anatomy. It may be the procedure of choice in patients who develop a recurrence following a previous open hernia repair. Laparoscopic incisional hernia repair can be performed safely with no increased morbidity or mortality, but the ultimate outcome in assessing the success of any hernia repair must be the rate of recurrence. The literature suggests that the laparoscopic approach, regardless of where the mesh is placed, has a midterm recurrence rate that is at least as good as that seen after the open operation. However, long-term assessment from large, well-controlled, prospective studies is needed to confirm the expected advantages of the laparoscopic approach.

10 11 12

13

14 15

16 17 18

19

20 21 22

23 24 25

26

REFERENCES 1 2 3

4

5 6 7

8

9

Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am 1993; 73: 557–70. Makela JT, Kiviniemi H, Juvonen T, et al. Factors influencing wound dehiscence after midline laparotomy. Am J Surg 1995; 170: 387–90. Niggebrugge AH, Hansen BE, Trimbos JB, et al. Mechanical factors influencing the incidence of burst abdomen. Eur J Surg 1995; 161: 655–61. Meissner K, Jirikowski B, Szecsi T. Repair of parietal hernia by overlapping onlay reinforcement or ‘gap-bridging’ replacement polypropylene mesh: preliminary results. Hernia 2000; 4: 29. Larson GM. Ventral hernia repair by the laparoscopic approach. Surg Clin North Am 2000; 80: 1329–40. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic ventral and incisional repair in 407 patients. J Am Coll Surg 2000; 190: 645–50. Luijendijk RW, Hop WC, van den Tol P, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 2000; 343: 392–8. Leber GE, Garb JL, Alexander AI, et al. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998; 133: 378–82. Amid PK, Shulman AG, Lichtenstein I, et al. Preliminary evaluation of composite materials for the repair of incisional hernias. Ann Chir 1995; 49: 539.

27 28

29 30 31

32

33 34 35

Amid PK. Classification of biomaterials and their related complications in abdominal wall hernia surgery. Hernia 1997; 1: 15. Morris-Stiff H. The outcomes of nonabsorbable mesh. J Am Coll Surg 1998; 186: 352. Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: A personal series and review of the literature. JSLS 1999; 3: 293–304. Marchal F, Brunaud L, Sebbag H, et al. Treatment of incisional hernias by placement of an intraperitoneal prosthesis: a series of 128 patients. Hernia 2000; 3: 141. Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of recurrent ventral hernias. Am Surg 1998; 64: 1126–7. Luijendijk RW, Lemmen MHM, Hop WCJ, et al. Incisional hernia recurrence following ‘vest-over-pants’ or vertical Mayo repair of primary hernias of the midline. World J Surg 1997; 21: 62–5. Stoppa R. The treatment of complicated groin and incisional hernias. World J Surg 1989; 13: 545–54. Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional hernias. Surg Laparosc Endosc 1996; 6: 123–8. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. Hashizume M, Migo S, Tsugawa Y, et al. Laparoscopic repair of paraumbilical ventral hernia with increasing size in an obese patient. Surg Endosc 1996; 10: 933–5. Scott-Roth J, Park AE, Witzked, et al. Laparoscopic incisional/ ventral herniorrhaphy: a five-year experience. Hernia 1999; 4: 209. Wants GE. Incisional hernioplasty with Mersilene. Surg Gynecol Obstet 1991; 172: 129. Barie PS, Mack CA, Thompson WA. A technique for laparoscopic repair of herniation of the anterior abdominal wall using a composite mesh prosthesis. Am J Surg 1995; 170: 62–3. Larson GM: Laparoscopic repair of ventral hernia. In: Scott-Conner CEH, ed. The SAGES Manual. New York: Springer-Verlag, 1998: 379. Toy FK, Bailey RW, Carey S, et al. Prospective multicenter study of laparoscopic ventral hernioplasty. Surg Endosc 1998; 12: 955–9. Roll S, Benatti M, Roncada, P, et al. Laparoscopic incisional preperitoneal hernioplasty. Presented at the 7th World Congress of Endoscopic Surgery, Singapore, 1–4 June 2000. Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and incisional hernioplasty. Surg Endosc 1997; 11: 32–5. Park AE, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998; 124: 816. Carbajo MA, Martín 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 1999; 13: 250–2. Chevrel JP, Rath AM. Classification of incisional hernias of the abdominal wall. Hernia 2000; 4: 7. Alexandre JH, Aouad K, Bethoux JP, et al. Recent advances in incisional hernia treatment. Hernia 2000; 4: 1. Balique JC, Alexandre JH, Arnaud JP, et al. Intraperitoneal treatment of incisional and umbilical hernias: intermediate results of a multicenter prospective clinical trial using an innovative composite mesh. Hernia 2000; 4: 10. Roll S, DePaula AL, Miguel P, et al. Laparoscopic transabdominal inguinal hernia repair with a preperitoneal mesh. Surg Endosc 1994; 8: 484. Saiz AA, Willis IH, Paul DK, et al. Laparoscopic ventral hernia repair: a community hospital experience. Am Surg 1996; 62: 336–8. Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. Sanders LM, Flint LM. Initial experience with laparoscopic repair of incisional hernias. Am J Surg 1999; 177: 227–31.


18 Hernioplasty with the double-crown technique SALVADOR MORALES-CONDE AND SALVADOR MORALES-MÉNDEZ

Principles Double-crown surgical technique Results of our series

133 135 141

Laparoscopic surgery continues to advance in achieving further benefits over the conventional approach for certain pathologies. In 1991, LeBlanc and coworkers carried out the first laparoscopic repairs of ventral hernias.1 Although ventral hernia was not originally considered to be a pathology that could benefit from this approach, laparoscopic repair of ventral hernias has attained wide acceptance in recent years because of the significant advantages afforded by improvements in prosthetic materials and in attachment methods, as well as in the surgical technique used. The laparoscopic procedure offers greater comfort during the postoperative period, reduces hospitalization time, and lowers complication rates. Even though many series still have a limited follow-up, the technique has shown lower rates of recurrence than the open methods, making it a procedure that solves a long-standing challenge to the surgeon. Nevertheless, there are certain points of controversy that should be clarified, starting with the simple fact of establishing more precise indications. In addition, a multitude of more specific technical details should be discussed, including how to perform adhesiolysis, how to manage the hernia sac, the postoperative seroma, the type and size of the mesh, and how to insert and secure the mesh. One of the most interesting points currently being debated is whether it is necessary to use sutures or tacks. We have developed a laparoscopic procedure without sutures for the repair of ventral hernias, a technique we have come to call the ‘double-crown’ technique. This system avoids the use of external (transfascial) sutures by fixing the mesh with a double crown of tacks alone (Figure 18.1). This ensures proper anchorage of the mesh, decreasing surgery time and diminishing


142 142

Hernia

Figure 18.1 Double-crown technique for laparoscopic ventral hernia repair. External sutures are avoided, and the mesh is fixed with a double crown of tacks alone.

postoperative pain at this level, and with the same recurrence rate as described by groups using transfascial sutures.

PRINCIPLES Indications and contraindications Indications for the double-crown technique are the same as indications for laparoscopic hernia repair with transfascial sutures. Basically, all ventral hernias can be repaired by laparoscopy as the standard procedure. Emergency operations performed in cases of strangulated hernias must be analyzed on an individual basis to


assess whether laparoscopy should be used. However, various factors place limits on the indications for laparoscopic repair, such as the size of the defect and the site where the defect has occurred. Subxiphoid, suprapubic, lumbar and parastomal hernias require special considerations for laparoscopic repair, and several technical details must still be considered. At the lower end of the size spectrum, hernias that can be repaired with local anesthesia, encompassing those under 3–4 cm, are usually excluded. However, in patients requiring laparoscopic surgery for other concomitant conditions and in obese patients, laparoscopic repair would be indicated despite the small size of the hernia. At the upper end of the hernia size spectrum, our group has performed many successful repairs of massive abdominal wall defects. We conclude, therefore, that until the limits are established clearly, the degree of difficulty in managing the instruments within the abdominal cavity is the only actual limit to the technique as far as large hernias are concerned. On the other hand, the characteristics of the sac of the hernia are important to determine the contraindications of this technique, since the evolution and complication of the seroma and the cosmetic results would be different depending on the type of sac. Definitive guidelines will have to be elaborated on the basis of results from prospective studies.

transfascial sutures.4,7,8 In fact, they demonstrated that one of the essential factors to avoid recurrence is the use of these sutures.9 Analysis of the data derived from these early series – data that were later the basis for recommendations on the use of sutures – shows that other factors could have been involved in the development of recurrence in these patients besides the use (or not) of transfascial sutures:

•

•

Sutures versus no sutures with double-crown technique

•

Why are transfascial sutures recommended? Laparoscopic surgery for ventral hernias offers enormous advantages over open surgery during the immediate postoperative period, with clearly lower morbidity2–4 and lower general costs of surgery.5,6 Another important issue is that patients who were operated on by laparoscopy appear to have lower recurrence rates.2–4 Despite the lower recurrence rate, various authors have made efforts to analyze the causes for recurrence in order to define adequately the laparoscopic technique and thereby achieve an even lower recurrence rate. Initial laparoscopic ventral hernia repair series established a direct correlation between recurrence and the absence of

Prostheses initially recommended were small, overlapping the defect by only 2–2.5 cm10–12 in all directions, and not the minimum of 3 cm currently recommended. Recently, we have demonstrated in an experimental study that expanded polytetrafluoroethylene (ePTFE) prostheses decrease in size once they have been implanted (by 1.63–4 cm after five weeks), probably because of the scar tissue reaction and the encapsulation process experienced by the mesh,13 so recurrence in these initial experiences could have happened mainly because of the smaller size of the mesh. The method of fixation was also inadequate, since tacks were not yet available and mesh patches were anchored with the old endo-staplers that did not ensure secure attachment of the material. This problem was particularly important with the ePTFE mesh because of its thickness. Thus, the use of transfascial sutures was necessary in these cases, and the real purpose of the endo-staplers was to prevent the bowel from slipping between the sutures rather than to fix the mesh.10,11,14 The learning curve of these initial series could be related more directly to the appearance of recurrences than to the placement (or not) of transfascial sutures.

Disadvantages of using transfascial sutures Based on the reasons noted above, we do not believe that these sutures are needed to reduce the recurrence rates, as reported by several authors. Nevertheless, they are associated with a number of disadvantages (Table 18.1):

•

Longer surgery time: surgery times associated with transfascial suture placement are longer because

Table 18.1 Comparison of factors related to the use of transfascial sutures Technique Double-crown (S. Morales-Conde) Other technique without transfascial sutures3 Series with transfascial sutures

Mean operating time (min) 79 62 120

Mesh infection rate (%)

Long-term pain (%)

Recurrence rate (%)

0 0

0 0

2.86 2

4.87

1.97

3.98

Hernioplasty with the double-crown technique 135

• • •

•

•

sutures are recommended every 5 cm,14 4–5 cm,12 or even 3–4 cm,9 in addition to at the four corners. The operating time in our series is around 79 minutes. The time in the other published series that use only tacks and no sutures is between 62 and 87 minutes.2,3 The operating times for groups using sutures were between 82 minutes4 and 210 minutes,15 with a mean of 120 minutes,4,12,15–17 showing a significant increase in surgery time due to the maneuvers needed to place these sutures. More incisions in the skin: transfascial suture placement involves incisions of 2–3 mm at a preestablished distance of 3–5 cm, as mentioned earlier. Poorer cosmetic results: small incisions are needed to place the sutures. The incisions require only a SteriStrip and typically leave a small scar; however, they do contribute to a higher number of scars. Greater infection rate: in our series, the mesh infection rate was zero, in keeping with results reported by other authors who do not use these sutures.6 The infection rate reported by groups using transfascial sutures was as high as 11.1 per cent,5 with a mean infection rate of 4.87 per cent.4,5,18 In addition to mesh infection, the subcutaneous sutures can become infected, or a superficial infection can develop in the small incisions in the skin. In the only case in our series in which sutures were used, the patient presented with a superficial skin infection at the site of the incisions made to place two of the sutures. Pain during the early postoperative period: the use of transfascial sutures involves taking 1–2 cm of tissue, trapping it, and compressing it by tying at the subcutaneous tissue level. This is associated with greater pain during the early postoperative period and in the longer term. In the short term, some authors defending the use of these sutures recognize that there is more pain during the immediate postoperative period than after laparoscopic cholecystectomy and that this pain could extend hospitalization.9 There may also be discomfort at the suture level during the first two weeks of the postoperative period.17 Long-term postoperative pain: the more significant problem is long-term pain, whether continuous or associated with movement, and the pulling sensation at the site of the sutures. In some cases, oral narcotics, non-steroidal anti-inflammatory drugs, or even injections of local anesthetics at the suture site have been required, perhaps due to nerve entrapment.17,18 Postoperative diagnostic laparoscopy has been recommended to assess the condition of the mesh and the sutures. This will allow the section of the offending sutures, if necessary.19

Recurrence rate: a reason to use the double-crown technique Irrespective of the disadvantages associated with sutures listed above, if the recurrence rate in our series were higher than in the series using transfascial sutures, then their use would be warranted. In series that advocate the use of sutures, the recurrence rate ranges anywhere from zero11 to 8.3 per cent,15 with a mean of 3.98 per cent.4,5,9–11,14–18 The recurrence rate of our series is 2.86 per cent, with a mean follow-up of 24 months. As we noted earlier, recurrence after laparoscopic repair of ventral hernias tends to appear more frequently during the first few months of the postoperative period. Analysis of our recurrences shows that they were not related directly to the use of sutures: one case was due to use of a short mesh at the beginning of our series and the other two cases were two suprapubic hernias with recurrence at the inferior margin. Recurrence in these two cases resulted from inadequate exposure of the pubis and Cooper’s ligament in order to anchor the mesh more securely at this level. This is a complicated area, which presents particular difficulty when placing transfascial sutures. Even authors who advocate the use of sutures do not recommend them at this level.

DOUBLE-CROWN SURGICAL TECHNIQUE Preoperative management A clinical preoperative evaluation is performed, and the indication for laparoscopic approach is set based on previous considerations. Patients are informed fully about the risk of the surgery, the possibilities of conversion into an open procedure, and the high frequency of the development of postoperative seroma (so that they do not confuse this seroma with an early recurrence). We administer antibiotic prophylaxis in all cases with a preoperative dose of a second-generation cephalosporin. If the patient has any risk factor, such as diabetes, the prophylaxis is continued with two additional doses in the postoperative period. Mechanical bowel preparation is not usually necessary; only patients who have undergone several previous surgeries and who are thought to have densely adherent or incarcerated viscera will undergo this preparation.

Instrumentation Laparoscope A 30-degree-angled laparoscope is essential to perform the laparoscopic approach of ventral hernias, since this offers an excellent view of the entire anterior abdominal wall and of the defect that will be repaired.


Trocars A variety of trocar sizes are available commercially, including 2-, 3-, 5-, 10-, 11- and 12-mm trocars. In general, we perform the technique using one 10-mm trocar and two 5-mm trocars. A series of factors should be considered when choosing the trocars:

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•

•

A trocar of at least 10 mm is required for introducing a mesh. Contamination of the mesh due to microorganisms on the skin of the abdominal wall can potentially occur when the mesh is introduced through the opening left by the trocar once it is removed. Because of this, we prefer to introduce the mesh through the trocar. As a result, we select the trocar based upon the size of the ePTFE patch. We most frequently use the sizes 10 ⫻ 15 cm, 15 ⫻ 19 cm and 18 ⫻ 24 cm (as well as others of larger size). We use a 10-mm trocar when we expect to use a 10 ⫻ 15-cm mesh, an 11-mm trocar for a 15 ⫻ 19-cm mesh, and a 12-mm trocar for an 18 ⫻ 24-cm prosthesis. For larger mesh sizes, we use a 10mm trocar and insert the mesh through the opening left in the skin by the trocar after it is removed, since larger meshes cannot be passed through any of the trocars. In such cases, the mesh to be inserted is wrapped in a sterile plastic material that covers the mesh in order to prevent contamination from microorganisms on the abdominal wall; this plastic is subsequently removed from the abdominal cavity. We prefer to use a 10-mm, 30-degree laparoscope because the visualization and illumination provided by the 5-mm, 30-degree laparoscope are not optimal in our institution. This, of course, requires a trocar of at least 10 mm. A 5-mm trocar is used for introduction of the ProTack device (U.S. Surgical Corp./Tyco International). Before this fixation system appeared on the market, this step was performed using an endo-stapler, which required the use of 12-mm trocars.

Under these premises, we believe that a 10-, 11- or 12mm trocar (depending on mesh size) should be used for laparoscopic repair of ventral hernias, as these accommodate a 10-mm, 30-degree laparoscope and can be used to introduce the mesh. A 5-mm trocar should be used to introduce the tacks (or other fixation device) that attach the mesh. Another 3- or 5-mm trocar should be used as a working trocar. Graspers, scissors, and other laparoscopic instrumentation Atraumatic bowel graspers are needed to manipulate the bowel and to provide gentle traction to reduce the contents of the hernia sac. Sharp scissors are required for proper dissection and prevention of bowel injury.

Different hemostatic systems, such as clips, must be available should their use become necessary. A needle-holder should be available in case of an enterotomy, so that one may repair the injury, thereby allowing the procedure to continue laparoscopically. If we find a full-thickness injury to the small intestinal wall that penetrates into the lumen, we usually repair it, either by laparoscopy or by an assisted mini-laparotomy, and then continue the technique by placing the mesh intraperitoneally. However, if a colonic injury occurs, we prefer to repair the bowel and, in the case of a large defect, repair the hernia defect by placing the patch a few days later or, in the case of a small defect, convert to an open repair without the use of a patch. Energy sources Monopolar cautery is acceptable as long as it is not used in close proximity to any viscera. Adhesiolysis must be performed with extreme care since missed bowel perforation could be life-threatening for the patient. For this reason, electrocautery should be used in a bleeding area after the adhesions are freed. During dissection, there is frequent hemorrhage, but this is usually minimal and insignificant if the proper plane of dissection is maintained. The harmonic scalpel has been advocated for lysis of adhesions, but the blunt tip of this instrument does not allow the easy localization of the proper plane to free the adhesions of the bowel. For this reason, we use this source of energy only for the lysis of omental adhesion and only when we are convinced that there is no bowel attached to the anterior abdominal wall behind the fatty tissue. This is particularly useful in cases in which the round ligament or the urachus must be dissected to guarantee a proper fixation of the mesh, since dissection of these structures is a time-consuming maneuver due to frequent bleeding. Prostheses Improvements are being made to attain the ideal prosthetic material, i.e. one that is biologically inert, that produces little or no foreign-body reaction, that is strong yet pliable, that maintains its shape after implantation, and that resists the formation of adhesions while supporting fibrous in-growth of connective tissue.20 Polypropylene mesh has been the most widely used prosthetic material in hernia repair since it was introduced in 1963.21 Numerous materials are currently available, such as ePTFE, with excellent properties closely resembling the ideal prosthesis, i.e. being biologically inert, producing fewer adhesions,22 and causing little or no inflammatory reaction, with its porous microstructure providing a lattice for the incorporation of connective tissue.23,24 Clinical and experimental experience indicates a variety of complications that may be related to the physical properties of polypropylene, such as the risk of bowel obstruction and/or fistula formation.25–27 Additionally, a


recent experimental study conducted in our laboratory revealed that polypropylene does not attach to the peritoneum as well as it does to the other layers of the abdominal wall previously dissected. ePTFE appeared to attach more firmly to these layers. The new ePTFE material is designed specifically to be placed intraperitoneally, since one (visceral) surface has very small pores, which inhibits tissue in-growth, while the opposite (parietal) surface that is placed on to the peritoneum has large pores to permit significant tissue in-growth. We usually use the DualMesh Plus with Holes (W. L. Gore & Associates), which is impregnated with chlorhexidine and silver. These antimicrobial agents decrease the possibility of contamination of the mesh. Chlorhexidine and silver also change the color of the ePTFE to brown; this minimizes the bright glare of the ePTFE, which can otherwise hamper the management of the mesh within the abdominal cavity because of the brightness of the light of the laparoscope. We also advocate the use of the mesh with holes since it will facilitate the drainage of the fluid retained between the mesh and the sac during the first hours of the postoperative period. The use of an external compressive bandage is also recommended, as this will aid in decreasing the size of the seroma that we have seen in some of our patients. Fixation devices We fix the mesh in all cases with helical tacks, which provide proper fixation of the mesh to the anterior abdominal wall, thereby avoiding the need of transfascial sutures. A new fixation device is now available, the SaluteTM (Onux Medical, Inc.), which delivers a cylindrical construct of stainless steel. We do use sutures in hernias that require a mesh larger than 18 ⫻ 2 4 cm to facilitate orientation and initial fixation of the mesh. These sutures may be of any type of material since they will be removed. They are placed at the four cardinal points of the patch and are passed through the abdominal wall with the aid of a suture-passer (W. L. Gore & Associates). These sutures are not tied once the mesh is fixed with the tacks. Instead, they are removed completely when the outer crown of tacks is placed and the mesh is properly extended.

hernias, midline hernias located in the lower of the abdomen, or if operation is likely to be prolonged. We use a nasogastric tube to decompress the stomach in patients with subxiphoid hernias or hernias in the upper third of the midline of the abdomen.

Operative technique Creation of pneumoperitoneum and placement of trocars In all cases, we start by creating the pneumoperitoneum using a Veress needle in the left hypochondrium. We do not use the Hasson trocar, regardless of the number of previous laparotomies that the patient has undergone. Our group has performed more than 4000 laparoscopic procedures for a variety of pathologies, and there has never been an injury to any structure because of the use of the Veress needle. Hence, we feel confident when creating the pneumoperitoneum with this technique, even in patients with a history of multiple operations. Once the pneumoperitoneum is created, we generally approach the hernia from the patient’s left side, placing three trocars in line, introducing the 10–12-mm trocar first and then placing the other 5-mm trocars under direct vision; the larger trocar is placed in the middle of the other two trocars. An important thing to remember when placing these trocars is to stay as far away as possible from the margin of the defect closest to the surgeon. This will provide proper visualization of the margin, making it easier to achieve a wide overlap of the mesh and perform any maneuvers needed to secure the prosthesis (Figure 18.2). When it is not possible to maintain a suitable distance

Operative room set-up The description below is based upon the repair of small to medium-sized (3–10 cm) primary or incisional hernias located in the midline but about 3 cm from the xiphoid and suprapubic areas. We usually place the patient in the supine position, with the surgeon and the assistant to the patient’s left and the monitor in front of them to the patient’s right. A urinary drainage catheter is used in patients with suprapubic

Figure 18.2 Pneumoperitoneum is created using a Veress needle in the left upper quadrant of the abdominal wall. The first trocar is introduced far enough from the defect so we do not have difficulty in fixing the proximal part of the mesh.


from this margin, we introduce another 5-mm trocar in the patient’s opposite flank in order to adequately fix the mesh on the margin closest to the trocar through which the laparoscope is placed. If necessary, a contralateral 10-mm trocar can be inserted to help anchor the mesh. Adhesiolysis Once the trocars are introduced, the adhesions are evaluated. We consider adhesiolysis to be a key point of this procedure, since incorrect performance of the adhesiolytic process can have extremely serious consequences for the patient. Nevertheless, if there are any doubts regarding the possibility of bowel perforation, the operation should be converted to the open technique or, alternatively, one of the trocar holes may be enlarged to evaluate the bowel. This is critical because a missed enterotomy is associated with high morbidity and mortality.

entire defect on the skin of the patient. In obese patients, it is difficult or impossible to feel the grasper on the outside. In these cases, we insert an intramuscular needle through the skin and abdominal wall. The tip of the needle is visualized inside the abdominal cavity under laparoscopic vision and, with multiple passes, is used to detect and trace the hernia defect on the patient’s skin (Figures 18.4 and 18.5). An exact measurement of the defect is determined when the abdomen is fully desufflated. The patch is then chosen to provide an overlap of at least 3 cm. We systematically use a DualMesh Corduroy Plus with Holes. Once the mesh is selected, several marks are traced on the patient’s abdomen and on the mesh surface that

Identification of the defect and selection of the mesh Once the adhesiolysis process is completed, we proceed to identify the defect and the sac (Figure 18.3). We use the electrocautery to coagulate the entire area where the adhesiolysis was performed. This is done to avoid any bleeding in these areas, which could then create a hematoma at this level. If this were to occur, tension could be produced that could result in the detachment of the tacks following implantation of the prosthetic biomaterial. Once the hernia is identified, the actual hernia defect must be delineated by marking the margins of the hernia (not the sac) on the skin of the patient. To facilitate the accurate identification of the fascial edges, a laparoscopic grasper is used (under direct vision) to exert pressure at the margins of the defect. The pressure exerted by this instrument is palpated on the outside of the abdominal wall. This is used to accurately outline and mark the

Figure 18.3 Defect of the hernia that needs to be covered once the adhesiolysis process is completed.

Figure 18.4 Once adhesiolysis has been performed, the defect is identified since it will be where the inner crown of tacks will be placed. In obese patients, the best way to localize the defect is by using needles from the outside under direct vision.

Figure 18.5 The defect identified previously is drawn on the patient’s skin and the needles are removed. The three trocars placed in line can be observed; one 10-mm trocar and two 5-mm trocars are usually used.


will be placed in contact with the viscera, in order to facilitate orientation of the prosthesis within the cavity (Figure 18.6). A circular mark is traced at the cranial end of the mesh. An identical mark is placed on the patient’s abdomen to denote the location where the mesh will be anchored. A triangle is then drawn at the caudad end of the mesh and the abdominal wall, followed by a line that passes through the triangle, starting at the lower limit of the hernia defect. This is the line where the caudad tack will be positioned, since the outside measurements are different from the internal measurements. Once the cranial tack is placed internally, the distance will not correspond exactly to the triangle drawn on the patient’s abdomen when the mesh is tightened. The second (caudad) tack will be placed at the level of the line that passes through the middle of the triangle. A cross is then drawn on the left side of the patient’s abdomen and on the mesh, and two crosses are drawn on the right in order to extend the mesh properly in both directions. Afterwards, we roll the mesh along its long axis, leaving the mesh side that will be in contact with the bowel rolled towards the inside (Figure 18.7a). This will make it easier

to perform the maneuvers needed to expand the mesh once attachment has begun. We prefer to introduce the mesh through one of the trocars to prevent potential contamination, which may occur if it is inserted through the skin, a strategy that is preferred by some authors (Figure 18.7b). If a large prosthesis is needed (⬎18 ⫻ 24 cm), we prefer to remove the trocar and insert the mesh wrapped in sterile plastic through the trocar hole, and then remove the plastic from inside the cavity. Placement and fixation of the mesh Once the mesh is inside the cavity and unrolled properly, it must be oriented by using the circle drawn on the mesh. The corresponding area of the abdominal wall where the mesh is to be fixed is located by pushing on the abdominal wall at that site. If the patient is extremely obese, we insert a needle at the level of the circle on the abdomen in order to locate the area where the first tack should be placed. When this tack is placed (Figure 18.8),

(a)

(a)

(b) (b)

Figure 18.6 (a) Different signs are drawn on the mesh to orient it once it has been introduced in the cavity. (b) The same signs are drawn on the patient’s skin on the cardinal points.

Figure 18.7 (a) The mesh is rolled along its long axis, with the area prepared to be placed in contact with the bowel in the inside. (b) Once it has been rolled, the mesh is grasped with a strong grasper to be introduced in the abdominal cavity through the 10–12-mm trocar.


(a)

Figure 18.8 The first tack is placed where the circle is drawn on the mesh, one of the cardinal points. The exact point to be placed is localized by pressing from the outside on the circle drawn on the skin.

we stretch the mesh in the caudad direction and perform the same maneuver, placing the second tack in the line that intersects the triangle traced earlier (Figure 18.9). Subsequently, the lateral tacks are placed following the same system with the crosses, avoiding the tendency of the mesh to move in the opposite direction from the point where the laparoscope is introduced. Once the mesh is fixed in the four cardinal points, we extend it adequately, adding an outer crown of tacks that are placed right on the margin of the mesh (Figure 18.10). These tacks are separated from each other by a distance of 1 cm, which is adequate to ensure that the intestinal loops do not slip between the tacks resulting in an acute incarceration. While the crown is being placed, the surgeon must exert strong pressure against the tacker from the outside to ensure that the mesh is attached to the surfaces closest to the wall surface, thereby reaching the muscle fascia. Once the mesh is extended adequately with the tacks of the outer crown, we check for any mesh areas that may not be extended adequately and that are adherent to the anterior wall of the abdomen, because adhesions would occur at the ‘hanging’ sections of the mesh (we have observed this phenomenon in an experimental study conducted by our group).13 We add the necessary tacks at this level to extend the mesh adequately so that these potential areas of adhesions are prevented. Once the outer crown is finished, we add the inner crown of tacks. Since this level contains a smaller amount of pre-peritoneal fat, the inner crown is placed at the margin of the hernia sac to ensure better attachment of the mesh (Figure 18.11). Similarly, to identify the sac margin, we draw the defect on the abdomen of the patient before inserting the mesh inside the cavity. Pressure can then be exerted from the outside, or a needle can be introduced at

(b)

Figure 18.9 (a) The second tack is placed on the opposite cardinal point (caudal) where the triangle was drawn. (b) If we have difficulty in localizing the place where we want the tack, we introduce a needle from the outside.

Figure 18.10 Once the tacks are placed in the four cardinal points, the outer crown of tacks is placed right at the margin of the mesh.

this level in obese patients, so that we can identify the area where the inner crown of tacks should be placed. These are also executed while exerting pressure from the outside to ensure good anchorage at this level. As in the case of the


effort to prevent seroma development. This bandage is kept in place for one week and is removed at the seven-day follow-up visit. Skin sutures are also removed at this time. Once the procedure is completed, we start the patient on fluid intake about six to eight hours after surgery, progressing to solid foods as tolerated. The patient is normally discharged within 24 hours of surgery. In terms of physical activity, we do not impose any limitations on the patient, but recommend only gradual resumption of regular daily activities based on the patient’s progress during postoperative recovery. Patient follow-up is carried out at one month, three months, six months, one year, and with yearly visits thereafter.

Figure 18.11 The inner crown of tacks is placed at the margin of the hernia sac to ensure better attachment.

Figure 18.12 The double crown of tacks is completed.

tacks used for the outer crown, the inner crown tacks are placed about 1 cm apart. Once all the tacks are placed (Figure 18.12), we proceed to identify and remove any that are left hanging from the wall or that are placed improperly, since they should be inserted through the entire thickness of the mesh. Poorly positioned tacks will lead to adhesions, as we have shown in our experimental study, and could cause major complications in the future, such as fistulas or obstruction.13

Postoperative management Once the procedure is completed, the abdomen is desufflated and trocar sites larger than 10 mm are closed. A compressive bandage is placed at the level of the hernia sac to reduce the space between the mesh and the sac in an

RESULTS OF OUR SERIES Between November 1998 and April 2002, we operated upon 105 ventral hernias on 102 patients using the doublecrown technique. Our series included 63 women and 42 men, with a mean age of 57.59 years (range 26–80 years). The ventral hernias included eight primary hernias (four umbilical hernias, four epigastric hernias) and 97 incisional hernias. The hernia site varied considerably, with 87 midline hernias and 18 lateral hernias. The mean size of the defect repaired was 115.87 cm2. Only three cases were converted to open surgery: one patient with extremely strong adhesions who had been operated upon previously for acute peritonitis of tuberculous origin; one patient who was converted due to technical difficulties; and one patient who was converted due to a strong adhesion from the colon to the hernia sac. Intraoperative complications included three intestinal perforations; one of these was sutured by laparoscopy and the other two required enlarging one of the trocar holes to perform resection and anastomosis, continuing later by laparoscopy. The following complications were encountered during the postoperative period: three clinical seromas that required drains, two abdominal wall hematomas, two prolonged paralytic ileus, and three reoperations. One of the reoperations was for missed intestinal perforation and peritonitis requiring emergency laparotomy. We sutured the bowel perforation and removed the mesh. The second reoperation was in a patient who had fever of 45 days’ duration. The seroma fluid was drained repeatedly, but cultures were negative. It was assumed that the patient had a foreign-body reaction and the mesh was removed. The third reoperation was performed due to small bowel ischemia, the etiology of which is undetermined. The mean hospital stay was 1.75 days, with a mean of 2.48 days in our first 45 cases and dropping to 1.12 days in the last 60 cases of our series. There were three recurrences, accounting for 2.86 per cent of all our cases, with


a mean follow-up of 24 months. These recurrences occurred in one patient in our initial series in whom a small mesh was implanted and in two cases of suprapubic hernias in which the pubis and Cooper’s ligament were not exposed adequately for suitable fixation of the mesh.

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CONCLUSION Our results indicate that the use of transfascial sutures is not necessary and that the double-crown technique, which uses only tacks, offers a number of clear advantages over the combined suture-and-tack method. When using the technique described, we obtained a similar recurrence rate as series that use sutures, while also reducing the hospital stay and short-, medium- and long-term postoperative pain. Hence, we consider the double-crown technique to be a valid alternative to ventral hernia repair with sutures.

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LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. Carbajo MA, Martín 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 1999; 13: 250–2. Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment of ventral abdominal wall hernias: preliminary results in 100 patients. JSLS 2000; 4: 141–5. Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65: 827–32. DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthesis patch repair of ventral hernia. Surg Endosc 2000; 14: 326–9. Morales-Conde S, López F, Tutosaus JD, et al. Cost-effectiveness of ‘Double Crown’ technique for laparoscopic ventral hernia vs open repair. Presented at the 9th International Congress of he European Association for Endoscopic Surgeons, Maastricht, 13–16 June 2001. Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: a personal series and review of the literature. JSLS 1999; 3: 293–304. Chari R, Chari V, Eisenstat M. A case controlled study of laparoscopic ventral hernia repair. Surg Endosc 1998; 12 (suppl): S09.

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Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of recurrent ventral hernias. Am Surg 1998; 64: 1121–7. Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional hernias. Surg Laparosc Endosc 1996; 6: 123–8. LeBlanc KA, Booth W, Whitaker JM. Laparoscopic repair of ventral hernias using an intraperitoneal onlay patch: report of current results. Contemp Surg 1994; 45. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998; 124: 816–22. Morales-Conde S, Cadet I, Tutosaus JD, et al. Macroscopic evaluation of mesh incorporation placed intraperitoneally for laparoscopic ventral hernia repair. Experimental model. In: Lomanto D, Kum CK, So CK, Goh PMY, eds. Proceedings of the 7th World Congress of Endoscopic Surgery (Singapore June 1–4, 2000). Bologna, Italy: Monduzzi Editore, 2000: 455–60. Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc 1998; 12: 955–9. Sanders LM, Flint LM, Ferrara JJ. Initial experience with laparoscopic repair of incisional hernias. Am J Surg 1999; 177: 227–31. Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience with the ‘four-before’ laparoscopic ventral hernia repair. Am Surg 2000; 66: 465–9. Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair: a report of 100 consecutive cases. Surg Endosc 2000; 14: 419–23. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000; 190: 645–50. LeBlanc KA. Current considerations in laparoscopic incisional and ventral herniorrhaphy. JSLS 2000; 4: 131–9. Condon RE, DeBord JR. Expanded polytetrafluoroethylene prosthetic patches in repair of large ventral hernia. In: Nyhus LM, Condon RE, eds. Hernia, 4th edn. Philadelphia: Lippincott Williams and Wilkins, 1995: 328–36. Usher FC. Hernia repair with knitted polypropylene mesh. Surg Gynecol Obstet 1963; 117: 239. Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and Gore-Tex to repair abdominal wall defects in the rat. Can J Surg 1989; 32: 244. Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal wall defects with expanded polytetrafluoroethylene (PTFE). Ann Surg 1987; 206: 765. Law NW, Ellis H. Adhesion formation and peritoneal healing on prosthetic materials. Clin Mater 1988; 3: 95. Kaufman Z, Engelberg M, Zager M. Fecal fístula: a late complication of Marlex mesh repair. Dis Colon Rectum 1981; 24: 543. Voyles CR, Richardson JD, Bland KI. Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 1981; 194: 219. Ponce González JF, Barriga Beltrán R, Martín Zurita I, et al. Prosthetic materials in incisional hernia. Experimental study. Cir Esp 1998; 63: 189–94.

19 Parastomal hernia repair KARL A. LEBLANC

Types of hernia Principles of management Indications and contraindications to surgery Preoperative preparation Operative techniques

143 144 144 145 145

Hernias that develop at the site of the various intestinal stomas are quite common and often lead to many problems. Parastomal hernias may present as problems of stoma care, difficulty with the fit of the appliances or irrigation, leakage of the fluids produced, a significant cosmetic deformity, or as complications of the hernia, such as intestinal obstruction or strangulation. The presence of a large protrusion may make repair a necessity irrespective of its other side effects because of a significant cosmetic deformity. Herniation is less frequent with ileostomy than colostomy, but the overall incidence of parastomal herniation is difficult to quantify. Burns, in 1970, found 16 paracolic hernias among 307 colostomates, an incidence of five per cent.1 Other authors have quoted figures that range from five to 48 per cent.2–6 It is apparent that few (approximately 20 per cent) of these hernias are repaired surgically. This may be due to the lack of significant symptoms in the majority of these patients and/or the age or infirmity of these individuals, which may prohibit surgical intervention.7,8 The incidence of para-ileostomy hernia is between five and ten per cent, while that of para-urostomy stomas in urological practice is between two and ten per cent.9,10 However, one radiological study of 28 ileostomies using clinical and computerized tomography (CT) evaluation found that the rate of herniation was 35 per cent; this was the same whether the ileum exited through or lateral to the rectus muscle.11

Postoperative management Results Conclusion References

147 148 149 149

TYPES OF HERNIA The anatomy of the herniation is variable. Four principal types can be identified:

•

•

•

Subcutaneous: there is herniation alongside the stoma, with a subcutaneous hernia sac containing omentum or small or large intestine. This is the most common form of paracolostomy hernia and, not infrequently, the colon is found in the sac situated just proximal to the stoma. This positioning of the intestine alters the path of the colon such that the ostomy can be very difficult to irrigate. Interstitial: there is a hernia sac lying within the muscle/aponeurotic layers of the abdominal wall, which may contain omentum or small or large intestine. In these cases, the stoma is asymmetrical, and is edematous and cyanotic if its vascular supply is compromised. The interstitial and subcutaneous hernias are considered to be variants of a sliding hernia. Because the ring of tissue that surrounds the contents of the hernia can be quite narrow, these hernias are particularly at risk of incarceration and strangulation. Prolapse: all stomas can prolapse, but transverse colostomies prolapse three times more frequently than any other stoma. A prolapsed stoma contains a


•

hernial sac within itself; other viscera, especially the small intestine, can enter this sac and even become strangulated. Large hernial sacs that can be associated with prolapse are often seen in neonates with a transverse colostomy for anorectal agenesis. Intrastomal: this type of hernia is seen only with end ileostomies. A loop of intestine may herniate alongside the stoma and lie between the emergent and the everted layer of the stoma. Intestinal obstruction has been described in such hernias.

PRINCIPLES OF MANAGEMENT The exact classification of the hernia is not critical to the laparoscopic surgeon. The approach to these different hernia types will not vary significantly, except in the situation in which the intestine may be strangulated. In this case, the use of the laparoscopic technique may be contraindicated. In the elective operation, the condition of the patient and any predisposing factors, such as cachexia, malignancy, obesity, and steroid usage, should influence the decision to proceed with surgical intervention, as it would for any operation. However, an accurate diagnosis and assessment of the anatomy of the hernia are essential. Therefore, the patient must be examined (1) supine and relaxed, (2) supine with the muscles tensed, and (3) in the erect position. Investigation of the detailed anatomy with CT scanning is useful to delineate large parastomal defects in the abdominal wall. CT scanning can also detect small impalpable defects around ileostomies that present with dysfunction.12 This information will assist the surgeon in the planning and execution of the operation. I have seen a herniation through the ileal conduit mesentery during the repair of a para-urostomy hernia. This was suspected by the findings on the preoperative CT scan and was confirmed at surgery. That procedure was modified intraoperatively due to this fact (see below). Patients who have had cancer surgery must be screened for recurrence before surgery is advised. Similarly, it is prudent to exclude recrudescent inflammatory bowel disease before undertaking operations in patients with ileostomies, although it should be noted that the risk of para-ileostomy herniation is similar in patients with ulcerative colitis and Crohn’s disease. An additional consideration that has become more commonplace is the life expectancy of the patient. An increasing number of patients of advanced age are seen with multiple medical problems that add to the risk of general anesthesia. If these illnesses will significantly shorten the life of the patient (i.e. by two to three years or more), or if they prohibit anesthesia, then one may not wish to proceed if there is no immediate need for surgical intervention.

There are four surgical options for treating a parastomal hernia: 1 Local repair of the stoma, in which case it is mobilized locally, the peritoneal sac is identified and the sac’s contents are reduced. The peritoneum and the musculo-aponeurotic defect are then closed. This is associated with an unacceptable recurrence rate. 2 Prosthetic repair by either an extraperitoneal or extraparietal route. There have been reports of erosion and perforation of the colon by the mesh used in this repair.13 3 Stoma relocation either with formal laparotomy or with limited transperitoneal transfer of the stoma. This can be a very effective procedure.14 However, many patients are quite comfortable with the location of the stoma and would rather maintain the current site if feasible. 4 Laparoscopy offers several advantages that encompass many of the attributes noted above. The laparoscopic approach offers the surgeon the ability to visualize the entire abdominal wall so that any incisional hernias may also be repaired at the same time. Additionally, the anatomical detail of the hernia is nearly always identified easily with the view that is provided with this technique. This repair requires that the prosthetic biomaterial be placed in the intraperitoneal position. The use of polypropylene has been described, but I believe that the preferred biomaterial is expanded polytetrafluoroethylene (ePTFE).15–18 The experience with this technique, however, is not vast; nor is there any significant long-term follow-up of the few patients that have undergone this hernioplasty. Currently, the initial reports are promising but the optimal method of repair has not been finalized. When attempted, it is very unusual that one cannot repair these hernias laparoscopically. However, it may sometimes be advisable to identify a potential site for relocation of the stoma if this proves necessary during the operation due to an inability to complete the procedure either laparoscopically or open.

INDICATIONS AND CONTRAINDICATIONS TO SURGERY Surgery is imperative in all cases of intestinal obstruction or strangulation related to any parastomal hernia. Urgent emergency surgery is also absolutely indicated in all cases of paracolostomy hernia where perforation has occurred during irrigation. Operative intervention is also the treatment of choice when a parastomal hernia causes abdominal wall distortion and the resultant difficulties

Parastomal hernia repair 145

with the fitting of an appliance or irrigating a stoma. Surgery should also be considered if the stoma has become out of the patient’s range of vision, or if its site on a hernia bulge makes it unmanageable in elderly patients, especially those with arthritis. The disfigurement caused by a bulging parastomal hernia may warrant surgery for cosmetic reasons. In special circumstances, the repair may need to be accompanied by an abdominoplasty to permit a good fit of the appliance. Contraindications to surgery include such general problems such as cardiorespiratory failure, inability to have general anesthesia, recurrent Crohn’s disease, extreme obesity, disseminated malignancy, and a short life expectancy from any disease process. However, even these may not be obstacles to surgery, depending upon the presentation of the patient. If the patient exhibits significant skin excoriation in the areas where the transfascial sutures are likely to be placed, then the open procedure may be preferred, unless these lesions can be eliminated by preoperative care.

PREOPERATIVE PREPARATION These patients are usually elderly and should be cleared for surgery in the manner that is common to all operations. If the patient has a colostomy secondary to a malignant resection, it may be advisable to carry out preoperative colonoscopy to assure that there is no recurrent disease. However, this will be dependent upon the number of disease-free years. As noted earlier, a preoperative CT scan is frequently helpful to identify the anatomy and the contents of the hernia. This is especially true for the para-ileal conduit hernia. I prefer to use gentle cleansing enemas on the day before the operation for patients that have a paracolostomy hernia. This does not assist in the operative procedure, but it may diminish the risk of infection if there is a colonic injury during laparoscopy. Preoperative antibiotics are not necessary if an antimicrobial is impregnated into the biomaterial that will be used to repair the hernia (e.g. DualMesh Plus).

OPERATIVE TECHNIQUES The patient is placed in the supine position on the operating table. It is best to place a roll underneath the ipsilateral side of the hernia. This elevates the patient and enables easier access to the area where the sutures will be placed (Figure 19.1). Typically, a gastric tube is placed for decompression, and a urinary catheter is used. The video monitors are usually located at the foot of the table and on the ipsilateral side of the hernia. The surgeon will

Figure 19.1 Patient position on a roll to elevate the ipsilateral side of the patient. Note the circle that is marked on the skin to identify the outermost site of the appliance.

stand on the contralateral side and position the trocars to triangulate the defect (see Chapter 16). The assistant surgeon will place a fourth trocar in the upper quadrant in the side of the abdomen with the hernia. We use 5-mm trocars exclusively for this procedure. A 2 ⫻ 2-cm gauze is placed over the paracolostomy or para-ileostomy stoma to prevent leakage during the procedure. If the ostomy is an ileal conduit, a urinary catheter is inserted to provide continuous drainage. The balloon is inflated with approximately 3 cc’s rather than 5 cc’s of saline due to the size of the bowel lumen. The entire abdomen is then covered by a sterile, iodineimpregnated plastic drape. Before the placement of this drape, the outer aspect of the position of the stomal appliance is marked on the skin with a marking pencil. This identifies the outermost boundaries of the potential sites of transfascial suture placement (Figure 19.1). The non-bladed trocar (with the laparoscope within it) is used for the initial entry into the abdomen. Occasionally, a Veress needle or the open approach may be preferred, but in our experience this is seldom necessary. As with other intra-abdominal hernia repairs, dissection of the adhesions is the most tedious and timeconsuming portion of the procedure. This should be done either sharply without electrocautery or with the cautious use of the Harmonic scalpel (see Chapter 16). The instruments that are used for this are shown in Figure 16.4. Although the use of a large catheter placed within the ostomy to palpate the stoma intraoperatively is appealing, it frequently provides little benefit. As with the usual incisional hernias, the entire fascial defect and the adjacent abdominal wall must be cleared of all adhesions (Figure 19.2). It is at this point that the measurement of the defect can be performed. This is somewhat difficult because of the presence of the stoma and the


Figure 19.3 Central cut-out and slit in the prosthesis of the initial DualMesh Plus prosthesis.

Figure 19.2 Fascial edges of the paracolostomy hernia. The arrows demarcate the borders of the hernia.

gauze that was placed at the outset of the operative procedure. It is usually necessary to use an oversized patch to provide a wide margin of coverage. The most frequently used biomaterial is the 15 ⫻ 19-cm DualMesh®Plus patch (W. L. Gore & Associates). This will invariably result in at least a 5-cm margin around the fascial defect. There are variations in the use of these prosthetic products to repair these hernias. To date, no one technique has proven to be superior to the others. We have used three different methods to repair these hernias, which are presented below. Continued follow-up of these patients will allow us to decide upon the best approach to the repair of parastomal hernias. One method involves the placement of two ePTFE products. In one version, we used two DualMesh Plus products; in another version, we used one MycroMesh Plus product and one DualMesh Plus product. In both, a central circle is cut to allow for the exit of the intestine, and a slit is made to allow the patch to be placed around the stoma (Figure 19.3). Usually, this central circle is 3–3.5 cm, which is adequate for the colon exit, but with the ileostomy 2.5–3 cm is preferred. This first patch is inserted and secured to the anterior wall in a manner that is similar to that of the incisional hernia repair. The slit is placed adjacent to the colon and directly opposite the fascial defect so that good fixation can be made at that point, and the defect is covered completely with the initial patch (Figure 19.4). Sutures are used adjacent to the bowel to re-approximate this slit. These sutures are pulled transfascially with a suture-passing instrument (see Chapter 16). Additional fixation of the patch is then applied using the Onux Salute®constructs (Onux Medical, Inc.). This initial step has been done using either the DualMesh Plus or the MycroMesh®Plus biomaterial, as noted above (see Chapter 3). The holes in the

Figure 19.4 Position of the initial prosthesis with the slit placed opposite the hernia defect. In the photograph, the slit is on the left and the hernia defect is covered with the prosthesis on the right.

latter product may provide better fixation for the second patch that will be placed in this method because no in-growth of collagen will occur through this first patch into the second one. A second biomaterial is then used, usually 18 ⫻ 24-cm DualMesh Plus, so as to completely cover the initial 15 ⫻ 19-cm patch. In this way, there will also be ingrowth of tissue to the periphery of the second patch. Additionally, this larger product will provide greater support than the smaller one to the anterior abdominal wall. Many of these patients will have a significant deformity of the anterior abdominal wall because of the size of the hernia itself. It is believed that the use of this second and larger prosthesis will result in a better cosmetic result and fit of the appliance. This second patch is cut similarly to the first one, inserted into the abdomen, and fixed with

Parastomal hernia repair 147

Figure 19.5 The potential space that can exist between the intestine and the opening in the prosthesis is shown by the arrows. One may elect to suture the colon at this site. The ePTFE sutures to the second patch are also seen on the left side of the colon.

Figure 19.6 Final appearance of the completed repair. One suture that has sutured the colon to the opening is seen in the middle of the photograph.

the initial sutures similar to the initial patch. However, the slit that is made in this patch is placed opposite the location of the slit in the initial patch. This placement is chosen to prevent herniation through the slit in the initial patch because the second patch protects that slit (Figure 19.5). The intent is to cover the first slit with the second patch so that the ring cannot enlarge and result in re-herniation.19 Fixation is then completed with the constructs and multiple transfascial sutures that are placed to include both the first and second patches, as described in Chapter 16. Occasionally, one may choose to suture the colon to the edge of the hole in the patch if it appears that there is a risk of passage of bowel into that space (Figure 19.6). The final appearance reveals good coverage of the defect (Figure 19.6).

Figure 19.7 Typical suture placement in the prosthesis for the onlay type of parastomal hernia repair.

Another method by which to repair these hernias is based upon the onlay technique described by Sugarbaker.20 A critical step in this operation is the lateralization of the intestine against the sidewall of the abdomen. This is done by suturing the herniated intestine at several locations at the antimesenteric border to secure it to the abdominal wall with permanent suture. The laparoscopic approach duplicates this repair but, in most patients, the use of the DualMesh Plus prosthesis has been chosen rather than polypropylene, which was used by Sugarbaker. The important points to this procedure include complete dissection of the adhesions that are present and identification of the fascial edges. A margin of at least 5 cm is also preferred with this repair. I prefer to place one suture at the midpoint of one axis of the prosthesis and two sutures at the other side of the patch (Figure 19.7). These latter sutures will be pulled on either side of the viscera that leads to the stoma. The exact location of these on the biomaterial will be dependent upon the size of the intestine and the location and size of the hernia itself. One must be careful that these two sutures are not pulled so tightly that a relative obstruction could result. Based upon our prior experiences with incisional hernia repairs, additional sutures are placed a minimum of 5 cm apart, and Salute constructs are placed 1 cm apart, along the periphery of the patch, as with all of these parastomal hernia repairs (see Chapters 16 and 20). This results in the placement of several sutures. Others, however, do not place as many sutures.6,21

POSTOPERATIVE MANAGEMENT Patients are usually maintained in the surgical unit, which allows for a one-night postoperative stay. The gastric and urinary tubes are discontinued in the recovery room. Patients are allowed a liquid diet immediately, although most have a short-term ileus. The diet is advanced as tolerated. Abdominal binders, which are used routinely for

148 Laparoscopic incisional and ventral hernioplasty Table 19.1 Laparoscopic parastomal hernia repair publications Reference

Patients (n)

Prosthesis

Location of prosthesis

Length of hospital stay (days)

Length of follow-up (months)

Porcheron et al. (1998)15 Bickel et al. (1999)16 Voitk (2000)17 Kozlowski et al. (2001)21 LeBlanc et al. (2002)18 Berger (2002)6

1 1 4 4 3 15

ePTFE Polypropylene Polypropylene ePTFE ePTFE ePTFE

Pre-peritoneal Intraperitoneal Intraperitoneal Intraperitoneal Intraperitoneal Intraperitoneal

4 6 2 (3 patients), 9 (1 patient) 3.8 1 (all patients) N/A

12 12 N/A 2–33 3–11 3–12

the incisional hernias, are placed selectively for this repair. The decision to use these is based upon the patient’s request, as they do aid in the management of postoperative pain and in the prevention of seromas. The level of activity of the patient is based upon the pain tolerance of the individual, and no restrictions are given.

RESULTS The laparoscopic repair of parastomal hernias has been utilized as a method to repair these defects only recently. At the time of writing, I am aware of only six reports in the literature of this methodology.6,14–17 Each of these articles detailed a slightly different technique, involving few patients (Table 19.1). Pocheron and coworkers closed the hernial orifice and used the patch only as a reinforcing layer with no slit used to allow egress of the colon.15 Bickel and colleagues created two strips of mesh, securing one to the abdominal wall and the other to the intraperitoneal colon.16 Voitk used a technique that mimicked that of Sugarbaker’s intraperitoneal repair.17 All of these authors used tacks alone to provide fixation to the abdominal wall. Although Bickel used polypropylene mesh (PPM) for the repair of that patient, he commented that the use of intraperitoneal PPM may lead to adhesion formation and that the use of a ‘dual mesh nonadherent surface on one side’ may be preferable. Kozlowski and coworkers used an onlay technique with four sutures; the exact technique is not described specifically in their paper, however.21 Berger uses an onlay technique that involves fixation with transfascial sutures and tacks.6 Unless the patch is greater than 20 cm, he does not use any more than four sutures. He also prefers an overlap of 5 cm for this procedure. As noted in Table 19.1, Berger has reported upon 15 patients. In the immediate postoperative period, one patient developed a hematoma and one patient required reoperation because of incarceration of the small bowel between the patch and the abdominal wall. This latter complication was due to a ‘dislocated tack’. Three of the patients (20 per cent) developed a recurrent hernia between two and four months. One could certainly

postulate that the method of fixation may be inadequate because of the relatively few transfascial sutures that were used in this repair. I believe that it is critical that these sutures are used at not more than 5 cm apart along the entire periphery of the patch unless there is a structure, such as the iliac bone, that prohibits its placement.22 In this case, the patch should be secured with many more metal fixation devices than would be the usual recommendation. Some surgeons have trephined the bone to place sutures to ensure fixation. My surgical group has now performed one of the operations described above on a total of nine patients (Table 19.2). The average length of stay is somewhat longer than our experience for incisional hernias, which is 1.25 days. This is not surprising, however, given the fact that all of these patients had multiple operations previously and several had recurrent parastomal hernias. The enterotomy occurred in the patient with the paraurostomy hernia. He had undergone two previous repairs, the latter of which included the repair of an incisional hernia with PPM intraperitoneally. I repaired this injury laparoscopically but did not repair the hernia at that time. His length of stay was increased because he remained in hospital until the hernia repair was carried out four days later. Interestingly, a counter-incision for open access was required during the second procedure because of the inability to accurately assess and reduce the incarceration of the hernia. In addition to the incarcerated small bowel in the hernia, the patient also had a herniation through the mesentery of the urostomy (Figure 19.8). This was reduced, and the repair was completed laparoscopically. The recurrence that was seen in the para-ileostomy hernia occurred after nearly one year. Small bowel had herniated through the slit of both of the patches used in the repair. This was reduced laparoscopically, and the small bowel was sutured to the abdominal sidewall to prevent migration into the slit again. The latter was also tightened. This failed after one year, and the patient has now undergone an open repair, which relocated the stoma to the left side of his abdomen. The other patients have done very well over the follow-up period, with the exception of the one fatality.

Parastomal hernia repair 149 Table 19.2 Parastomal hernioplasty experience Type of repair

Hernia type (n)

Average length of stay (days)

Complications

Average follow-up (months)

Two DM⫹

Paracolostomy (2) Para-ileostomy (1) Paracolostomy (3) Para-urostomy (1) Paracolostomy (2)

2.33 1 1.67 7 2

Seroma (1) Recurrence of para-ileostomy hernia Ileus (1) Enterotomy (1) Death (1)

21 20 8 2 2

Paracolostomy (7) Para-ileostomy (1) Para-urostomy (1)

1.86 1 7

Ileus (1) Seroma (1) Enterotomy (1) Recurrence (1) Death (1)

11 (range 2–25)

Onlay of DM⫹ MM and DM⫹ Total

DM⫹, DualMesh Plus; MM, MycroMesh.

laparoscopic recurrence rate of 20 per cent reported by Berger.6 The critical considerations are the use of a large biomaterial and adequate fixation. This fixation must include the use of metal fixation devices at 1–1.5 cm apart, preferably in a staggered fashion, and transfascial sutures placed circumferentially along the entire periphery of the patch (not more than 5 cm apart). Undoubtedly, there are other techniques that are being used today that have not been reported. I know of surgeons who are using a single prosthetic biomaterial with the keyhole and slit that was described above. Additionally, some surgeons are using other prosthetic biomaterials to complete this repair. Long-term follow-up is critical to identify the best procedure and biomaterial that should be chosen for this hernioplasty.

Figure 19.8 Mesenteric herniation of a para-ileal conduit hernia that was reduced with the incision lateral to the defect. The forceps are placed through the hernia defect.

This patient aspirated in the immediate postoperative period, suffered a cardiorespiratory arrest, and did not survive the latter event. Seromas and ileus are well-recognized occurrences following laparoscopic hernia repair, such that I do not consider them a true complication unless they are persistent or require intervention. The ideal method of repair for these hernias that should be used routinely has yet to be identified. However, with the experience of the recurrence of the ileostomy hernia, I would suggest that the preferred repair of the parastomal hernia that involves the small intestine should be the onlay technique. The peristalsis of the small bowel may predispose the other segments of that organ to invaginate into the slits of the two-patch repair. Currently, however, the recurrence rate of eight per cent is quite admirable. This is an improvement in the open repair of these defects and is better than the

CONCLUSION The repair of incisional hernias laparoscopically has provided us with the technology to repair parastomal hernias. The ideal method has not been identified, but the initial experience shows promise.

REFERENCES 1

Burns FJ. Complication of colostomy. Dis Colon Rectum 1970; 13: 448–50. 2 Phillips P, Pringle W, Evans C, Keighley M. Analysis of hospital based stomatherapy service. Ann R Coll Surg Engl 1985; 67: 37–40. 3 Sjodahl R, Anderberg B, Bolin T. Parastomal hernia in relation to the site of the abdominal wall stoma. Br J Surg 1988; 75: 339–41. 4 Londono-Schimmer EE, Leong APK, Phillips RKS. Life table analysis of complications following colostomy. Dis Colon Rectum 1994; 37: 916–20.

150 Laparoscopic incisional and ventral hernioplasty 5

6

7

8 9 10

11

12

13

Ortiz H, Sara MJ, Armendariz M, et al. Does the frequency of para-colostomy hernias depend on the position of the colostomy in the abdominal wall? Int J Colorectal Dis 1994; 9: 65–7. Berger D. Laparoscopic parastomal hernia repair: indications, technique, and results. In: Morales-Conde S, ed. Laparoscopic Ventral Hernia Repair. Paris, Springer-Verlag, 2002: 383–7. Burgess P, Matthew VV, Devlin HB. A review of terminal colostomy complications following abdominoperineal resection for carcinoma. Br J Surg Engl 1984; 71: 1004. Martin L, Foster G. Parastomal hernia. Ann R Coll Surg 1996; 78: 81–4. Marshall FF, Leadbetter WF, Dretler SP. Ileal conduit parastomal hernias. J Urol 1975; 113: 4–42. McDougal WS. Use of intestinal segments and urinary diversion. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell’s Urology. Philadelphia: W. B. Saunders Co., 1998: 3121–61. Williams JG, Etherington R, Hayward MWJ, Hughes LE. Para-ileostomy hernia: a clinical and radiological study. Br J Surg 1990; 77: 1355–7. Toms AP, Dixon AK, Murphy MP, Jamieson NV. Illustrated review of new imaging techniques in the diagnosis of abdominal wall hernias. Br J Surg 1999; 86: 1243–50. Aldridge AJ, Simson JN. Erosion and perforation of colon by synthetic mesh in a recurrent paracolostomy hernia. Hernia 2001; 5: 110–12.

14

15 16

17 18 19

20 21

22

Rubin M, Schoetz DJ, Matthews JB. Para-stomal hernia: is the stoma relocation superior to fascial repair. Arch Surg 1994; 129: 413–19. Porcheron J, Payan B, Balique JG. Mesh repair of paracolostomal hernia by laparoscopy. Surg Endosc 1998; 12: 1281. Bickel A, Shinkarevsky E, Eitan A. Laparoscopic repair of paracolostomy hernia. J Laparoendosc Adv Surg Tech 1999; 9: 353–5. Voitk A. Simple technique for laparoscopic paracolostomy hernia repair. Dis Colon Rectum 2000; 43: 1451–3. LeBlanc KA, Bellanger DE. Laparoscopic repair of para-ostomy hernias: early results. J Am Coll Surg 2002; 194: 232–9. De Ruiter P, Bijnen AB. Successful local repair of paracolostomy hernia with a newly developed prosthetic device. Int J Colorectal Dis 1992; 7: 132–4. Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of paraostomy hernias. Ann Surg 1985; 201: 344–6. Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of incisional and parastomal hernias after major genitourinary or abdominal surgery. J Endourol 2001; 15: 175–9. LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg 2000; 180: 193–7.

20 Lumbar hernia and ‘denervation’ hernia repair KARL A. LEBLANC

Anatomy Indications and contraindications for surgery Operative technique

151 152 152

Primary and acquired lumbar hernias are quite uncommon. There have been about 300 cases of primary hernias reported in the literature.1 Acquired lumbar hernias are the result of flank incisions for renal or other retroperitoneal operations, notably anterior lumbar interbody fusion. These acquired hernias can also be the result of division of the anterior branches of nerves that originate from T6 to T12. In these latter circumstances, there is no fascial defect with these denervation injuries, so they are not true hernias. These ‘pseudo-hernias’ are difficult to treat surgically. Rarely, they can also be seen with diabetic radiculopathy. Approximately 55 per cent of these hernias are primary, 25 per cent are acquired, and the remainder are congenital in origin.2 The latter can sometimes be bilateral. Primary lumbar hernias are found most frequently on the left side; two-thirds of these are seen in men.3,4

ANATOMY The lumbar area is bounded above by the twelfth rib, below by the iliac crest, behind by the erector spinae muscles (sacrospinalis), and in front by the posterior border of the external oblique (a line passing from the tip of the twelfth rib to the iliac crest). Within this area, two triangles are described: the superior lumbar triangle (of Grynfelt) and the inferior lumbar triangle (of Petit). The superior lumbar triangle is an inverted triangle: its base is the twelfth rib, its posterior border is the erector spinae muscles, its anterior border is the posterior margin of the external oblique, and its apex is at the iliac crest

Results Conclusion References

153 153 154

inferiorly. The base of the inferior lumbar triangle is the iliac crest, its anterior border is the posterior margin of the external oblique muscle, its posterior border is the anterior edge of the latissimus dorsi muscle, and its apex is superior (Figure 20.1). Lumbar hernias may contain a variety of intraabdominal organs. Hernias of the colon are the most frequent, but small intestine, stomach and spleen are also likely candidates for herniation. A particular curiosity is the sliding hernia of the colon, which causes intermittent obstructive symptoms. Differential diagnoses include tumors of the muscles, lipoma, hematoma associated with blunt trauma, abscess, and renal tumors. Small fatty protrusions of retroperitoneal fat through the lumbodorsal fascia have been implicated as a cause of lower back pain. Computerized tomography (CT) is the best test for delineating the etiology and defining the anatomy of the hernia. Patients that have the ‘denervation’ injury that leads to the protrusion of the flank will frequently complain of back pain related to the defect. It is difficult to explain the source of this, as many of these patients will have had a long, pre-existing complaint of back pain requiring disk surgery. The most common presentation is the acknowledgment of the significant cosmetic deformity that is caused by the musculature paralysis. This will cause a broad laxity of the affected abdominal wall (Figure 20.2). This appearance will become most pronounced if the process is long-standing, if the patient experiences significant weight gain, or if the patient is morbidly obese. CT scanning is not so helpful for delineating this problem, but it can eliminate other pathological entities.


Serratus posterior External oblique muscle 12th rib Superior (Grynfelt's) triangle Latissimus dorsi Internal oblique Inferior (Petit's) triangle

External oblique

Figure 20.1 Anatomy of the ‘true’ lumbar hernias.

Umbilicus

Iliac crest

Trocar sites

Arm on pillow

Figure 20.3 Typical patient position for repair of lumbar hernias. Easy access to the posterior aspect of the patient must be preserved.

Figure 20.2 Appearance of the abdominal wall following a right nephrectomy that resulted in a ‘denervation hernia’.

INDICATIONS AND CONTRAINDICATIONS FOR SURGERY These defects will increase in size over time. The cosmetic appearance will deteriorate because of this, but there is a risk of incarceration and strangulation with primary hernias. All primary hernias should be repaired, but it is not clear whether surgery can offer a permanent solution to the pseudo-hernia. Careful follow-up is needed to evaluate the effectiveness of the laparoscopic approach to this entity.

OPERATIVE TECHNIQUE The open approach to a primary, acquired or denervation hernia is generally a formidable operation. Suture closure

of these hernias is associated with a high failure rate because of the tension that occurs with the repair. The use of a prosthetic biomaterial placed in the pre-peritoneal position has been shown to be the most effective method of repair for true hernias.5 The open procedure often requires a very extensive incision to repair these defects. Pseudo-hernias are sometimes repaired with abdominal wall plication followed by placement of a prosthetic biomaterial over the plicated muscle, but this also requires a large incision if the mesh is to cover the entire area of paralysis. The laparoscopic approach has been applied to this type of herniation. Its concept is similar to the repair of incisional hernias (see Chapter 16). A tube to decompress the stomach is used routinely, but a urinary catheter is placed only selectively. One significant difference is that the patient must be turned in the semi- or full lateral decubitus position (Figure 20.3). A beanbag greatly assists in this position. Trocar site positions are critical for this operation. As with incisional hernia repair, the initial efforts focus upon the dissection of the adhesions and the identification of the fascial edges. With the superior hernias, this must extend posterior to

Lumbar hernia and ‘denervation’ hernia repair 153

the kidney. The colon will usually be reflected for either hernia. The use of DualMesh®Plus is recommended because this procedure is intraperitoneal. The prosthesis should be at least 4–5 cm larger than the defect itself. This is slightly larger than that considered necessary for traditional incisional hernia repair. It appears that fixation in these areas is rather difficult, and this larger overlap will help prevent a recurrence. When undertaking the repair of a denervation hernia, I prefer to use a minimum of 5–6 cm of overlap, but I would recommend the use of as large a patch as possible. Fixation on to the diaphragm will frequently be necessary. One must not enter the chest with the use of these fixation methods. It is usually necessary to sew the upper portion of the biomaterial to the diaphragm itself to provide fixation of that portion of the biomaterial. Suture placement that encircles the ribs will frequently result in long-term pain that is difficult to treat. Therefore, this is not recommended unless absolutely necessary. The use of transfascial sutures and metal fixation devices is identical to the incisional hernia, except as noted above. Repair of a pseudo-hernia necessitates the use of a very large prosthesis. This must cover the entire paralyzed muscle from the lumbar area to a point across the midline of the patient. Because of the positioning of the patient, fixation may be very difficult near the midline. It is sometimes necessary to place two trocars laterally through the biomaterial to allow the visualization and fixation at that site. These holes are then closed with sutures placed with a suture-passing device.

RESULTS There have been only ten laparoscopic lumbar hernioplasties reported in the literature.6–8 All were case reports, except for one report that included seven patients.9 This latter report included five hernias that were acquired; two were congenital and two were recurrent. Two patients had two or three separate hernia defects. The hernias ranged in size from 1.5 ⫻ 1.5 cm to 8 ⫻ 11 cm, averaging 77.8 cm2. As noted above, a large overlap of the expanded polytetrafluoroethylene (ePTFE) patches was used; the average patch size was 336.4 cm2. One of these patients developed an abscess over the repair, which required removal of the prosthesis. The remaining six patients were free of recurrence after 1–15 months of follow-up. This author has repaired six denervation hernias. All were performed using the technique described above. One of these patients had an implantation of DualMesh Plus with Holes. This product is 1.5 mm thick, compared with the 1-mm thickness of DualMesh without Holes. It was hoped that the thicker material would result in a better

Figure 20.4 Postoperative (six months) appearance of a repair of a ‘denervation hernia’ subsequent to an anterior lumbar interbody fusion.

cosmetic result. With these patients, the intent is that the shrinkage of the tissues caused by scar contraction will result in an acceptable cosmetic result. One patient had prolonged postoperative pain thought to be related to the use of suture around a rib. One patient developed a symptomatic seroma. Both of these problems resolved without intervention. Follow-up ranged from nine months to three years. The cosmetic result with this method has been acceptable to all the patients and has been excellent in some (Figure 20.4).

CONCLUSION The incidence of lumbar hernias is low. The problem of denervation hernias may become more prevalent in the future due to the increasing use of the anterior approach for disk disease by spine surgeons. Repair of these deformities can be difficult and fraught with failure if it is not approached in a reasoned manner. The use of prosthetic reinforcement is thought to be best, and the laparoscopic approach may be of benefit, although more studies and follow-up are needed.

REFERENCES 1

Gentileschi P, Kini S, Gagner M. Laparoscopic repair of unusual hernias: lumbar, spigelian and other special hernias. In: MoralesConde S, ed. Laparoscopic Ventral Hernia Repair. Paris: SpringerVerlag, 2002: 363–74. 2 Swartz WT. Lumbar hernias. J Ky Med Assoc 1954; 2: 673–8. 3 Thorek M. Lumbar hernia. J Int Coll Surg 1950; 14: 367–93.

154 Laparoscopic incisional and ventral hernioplasty 4 5

Watson LE. Hernia, 3rd edn. St Louis, MO: Mosby, 1948: 443–5. Knol JA, Eckhauser FE. Inguinal anatomy and abdominal wall hernias. In: Greenfield LJ, ed. Surgery: Scientific Principles and Practice. Philadelphia: JB Lippincott, 1993: 1081–107. 6 Burick AJ, Parascandola SA. Laparoscopic repair of a traumatic lumbar hernia: a case report. J Laparoendosc Surg 1996; 6: 259–62.

7 8

9

Bickel A, Haj, Eitan A. Laparoscopic management of lumbar hernia. Surg Endosc 1997; 11: 1129–30. Woodward AM, Flint LM, Ferrera JJ. Laparoscopic retroperitoneal repair of recurrent postoperative lumbar hernia. J Laparoendosc Adv Surg Tech A 1999; 2: 181–6. Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of lumbar hernias. J Am Coll Surg 1998; 2: 147–52.

21 Results of laparoscopic incisional and ventral hernia repair RODRIGO GONZALEZ AND BRUCE J. RAMSHAW

Results of series Results of comparative studies

155 157

Although the principles of abdominal wall repair are well established and the complication rate has decreased significantly over the past decade, the complication and recurrence rates for open incisional hernia repair are far from ideal. A prospective, randomized, multicenter study recently reported a 46 per cent recurrence rate after primary open repair of ventral hernias when a prosthetic material was not employed.1 Others have reported recurrence rates of 25 per cent and 52 per cent for fascial defects smaller and larger than 4 cm, respectively.2–4 Recurrences are also associated with the number of repairs performed, with 18–43 per cent after initial repair and over 50 per cent after recurrent repair.1,3 It is common to perform a primary repair for ventral hernias smaller than 4 cm in diameter. For larger defects, the use of a prosthetic material is recommended to allow for a tension-free repair. The use of a variety of mesh materials for open hernia repairs has resulted in a lower recurrence rate compared with primary repairs,1,5 but they have been associated with other types of complications, including wound infection, seromas, mesh extrusion, fistula formation, and adhesions.5–7 Infections can occur in up to 15 to 45 per cent of open mesh repairs and may also correlate with recurrence rates.1,8 This high infection rate is thought to be secondary to the large incision with which the mesh is in contact and the wide dissection necessary for adequate mesh placement. The laparoscopic technique involves access to the abdominal cavity away from the defect, avoiding placement of the mesh through a large incision, thereby reducing the probability of contamination and infection.9 It also allows


159 160

fixation of a large mesh without subcutaneous tissue dissection in patients with large hernia defects.10–12 Laparoscopic ventral hernia repair is based on the method described by Stoppa for open incisional hernia repair,4 reported to have the lowest recurrence rate. It involves posterior reinforcement of the abdominal wall with a large piece of prosthetic material based on Laplace’s law. The large surface area of the mesh allows substantial ingrowth of tissue for permanent mesh fixation, and the intra-abdominal pressure tends to hold the mesh in apposition to the posterior abdominal wall over a wide surface area.13,14

RESULTS OF SERIES Patient demographics Since the first report of laparoscopic ventral hernia repair,15 numerous series have been published supporting the use of this technique. Table 21.1 summarizes the results of 2002 laparoscopic ventral hernia repairs published in the literature. We have tabulated these data and will discuss the averages from this information. Demographic data show a slightly higher predominance of females (56 per cent), with a mean age of 55 years. Fifty-six per cent of the patients were obese, with a mean body mass index (BMI) of 34 kg/m2. Consistent with previous literature, the prevalence of incisional hernias (89 per cent) is higher than for primary hernias (11 per cent).

Table 21.1 Results of laparoscopic ventral hernia repair

Reference LeBlanc et al. (1994)16 Saiz et al. (1996)17 Park et al. (1996)18 Tsimoyiannis et al. (1998)19 Franklin et al. (1998)20 Toy et al. (1998)21 Constanza et al. (1998)22 Sanders et al. (1999)23 Kyzer et al. (1999)24 Roth et al. (1999)25 Koehler and Voeller (1999)26 Balique et al. (2000)27 Farrakha (2000)28 Carbajo et al. (2000)29 Reitter et al. (2000)30 Heniford et al. (2000)31 Heniford et al. (2000)32 Szymanski et al. (2000)33 Chowbey et al. (2000)34 Kozlowski et al. (2001)35 LeBlanc et al. (2001)36 Birgisson et al. (2001)37 Moreno-Egea et al. (2001)38 Bageacu et al. (2002)39 Ben Haim et al. (2002)40 Total a

Seromas persisting ⬍ 6 weeks. Seromas persisting ⬎ 4 weeks.

b

Prior repairs (%)

Hernia size (cm2)

Operating room time (min)

28 10 28 11 176 144 16 12 53 75 32 29 18 100 49 100 415 44 202 17 100 64 20 159 100

7 20 – – 39 26 100 58 55 – 41 – 33 – 37 49 33 20 – – 18 42 75 23 25

– – 104 – – 98 130 – – 101 – – – 93 – 87 100 20 – – 155 34 7 – 6

– 68 108 49 – 120 – 210 89 105 101 – 85 62 152 88 97 – 50 240 – 130 – 89 119

2002

32

89

114

Patients (n)

Conversion rate (%)

Hospital stay (days)

Seroma rate (%)

Infection rate (%)

Mesh removed (%)

Follow-up (months)

Recurrence rate (%)

0 0 0 0 3 – 6 8 4 3 – – 0 1 4 0 2 9 0.5 0 4 0 0 14 7

– 2 4.1 3 – 2.3 2 3.5 3.3 2.9 1.9 – 3.2 1.2 4.3 1.6 1.8 – 1.8 – 1.2 1.7 – 3.5 5

4 10 0 9 0a 16 – 36 – 4 – 14 33 10 0 3b 5a 2 18 – 7 5 15 16 11

4 10 4 9 2 3 – 8 2 4 6 3 0 0 2 2 2 5 2 – 2 4 0 3 1

4 0 – 0 1 4 – 0 2 – 6 – 0 0 2 2 1 – – – 1 0 0 – 1

10 – 8 15 30 7 18 13 12 – 20 – 22 30 27 23 23 – 35 – 51 10 12 49 19

0 0 4 0 1 4 6 8 2 9 9 – 6 2 6 3 3 5 1 12 9 2 0 16 2

3

1.9

7.5

1.5

26

3.3

2.2

Results of laparoscopic incisional and ventral hernia repair 157

This includes 11 per cent umbilical and 0.6 per cent Spigelian hernias. Sixteen per cent of the hernias were multiple and 32 per cent were recurrent.

is estimated that about 80 per cent of hernias are repaired utilizing ePTFE mesh, 15 per cent with polypropylene mesh, and five per cent with polyester mesh.

Intraoperative complications

Operative and postoperative results

Laparoscopic repair was shown to be safe, even in large ventral defects, with an intraoperative complication rate of one per cent. The most frequent major intraoperative complication was bowel injury, occurring in 0.8 per cent of cases. Conversions to open repair were reported in three per cent of cases and were more frequent during the early phase of the learning curve.9 The most common reasons for conversion were bowel injuries, failure to reduce incarcerated hernias, and extensive adhesions. Enterotomies are most likely to occur during adhesiolysis and reduction of hernia sac contents. The occurrence of an enterotomy is considered a reason for conversion by some surgeons; it may also be a contraindication for mesh placement due to potential contamination. The incidence of unrecognized or delayed bowel injury is reported to be between zero and five per cent. These can be the result of missed injury or thermal or partial-thickness injury that progresses to full-thickness injury over time, and can result in serious complications such as sepsis and even death.10,11,30

The mean operative time was 114 minutes, with an estimated blood loss of 80 cc. The return of bowel function was 1.7 days after surgery. The average hospital stay was 1.9 days, and the average return to normal activities was two weeks after the operation. Postoperative wound complications were minimal after laparoscopic ventral hernia repair. They included infection (2.2 per cent), seroma persisting for more than six weeks (7.5 per cent), and hematoma formation (six per cent). In 1.5 per cent of patients, mesh removal was required due to mesh infection or reoperation for missed or delayed bowel injury. Other complications included ileus (2.4 per cent), urinary retention (1 per cent), bowel obstruction (0.5 per cent), and trocar site bleeding (0.3 per cent). Chronic pain can develop at sites where full-thickness abdominal wall sutures are used for mesh fixation; this has been reported in 0.2–2 per cent of patients. Most instances of pain resolve without intervention. Some authors have reported the use of injection of local analgesics for the relief of pain. Occasionally, repeat injections are necessary to achieve pain relief. Reoperation for suture removal is required rarely. These sutures are considered an essential step by most surgeons to help reduce hernia recurrences by preventing mesh migration.

Choice of prosthetic Laparoscopic surgery allows placement of a large overlay of mesh without soft-tissue dissection. The mean size of all hernia defects was 89 cm2 and the mean mesh size was 201 cm2. Most surgeons used expanded polytetrafluoroethylene (ePTFE) DualMesh®as the prosthetic material of choice. The 3-␮m-size pores on the side of the mesh in contact with the abdominal contents result in a low incidence of adhesion formation between the biomaterial and the viscera. More importantly, even if bowel is adherent to the mesh, the ePTFE DualMesh inhibits ingrowth, preventing fistula formation and bowel obstruction. A variety of composite mesh products are available and are being evaluated (see Chapter 4). One side of the composite mesh is made of polypropylene or polyester to promote ingrowth into the abdominal wall (although the mesh is actually placed in direct contact with the peritoneum in most cases). The other side of the mesh is made of either permanent ePTFE or an absorbable antiadhesion barrier. This side is placed toward the abdominal cavity with the intention of preventing ingrowth to the polypropylene (ePTFE permanent material) or preventing adhesions (absorbable material). The great majority of authors who have published series of laparoscopic ventral hernia repair refrained from using polypropylene or polyester mesh that would allow potential direct contact with intra-abdominal organs, especially large and/or small intestine. Based on published series, it

Recurrence The mean recurrence rate from the series in Table 21.1 was 3.3 per cent, at a mean follow-up of 26 months. Few additional recurrences are expected in these series, since up to 90 per cent of recurrences occur within the first two years after ventral hernia repair.1,31 In fact, future recurrence rates for laparoscopic ventral hernia repair may actually be lower, because most of these reports included surgeons’ experience during their learning curve. A common cause for recurrence noted in some series is a lack of suture fixation.26,32,36

RESULTS OF COMPARATIVE STUDIES Comparative studies between laparoscopic and open ventral hernia repairs have consistently reported advantages for the laparoscopic approach, especially in the evaluation of wound complications and recurrence rates. Results of eight of these series are summarized in Table 21.2. In most comparative series, the technique is selected based on each surgeon’s experience, and most are retrospective

Table 21.2 Results of comparative studies between laparoscopic and open ventral hernia repair

Reference

Technique

Patients (n)

Holzman et al. (1997)41

Open Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open Laparoscopic Open with mesh Open without mesh Laparoscopic

16 20 49 56 30 30 174 79 18 21 14 14 23 31 90 119 86

Park et al. (1998)42 Carbajo et al. (1999)43* Ramshaw et al. (1999)10 DeMaria et al. (2000)44 Chari et al. (2000)45 Robbins et al. (2001)13 Wright et al. (2002)12

*Prospective randomized study.

Previous repairs (n)

Hernia size (cm2)

Operating room time (min)

Length of stay (days)

Postoperative complication rate (%)

Infection rate (%)

Seroma rate (%)

Follow-up (months)

Recurrence rate (%)

4 8 9 16 22 23 51 36 3 11 – – – – 28 6 15

148 105 105 99 141 140 34 73 – – – – – – 79 12 112

98 128 78 95 112 87 82 58 – – 78 124 – – 102 70 131

5 1.6 6.5 3.4 9.1 2.2 2.8 1.7 4.4 0.8 5.5 5 – – 2.5 1.5 1.5

31 23 37 18 50 20 26 15 72 57 14 14 – – 28 22 24

6 5 2 0 18 0 3 0 33 10 0 7 30 16 13 10 9

0 5 2 4 67 13 – – 50 19 – – – – 12 4 9

19 10 54 24 27 27 21 21 24 24 – – – – 32 24 24

13 10 35 11 7 0 21 3 0 6 – – – – 6 9 1

Results of laparoscopic incisional and ventral hernia repair 159

studies. Surprisingly, in many reports, the patients in the laparoscopic group had a tendency to have larger hernia defects10,13,44 and a higher incidence of previous hernia repairs10,41,42,44 than in the open group. This suggests that the results are even more favorable for the laparoscopic repair, since recurrences occur more frequently in large defects and after previous repairs.3,42 Some series have reported increased operative times with the laparoscopic technique.13,42 This is important when considering anesthesia times and operating room expenses. However, once beyond the learning curve, the laparoscopic repair can frequently be completed in a shorter time than a comparable open repair, even in the presence of large hernia defects.10,34 Laparoscopic repair is also associated with reduced estimated blood loss.10 Most comparative series have reported lower overall postoperative complication rates with the laparoscopic technique than with the open technique (20 v. 31 per cent, respectively) (Table 21.2). The laparoscopic approach results in lower wound complication rates,10,11,13,42 including fewer seromas,42,43 fewer infections,10,11,13,44 and fewer dehiscences.13 Since wound complications that may be present after laparoscopic hernia repairs occur in small trocar incisions, they tend to be less severe, to be treated more easily, and to require mesh removal less frequently than in open repairs.10,43 Seromas are frequently observed following a ventral hernia repair whether performed through an open or laparoscopic approach. Ultrasound examinations revealed seroma formation in 100 per cent of patients, with a peak occurrence seven days after the operation, and almost complete resolution after 90 days.46 Seromas may be a source of concern to patients not informed of the likelihood of their occurrence. Most surgeons agree that they should not be considered a complication unless they persist, increase steadily in size, or cause symptoms. Aspiration of seroma contents should be approached with caution, since even under sterile conditions there is a potential for contamination. Infection requiring mesh removal has been reported following aspiration of a seroma.44 After repair of large hernias, the use of binders can be considered in an attempt to reduce seroma formation. Another advantage consistently reported with the laparoscopic technique is the shorter length of hospitalization.10,42–44 This may be due partially to decreased pain,44 fewer complications,10,11,13,42,43 earlier oral intake,45 infrequent use of drains,10 and reduced postoperative ileus.10,42 In general, these patients ambulate earlier than patients undergoing open repair. Laparoscopic ventral hernia repair can be performed on an outpatient basis in some cases.41,44 The shorter operative time and length of stay after laparoscopic repair may offset the increased operative costs for surgical equipment compared with open techniques.41 One study shows lower costs for the laparoscopic approach, even when accounting for the costs of treating complications.44

Finally, the favorable cosmetic results for primary ventral hernia repair with the laparoscopic technique may be an important consideration for some patients. Wright and colleagues compared the laparoscopic approach with two techniques of open repair, with and without use of mesh.12 The group that underwent open repair with mesh had a higher incidence of previous repairs. The laparoscopic group had larger hernia defects and larger mesh sizes. The laparoscopic technique resulted in a longer mean operative time and lower wound complication rates. The laparoscopic approach also resulted in lower recurrence rates, but the difference was significant only when compared to open repair without mesh. In the only prospective randomized study so far, Carbajo and coworkers reported a shorter operative time and hospital stay, as well as lower recurrence and complication rates (including infections and seromas) with the laparoscopic approach.43 The patients in each group had a similar incidence of previous repairs and hernia size. Two recurrences occurred in the open group with a 27month follow-up. Two mesh explantations were required in the open group for postoperative infections. There were no recurrences or late complications in the laparoscopic group. A primary goal for ventral hernia repair is to minimize recurrence rates. Factors associated with recurrences include larger hernias,3,42 previous hernia repairs, lateral defects, and postoperative complications (mainly infections). The laparoscopic technique has resulted in lower recurrence rates, even in the presence of larger defects,10,13 and higher rates of previous repairs.10,42 Indeed, as demonstrated in Table 21.2, the recurrence rate was 15 per cent for the open repair, with a 33-month follow-up, and 4.5 per cent for the laparoscopic technique, with a 22-month follow-up.

CONCLUSION Laparoscopic repair of ventral and incisional hernias is an attractive approach for a difficult problem. The achievement of a low recurrence rate while minimizing wound complications is a combination of goals that has eluded open approaches for ventral hernia repair. While the laparoscopic approach makes sense and is being adopted by many surgeons, it remains an advanced laparoscopic procedure with inherent potential complications, especially during the learning curve. Results of the studies presented in this chapter point out the importance of good patient selection and recognition of the potential for intraoperative and delayed visceral injury. Improvements in training and education of minimally invasive surgical procedures will help to maximize the safe adoption of advanced laparoscopic techniques, such as laparoscopic ventral hernia repair.


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45

46

Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic incisional/ventral herniorrhaphy: a five-year experience. Hernia 1999; 4: 209–14. Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: a personal series and review of the literature. JSLS 1999; 3: 293–304. Balique JG, Alexandre JH, Arnaud JP, et al. Intraperitoneal treatment of incisional and umbilical hernias: Intermediate results of a multicenter prospective clinical trial using an innovative composite mesh. Hernia 2000; 4 (suppl): S10–16. Farrakha M. Laparoscopic treatment of ventral hernias. Surg Endosc 2000; 14: 1156–8. Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment of ventral abdominal wall hernias: preliminary results in 100 patients. JSLS 2000; 4: 141–5. Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience with the ‘four-before’ laparoscopic ventral hernia repair. Am Surg 2000; 66: 465–9. Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair. A report of 100 consecutive cases. Surg Endosc 2000; 14: 419–23. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000; 190: 645–50. Szymanski J, Voitk A, Joffe J, et al. Technique and early results of outpatient laparoscopic mesh onlay repair of ventral hernias. Surg Endosc 2000; 14: 582–4. Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic ventral hernia repair. J Laparoendosc Adv Surg Tech A 2000; 10: 79–84. Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of incisional and parastomal hernias after major genitourinary or abdominal surgery. J Endourol 2001; 15: 175–9. LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy. Our initial 100 patients. Hernia 2001; 5: 41–5. Birgisson G, Park AE, Mastrangelo MJ, et al. Obesity and laparoscopic repair of ventral hernias. Surg Endosc 2001; 15: 1419–22. Moreno-Egea A, Lirón R, Girela E, Aguayo JL. Laparoscopic repair of ventral and incisonal hernias using a new composite mesh (Parietex). Surg Laparosc Endosc Percutan Tech 2001; 11:103–6. Bageacu S, Blanc P, Breton C, et al. Laparoscopic repair of incisional hernia. A retrospective study of 159 patients. Surg Endosc 2002; 16: 345–8. Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia. Surg Endosc 2002; 16: 785–8. Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and incisional hernioplasty. Surg Endosc 1997; 11: 32–5. Park A, Birck DW, Lovrics P, et al. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998; 124: 816–22. Carbajo MA, Martín 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 1999; 13: 250–52. DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Prospective comparison to open prefascial polypropylene mesh repair. Surg Endosc 2000; 14: 326–9. Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of laparoscopic incisional hernia repair. Surg Endosc 2000; 14: 117–19. Susmallian S, Gewurtz G, Ezri T, Charuzi I. Seroma after laparoscopic repair of hernia with PTFE patch: is it really a complication? Hernia 2001; 5: 139–41.

22 Complications and their management SAMUEL K. MILLER, STEPHEN D. CAREY, FRANCISCO J. RODRIGUEZ AND ROY T. SMOOT, JR

Bowel injury Laparoscopic assisted hernia repair Mesh infection Seroma Postoperative/suture pain

161 163 164 165 166

A ventral hernia is any protrusion through the anterior abdominal wall with the exception of the inguinal area. Ventral defects include those found in the umbilical, epigastric, Spigelian, incisional, and parastomal locations. Five to fifteen per cent of laparotomies will result in ventral incisional hernias, with the incidence of incisional hernia rising to nearly 40 per cent following wound infection.1,2 Approximately 100 000 ventral hernias are repaired in the USA each year, comprising about 13 per cent of all hernia repairs annually. Over the past decade, techniques for the laparoscopic approach to ventral hernia repair have been developed. Potential advantages include avoidance of large incisions with associated flaps and drains, tension-free repairs stabilized by intra-abdominal pressures (Laplace’s law), reduced length of stay with reduced convalescence and more rapid return to full activity, and lower complication and recurrence rates. A review of the literature on laparoscopic ventral and incisional hernia repair as well as our clinical experience over ten years was undertaken. A Medline search demonstrated 18 articles suitable for analysis. These articles contained data on complications and recurrences. This chapter will give an overview of the complications associated with laparoscopic ventral and incisional hernia repairs, and will suggest strategies to address these complications. Table 22.1 lists the articles chosen for review. In comparison to open hernia repairs, overall complication rates for laparoscopic hernia repairs are much lower. Complication rates reported for recent series of open repairs may be high as 27–34 per cent.16,19,21,22

Prolonged ileus/persistent nausea and vomiting Recurrence of hernia Conclusion References

166 166 168 168

Review of laparoscopic hernia repairs demonstrates an overall complication rate ranging from five to thirty per cent,3–16,18,19 with a mean of 15.2 per cent. The major advantage of laparoscopic ventral hernia repair is a decreased rate of major wound complications19 and lower recurrence rates.3–18,20

BOWEL INJURY The most feared complication associated with the laparoscopic approach to ventral hernia is enterotomy. Bowel injury has resulted in serious morbidity and mortality. Several authors report bowel injuries,3,4,9,11–13,18 with an overall average incidence of 1.1 per cent. Table 22.2 presents the series reporting bowel injuries. Holzman and colleagues describe a single enterotomy during laparoscopy that required conversion to an open procedure to avoid placement of prosthetic material.3 Toy and coworkers mention two enterotomies in their prospective multicenter study but do not give any further details.4 Ramshaw and colleagues had two serious bowel injuries: one was recognized and repaired at the time of injury but subsequently it dehisced and required reoperation; the second went unrecognized and required reoperation with mesh removal.9 Ramshaw and colleagues also had one minor serosal bowel injury with no sequelae.9 Koehler and Voeller mention two unrecognized bowel injuries, with one patient ultimately dying of hepatic failure on the twenty-ninth postoperative day.11 This death

162 Laparoscopic incisional and ventral hernioplasty Table 22.1 Reported series analyzed, with recurrence rates and total complication rates Reference

Cases (n)

Holzman et al. (1997)3 Toy et al. (1998)4 Franklin et al. (1998)5 Costanza et al. (1998)6 Tsimoyiannis et al. (1998)7 Park et al. (1998)8 Ramshaw et al. (1999)9 Kyzer et al. (1999)10 Koehler et al. (1999)11 Roth et al. (1999)12 Chari et al. (2000)13 LeBlanc et al. (2000)14 Carbajo et al. (2000)15 DeMaria et al. (2000)16 Reitter et al. (2000)17 Heniford et al. (2000)18 Robbins et al. (2001)19 Kozlowski et al. (2001)20 Personal series (2002) Total Mean

20 144 176 15 10 56 79 53 34 75 14 96 100 21 42 407 31 17 182

Mean follow-up (months)

Recurrence (%)

Complications (%)

10.2 7.4 33.6 18 15 24 21 12 20 17 – 51 30 – 27 23 – – 31

1.0 4.2 1.1 0 0 11.0 2.5 0 8.8 9.3 7.0 9.3 2.0 4.8 7.1 3.4 – 11.8 2.7

25 25 5 13 30 18 19 11 21 19 14 15 16 10 – 13 16 24 17

22.7

65/1541 4.2

233/1530 15.2

1572

Table 22.2 Series reporting bowel injuries Reference Holzman et al. (1997)3 Toy et al. (1998)4 Ramshaw et al. (1999)9 Koehler and Voeller (1999)11 Roth et al. (1999)12 Chari et al. (2000)13 Heniford et al. (2000)18 Reporting no injuries Total

Cases (n)

Enterotomies (n)

Complications (%)

20 144 79 34 75 14 407 799

1 2 3 2 2 2 6 0

5.0 1.4 3.8 5.9 2.7 14.3 1.5 0

1572

17

1.1

occurred in a patient requiring lysis of densely adherent small-intestinal loops to the polypropylene mesh. The other patient presented on the fifth postoperative day with an enterocutaneous fistula, and required removal of the patch and segmental resection of the small bowel. Kyzer and coworkers had two recognized small-bowel injuries, which were both converted to open laparotomy: one required a bowel resection and the other required simple suture closure.10 Roth and colleagues had two cases of intraoperative enterotomies recognized at the time of operation: in one case, the operation was converted to an open procedure; the second enterotomy was closed laparoscopically, but no prosthetic patch was placed.12 Chari and coworkers, in a small case–control study, describe two patients with enterotomies in the laparoscopic group.13 One patient required removal of the

mesh due to infection. The second enterotomy resulted in a prolonged postoperative course, with respiratory failure and sepsis; the patient survived. Finally, Heniford and colleagues, with the largest retrospective study involving 407 patients, describe six patients with small bowel enterotomies.18 Minimal spillage was noted in four cases. These four patients had their enterotomies repaired laparoscopically and the hernia repairs completed. The fifth patient was converted to an open repair. None of the five patients had infectious complications or recurrence of the hernia. The sixth patient had an unrecognized enterotomy and subsequently underwent a laparotomy with resection of a short segment of small bowel and removal of the mesh. Bowel injury can occur during initial entry into the peritoneal cavity, although no such injury has been


reported in the literature describing laparoscopic ventral incisional hernia repairs. Most surgeons, including Voeller and Heniford,18,23 prefer the Hasson technique in a site well away from the hernia defect and in a quadrant free of previous surgery. We agree with this technique and use the Hasson technique for nearly all cases. LeBlanc, however, favors the use of the Optiview trocar (Ethicon Endosurgery, Inc.).23 Nearly all reported bowel injuries have occurred during lysis of adhesion. Ramshaw and coworkers9 and Park and coworkers23 considered this to be the most dangerous part of laparoscopic ventral hernia repair, and Koehler and Voeller described it as the most challenging part of laparoscopic incisional ventral hernia repair.11 Robbins and colleagues, however, believe that the most difficult part of the procedure is adhesiolysis and reduction of the hernia contents.19 The mechanisms of injury include direct injury during sharp dissection and thermal injury from various energy sources.24,25 We recommend that all adhesiolysis is done with cold scissors under direct vision, with absolute minimal use of energy. Ramshaw and colleagues,9 Park and colleagues,23 Robbins and colleagues,19 and others support this position. Cautery and harmonic dissection can produce immediate perforations as well as delayed perforation. Delayed perforations are more common with harmonic dissection because the edges are sealed immediately and the mucosa is not seen readily. Kyzer and coworkers note several special situations in which the risk of bowel injury is particularly high.10 These include patients with previous episodes of peritonitis, patients in whom a previous repair utilized intraperitoneal Marlex mesh, and cases of giant hernias that contain multiple irreducible bowel loops. Koehler and Voeller also warn of the dangers during adhesiolysis in the setting of previous synthetic mesh repair.11 Adhesions to the prosthetic material can be fairly dense, and lysis of adhesions may be almost impossible. An excellent strategy in this situation is conversion to open enterolysis, closure of the abdominal wall, and completion of the hernia repair laparoscopically. Many others are advocates of this technique.9,10,13,23 Heniford and coworkers describe conversion to open surgery in eight of 415 patients:18 two patients were opened because of an inability to reduce incarcerated intestine, one was opened for loss of abdominal domain, one for resection of strangulated bowel, and one for enterotomy. As noted above, a special circumstance in which enterotomy may occur is in the setting of previous hernia repair with the use of synthetic mesh. Adhesions to polypropylene and polyester mesh tend to be dense and vascular, with clear planes of dissection that are difficult to define. Our one enterotomy occurred in the face of a previous repair with Prolene mesh. This prompted us to be especially wary of the risk of enterotomy when working adjacent to a previous mesh repair. A good rule to follow is

‘beware of mesh’, although a previous mesh repair is not a contraindication to the laparoscopic approach. Management of enterotomies requires sound clinical judgment. In most cases, we recommend conversion to open laparotomy to repair bowel injuries. Koehler and Voeller advise the same, especially for surgeons that are still early in their laparoscopic ventral hernia repair experience.11 The decision to place any prosthetic material in the setting of bowel perforation depends on the degree of contamination and whether the injury involves the colon. If a colonic injury is suspected, then prosthetic hernia repair must be aborted.11,26 The injury must be addressed, and the incisional hernia can be repaired at a later time. In the setting of a small bowel injury, we recommend conversion to a laparotomy and repair of the bowel injury in most cases. A decision to place prosthetic material in a contaminated field must be taken with great caution. We would err on the side of conservatism and avoid the use of any prosthetic material because of the risk of infection. Many others agree with this.10,11,13 The only exception to this would be in a setting where there is a skilled laparoscopic surgeon who can routinely repair bowel perforation in a proficient manner and there is minimal contamination. Heniford and colleagues describe six bowel injuries.18 In four patients, the enterotomy was repaired laparoscopically, one was converted to open repair, and the hernia repair was completed in each. In spite of their good outcomes with no mesh infections, they caution strongly against placement of mesh in the setting of bowel perforation and contamination. If there is any doubt about the situation, then we recommend conversion to laparotomy. Once the enterotomy is repaired and a decision is made not to proceed with the mesh repair, then the patient can be closed, placed on intravenous antibiotics, and returned to the operating room in three to seven days for completion of the laparoscopic hernia repair.23 Koehler and Voeller describe a similar second-stage patch placement if an enterotomy is made and repaired.11 Lastly, sage advice given by Koehler and Voeller is that one should always consider the possibility of the conversion of an occult partial-thickness injury into a fullthickness bowel injury when a patient is clinically deteriorating after an uneventful laparoscopic ventral hernia repair.11 We second this opinion and do not hesitate to relaparoscope a patient who is not doing well clinically and who is deteriorating.

LAPAROSCOPIC ASSISTED HERNIA REPAIR The techniques of laparoscopic assisted ventral hernia repair should be part of the armamentarium of all surgeons who perform hernia repairs using the laparoscopic


approach. Indications for this approach include inability to gain access to the peritoneal cavity, inability to complete safe lysis of adhesions laparoscopically, any question of visceral injury, and incarcerated hernias for which reduction using laparoscopic techniques is impossible. When these indications are encountered, the abdomen is opened through a limited incision. The bowel is inspected if visceral injuries are suspected, and any injuries are repaired in the appropriate fashion. The remainder of the adhesiolysis is then completed with the abdomen open. The defect is then measured, and an appropriately sized patch is prepared, including placement of pre-tied sutures. The patch is then introduced into the abdomen, unrolled, and oriented. The abdomen is closed in an airtight fashion. The pneumoperitoneum is re-established and the procedure completed in the standard laparoscopic fashion. Other authors have employed this technique.9,10,13,23 The laparoscopic assisted technique provides the surgeon with an alternative to complete abandonment of the laparoscopic approach should the problems described above be encountered. It also provides the surgeon with a safe alternative if visceral injury is suspected. Until a surgeon gains experience with laparoscopic ventral hernia repair, this may initially be the procedure of choice.

MESH INFECTION Mesh infections (Table 22.3) are a very serious complication reported in multiple series, with an average reported incidence of 1.4 per cent.4–6,8,10–12,16,18,19 Infection rates for open incisional hernia repairs are 16 per cent.27 Avoidance of infection includes strict attention to sterile technique. The patient should be carefully prepped and

draped. Many surgeons recommend the use of an adhesive barrier drape, as is commonly done in vascular surgery. The mesh itself should be treated in the same fashion as any vascular graft, in that contact with the skin should be avoided. Even the largest expanded polytetrafluoroethylene (ePTFE) patches can easily be drawn into the abdomen through a standard Hasson trocar. Use of antibiotic-impregnated prosthetics may offer some measure of protection against infection. The lower infection rates in laparoscopic repairs may be due to the avoidance of long incisions, wide dissection or flap creation, opening of the hernia sac, and placement of drains.4,8,18,28 With rare exception, all infected biomaterials placed laparoscopically to repair incisional hernias must be removed to control infection and sepsis. Toy and colleagues describe five wound infections, four of which started at a trocar site.4 Three responded to intravenous antibiotic therapy without mesh removal, and two cases required removal of the mesh. Franklin and coworkers document only a single mesh infection with staphylococcus in series of 176 patients.5 The mesh infection occurred 14 months postoperatively and the mesh was removed. Kyzer and coworkers had a single mesh infection that required removal and subsequently led to a recurrent hernia.10 Koehler and Voeller11 and Roth and colleagues12 mention two mesh infections in each of their respective series, but they fail to give any further clinical details. DeMaria and coworkers had a single mesh infection requiring mesh removal because of an abscess.16 The author felt that seroma aspiration led to contamination and subsequent abscess formation. Heniford and colleagues had four mesh infections in 407 patients, and all required removal of the mesh.18 Two had prior mesh infections with open hernia repair. One developed skin necrosis over the mesh, which eventually became exposed. The last patient developed a mesh infection several weeks

Table 22.3 Series reporting mesh infections Reference Toy et al. (1998)4 Franklin et al. (1998)5 Costanza et al. (1998)6 Park et al. (1998)8 Kyzer et al. (1999)10 Koehler et al. (1999)11 Roth et al. (1999)12 DeMaria et al. (2000)16 Heniford et al. (2000)18 Robbins et al. (2001)19 Personal series (2002) Reporting no mesh infections Total

Cases (n)

Mesh infection (n)

Complications (%)

144 176 15 56 53 34 75 21 407 31 182 378

2 1 1 2 1 2 2 1 4 1 5 0

1.4 0.6 6.7 3.6 1.9 5.9 2.7 4.8 1.0 3.2 2.7 0

1572

22

1.4


postoperatively. Robbins and coworkers reported 31 laparoscopic hernia repairs with a single abdominal wall abscess in the hernia site.19 Ultimately, the mesh had to be removed. In our series, we had one infection that required patch removal; the hernia recurred and was later repaired laparoscopically. Once the infected mesh is removed, options for closure of the abdominal defect include primary closure of the fascia or closure of the fascial defect with biological grafts. The wound is generally left open to close secondarily. After the open wound has closed completely, and at least three to four months have passed since the infection developed and the mesh was explanted, the patient can return to the operating room for laparoscopic hernioplasty.

SEROMA The standard laparoscopic techniques for ventral hernia repair involve reduction of the hernia contents followed by coverage of the defect with an appropriately sized piece of mesh. The hernia sac is left in situ. Fluid accumulation in the hernia sac is very common in our experience and confirmed by many others.3–5,7–9,11,12,14,15,18,23 LeBlanc and colleagues considered postoperative seromas to be the most common ‘minor complication’.14 Heniford and coworkers state that many patients develop ‘small, self-limited collections’ of fluid over the mesh.18 The definition of ‘significant’ collection varies among reported series. Some authors define a significant fluid collection as one that requires aspiration because of steady growth or clinical symptoms. Others define a significant fluid collection as one that lasts for more than six weeks.8,18 Review of the literature demonstrates a

reported average incidence of 4.4 per cent, with a range of 0–16 per cent (Table 22.4). Toy and colleagues describe the largest number of seromas in their prospective, multicenter study.4 Seromas occurred in 23 (16%) patients. Fifteen of these seromas resolved within 30 days, two resolved after 30 days, and six required aspiration. These six patients required aspiration because of the size of the seroma, per patient request, or because there was suspicion of infection. None of the seromas became infected after aspiration. Tsimoyiannis and coworkers describe a single seroma that was aspirated, but they give no details of the indication for drainage.7 Park and colleagues aspirated two seromas because of symptoms or their presence for more than six weeks.8 Ramshaw and coworkers described two seromas, one of which was drained under computerized tomography (CT) guidance.9 The patient subsequently developed a subcutaneous abscess that required open drainage, but the underlying mesh did not have to be removed. Koehler and Voeller had two obvious seromas, but neither required drainage and both resolved over a period of three to six weeks.11 LeBlanc and colleagues had seven seromas, none of which required aspiration.14 They have instituted bulky dressings for 72 hours to help minimize seroma fluid accumulation. Heniford and coworkers described eight seromas that were defined as fluid collections over the mesh that lasted for six to ten weeks.18 They stated that no long-term complications occurred, regardless of whether the seromas were aspirated. Most fluid collections can simply be observed, because they will resolve spontaneously over four to ten weeks. Therefore, we recommend observation for the vast majority of postoperative seromas.14,23 Not all authors agree, however. Carbajo and colleagues described ten seromas, all of which were managed with aspiration.15 No comments

Table 22.4 Series reporting seromas Reference Holzman et al. (1997)3 Toy et al. (1998)4 Franklin et al. (1998)5 Tsimoyiannis et al. (1998)7 Park et al. (1998)8 Ramshaw et al. (1999)9 Koehler and Voeller (1999)11 Roth et al. (1999)12 LeBlanc et al. (2000)14 Carbajo et al. (2000)15 Heniford et al. (2000)18 Personal series (2002) Reporting no seromas Total

Cases (n)

Seromas (n)

Complications (%)

20 144 176 10 56 79 34 75 96 100 407 182 193

1 23 2 1 2 2 2 3 7 10 8 8 0

5.0 16.0 1.1 10.0 3.6 2.5 5.9 4.0 7.3 10.0 2.0 4.4 0

1572

69

4.4


were made as to when and why these seromas required aspiration. DeMaria and coworkers also aspirated all seromas; they stated that most resolved with one or two aspirations, with three attempts at most.16 DeMaria and coworkers also described an abdominal wall abscess developing in a patient who had a seroma aspirated in the early postoperative period. The mesh ultimately had to be removed, and they concluded that the infection occurred because of inadequate sterile technique during seroma aspiration. Park and colleagues feel that routine aspiration of seromas has resulted in mesh infection, and they advise against this practice.23 Although not well described in the literature, our experience shows that many postoperative seromas will display subtle signs of inflammation, such as localized warmth, erythema, and minimal tenderness to palpation, but do not represent true infections. Subtle signs of inflammation do not require any specific treatment other than observation. There is also no associated leukocytosis or fever. These findings generally resolve spontaneously as the fluid is reabsorbed. The level of comfort in observing these subtle signs will depend upon one’s clinical experience. Close clinical follow-up is critical in this setting. Development of worsening pain, fever, and increasing erythema would all be indications to start oral antibiotics. There are very few indications for the aspiration of seromas. Toy and colleagues stated that they try to avoid aspiration because it may contaminate the seroma and cause an abscess.4 Aspiration may be required for seromas that are painful and enlarging. Park and coworkers and other experts feel that aspiration of seromas tends to increase the rate of mesh infections.23 Removing fluid may be both therapeutic and diagnostic in this setting. Clear, straw-colored fluid is normal; however, turbid and purulent fluid is highly suggestive of infection, requiring removal of the prosthetic material.

POSTOPERATIVE/SUTURE PAIN We have found that laparoscopic ventral and incisional hernia repairs tend to be exceedingly painful compared with other minimally invasive surgeries. Ramshaw and colleagues report similar findings.9 They believe that the pain is related to the number of full-thickness sutures and posterior fascial tacks used. Length of hospital stay will be proportional to the degree of pain. We generally keep patients in the hospital for three to four days for postoperative pain management. This is several days longer than the average length of stay reported in the literature. Our preferred method of analgesia is patientcontrolled analgesia (PCA) with morphine. The reported incidence of suture and/or protracted pain is around 1.3 per cent. Heniford and colleagues

defined prolonged suture site pain as pain lasting for more than eight weeks.18 They describe eight cases in their report, most of which resolved with time (in six patients) or injection (in two patients) of bupivacaine.

PROLONGED ILEUS/PERSISTENT NAUSEA AND VOMITING Several authors report prolonged ileus or persistent nausea and vomiting following these procedures. The cumulative reported incidence is two per cent.3,4,8,9,12,14,18,20 Other authors have also reported prolonged ileus and persistent nausea and vomiting, but they did not comment further. We generally do not use nasogastric tubes in the postoperative period. If patients develop nausea, this is treated with anti-emetics, such as ondansetron hydrochloride 4 mg every four hours, as necessary. If patients develop protracted emesis along with their ileus, a nasogastric tube will be placed, but this will be removed as soon as possible. Early ambulation and activity are encouraged to prevent ileus.

RECURRENCE OF HERNIA Overall recurrence rates for open ventral incisional hernia repairs have been high and range from 30 to 60 per cent.4,29–37 A review of the literature demonstrates that laparoscopic hernia repair has lowered this dramatically to approximately four per cent (with a mean follow-up period of 22.5 months) (Table 22.1). Several factors are reported to increase the risk of recurrence after ventral hernia repairs. These include infection at the original operation38 and size of the original hernia.31 Other authors have noted wound infections, obesity, advanced age, pulmonary complications, hepatic insufficiency, and male gender as risk factors for recurrence.6 Park and colleagues report higher recurrences with larger hernias, hernias in a central or midline location compared with lateral hernias, and wound complications after hernia repair.8 Roth and coworkers, on the other hand, found no association between the size and the number of previous repairs, age, postoperative complications, or location of recurrence.12 Koehler and Voeller warn us to consider occult liver disease in any hernia recurrence that cannot be explained by infection or collagen-vascular disease, and they give supporting references.11,39,40 LeBlanc and colleagues state that their recurrences are generally associated with large and multiple defects, the use of only one method of fixation for the prosthetic patch, and an inadequate patch size.14 Hesselink and coworkers noted a 41 per cent cumulative


recurrence rate at five years, with second, third and fourth incisional hernia repairs having recurrence rates of 56, 48 and 47 per cent, respectively.31 Several factors are crucial for the maintenance of low recurrence rates. The defect must be defined completely, the adhesions must be separated, and the repair must not have any tension. The prosthetic patch should be below the plane of the fascial defect, and the size of the patch must be larger than the hernia defect.41,42 The use of prosthetic materials is by far the most important step in the evolution of recurrent hernia repairs.37,39,43,44 In the early reports of laparoscopic ventral and incisional hernia repairs, many authors reported that their early recurrences were due to the use of only one type of fixation method, such as staples or tacks alone, without properly fixing the mesh with sutures. Conversely, pure suture repair of hernias without using mesh is also not advisable. This advice is confirmed by Franklin and colleagues, who report that one recurrence (out of two) was due to the lack of use of a prosthetic patch.5 Tension-free placement of a prosthetic patch on the posterior surface of the abdominal wall is important, and this alone has led to lower recurrence rates.26,29,31,35,41,45–47 The intra-abdominal pressure tends to hold the mesh in place by Laplace’s law. We believe, like others, that tissue in-growth into the mesh material is important for long-term fixation.4,48–50 However, in the immediate postoperative period, sutures and spiral tacks play a critical role in fixation. Franklin and colleagues5 and Reitter and colleauges17 all place strong emphasis on full-thickness transabdominal wall sutures to prevent recurrent hernias. However, they felt that tacks and staples were necessary only to hold the mesh in place initially and to fill in the gaps between the sutures. Ramshaw and coworkers describe one recurrence in a laparoscopic repair where only a hernia stapler was used for fixation (i.e. without sutures or tacks).9 They subsequently modified their technique using sutures and tacks in all but the smallest (⬍2 cm) hernia defects. Heniford and colleagues state that 43 per cent (6/14) of their recurrences developed in patients in whom sutures were not used at all or not placed in difficult areas, such as the costal margins.18 We feel, as do Heniford and coworkers,6 Ramshaw and coworkers,9 and LeBlanc and coworkers,14 that suture fixation is extremely important to the success of the laparoscopic hernia repair. Without suture fixation, the prosthetic patch can pull away from the abdominal wall, eventually leading to recurrence. This has been documented clearly.3,11,14,18,26,51–54 However, we and Park and colleagues8 feel that spiral tacks are just as important. The mesh should be secured to the abdominal wall with spiral tacks placed 1 cm apart. Not all authors agree: Carbajo and colleagues felt that sutures led to more complications (hematomas, increased postoperative pain) and abandoned them for helical tacks only.15

We believe that sutures and spiral tacks are needed in all repairs. To place transabdominal nonabsorbable sutures, we employ a suture-passer to place them 4–5 cm apart. Heniford and coworkers also place full-thickness abdominal-wall sutures every 4–5 cm.18 The sutures should be placed no more than 5 cm apart. Koehler and Voeller state that tacks should be placed every 1.5 cm on the periphery, with sutures every 6 cm.11 They also suggest using three to four tacks around the edges of the hernia defect to minimize the dead space. LeBlanc and colleagues believe that both sutures and tacks are important for securing the mesh.14 Overlapping the hernia defect with the prosthetic patch of an adequate size is also critically important. Several studies have demonstrated that side-to-side suturing of the patch to the edge of the hernia defect leads to recurrence rates of 11–42 per cent.55–57 Tsimoyiannis and colleauges7 and Park and colleagues8 state that the overlap must be at least 2.5 cm. Ramshaw and coworkers,9 LeBlanc and coworkers,14 and Robbins and coworkers19 prefer a 3–4-cm overlap beyond the edge of the defect. Kyzer and colleagues10 and Koehler and Voeller11 suggest that the overlap should be 5 cm or greater. Koehler and Voeller describe a recurrence due to patch disruption with a 9-cm overlap but with no suture fixation.11 Gillion and colleagues have shown clearly that overlapping the mesh with the hernia defect lowers the recurrence rate significantly.58 We feel that complete coverage of the entire incision is important whenever possible, even though the actual recurrent hernia defect may encompass only a small portion of the entire incision. Koehler and Voeller also state that coverage of the entire incision is crucial to minimize recurrence risk.11 For example, if a patient has a midline incision with a recurrence at one end, we would cover the entire midline incision with the prosthetic material to minimize recurrence. In our personal series, several of the recurrent hernias were noted above or below the previously placed prosthesis. We have not seen a recurrence in which the prosthetic material failed intrinsically. Most laparoscopic recurrences tend to occur within the first two years, and this has also been our experience. Toy and colleagues had six patients (other than those recurrences from removal of infected mesh) with recurrences of their ventral hernias.4 All six recurrences presented by nine months postoperatively, with none thereafter. Franklin and coworkers report two recurrences, one at four months and the other at 13 months following the operation.5 The first recurrence occurred after a non-prosthetic umbilical hernia repair. The second recurrence followed the removal of an infected prosthetic biomaterial. LeBlanc and colleagues report nine hernia recurrences at a mean of 24 months, with a range of four to 47 months.14 Recurrence in one patient was recorded at 47 months. If this patient is excluded, then


the mean time of recurrence was 22 months. LeBlanc and coworkers also report four of nine recurrences occurring after 30 months.14 We have had five recurrences in 182 laparoscopic hernia repairs. They all occurred within the first 24 months after repair. Other series report nearly all of the recurrences by two years.8,11,12,16

4

5 6 7

8

CONCLUSION With the adaptation of laparoscopic techniques to general surgical procedures over the past 15 years, several questions have arisen relative to ventral hernia disease. Could ventral and ventral incisional hernias be repaired laparoscopically? Would the laparoscopic approach result in a reduction in surgical complications as well as a reduction in recurrence rates? Finally, would the techniques result in increased patient satisfaction with reduced convalescence and early return to full activity and work? Over ten years’ experience with laparoscopic ventral hernia repair has helped us to answer these questions. The laparoscopic techniques could easily be adapted to ventral hernia repair. The procedure is technically feasible and can be mastered by surgeons skilled in advanced laparoscopic surgery. In addition, the procedure has resulted in reduced morbidity, with a reduction in operative and postoperative complications. Recurrence data are very encouraging and appear to reveal a marked reduction in recurrence rates versus open repair. Patient satisfaction is very high, with patients who have undergone multiple repairs of recurrent hernias finally finding a solution to their problem. The data on length of stay, return to full activity, and return to work attest to the benefits of the laparoscopic approach. Laparoscopic ventral hernia repair has shown itself to be an excellent solution to what has been a serious problem in surgery, namely ventral and incisional hernia disease. The future of the procedure rests upon the sound judgment of the surgeons performing the procedure. Surgeons must adhere to basic surgical principles and always make the safety of the patient their priority. The initial results of the procedure are encouraging, and long-term follow up is essential to verify the long-term benefit of the procedure.

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Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985; 72: 70–1. 2 Munson JL. Problems in General Surgery 1985; 2: 589–614. 3 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and incisional hernioplasty. Surg Endosc 1997; 11: 32–5.

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Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc 1998; 12: 955–9. Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of recurrent ventral hernia. Am Surg 1998; 12: 1121–7. Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic intraperitoneal onlay mesh repair of incisional hernia. Surg Laparosc Endosc 1998; 8: 360–2. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998; 124: 816–22. Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65; 827–32. Kyzer S, Alis M, Aloni Y, Charuzi I. Laparoscopic repair of postoperation ventral hernia. Early postoperation results. Surg Endosc 1999; 13: 928–31. Koehler RH, Voeller G. Recurrence in laparoscopic incisional hernia repairs: a personal series and review of the literature. JSLS 1999; 3: 293–304. Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic incisional/ventral herniorrhaphy: a five year experience. Hernia 1999; 4: 209–14. Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of laparoscopic incisional hernia repair. Surg Endosc 2000; 14: 117–19. LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg 2000; 180: 193–7. Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic treatment of ventral abdominal wall hernias: Preliminary results of 100 patients. JSLS 2000; 4: 141–5. DeMaria EJ, Moss JM, Surgerman HJ. Laparoscopic intraperitoneal polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral hernia. Surg Endosc 2000; 14: 326–9. Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience with the ‘Four-Before’ laparoscopic ventral hernia repair. Am Surg 2000; 5: 465–9. Heniford TB, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. JACS 2000; 190: 645–50. Robbins SB, Pofahl W, Gonzales RP. Laparoscopic ventral hernia repair reduces wound complications. Am Surg 2001; 9: 896–900. Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of incisional and parastomal hernias after major genitourinary or abdominal surgery. J Endourol 2001; 15: 175–9. Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 1998; 133: 378–82. White TJ, Santos MC, Thompson JS. Factors affecting wound complications in repair of ventral hernias. Am Surg 1998; 64: 276–80. Park A, Heniford BT, LeBlanc KA, Voeller GR. Laparoscopic repair of incisional hernias. Part 2: surgical technique. Contemp Surg 2001; 57: 225–38. Brill AI, Feste MD, Hamilton TL. Patient safety during laparoscopic monopolar electrosurgery – principles and guidelines. J Soc Laparoendosc Surg 1998; 2: 221–5. Vancille TG. Active electrode monitoring; how to prevent unintentional thermal injury associated with monopolar electrosurgery at laparoscopy. Surg Endosc 1998; 12: 1009–12. Temudom T, Siadati M, Sarr MG. Repair of complex giant or recurrent ventral hernias by using tension-free intraperitoneal prosthetic mesh (Stoppa technique): lessons learned from our initial experience (fifty patients). Surgery 1996; 120: 738–44.

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Houck JP, Rypins EB, Sarfeh IJ, et al. Repair of incisional hernia. Surg Gynecol Obstet 1989; 169: 397–9. 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 1999; 13: 250–2. Langer S, Christiansen J. Long-term results after incisional hernia repair. Acta Chir Scand 1985; 151: 217–19. Van der Linden FT, van Vroonhoven TJ. Long-term results after correction of incisional hernia. Neth J Surg 1988; 40: 127–9. Hesselink VJ, Luijendijk RW, de Wilt JWH, et al. An evaluation of risk factors in incisional hernia recurrence. Gynecol Obstet 1993; 176: 228–34. Santora TA, Roslyn JJ. Incisional hernia. Surg Clin N Am 1993; 73: 557–70. Paul A, Korenkov M, Peters S, et al. Unacceptable results of the Mayo procedure for repair of abdominal incisional hernia. Eur J Surg 1998; 164: 361–7. Luijendijk RW, Lemmen MH, Hop WC, Wereldsma JC. Incisional hernia recurrence following ‘vest over pants’ or vertical Mayo repair of primary hernia of the midline. World J Surg 1997; 21: 62–6. Koller R, Miholic J, Jakl RJ. Repair of incisional hernias with expanded polytetrafluoroethylene. Eur J Surg 1997: 163: 261–6. Gecim II E, Kocak S, Ersoz S, et al. Recurrence after incisional hernia repair: results and risk factors. Surg Today 1996; 26: 607–9. George CD, Ellis H. The results of incisional hernia repair: a twelve year review. Ann R Coll Surg Engl 1986; 68: 185–7. Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a prospective study of 1129 major laparotomies. Br Med J 1982; 284: 931–3. Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal wall defects with ePTFE. Ann Surg 1987; 206: 765–9. Lamont PM, Ellis H. Incisional hernia in re-operated abdominal incisions: an overlooked risk factor. Br J Surg 1988; 75: 374–6. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 1989; 13: 545–54. Condon RE. Prosthetic repair of abdominal hernias. In: Nyhus LM, Condon RE, eds. Hernia, 4th edn. Philadelphia: JB Lippincott, 1995: 188–210. Wantz G. Incisional hernioplasty with Mersilene. Surg Gynecol Obstet 1991; 172: 129.

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Condon RE. Incisional hernia. In: Nyhus LM, Condon RE, eds. Hernia, 4th edn. Philadelphia: JB Lippincott, 1995: 319–39. Mclanahan D, King LT, Weems C, et al. Retrorectus prosthetic mesh repair of midline abdominal hernia. Am J Surg 1997; 173: 445–9. Amid PK, Shulman AG, Lichtenstein L. A simple stapling technique for prosthetic repair of massive incisional hernias. Am Surg 1995; 60: 934–7. Ramshaw BJ, Schwab J, Mason EM, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65: 827–31; 831–2. Cristoforoni PM, Kim YB, Preys Z, et al. Adhesion formation after incisional hernia repair: a randomized porcine trial. Am Surg 1996; 62: 935–8. Law NW, Ellis H. Adhesion formation and peritoneal healing on prosthetic materials. Clin Mater 1988; 3: 95–101. Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and Gore-Tex to repair abdominal wall defects in the rat. Can J Surg 1989; 32: 244–7. Molloy RG, Moran KT, Walaron RP, et al. Massive incisional hernia: abdominal wall replacement with Marlex mesh. Br J Surg 1991; 78: 242–4. McCarthy JD, Twiest MW. Intraperitoneal polypropylene mesh support incisional herniorrhaphy. Am J Surg 1981; 142: 707–11. Bellon JM, Contreras LA, Sabeter C, Bujan J. Pathologic and clinical aspects of repair of large incisional hernias after implant of PTFE prosthesis. World J Surg 1997; 21: 402–7. Monaghan RA, Meban S. ePTFE patch in the hernia repair: a review of clinical experience. Can J Surg 1991; 34: 50–55. Ambrosiani N, Harb J, Gavelli A, Huguet C. Echec de la cure des eventrations et des hernies par plaque de PTFE (111 cas). Ann Chir 1994; 48: 917–20. Saiz AB, Willis IH, Paul DK, Sivina M. Laparoscopic ventral hernia repair: a community hospital experience. Am Surg 1996; 5: 336–8. Ven der Lei B, Bleichrodt RP, Simmermacher RKJ, van Schilgaarde R. Expanded polytetrafluoroethylene patch for the repair of large abdominal wall defects. Br J Surg 1989; 76: 803–5. Gillion JF, Begin GF, Marecos C, Fourtanir G. Expanded polytetrafluoroethylene patches used in the intraperitoneal or extraperitoneal position for repair of incisional hernias of the anterolateral abdominal wall. Am J Surg 1997; 174: 16–17.


PART

4

Laparoscopic treatment of diaphragmatic herniation

23 24 25 26 27 28

History Anatomy and physiology Preoperative evaluation Gastroesophageal reflux disease Para-esophageal hernias Traumatic and unusual herniation

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29 Etiology of recurrent gastroesophageal reflux disease 30 Reoperation for recurrent gastroesophageal reflux disease 31 Results of laparoscopic treatment of hiatal hernias 32 Complications and their management

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23 History RAYMOND C. READ

Initial experience Short esophagus Phillip Allison’s contribution Rudolph Nissen’s contribution

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Even though Barrett did not introduce the term ‘reflux oesophagitis’ until 1950,1 this entity is now considered to be the most common chronic disease afflicting the Western world. Forty per cent of the population complain of occasional heartburn, and a third of these require longterm medical treatment. A significant minority progress to Barrett’s metaplasia. Other complications include esophagitis, ulceration, stricture, herniation and neoplasia, many of which require surgery. The purpose of this chapter is to trace the evolution of such therapy.

INITIAL EXPERIENCE Herniation of abdominal contents through the diaphragm has been recognized for centuries. According to Reid, the lesion was first documented by Sennertus in 1541 at postmortem examination.2 Boyle described the clinical findings in 1812.3 Successful repair was accomplished by Potemski in 1889.4 Congenital diaphragmatic herniation was reported in 1701 by Holt.5 Operative correction was effected in 1902 by Heidenhain.6 Ambroise Pare in 1610, quoted by Hedblom,7 described cases of hiatus herniation and post-traumatic protrusion at autopsy, but it was not until 1908 that the former, discovered fortuitously at laparotomy, was dealt with in a living person. Even

Part of this review was presented at the third Annual Scientific Meeting of the American Hernia Society, Toronto, 15 June 2000, and has been published previously as ‘Contribution of Allison and Nissen to laparoscopic hiatal herniorrhaphy’ in Hernia 2002; 5: 200–203.

Laparoscopic approach Conclusion References

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though diaphragmatic hernias were considered rare, Hedblom reviewed almost 400 cases (19 at the Mayo Clinic) operated upon worldwide by 1925. The following year, Akerlund published his radiological studies;8 these were performed with barium, the patient being placed in the Trendelenburg position, as recommended by Soresi.9 Most surgeons operated only on large protrusions (mainly para-esophageal) because of their known risk of incarceration, volvulus and strangulation. Based on experience with external hernias, pain and dysphagia were attributed to ‘pinching’ of the stomach by the hernial ring. Harrington considered diaphragmatic herniation to be the ‘great masquerader’ because it was frequently confused (and associated) with the more commonly recognized peptic ulcer disease or cholecystitis.10 Therefore, in contrast to most surgeons of his time, he preferred the abdominal approach. Thoracotomy allowed phrenic nerve crush, which was still being recommended in the 1950s to facilitate return of the stomach to the abdomen.11 Gastropexy was used to limit recurrence and prevent postoperative volvulus.12

SHORT ESOPHAGUS Harrington10 and other surgeons in the period between the two world wars encountered some patients, young and old, whose stomachs could not be reduced below the diaphragm because of shortening and narrowing of the esophagus. Forceful taxis resulted in disruption. These individuals were therefore not operated upon, being managed instead by bougienage. Harrington, as pointed

174 Laparoscopic treatment of diaphragmatic herniation

out by Hayward,13 also deserves credit for being the first to distinguish between ‘really’ short esophagus and one that is ‘apparently’ so.14 He also separated para-esophageal hiatus herniation from the sliding type, the latter, the more common, having a higher incidence of stricture. A seminal but ultimately malign contribution to our understanding of these cases was made by Findlay and Kelly in 1931.15 Their paper was entitled ‘Congenital shortening of the esophagus and the thoracic stomach resulting therefrom’. In this, they described nine infants and children who presented with dysphagia from high strictures of the esophagus. Distally, the remaining foregut in the chest was shown by endoscopic biopsy to be lined by ‘gastric’ mucosa. This structure was therefore considered to be the stomach. Since their youngest patient was only five days old, its intrathoracic position was presumed to have been present before birth; thus it was not a hernia but a congenital misplacement. To support this concept, Findlay and Kelly cited seven necropsies, mostly of elderly men whose intrathoracic stomach had been thought previously to be herniation. Kelly later reported further examples of congenital intrathoracic stomach, but he did accept that in some patients herniation could occur postnatally.16 The associated strictures were considered to arise from esophagitis, spasm, and ascending fibrosis. During barium studies on normal children, these authors incidentally observed longitudinal muscular spasm producing hiatal herniation during deglutition. This was the first evidence for the modern concept that hernia may follow rather than cause gastroesophageal reflux disease (GERD).

PHILLIP ALLISON’S CONTRIBUTION This thoracic surgeon (1908–74) was born and educated and, for most of his career, practiced in Yorkshire, England. In the late 1930s, while at the University of Leeds, he pioneered intrapericardial pneumonectomy. In 1954, he was appointed Nuffield Professor of Surgery at Oxford University. Unfortunately, because of petty parochialism practiced by the Harley Street surgeons of London, his achievements were appreciated more overseas than in his native land. In 1943, he and his colleagues described ten middle-aged or elderly men and women with short esophagus and peptic ulceration. They had complained for months or years of substernal pain, dysphagia and, in half, occasional bleeding. Symptoms responded to dilation and antacids, and endoscopy demonstrated fibrotic narrowing. Some patients also had gastric or duodenal ulceration. Allison and colleagues’ conclusion was that ‘the deformity referred to as congenitally short esophagus may be acquired and result from herniation of the stomach with ulceration and scarring’.17

Barrett in 1950 distinguished between peptic ulceration of the esophagus lined with squamous epithelium and gastric ulceration distally in what he called thoracic stomach, even though it had no serosal covering to go along with its adenomatous mucosa.1 (Barrett’s rejoinder to such quibblers was ‘Neither does the cardia!’) Three years later, Allison and Johnstone, in a paper entitled ‘The esophagus lined with gastric mucous membrane’, argued that Barrett’s thoracic stomach was actually esophagus with an abnormal mucosa.18 They conferred his name on both the epithelium and ulcers arising therein. They also noted the presence of sliding hiatus herniation with or without a para-esophageal component in their patients, all of whom demonstrated ‘peptic esophagitis’ (Allison’s term) or Barrett’s ‘reflux esophagitis’. In over 100 patients with peptic stricture of the esophagus, less than ten per cent were in the ‘gastric’ lining. Most occurred at the junction of squamous and adenomatous epithelium. Their conclusion was that the ‘gastric’ epithelium in the esophagus, rather than being congenital in origin, might develop by healing of reflux esophagitis with metaplasia. LortatJacob19 and Hayward13 concluded that all such cases were acquired. Interestingly, the former, a Frenchman, introduced the term ‘endo-brachy-oesophage’, analogous to the English ‘short esophagus’. Lortat-Jacob agreed with Allison that reflux esophagitis could shorten the squamous-lined esophagus when its inferior portion became lined with gastric-type mucosa. One of Allison and Johnstone’s patients developed a cancer in the adenomatous lining of the esophagus.18 At 72 years of age, he had complained of hiccup, epigastric pain, flatulence, and nocturnal regurgitation on and off for his entire life. Increasing dysphagia had started eight weeks before admission. Olsen and Harrington had previously reported on four such examples of malignancy associated with short esophagus and hiatus herniation.20 In discussion, Sweet commented that 13 per cent of his resections for cancer of the cardia at the Massachusetts General Hospital had been in patients with the short esophagus–hiatus hernia syndrome. Cases of the latter presenting with perforation or massive hemorrhage had ulcers arising in the adenomatous epithelium of the esophagus (Barrett’s), not in the squamous lining above. To prevent reflux esophagitis, Allison focused on hiatus herniorrhaphy.21 Since there was, at the time, no anatomical or physiological evidence for a sphincter at the esophagogastric junction, he set out to re-establish both the angle of His and the diaphragmatic ‘pinchcock’ formed by the right crus of the diaphragm and the phreno-esophageal ligaments. The situation being considered analogous to that of the puborectalis sling around the anorectal junction, Allison felt that a posterior rather than the popular anterior repair was indicated. His herniorrhaphy was conducted through the chest, the diaphragm being incised to expose the abdomen.

History 175

Unfortunately, Allison’s repair, which was adopted widely, proved unsatisfactory because a significant number of patients suffered symptomatic relapse. Collis cited these results in recommending a return to anterior closure of the defect in the dome of the diaphragm.22 This surgeon, who also worked in the UK (Birmingham), had described in 1957 an operation for patients with hiatus hernia and short esophagus that has stood the test of time.23 This involved constructing a neo-esophagus from the ‘Magenstrasse’ of the stomach. Hiebert and Belsey provided an explanation for the failure of Allison’s procedure when they documented incompetence of the gastric cardia in the absence of hiatal herniation.24 The problem was primary incompetence of the intrinsic gastroesophageal sphincter of Code and colleagues.25

RUDOLPH NISSEN’S CONTRIBUTION This distinguished thoracic surgeon (1896–1981), the son of a surgeon, was an assistant between 1921 and 1933 to Professor Sauerbruch of Munich and Berlin. Being Jewish, Nissen was forced to emigrate to Turkey, from his Fatherland despite being wounded in the lung during World War I. In 1931, he performed the world’s first successful pneumonectomy on a 12-year-old girl with a torn left mainstem bronchus. While in Istanbul, he undertook a transthoracic gastroesophagectomy for benign ulceration of the cardia.26 He later learned that this was the second such resection to be accomplished successfully, the first being performed by the Japanese in 1933. It is interesting that Sauerbruch pioneered the procedure experimentally in the dog in 1906. Since almost all previous attempts had failed in humans because of anastomotic leakage, Nissen buried the anastomosis of the transected esophagus in the fundus of the stomach. He brought up two folds in the manner of a Witzel gastrostomy. Amazingly, while he was Chief of Surgery at Basel, Switzerland, 17 years after this operation he obtained follow-up information from a relative of the patient. The patient was well and had no symptoms of reflux esophagitis. Two years later, Nissen decided to perform fundoplication alone for esophageal reflux disease. He undertook this procedure in a man and a woman who each had the signs and symptoms of reflux esophagitis without evidence of hiatal herniation. Nissen reported success in 1956.27 In agreement with modern thought,28 he believed that hiatus herniation was the result rather than the cause of reflux esophagitis. Therefore, in cases of symptomatic hiatus herniation, he paid no attention to the hernial sac, considered closure of the defect unnecessary, and with short esophagus performed transthoracic fundoplication. He always conducted the procedure over a large-bore bougie to prevent postoperative dysphagia,

and stitched the fundoplication to the esophageal wall to obviate slippage. He mobilized the lesser curvature of the stomach, being careful to preserve the vagi and their branches. The left gastric vasculature rather than the short gastric vessels was divided. A nasogastric tube was left postoperatively to prevent vomiting. Initially, Nissen performed a partial wrap since he did not mobilize the fundus by dividing its blood supply. Later, he recommended 360-degree rotation, since he ligated the short gastric vessels rather than branches of the left gastric on the lesser curvature. Today, both partial and complete fundoplications are performed, depending on the emptying characteristics of the esophagus and stomach. Whereas Nissen was not concerned about an intrathoracic location of the fundoplication, either intraoperatively with short esophagus or, later, secondary to herniation, surgeons have adopted Belsey’s recommendation that the intra-abdominal portion of the esophagus should be restored and maintained by repair of any hiatal herniation.24 Any shortening of the esophagus from scarring, secondary to GERD, is eliminated by the use of Collis’ procedure.23 To avoid gas bloat and dysphagia, the length of the wrap, which is floppy, has been halved. Nissen retired from surgical practice in 1967 and died in 1981. Despite modifications, his operation continues to be the basis for the surgical relief of complications arising from reflux esophagitis with or without hiatus herniation.

LAPAROSCOPIC APPROACH This mini-invasive surgical technique evolved from endoscopy,29 which began on the island of Kos with the school of Hippocrates (460–375 BC), who described the rectal speculum. A three-bladed vaginal speculum was recovered from the ruins of Pompeii. The earliest light sources were mirrors, introduced by the Arabs before 1000 AD. In 1587, Aranzi described the use of the camera obscura, popularized by Leonardo da Vinci in 1519. A spherical glass flask filled with water was used to focus a beam of sunlight into the nasal cavity. In the seventeenth century, Borell employed a lantern. Bozzini in 1806 initiated modern endoscopy by developing a complex tubular system to convey light from a candle allowing observation of the bladder or cervix through a second channel. Segal in 1826 used a similar arrangement to fabricate a cystoscope without lenses. Desormeaux in 1865 and Nitze in 1879 developed telescopic instruments. Originally, their light source was an overheated, water-cooled platinum wire (described by Bruck in 1867), but after the electric light bulb was invented in 1880 by Edison, this was incorporated into a gastroscope by Mickulicz in 1881 and into a cystoscope by Newman in 1883. Later, the bulb was mounted distally,


an operating channel was added, and the lens was separated therefrom. Laparoscopy began in 1901 when Ott reported on culdoscopy and later (1909) on ‘ventroscopy’ using a speculum. Kelling in 1902 suggested that a better view of the compressed viscera could be obtained by inducing pneumoperitoneum, this having been performed earlier in the treatment of tuberculosis. His first observations, Koelioskopie, were made on animals but in 1910 Jacobeus reported 17 ‘lapothorakoskopies’ on patients with ascites employing a Nitze cystoscope. Further developments included the use of the Trendelenburg position and a trocar endoscope by Nordentoeft in 1912. The automatic spring insufflating needle was invented by Goetz in 1918. Carbon dioxide, which is absorbed more rapidly than air, was substituted for air by Zollikofer in 1924. Kalk in 1929 devised a new lens system that permitted oblique (135-degree) viewing, along with a dual-trocar technique. In the 1930s, laparoscopy was performed largely by general surgeons and internists (e.g. Ruddock) for the diagnosis and biopsy of visceral disease. The stomach, bladder and rectosigmoid were sometimes transilluminated for better evaluation. The first operation using laparoscopy, adhesiolysis, was carried out by Fervers in 1933. Boesch in 1936 used the procedure for sterilization, coagulating the fallopian tubes. Palmer expanded its use in gynecology. Advances in instrumentation enhanced its popularity: cold light illumination (Foursestiere in 1943), fiber-optics (Hopkins in 1952), and new instruments (Frangenheim in 1954, Semm in 1963). Semm also introduced the automatic insufflator. Later, bipolar coagulation (Frangenheim in 1972) and laser technology (Bruhat in 1979) were added. Nevertheless, the major breakthrough was the invention of the computer-chip video camera in 1986. This enabled assistants and students to view the progress of the operation. In 1981, Semm performed laparoscopic appendectomy; cholecystectomy followed (Muhe in 1986, Mouret in 1987). Despite initial censure, laparoscopic herniorrhaphy, hysterectomy, bowel resection, gastrectomy, nephrectomy, cystectomy, splenectomy, adrenalectomy, vagotomy and esophagectomy followed rapidly. Thoracoscopy was rejuvenated. Laparoscopic fundoplication was introduced independently by Geagea and Dallemagne in 1991. Since then, it has been adopted worldwide and has supplanted the open Nissen procedure. Hospital stay is reduced along with postoperative morbidity. Treatment costs are thereby reduced. An increase in operating time can be eliminated by experience. Follow-up studies, many of which are prolonged and randomized, show that results are as good as those obtained by classical open procedures, except perhaps with esophageal shortening or giant para-esophageal herniation. Here, restoration of the abdominal esophagus or recurrence pose problems.

Whereas a 360-degree fundoplication is the most common procedure, partial wraps are favored by some surgeons, especially if emptying of the esophagus or stomach is inadequate. The mini-invasive nature of laparoscopy has made surgery more acceptable, and it has become competitive with long-term medical treatment. Improved outpatient pH monitoring and other diagnostic measures have expanded the population known to be suffering from GERD. The success of laparoscopic fundoplication, complete or partial, in both children and adults has extended this technique to prosthetic repair of hiatal defects, the Collis operation for short esophagus, and the management of incarcerated para-esophageal herniation. Other diaphragmatic hernias protruding through the foramina of Bochdalek and Morgagni have been dealt with similarly, along with blunt or penetrating injuries seen early or late. Heller cardiomyotomies have also been performed for achalasia. Smaller ports, narrower instruments, and joystick controls have facilitated these procedures.30 Robotics are now on emerging technology.

CONCLUSION Our understanding of the common ailment, reflux esophagitis, has been shown to be based largely on the pioneering efforts of European thoracic surgeons. By unraveling congenital misplacement, hiatus herniation, short esophagus, stricture, ulceration, adenomatous hyperplasia, and its malignant transformation, they made modern surgical therapy possible. European surgeons again played a leading role in the evolution of laparoscopy from endoscopy. The successful application of this technique to appendectomy and cholecystectomy stimulated its use, a decade ago, in the management of GERD. This approach has now supplanted open fundoplication. It has been adopted for prosthetic repair of various diaphragmatic hernias, Heller myotomy, Collis gastroplasty and, combined with thoracoscopy, esophagectomy. Technical advances and new instrumentation continue to improve patient outcome while reducing costs and hospitalization.

REFERENCES 1 Barrett NR. Chronic peptic ulcer of the oesophagus and ‘oesophagitis’. Br J Surg 1950; 38: 175–82. 2 Reid J. Case of diaphragmatic hernia produced by a penetrating wound. Edinburgh Med J 1840; 53: 104–12. 3 Boyle A. Case of wounded diaphragm. Edinburgh Med J 1812; 8: 42–4. 4 Potemski M. Nouvo processo operativo per la reduzione cruenta della cruie diaframmatiche da trauma e per la sutura della ferite del diaframma. Bull Reale Acad Med Roma 1889; 15: 191.

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Holt C. Child that lived two months with congenital diaphragmatic hernia. Philos Trans 1701; 22: 922. Heidenhain L. Geschichte eines Fallas von chronischer Incarceration des Magens in einer angeborenen Zwerch fellhernie welcher durch Laparotomie geheilt wurde, mit anschliessen – den Bemerkungen ueber die Moglichkeit. Das Kardiocarcinom der Speiserohre zu reseciren. Deutsch Ztschr Chir 1905; 76: 394–403. Hedblom CA. Diaphragmatic hernia: a study of three hundred and seventy eight cases in which operation was performed. JAMA 1925; 85: 947–53. Akerlund A. Hernia diaphragmatic Hiatusoesophagei vom anatomischen und rontgenologischen Gesicfhtspunkt. Acta Radiol 1926; 6: 3–22. Soresi AL. Diaphragmatic hernia, its unsuspected frequency: its diagnosis, technique for radical cure. Ann Surg 1919; 69: 254–70. Harrington SW. Diagnosis and treatment of various types of diaphragmatic hernia. Am J Surg 1940; 50: 377–446. Adams HD, Lobb AW. Esophagoaortal hiatus hernia. N Engl J Med 1954; 250: 143–8. Boeremia I, Germs R. Anterior geniculate gastropexy for hiatal hernia of the diaphragm. Zentralbl Chir 1955; 80: 1585–93. Hayward J. The treatment of fibrous stricture of the esophagus associated with hiatal hernia. Thorax 1961; 16: 45–64. Harrington SW. The surgical treatment of the more common types of diaphragmatic hernia. Ann Surg 1945; 122: 546–68. Findlay L, Kelly B. Congenital shortening of the esophagus and the thoracic stomach resulting therefrom. J Laryngol Otol 1931; 46: 797–816. Kelly AB. Some oesophageal affections in young children. J Laryngol Otol 1936; 51: 78–99. Allison PR, Johnstone AS, Royce GB. Short esophagus with simple peptic ulceration. J Thorac Surg 1943; 12: 432–57.

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Allison PR, Johnstone AS. The esophagus lined with gastric mucous membrane. Thorax 1953; 8: 87–101. Lortat-Jacob JL. Les malpositions cardia-tuberositaires. Arch Mal App Dig 1953; 42: 750–74. Olsen AM, Harrington SW. Esophageal hiatal hernias of the short esophagus type: etiologic and therapeutic considerations. J Thorac Surg 1948; 17: 189–209. Allison PR. Reflux esophagitis, sliding hiatal hernia and the anatomy of repair. Surg Gynecol Obstet 1951; 92: 419–31. Collis JL. Review of surgical results of hiatus hernia. Thorax 1961; 16: 114–23. Collis JL. An operation for hiatus hernia with short esophagus. J Thoracic Surg 1957; 34: 768–78. Hiebert CA, Belsey RHR. Incompetency of the gastric cardia without radiologic evidence of hiatal hernia, the diagnosis and management of 71 cases. J Thorac Cardiovasc Surg 1961; 42: 352–71. Fyke FE, Code CF, Schlegel JF. The gastroesophageal sphincter in healthy human beings. Gastroenterologia 1956; 86: 135–47. Nissen R. Die Transpleurale Resektion der Kardia. Deutsche Ztschr Chir 1937; 249: 311–16. Nissen R. Gastropexy as the lone procedure in the surgical repair of hiatus hernia. Am J Surg 1956; 92: 389–92. Dunne DP, Paterson WG. Acid-induced esophageal shortening in humans: a cause of hiatus hernia? Can J Gastroenterol 2000; 10: 847–50. Lau WY, Leow CK, Li AKC. History of endoscopic and laparoscopic surgery. World J Surg 1997; 21: 444–53. Awad ZT, Filipi CJ. Commentary: the short esophagus, pathogenesis, diagnosis and current surgical options. Arch Surg 2001; 136: 113–14.


24 Anatomy and physiology MARK A. REINER

Anatomy Physiology Surgical considerations for diaphragmatic repair in patients with gastroesophageal reflux disease

179 183


185 185

184

In an attempt to elucidate the etiological factors that contribute to gastroesophageal reflux disease (GERD), it is necessary to have a full understanding of normal diaphragmatic anatomy and physiology. Pathological reflux occurs when there are anatomical and physiological abnormalities at the gastroesophageal junction and crura. These abnormalities are influenced by postural changes and gradients between intra-abdominal and intrathoracic pressures. Corrective surgery must include a proper diaphragmatic repair in order to minimize the potential for recurrence. Postoperative management must be tailored to the patient’s age, the size of the hiatal defect, and the patient’s lifestyle.

ANATOMY The diaphragm separates the abdominal and thoracic cavities. It is composed of a non-contractile central tendon and three peripheral or skeletal muscular components, the sternal, costal, and lumbar or crural.1 The central tendon connects all of the muscular components by acting as a central focal point from which these three muscle groups radiate. The sternal portion of the muscular component originates from the undersurface of the sternum and may be considered as an independent structure or as the medial aspect of the costal segment.1,2 The costal portion originates from the undersurface of the lower six costochondral junctions, extending on to these ribs, and then ending by interdigitating with the transversus abdominis muscles bilaterally. The lumbar or crural segment originates from

the first three lumbar vertebrae.1 These segments have four components: the medial and lateral lumbosacral arches or internal and lateral arcuate ligaments, and the right and left crura.1,3 The medial lumbosacral arch (internal arcuate ligament) drapes over the psoas muscle; it is fixed to the transverse processes of the first and second lumbar vertebra, and fuses into the lateral portion of the contiguous crus. The lateral lumbosacral arch (external arcuate ligament) covers the quadratus lumborum and becomes fixed to the first lumbar vertebrae and twelfth rib.1,3 The crura originate as tendons that are a direct extension of the longitudinal ligament of the vertebral column and as such are attached to the lumbar vertebrae. The tendon of the left crus is shorter and thinner than the right crus. It originates from the ventral surface of the bodies and intervertebral disks of L1 and L2. The right crus, the stronger and longer of the two, originates from the ventral surfaces and intervertebral cartilages of L1, L2 and L3. The crura muscular fibers, originating from their respective tendons, then merge and surround the esophageal hiatus at the level of T10.1,3,4 Before doing this, the medial margins of the crura pass ventrally and then merge medially near the midline to surround the anterior surface of the aorta. The muscular fibers coming off the crural tendons then integrate and connect into the central tendon. The right crus muscular fibers split into two segments. The medial segment completely surrounds the esophageal hiatus, while the lateral segment merges directly into the central tendon. The muscular fibers of the left crus enter directly into the central tendon. Occasionally, muscle bundles will overlap and may be derived from both tendons (Figure 24.1).1,3,5,6

180 Laparoscopic treatment of diaphragmatic herniation Costal origin

Esophageal hiatus

Vena cava foramen Lumbar crural Right crus

Median arcuate ligament

Aortic hiatus Left crus

Medial arcuate ligament Lateral arcuate ligament

Quadratus lumborum

Lumbar vertebrae

Figure 24.1 Normal diaphragmatic anatomy.

Central component Right component

Left component

Figure 24.2 Central tendon.

The muscular components of the diaphragm merge centrally into the central tendon. This structure is a strong aponeurosis broken down into three components. The largest is the right component, followed by the central and left components. The entire structure is slightly off-center, being biased slightly anteriorly and to the right.1 The tendon gets its considerable strength because the fibers merge at different angles (Figure 24.2). Anatomical rents in the diaphragm exist so that passage of structures can occur between the thoracic and abdominal cavities. There are three main and five minor defects or apertures in the diaphragm. The minor defects serve for passage of small vessels, such as the superior epigastric artery and vein anteriorly, and the hemiazygos vein and splanchnic and sympathetic nerves posteriorly. The three major apertures are for the vena cava, the aorta, and the esophagus. The innervation of the diaphragm is from the phrenic nerves, which arise mainly from the fourth and to a lesser degree the third and fifth cervical nerves. The blood supply is from the inferior phrenic arteries. The right phrenic artery is more lateral, while the left phrenic artery is more medial. The right vessel passes anterior to

the inferior vena cava and along the right side of its hiatus. The vessel divides into a medial and lateral branch. The medial branch angles further anteriorly and anastomoses with the same branch of the opposite side, as well as the musculophrenic and pericardiophrenic vessels. The lateral branch courses laterally to anastomose with the posterior intercostal arteries.1 The left vessel is significantly more medial and runs anterior to the esophagus and ventrally along the left side of the esophageal hiatus.1,4 It must be noted carefully at this site to prevent inadvertent injury during anti-reflux procedures, especially when closing the diaphragmatic rent. Branches of the inferior phrenic vessels and occasionally an arterial branch off the left gastric artery will pass just anterior to the ventral margin of the esophageal hiatus.5 These vessels can be injured when mobilizing the left lateral segment of the liver or when a probe is placed in the hiatus for anterior displacement aiding visualization during an anti-reflux procedure. If this vessel is near the apex, I prefer to use a more flat or fan retractor to help prevent injury. The next integral anatomical component in preventing reflux disease is the phreno-esophageal ligament. This

Anotomy/physiology 181

Lower esophageal attachment Gastrophrenic ligament attachment Pars condesa attachment Anterior cardial attachment

Figure 24.3 Phreno-esophageal ligament.

Elliptical hiatus

Figure 24.4 Normal esophageal hiatus.

is a misnomer, being not a true ligament but rather a continuation of the subperitoneal fascia. Its attachments are the anterior portion of the cardia of the stomach, the lower 4 cm of the esophagus, and the left and right sides of the crura around the esophageal hiatus. It terminates on the left by merging into the gastrophrenic ligament and on the right into the pars condensa of the lesser omentum (Figure 24.3).4,7 The phreno-esophageal ligament is the only structure that establishes a direct connection between the lower esophageal sphincter and the crural diaphragm. This structure has been considered an important factor in preventing reflux. It tends to be stretched and distracted in hiatal hernias.7–10 When this occurs, it minimizes or eliminates any positive effect that a normal ligament will have on reflux prevention. This stretching, when seen in conjunction with a hiatus hernia, allows a segment of gastric cardia to herniate through the hiatus into the mediastinum, shortening the length of the abdominal esophagus. When this occurs in the presence of a hypotensive or atonic lower-esophageal sphincter (LES), the patient will experience the symptoms

of GERD. The etiology of this laxity remains obscure, but it has been attributed to a variety of factors, including atrophic changes as seen with age, chronic stretching secondary to each peristaltic contraction,10 obesity, pregnancy, surgical destruction, and trauma. Since the physiological benefits of the phreno-esophageal ligament are diminished in the presence of a hiatus hernia, wide dissection of the ligament in anti-reflux surgery has no detrimental effect. Adequate dissection of the crura, proximal stomach, and lower esophagus are mandatory in order to perform an adequate repair. This condition is not present in patients having upper-esophageal surgery for conditions other then reflux disease, such as a Heller myotony for achalasia. Minimal dissection of the phreno-esophageal ligament in these cases may help minimize postoperative GERD. The structural anatomy of the normal esophageal hiatus has a significant impact in preventing reflux disease. In its normal form, it is elliptical in shape and present in the muscular portion of the diaphragm (Figure 24.4). The hiatus is located at the level of the tenth thoracic


Oval-shaped

Figure 24.5 Esophageal hiatal hernia.

Central tendon

Interlocking anterior muscle fibers

Figure 24.6 Muscle and tendon borders of the esophageal hiatus.

vertebra,1 and its lateral borders are formed by a split in the muscular fibers of the right crus with only minor reinforcement on the left side by the left crus. The anterior surface of the hiatus is supported by a sling of muscle fibers and tendinous attachments merging into the junction between the medial and lateral leaflets of the central tendon. The posterior segment of the esophageal hiatus is supported only by a sling of muscular tissue that is comprised almost exclusively of fibers originating from the right crus. The presence of a hiatus hernia reflects a breakdown in the anatomical structures of the hiatus. As the hernia enlarges, the defect becomes more oval in shape (Figure 24.5).9 Stress on the hiatus causes an enlarging defect in the muscular boundaries. The anterior border is more resilient, being supported by interlocking muscle fibers reinforced by tendinous fibers of the central and left leaflets of the central tendon (Figure 24.6). This area tends to resist forces that would cause the hiatus to enlarge. The

lateral muscular fibers of the hiatal borders stretch, especially as the phreno-esophageal ligaments elongate. This causes a circular deformity of the esophageal hiatus without significantly enlarging its cross-sectional diameter. The weakest portion of the hiatus is formed at the triangular shaped merging of the right crus fibers posteriorly (Figure 24.7).7,9 This is an inherent site of anatomical weakness that cannot be overcome by the extra support provided by the prevertebral fascia. Forces that influence the development of a hiatal hernia cause the rounding or separation of these V-shaped muscular fibers, with the subsequent effect of increasing the size of the esophageal hiatus. Since the majority of the defect seen in hiatal hernias occurs dorsally, repair should be performed posterior to the esophagus in order to re-establish normal anatomy. I prefer to do the repair in the presence of a 56–60 French dilator so that I do not inadvertently make the new hiatal size too narrow. Care must be taken to avoid injury to the


Triangular shaped merging of the right crus fibers posteriorly

Figure 24.7 Posterior border of the esophageal hiatus.

Intrathoracic esophagus

Lower esophageal sphincter

Intra-abdominal stomach

Figure 24.8 Anatomy of the lower esophageal sphincter.

aorta at this stage because of its proximity to the posterior aspect of the defect.

PHYSIOLOGY The physiology of diaphragmatic function has a direct effect on the presence or absence of symptomatic reflux. A brief review of the etiological factors causing GERD is warranted before we consider how to integrate the diaphragmatic repair into the surgical treatment of reflux disease. Reflux occurs when gastric contents are regurgitated into the esophagus. The normal stomach resides in an area of higher pressure than the thoracic esophagus. In order for reflux not to occur, a pressure barrier must exist between these areas of low and high pressure. A segment of esophagus approximately 2 cm long, of which at least 1 cm usually resides intra-abdominally, called the LES, is the junction between the two different pressure zones (Figure 24.8). The presence of pathological reflux is dependent on failure of the LES. Three factors come into

play. The first two are the normal average pressure and the length of the sphincter.11 The third component of this anti-reflux triad is the lower esophageal position. The adequate presence of all three components will prevent GERD under the conditions of rest, changing body positions, ingestion of moderate amounts of food and drink, and physical activity that results in significant increases in intra-abdominal pressures. A functional change in any one of these components, without a corresponding compensatory adjustment in another of the other components, will result in GERD. An example of this adjustment can be demonstrated in a patient with a shortened LES segment. Reflux would occur unless there was a compensatory rise in the LES pressure. There is, however, one situation in which there is an alteration in the balance between these three factors that is physiologically normal and the most common cause of non-pathological reflux: transient lower esophageal sphincter relaxation (tLESR). This occurs when there is gastric distention secondary to ingestion of excess food, air, or gas, such as is seen with carbonated beverages. This is unrelated to swallowing or esophageal peristalsis, and it may have a neuromuscular


component, a purely mechanical component, or combinations of both.10–12 The presence of the LES is not defined by any specific anatomical landmarks, but it is well demonstrated by placing an intragastric pressure monitor and withdrawing it into the distal esophagus. A high-pressure zone will exist in the lower esophagus as compared with the gastric baseline.11 In normal individuals, this will fall only during swallowing or when the gastric fundus overfills with gas or food. This segment of elevated pressure is partially dependent on the length of the distal esophagus exposed to intra-abdominal pressure. This length can be altered by gastric distention, resulting in tLESR, the shortening of the intra-abdominal component in the presence of a hiatal hernia, or a shortened esophagus as seen in chronic reflux. Once the pressure of the highpressure zone falls below an average of 6 mmHg, an average intra-abdominal length of 2 cm or less and/or an average length exposed to the positive intra-abdominal pressure of 1 cm or less than the LES is permanently destroyed.11 These patients require surgical intervention when they cannot be controlled adequately by medical management. A number of explanations have been postulated in an effort to explain the relationship between the diaphragm, the lower esophageal pressure, and the intra-abdominal or distal few centimeters of esophagus. Allison believed that when the right crus of the diaphragm contracts during inspiration, it compresses the esophagus together at the same time increasing its angulation.6 This action combined with a normal phreno-esophageal ligament produces adequate intra-abdominal esophageal length, thus allowing an acceptable LES pressure to be generated to prevent reflux. Delattre and colleagues believe that diaphragmatic contraction causes the changes in LES pressures and should not be attributed solely to changes in intra-abdominal pressure.5 Most authors, however, believe that there is both an intrinsic and an extrinsic mechanism to prevent esophageal relux.4,11,13–15 The intrinsic component is made up of the smooth muscle of the distal esophagus under a variety of neuro-hormonal controls. This component is referred to as the LES. A variety of pathophysiological conditions affect this non-anatomical sphincter. These effects can be mostly asymptomatic and normal, as found with physiological reflux associated with tLESR. They can also be pathological, causing symptoms of GERD, as demonstrated by patients with a hypotensive or atonic LES. The extrinsic component is comprised of the diaphragm, with its reaction to respiration, position, varying intra-abdominal pressures, and the phrenoesophageal ligament. GERD is most often expressed as a result of a combination of intrinsic and extrinsic components. The tLESRs are affected by diaphragmatic contractions and relaxations mediated partially by their mutual attachments to the phreno-esophageal ligament.15 LES

pressures are also affected by the contraction of the diaphragm. The presence of a large hiatal hernia, with the subsequent stretching of the phreno-esophageal ligament, will disrupt the angle of His and diminish the length of intra-abdominal esophagus. This, in conjunction with intrinsic LES factors, will affect the development of GERD. The size of a hiatal hernia has been shown to affect the severity of GERD.10,14,16 A larger defect will have a shorter sphincter length and lower LES pressures. Not surprisingly, the amount of reflux will be greater, with decreased efficiency of acid clearance and a higher degree of esophagitis.

SURGICAL CONSIDERATIONS FOR DIAPHRAGMATIC REPAIR IN PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE Patients with hiatal hernias and GERD have a large posterior diaphragmatic defect. In these patients, the phrenoesophageal ligament has lost its anatomical importance due to stretching or laxity developed as a result of the increasing size of the hiatus. In this condition, the lower esophagus and stomach can herniate into the chest. This will then alter the angle of His and diminish or eliminate the incursion of the lower esophagus into the abdomen. These anatomical changes reduce the LES pressure, shorten the abdominal esophagus, and diminish the total length of the LES. Reflux can occur and, if treated inadequately, can result in chronic esophagitis with extensive fibrosis and total irreversible atony of the LES. Surgical repair is directed at increasing the efficacy of the malfunctioning LES and re-establishing the presence of the abdominal esophagus. The laparoscopic gold standard is the Nissen fundoplication coupled with an adequate crural repair. In their reviews of fundoplication failures, Soper and Dunnegan17 and Hunter and coworkers18 showed that the most frequent anatomical cause for failure was transdiaphragmatic herniation. The correct surgical approach for diaphragmatic repair is mandatory in order to minimize operative failures in the treatment of reflux disease. The repair should be done posterior to the esophagus, using a mattress suture of adequate strength nonabsorbable suture material (Figure 24.9). Pledgets are not usually needed, but in elderly patients or in exceptionally large defects their use may be warranted. The size of the defect should be just large enough to easily fit a 56–60 French dilator. To prevent crural disruption in the immediate postoperative period, extubation should be smooth to prevent bucking against the endotracheal tube. Anti-emetics should be used generously to prevent violent postanesthesia retching. Delayed disruption can be avoided if the patient refrains from strenuous competitive


Esophagus

Pledget Crural closure

Figure 24.9 Posterior crural repair.

sports, where sudden abdominal impact could cause a significant and rapid rise in intra-abdominal pressure. Caution must also be given to weight-lifters, who possess thicker and stronger muscular diaphragms, about lifting practices that could disrupt the repair.

5 6 7 8

CONCLUSION The surgical treatment of GERD can be addressed successfully and safely only after fully understanding the normal anatomy and physiology of the diaphragm, the lower esophageal forces that prevent and cause reflux, and the abnormal anatomical defects found in patients with hiatus hernias. Failures can be kept to a minimum by the diligent performance of a meticulous posterior repair of the diaphragm before completing the fundoplication.

REFERENCES

9

10 11

12 13

14 15

1

Goss CM, ed. Gray’s Anatomy, 28th edn. Philadelphia: Lea & Febiger, 1966. 2 Poole DC, Sexton WL, Farkas GA, et al. Diaphragm structure and function in health and disease. Med Sci Sports Exerc 1997; 29: 738–54. 3 Agur AMR, Lee MJ, eds. Grant’s Atlas of Anatomy, 10th edn. Philadelphia: Lippincott Williams & Wilkins, 1999. 4 Delattre JF, Aviss C, Marcus C, Flament JB. Functional anatomy of the gastroesophageal junction. Surg Clin North Am 2000; 80: 241–60.

16

17

18

Delattre JF, Palot JP, Ducasse A. The crura of the diaphragmatic passage. Anat Clin 1985; 7: 271. Allison PR. Reflux esophagitis, sliding hiatal hernia, and the anatomy of repair. Surg Gynecol Obstet 1951; 92: 419–31. Postlethwait RW. Surgery of the Esophagus, 2nd edn. Norwalk, CT: Appleton-Century-Crofts, 1986. Eliska O. Phrenoesophageal membrane and its role in the development of hiatal hernia. Acta Anat (Basel) 1973; 86: 137–50. Marchand P. A study of the forces productive of gastroesophageal regurgitation and herniation through the diaphragmatic hiatus. Thorax 1957; 12, 189–202. Kahrilas PJ. Suoraesophageal complications of reflux disease and hiatal hernia. Am J Med 2001; 111: 51S–5S. DeMeester TR, Peters JH, Bremner CG, Chandrasoma P. Biology of gastroesophageal reflux disease: pathology relating to medical and surgical management. Annu Rev Med 1999; 50: 469–506. Richter J. Do we know the cause of reflux disease? Eur J Gastroenterol Hepatol 1999; suppl 1: 83–9. Cuomo R, Grasso R, Sarnelli G, et al. Role of diaphragmatic crura and lower esophageal sphincter in gastroesophageal reflux disease. Dig Dis Sci 2001; 45: 2687–94. Kahrilas P. The role of hiatus hernia in GERD. Yale J Biol Med 1999; 72: 101–11. Orlando RC. Overview of the mechanisms of gastroesophageal reflux. Am J Med 2001; suppl 8A: 174S–7S. Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury. Am J Surg 1995; 171: 182–6. Soper NJ, Dunnegan D. Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–77. Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication failures. Ann Surg 1999; 230: 595–606.


25 Preoperative evaluation MARCO G. PATTI AND PIERO M. FISICHELLA

Preoperative evaluation for anti-reflux surgery Esophageal manometry Ambulatory pH monitoring

187 188 189

Laparoscopic Nissen fundoplication is one of the operations performed most frequently by general surgeons today. The past decade has seen a progressive increase in the number of laparoscopic Nissen fundoplications performed throughout the USA due to the recognition that although the laparoscopic approach gives results similar to those obtained with the open approach (excellent control of symptoms in about 90 per cent of patients), it is also associated with shorter hospital stay, less postoperative discomfort, and faster recovery time.1–5 The increased number of patients referred for surgical treatment has allowed us to improve the understanding of the pathophysiology of the disease and to define the technical elements that play a role in the performance of an effective and durable fundoplication.2 Traditionally, gastroenterologists have referred patients for surgery based on clinical evaluation and findings of endoscopy, particularly if they had a poor response to acidreducing medication. Today, however, this approach is unacceptable for the following reasons: (1) many patients undergo surgery for control of symptoms in the absence of esophagitis; (2) more patients are referred for treatment of atypical symptoms of gastroesophageal reflux disease (GERD) such as cough or chest pain;6,7 and (3) because of the efficacy of proton-pump inhibitors, in patients who do not respond to these medications a diagnosis other than GERD should be sought.8,9 Therefore, a careful and complete preoperative evaluation is of key importance for the success of the operation.

Evaluation for failed anti-reflux surgery References

190 191

PREOPERATIVE EVALUATION FOR ANTI-REFLUX SURGERY All patients who are candidates for laparoscopic fundoplication should undergo the following preoperative evaluation in order to determine whether abnormal reflux is present, whether the symptoms are caused by the reflux, and whether complications of GERD, such as Barrett’s esophagus, are present, and to define the anatomy and pathophysiology of the disease in the individual patient.

Symptomatic evaluation Patients are questioned regarding the presence of typical and atypical symptoms (Table 25.1). The severity of the symptoms is scored from 0 (asymptomatic) to four (severely affecting quality of life). Symptoms alone, however, are not diagnostic of GERD. Unfortunately, many clinicians are overly confident that a diagnosis of GERD can be based firmly on the clinical findings, even though it has been shown that symptoms are unreliable in diagnosing GERD.8–10 For instance, our group found that among 822 consecutive patients referred for esophageal function tests with a clinical diagnosis of GERD (based on symptoms and endoscopic findings), 30 per cent had no abnormal reflux by pH monitoring (GERD⫺ patients).8 Heartburn and regurgitation were as frequent in GERD⫹ and GERD⫺ patients, so symptoms alone could

188 Laparoscopic treatment of diaphragmatic herniation Table 25.1 Symptoms of gastroesophageal reflux disease Typical symptoms

Atypical symptoms

Heartburn Regurgitation Dysphagia

Cough Wheezing Chest pain Hoarseness Otitis media Enamel problems

not distinguish between those with and those without genuine reflux. Other studies have shown that heartburn and regurgitation have a low sensitivity and specificity, with positive predictive values of 59 and 66 per cent, respectively.9 The response to proton-pump inhibitors is a better predictor of the presence of abnormal reflux. For example, in our study 75 per cent of GERD⫹ patients but only 26 per cent of GERD⫺ patients reported a good or excellent response to these medications.8 Similarly, in a multivariate analysis of factors predicting outcome of laparoscopic fundoplication, Campos and colleagues found that a clinical response to acid-suppression therapy was one of three factors predictive of a successful outcome, along with an abnormal 24-hour pH score and the presence of a typical primary symptom, such as heartburn or regurgitation.11

Barium swallow This test provides information about the presence and size of a hiatal hernia, the presence and length of a stricture, and the length of the esophagus. The test is not diagnostic of GERD, as a hiatal hernia or reflux of barium can be present in patients who do not have GERD. However, it has been shown that among patients with proven GERD, a large hiatal hernia impairs the function of the loweresophageal sphincter (LES) and prolongs esophageal acid clearance, producing more severe mucosal injury and increasing the risk of pulmonary symptoms.12

•

247 patients with negative pH studies, 60 (25 per cent) had been found to have grade I or II esophagitis.8 Major interobserver variation exists for esophageal endoscopy, particularly for the low grades of esophagitis.14

Therefore, we feel that the major value of endoscopy is to exclude other pathology and to detect the presence of Barrett’s esophagus, which occurs in about 12 per cent of patients with GERD.15

ESOPHAGEAL MANOMETRY This test provides information about the length and resting pressure of the LES and the quality of esophageal peristalsis (amplitude, duration and velocity of the peristaltic waves). In most patients with GERD referred for surgery, the LES is hypotensive. However, in some patients, the resting pressure of the LES is normal, and it is assumed that transient LES relaxations account for the majority of reflux episodes.16 Regardless of the mechanism underlying the abnormal reflux, a fundoplication restores the function of the LES by increasing the pressure and length of the sphincter1–3 or by decreasing the frequency of episodes of transient LES relaxation.17 In addition, esophageal manometry provides information about esophageal peristalsis, which is the most important factor in acid clearance.18 Among 1006 consecutive patients with GERD confirmed by pH monitoring, we found that peristalsis was normal in 56 per cent of patients, severely abnormal in 21 per cent of patients (ineffective esophageal motility, IEM), and mildly abnormal in 23 per cent of patients (non-specific esophageal motility disorder, NSEMD) (Figure 25.1). Patients with

Endoscopy Endoscopy is usually the first test performed to confirm a symptom-based diagnosis of GERD. However, the approach has the following pitfalls:

•

•

Even though the goal of endoscopy is to assess the mucosal damage due to reflux, mucosal changes are absent in about half of patients who have GERD.13 For instance, in our study esophagitis was absent in 54 per cent of the patients who had positive pH-monitoring studies.8 The sensitivity of endoscopy is low, particularly for low grades of esophagitis.9 In our study, among

23% 56%

21%

Normal

NSEMD

IEM

Figure 25.1 Esophageal peristalsis in 1006 patients with GERD.

Preoperative evaluation 189

IEM had more severe reflux, slower acid clearance, worse mucosal injury, and more frequent respiratory symptoms.18 Thus, manometry (and pH monitoring) can help in staging the severity of the disease, identifying patients who might benefit most from surgical treatment. Finally, esophageal manometry allows proper placement of the pH probe for ambulatory pH monitoring (5 cm above the upper border of the LES), avoiding the false positive and negative results that occur in about 75 per cent of patients when the probe is placed with the ‘step technique’.19

AMBULATORY pH MONITORING Ambulatory pH monitoring is the most reliable test in the diagnosis of GERD, with a sensitivity and specificity of about 92 per cent.20 The results of the test are reproducible, and false positive or negative results are rare. Acidsuppressing medications are discontinued three days (H2-blocking agents) or 14 days (proton-pump inhibitors) before the study. Diet and activity are unrestricted during the study in order to mimic a typical day in the patient’s life. This test is of key importance for the following reasons:

•

It determines whether abnormal reflux is present. In our study, 30 per cent of patients with a clinical diagnosis of GERD had a normal pH-monitoring test.8 Therefore, in these patients, the test avoided the continuation of inappropriate and expensive drugs, such as proton-pump inhibitors, or the performance of a fundoplication. In addition, it prompted further investigation that pointed to other diseases, such as cholelithiasis, irritable bowel syndrome, or primary esophageal motility disorders.

•

It establishes a correlation between symptoms and episodes of reflux. This is particularly important when atypical symptoms such as cough or wheezing are present, as 50 per cent of these patients do not experience heartburn and 50 per cent do not have esophagitis on endoscopy.13 In these patients, we use a pH probe with two antimony sensors spaced 15 cm apart (5 and 20 cm above the upper border of the manometrically determined LES) in order to determine the proximal extent of the reflux.21 The pH monitoring tracings need to be analyzed for a temporal relationship between an episode of cough and an episode of reflux (signified by a drop of the pH to ⬍4.0). An episode of coughing is induced by reflux if it occurs within three minutes of an episode of reflux in the distal or the distal/proximal esophagus (Figure 25.2). In a study of the effect of laparoscopic fundoplication on GERD-induced respiratory symptoms, we found that pH monitoring helped to identify the patients most likely to benefit from anti-reflux surgery. Following surgery, respiratory symptoms resolved in 83 per cent of patients when a temporal correlation between cough and reflux was found on pH monitoring, but in only 57 per cent when this correlation was absent.6 Ambulatory pH monitoring with symptom correlation is also the single best test for evaluating non-cardiac chest pain.22 In our experience, the test helps in predicting the outcome of a fundoplication. Following laparoscopic fundoplication, chest pain improved in 85 per cent of patients when a temporal correlation between chest pain and reflux was found on pH monitoring (Figure 25.3), and specifically in 96 per cent of patients when a strong correlation (⬎40 per cent) was present.7

Figure 25.2 GERD and respiratory symptoms. Dual-sensor pH monitoring: red line, acid reflux 5 cm above LES; green line: acid reflux 20 cm above lower esophageal sphincter. The image shows the correlation between cough and reflux in the distal esophagus; and a correlation between cough and reflux in the distal and proximal esophagus; (c) ⫽cough.


Figure 25.3 GERD and chest pain: correlation between chest pain and reflux.

•

It stages the disease according to severity. Ambulatory pH monitoring and esophageal manometry allow us to stratify patients according to the severity of the disease, identifying a subgroup characterized by worse esophageal motor function (defective LES, abnormal esophageal peristalsis), more acid reflux in the distal and proximal esophagus, and slower acid clearance. As a consequence, these patients experience more stricture formation and Barrett’s metaplasia.18 It is very important to identify these patients, as they should benefit from early anti-reflux surgery.

EVALUATION FOR FAILED ANTI-REFLUX SURGERY During the past five years, we have seen an increased number of patients referred to our Swallowing Center for evaluation and treatment of foregut symptoms after laparoscopic anti-reflux surgery. In these patients, it is essential to repeat the entire preoperative work-up while trying to answer the following questions:

• • •

Are the symptoms due to persistent gastroesophageal reflux? Are the symptoms due to the fundoplication per se? Can a cause of the failure be identified and corrected by a second operation?

Barium swallow A barium swallow is essential in order to define the anatomy of the gastroesophageal junction. As shown by

Horgan and colleagues from the University of Washington, three types of configuration are usually present:23

•

• •

Type I hernia: the gastroesophageal junction is above the diaphragm (type IA, both the gastroesophageal junction and the wrap are above the diaphragm; type IB, only the gastroesophageal junction is above the diaphragm). Type II hernia: para-esophageal configuration. Type III hernia: the gastroesophageal junction is below the diaphragm, there is no evidence of hernia, but the body rather than the fundus of stomach has been used to perform the wrap.

Endoscopy This determines whether esophagitis is present and whether there is distortion of the gastroesophageal junction.

Esophageal manometry This determines the length and pressure of the LES and its ability to relax in response to swallowing. In addition, it assesses eventual changes in peristalsis.

Ambulatory pH monitoring It is often assumed that if a patient has heartburn after a fundoplication, then this is due to a failed operation, so acid-reducing medications are restarted. However, this approach is wrong in the majority of patients, as postoperative pH monitoring is abnormal in only about 20 per cent of patients.24 In addition, this test determines whether

Preoperative evaluation 191

a correlation exists between symptoms experienced by the patient and episodes of reflux. If abnormal reflux is present, then the choice is between medical therapy and a second operation.

11

12

13

REFERENCES 14 1

2

3

4

5 6

7

8

9

10

DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for gastroesophageal reflux disease: evaluation of primary repair in 100 consecutive patients. Ann Surg 1986: 204; 9–29. Patti MG, Arcerito M, Feo CV, et al. An analysis of operations for gastroesophageal reflux disease: identifying the important technical elements. Arch Surg 1998; 133: 600–6. Peters JH, DeMeester TR, Crookes P, et al. The treatment of gastroesophageal reflux disease with laparoscopic Nissen fundoplication: prospective evaluation for 100 patients with ‘typical’ symptoms. Ann Surg 1998; 228: 40–50. Hunter JG, Smith DC, Branum GD, et al. Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 1999; 230: 595–604. Eubanks TR, Omelanczuk P, Richards C, et al. Outcomes of laparoscopic antireflux procedures. Am J Surg 2000; 179: 391–5. Patti MG, Arcerito M, Tamburini A, et al. Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms. J Gastrointest Surg 2000; 4: 143–9. Patti MG, Molena D, Fisichella PM, et al. GERD and chest pain. Results of laparoscopic antireflux surgery. Surg Endosc 2002; 16: 563–6. Patti MG, Diener U, Tamburini A, et al. Role of esophageal function tests in diagnosis of gastroesophageal reflux disease. Dig Dis Sci 2001; 46: 597–602. Johnsson F, Joelsson B, Gudmundsson K, Greiff L. Symptoms and endoscopic findings in the diagnosis of gastroesophageal reflux disease. Scand J Gastroenterol 1987; 22: 714–18. Costantini M, Crookes PF, Bremner RM, et al. Value of physiologic assessment of foregut symptoms in a surgical practice. Surgery 1993; 114: 780–7.

15 16

17 18 19

20

21

22

23

24

Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 1999; 3: 292–300. Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size affects lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury. Am J Surg 1996; 171: 182–6. Richter JE. Typical and atypical presentations of gastroesophageal reflux disease. The role of esophageal testing in diagnosis and management. Gastroenterol Clin North Am 1996; 25: 75–102. Bytzer P, Havelund T, Hansen JM. Inter-observer variation in the endoscopic diagnosis of reflux esophagitis. Scand J Gatroenterol 1993; 28: 119–25. Patti MG, Arcerito M, Feo CV, et al. Barrett’s esophagus: a surgical disease. J Gastrointest Surg 1999; 3: 397–403. Doods WJ, Dent J, Hogan WJ, et al. Mechanisms of gastroesophageal reflux in patients with reflux esophagitis. N Engl J Med 1982; 307: 1547–1552. Ireland AC, Holloway RH, Toouli J, Dent J. Mechanisms underlying the antireflux action of fundoplication. Gut 1993; 34: 303–8. Diener U, Patti MG, Molena D, et al. Esophageal dysmotility and gastroesophageal reflux disease. J Gastrointest Surg 2001; 5: 260–5. Molena D, Patti MG, Diener U, Way LW. Esophageal manometry is a prerequisite for pH monitoring. Gastroenterology 2000; 118: 715. Fuchs KH, DeMeester TR, Albertucci M. Specificity and sensitivity of objective diagnosis of gastroesophageal reflux disease. Surgery 1987; 102: 575–80. Patti MG, Debas HT, Pellegrini CA. Clinical and functional characterization of high gastroesophageal reflux. Am J Surg 1993; 165: 163–8. Hewson GE, Sinclair JW, Dalton CB, et al. Twenty-four hour pH monitoring: the most useful test for evaluating non-cardiac chest pain. Am J Med 1991; 90: 576–83. Horgan S, Pohl D, Bogetti D, et al. Failed antireflux surgery. What have we learned from reoperations? Arch Surg 1999; 134; 809–15. Lord RVN, Kaminski A, Oberg S, et al. Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication. J Gastrointest Surg 2002; 6: 3–10.


26 Gastroesophageal reflux disease J. BARRY McKERNAN AND CHARLES R. FINLEY

Treatment Discussion

193 200

Over the past decade, there has been a significant shift in the role of surgery for the treatment of gastroesophageal reflux disease (GERD). Anti-reflux surgery, once reserved for severe disease refractory to medical therapy, is now considered appropriate for many patients without mucosal complications. Several factors have contributed to the growing acceptance of surgery for reflux disease. One such factor is the appreciation that abnormal reflux can result in serious esophageal complications, such as ulcerations, strictures, and the development of Barrett’s metaplasia. It is well recognized that many of the extraesophageal symptoms observed in patients with GERD, including laryngitis, erosion of dental enamel, and pulmonary disorders (asthma, chronic cough, bronchitis), are due to refluxed gastric material entering the oropharyngeal cavity and lungs. Although medical therapy with proton-pump inhibitors is fairly effective in controlling heartburn and esophagitis, it is less effective in controlling these extra-esophageal symptoms. Current evidence suggests that treatments directed at restoring normal competence to the lower esophageal sphincter (LES) will be more effective than those aimed at controlling acid secretion.1,2 The introduction of safe and effective minimally invasive anti-reflux procedures has contributed greatly to the shift in the role of surgery for treating GERD. Medical therapy is directed at alleviating uncomfortable symptoms, whereas surgery is directed towards repairing the functional defect. Laparoscopic anti-reflux procedures are comparable to their open counterparts in terms of high rates of symptom relief coupled with low rates of complications, but they offer advantages in terms of shorter hospital stay, quicker recovery, and cost-savings.3–5 For many patients, operative therapy has become an alternative rather than a last resort to treat their abnormal

References

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reflux and prevent the development of complications associated with GERD. The laparoscopic approach, as in cholecystectomy, adrenalectomy and splenectomy, has replaced the open technique as a method of choice. Patients considered candidates for laparoscopic anti-reflux surgery are those who have failed medical therapy, those who cannot afford medical therapy, those who have recurrence of symptoms, those with extra-esophageal manifestations or strictures, and those with para-esophageal hernias. Previous open abdominal surgery, either for reflux disease or for other reasons, does not prevent the patient from having a successful laparoscopic anti-reflux procedure.

TREATMENT Non-surgical therapy Although this chapter focuses primarily on the laparoscopic treatment of GERD, several other non-surgical treatment modalities for GERD and related disorders deserve mention. Patients are becoming more knowledgeable and inquisitive about their disease, in particular through the use of the Internet. Two recent procedures have caught the attention of patients with reflux disease who are seeking non-surgical alternatives to the treatment of GERD. The first is the Stretta Procedure™ (Curon Medical), which involves endoscopic delivery of radiofrequency energy to the gastroesophageal junction. Indicated in patients with minimally active esophagitis and a hiatal hernia of less than 2 cm in size, one study revealed a significantly improved quality of life and esophageal acid exposure while eliminating the need for antisecretory medication in the majority of patients


studied.6 Another recently studied modality for patients with minimal esophagitis and hiatal hernia less than 2 cm in size is the use of an endoscopic suturing device to perform endoscopic gastroplasty. The authors noted an improvement in heartburn severity score and an improvement in postoperative 24-hour pH monitoring.7

Surgical therapy We employ a selective approach to treating GERD, tailoring the anti-reflux procedure to each patient’s underlying anatomical and functional defect. The most commonly performed procedures for GERD are Nissen fundoplication, modified Toupet fundoplication, and Collis gastroplasty combined with a fundoplication. Additionally, we have chosen a team approach for the treatment of GERD, utilizing an ambulatory surgical center focused on endoscopic surgery as well as a team of nursing staff and anesthesiologists intimately familiar with the perioperative care of patients undergoing laparoscopic foregut surgery. Patients are admitted to the outpatient surgery center one hour before the induction of anesthesia. Liberal use of metoclopramide and ondansetron perioperatively has greatly reduced the incidence of postoperative nausea and vomiting (PONV). Patients are given a single dose of prophylactic antibiotics and pneumatic sequential compression hose to prevent deep venous thrombosis.8

primary surgeon and the assisting surgeon utilize a twohanded technique. This enhances exposure and speeds up the operation. The patient is placed in the Trendelenburg position, with the back elevated to approximately 30 degrees. The 10-mm, zero-degree laparoscope is then replaced with a 45-degree laparoscope. An angled laparoscope is used on every case as it provides optimum exposure to the areas of the gastroesophageal junction, the splenic hilum, the posterior esophageal area, and the posterior mediastinum. Initially, peritoneal attachments between the fundus of the stomach and the diaphragm are divided with the surgeon’s energy system of choice.

Liver retraction

Surgeon left hand Surgeon right hand

15 cm

Assistant right hand Assistant left hand

Operative techniques Mobilization Patients are placed on the operating table in the supine position. Six trocars are utilized routinely, as shown in Figure 26.1. Some surgeons prefer the semi-lithotomy position. A 10-mm incision is made just to the left of the midline (paramedian), approximately 15 cm below the xiphoid process. A zero-degree laparoscope with a 10-mm optically dilating trocar is used to gain entrance into the peritoneal cavity. The use of the optically dilating trocar cannot be overstated, as it has allowed access to the peritoneal cavity in many patients who have had previous open and closed abdominal procedures. The trocar is used in the following manner: after the skin incision is made, the trocar is advanced slowly through sequential layers of the abdominal wall, allowing each layer to be identified. Upon arriving visually at the posterior sheath/ peritoneal layer, the scope is manipulated, which reveals any adherent bowel, thereby preventing inadvertent injury (see Chapter 3).9 The abdomen is then insufflated with carbon dioxide. The remaining 5-mm trocars are placed under direct vision. A locking Allis clamp is attached to the diaphragm just above the apex of the esophageal hiatus to allow for liver retraction (Figure 26.2). It is very important that both the

10 mm optical trocar 5 mm trocar

Figure 26.1 Typical trocar placement for laparoscopic fundoplication, with patient in supine position.

Figure 26.2 Locking Allis clamp through the epigastric port on the diaphragm for liver retraction.

Gastroesophageal reflux disease 195

Attention is now turned to the lesser omentum, which is opened over the caudate lobe of the liver. There is one vascular anomaly that deserves mention. In approximately ten per cent of cases, a large branch of the left hepatic artery traverses the lesser omentum in this area. This vessel should be preserved if it is felt to be larger than 5 mm in diameter. If there is any doubt about this vessel’s contribution to hepatic blood flow, then it may be occluded temporarily with a grasper and any color change noted in the liver. Next, the right crus of the diaphragm is identified, along with its peritoneal attachment, or ‘the white line of the right crus of the diaphragm’. This dissection of the right crus of the diaphragm is carried down to the point at which the median arcuate ligament is identified. Now, dissection proceeds along the left crus of the diaphragm until a retro-esophageal window is created. A grasper is passed behind the esophagus, and a blue silastic vessel loop is grasped, encircling the esophagus and secured in place with a chromic endo-loop. Occasionally, a branch of the inferior phrenic artery is encountered, requiring cauterization. Also, a few cases of thoracic duct injury have been reported, which presumably resulted from its location in proximity to this portion of the dissection. The assistant gently grasps the vessel loop providing traction and excellent exposure for the surgeon. Dissection is begun along the right crus, dividing the phreno-esophageal ligament circumferentially, until the esophagus is completely mobilized. Both anterior and posterior vagus nerves are identified at this point of the dissection. It should also be noted that in nearly all cases, the esophageal dissection is performed bluntly without the use of cautery for fear of esophageal, vagal or pleural injury (Figure 26.3). Care must be taken to adequately mobilize the esophagus in such a way that the fundoplication will be placed

Figure 26.3 Complete mobilization of the distal esophagus, with blue silastic vessel loop for gentle anterior retraction. The right and left crus and the vagus nerve are visualized.

at the level of the LES. Intraoperative esophagogastroduodenoscopy (EGD) is performed in all ‘redo’ fundoplications, in patients with para-esophageal hernias, and in any cases in which there is uncertainty as to the location of the LES at the time of surgery. EGD is also carried out after the performance of a Collis gastroplasty to verify that there are no leaks at the site of the staple lines. Furthermore, intraoperative EGD is performed following all cases of esophageal myotomy. Once the esophagus has been mobilized, the short gastric vessels are divided. Various methods of division and ligation have been utilized, including clips, the harmonic scalpel, vascular staplers, and bipolar cautery forceps. The use of bipolar cautery forceps with monopolar division seems to be the most efficient method, with both surgeons using the two-handed technique. Routine division of the short gastric vessels ensures a loose, floppy fundus. A recent prospective, double-blind, randomized trial with five-year follow-up showed no improvement in any measured clinical outcome by division of the short gastric vessels at the time of laparoscopic Nissen fundoplication.10 If the surgeon chooses not to divide the short gastric vessels, then adequate mobilization of the posterior surface of the fundus should include division of congenital adhesions, adhesions encountered in patients with prior pancreatitis, and the occasional vascular anomaly in which there is a direct branch from the splenic artery to the posterior fundus of the stomach. Crural closure We routinely measure the size of the crural opening with an endoscopic ruler. This has significance with respect to recurrence rate, as those with openings greater than 5 cm have a higher rate of recurrence. Simple crural closure is accomplished with interrupted 0-Ethibond (Ethicon, Inc.) sutures tied extracorporally. Several options are available for the difficult hiatal closure. Materials such as expanded polytetrafluoroethylene (ePTFE) and bovine pericardium have been used successfully. These are secured in place with either a hernia stapler or sutures. Recently, we have utilized Surgisis Gold™(Cook Surgical), a biodegradable mesh, secured with sutures or the hernia stapler. Regardless of the material used, it is important to remember that the area of the gastroesophageal junction is mobile. Care should be taken to avoid direct contact between the materials and the esophagus itself, the obvious concern being erosion of the prosthetic material into the esophagus. In some cases, a relaxing incision is made in the diaphragm, just medial to the right crus of the diaphragm (Figures 26.4 and 26.5). The angled laparoscope provides visualization into the chest, just above and to the right of the right crus of the diaphragm. The incision is then made with the harmonic scalpel over the liver. The crura of the diaphragm are then approximated


Figure 26.4 Location of relaxing incision in the diaphragm for a very large hiatal hernia.

Figure 26.6 Buttressed closure of the relaxing incision in the diaphragm. Sutures or staples (surgeon’s preference) for mesh fixation.

passes the fundus through the retro-esophageal window. An appropriate area of the fundus, usually near the recently divided short gastric vessels, is then grasped. The anesthesiologist then passes a number 50 French bougie dilator as he or she watches its progression into the stomach on the monitor. The planned fundoplication is then calibrated over the dilator in order to perform a loose fundoplication. The fundus is sutured to the esophagus at the upper border of the LES. Three sutures of 0-Ethibond are used most frequently, the middle suture incorporating only fundus to fundus. Care is taken to avoid the anterior vagus nerve while suturing, as it passes from the esophagus towards the lesser curvature of the stomach. Modified Toupet fundoplication

Figure 26.5 Relaxing incision in the diaphragm performed with harmonic scalpel and closure of the hiatus. Crural sutures are rarely placed anteriorly.

with Ethibond sutures and the relaxing incision can be buttressed with one of the above-mentioned prosthetic materials (Figure 26.6).11 Nissen fundoplication Up to this point in the operation, no bougie dilator has been placed during the procedure. The assistant gently

Esophageal motility is performed in all patients preoperatively. A careful history of any difficulty in swallowing is also elicited. A modified Toupet fundoplication is utilized in patients with poor esophageal motility, as demonstrated by esophageal manometrics or in patients with significant difficulty in swallowing. The classic Toupet fundoplication did not involve crural closure. Furthermore, the fundus was sutured to the crura laterally and posteriorly and to the esophagus anteriorly, creating a 180-degree fundoplication. Theoretically, this caused an unusual degree of tension and mobility between the esophageal and fundic suture lines, which resulted in a high incidence of recurrence. The modified Toupet fundoplication requires only crural closure, and the two most cephalad sutures anchor the esophagus to the fundus and the crura. In the event that a


Fundus

Right crus

Esophagus

Left crus

Figure 26.9 The 1 o’clock anchoring suture, incorporating the left crus, fundus and esophagus (mirroring the previously placed 11 o’clock suture). Figure 26.7 Posterior suture in modified Toupet fundoplication, incorporating the fundus to the left crus. This anchors the fundus to the left crus posteriorly. E, esophagus; F, fundus; LC, left crus; RC, right crus.

Figure 26.8 The 11 o’clock suture. The needle is shown after passing through the esophagus. The esophagus will then be sutured to the fundus (directly inferior to the needle in the photograph) and then to the right crus (just to the left of the fundus in the photograph).

modified Toupet fundoplication is indicated, a grasper is placed behind the esophagus and the fundus is grasped and retracted medially behind the esophagus, such that a 270degree wrap can be performed. The first suture in the modified Toupet fundoplication is placed through the fundus posteriorly and through the left crus using a 0-Ethibond suture (Figure 26.7). A second suture is placed through the wrap posteriorly and through the right crus. Next, the esophagus is anchored to the right crus of the diaphragm by passing the suture through the esophagus at 11 o’clock, then through the fundus, and finally through the crus (Figure 26.8). Additional sutures are then placed caudad

Figure 26.10 Completion of the modified Toupet fundoplication.

to this suture between the esophagus and the fundus. Attention is then turned laterally, and a number 38 French bougie dilator is advanced into the stomach. At the 1 o’clock position, approximately 2–3 cm from the esophagus, a suture is passed through the fundus, through the left crus of the diaphragm, and finally though the esophagus, thus anchoring the wrap laterally (Figure 26.9).12 Additional sutures are then placed between the fundus and the esophagus, thus completing the left side of the fundoplication (Figure 26.10). Usually, three sutures incorporate fundus to crura, two sutures anchor esophagus to fundus to crura at 11 and 1 o’clock, and there are two sutures on each side between fundus and esophagus.


Collis gastroplasty

Esophagomytomy

The true occurrence of shortened esophagus is debatable. In our experience, it occurs in one to two per cent of cases. Adequate esophageal mobilization well into the chest will usually allow the creation of an intra-abdominal fundoplication without the need for a Collis gastroplasty. If there is any doubt as to the location of the gastroesophageal junction, then intraoperative esophagoscopy is performed. If the LES, after maximal retroperitoneal mobilization, cannot be brought below the planned crural closure, then a Collis gastroplasty may be indicated. The Collis gastroplasty is performed prior to closure of the hiatal hernia. A number 50 French bougie dilator is placed along the lesser curve of the stomach to be used as a stent in the formation of the neo-esophagus. An additional 10-mm trocar is then placed just below the subcostal margin in the left midclavicular line. The fundus is splayed out laterally, and the angled linear cutter is introduced into the recently placed 10-mm trocar. The linear cutter is then angled medially to transect the stomach from a point along the greater curvature to a point approximately 3–4 cm below the crural opening (Figure 26.11). This usually requires more than one firing of the stapler. The goal is to have at least 4–5 cm of neo-esophagus below the crural opening. Then the angled linear cutter is placed parallel to the bougie and fired cephalad (this may require more than one firing), thus creating the neo-esophagus and in the process removing a small triangular portion of the fundus of the stomach (Figure 26.12). The remaining stapled lateral fundus is invaginated into a Nissen repair or, if the patient had significant preoperative dysphagia, into a modified Toupet repair (Figure 26.13). We usually perform a highly selective vagotomy in the neo-esophagus to prevent gastritis.

Achalasia is secondary to a loss of ganglion cells in the lower esophagus, resulting in failure of relaxation of the LES with subsequent hypertrophy of the muscle and aperistalsis of the esophageal body. The diagnosis of achalasia is made primarily utilizing esophageal manometry along with the typical radiographic findings on barium esophagogram of the bird-beak appearance of the esophagus. The surgeon generally sees these patients after the failure of standard medical therapy, esophageal dilation, and possibly botulinum toxin injection. Surgical treatment

Figure 26.12 Creation of the neo-esophagus.

5 cm

Figure 26.11 Initial application of linear cutting device.

Figure 26.13 Remaining fundus utilized for either modified Toupet or Nissen fundoplication.


involves esophagomyotomy and an anti-reflux procedure, typically a modified Toupet fundoplication or Dor anterior fundoplication. Spastic disorders of the esophagus include nutcracker esophagus, diffuse esophageal spasm (DES), and hypertensive LES. DES and nutcracker esophagus primarily involve the lower third of the esophagus. Nutcracker esophagus is typified by significant chest pain and, to a lesser extent, dysphagia. Esophageal manometry generally shows slightly elevated resting LES pressures and normal relaxation, combined with average esophageal pressures of greater than 180 mmHg. Nutcracker esophagus is usually identified easily on standard manometry, as it is a fairly continuous disorder. Diffuse esophageal spasm, on the other hand, may not be identified on standard or ambulatory esophageal manometry, due to its episodic nature. DES is characterized by simultaneous, mostly high-amplitude esophageal contractions. Each case should be treated on an individual basis, and patients should be selected carefully for surgical therapy. We usually perform a laparoscopic esophagomyotomy combined with an anti-reflux procedure (either a Nissen or a modified Toupet fundoplication). Hypertensive LES, less common than the other spastic disorders of the esophagus, is characterized by high resting LES pressures (⬎40 mmHg or more than two standard deviations above normal) and normal relaxation of the LES, combined with relatively normal esophageal body motility. Reflux does occur in this population, presumably as a result of transient relaxation of the LES with subsequent delayed esophageal clearing of the refluxed acid. Considerable controversy surrounds the appropriate management of this condition. The various treatment options include pharmacological agents to decrease LES pressure, esophageal dilation, and surgery. Only a small number of these patients require surgery. We most commonly perform an esophageal myotomy and modified Toupet fundoplication when treating this group of patients surgically.

Technique Once esophageal and fundic mobilization has been completed, and before closure of the esophageal hiatus, the anterior esophagus is exposed between 11 and 12 o’clock. This area avoids the anterior vagus nerve. Beginning approximately 2 cm above the gastroesophageal junction, the longitudinal fibers in the first muscular layer of the esophagus are sharply dissected and separated with scissors. We use disposable endoscopic scissors with no cautery, since we find that cautery is needed only rarely on the small vessels in the esophagus. Once the longitudinal fibers have been bluntly separated, the circular fibers become exposed. These are divided under direct visualization. The assistant uses a suction irrigator to

keep the field clear for dissection. Once the circular fibers are divided down to the mucosa, the mucosa can be pushed bluntly inferiorly, and the dissection can proceed in a cephalad direction. The total length of the myotomy will depend on the indication for the procedure. For a primary motility disorder such as achalasia, nutcracker esophagus, or diffuse esophageal spasm, a length of 6–8 cm is usually sufficient. For a hypertensive LES, typically only a 4-cm myotomy is needed (length of the LES) to relieve the obstruction. Once the proximal portion of the myotomy is completed, the more distal segment, which involves the gastroesophageal junction, is approached. Dissection is carried inferiorly until it impinges upon the decussating fibers of the stomach wall and the presumed location of the gastroesophageal junction. It is our practice, in patients undergoing esophageal myotomy, to perform an intraoperative EGD to determine accurately the location of the gastroesophageal junction. The intraoperative EGD serves two purposes: it ensures that the myotomy extends beyond the gastroesophageal junction to totally relieve any distal obstruction, and it ensures that there is no iatrogenic perforation of the mucosa prior to closure. Once the myotomy is complete, the muscular layer is swept laterally to expose approximately 1.5 cm of mucosa. The site is inspected for bleeding and the fundoplication is performed. When performing a myotomy with a modified Toupet fundoplication, the fundus is sutured to the divided muscular edges of the esophageal myotomy, taking care not to injure the bulging mucosa. Pyloroplasty Approximately 10–50 per cent of patients with GERD have delayed gastric emptying. This frequently manifests itself in the form of recurrent reflux symptoms after a successful anti-reflux procedure. The patient’s history, EGD, upper gastrointestinal radiological studies, and a nuclear medicine gastric-emptying scan are all helpful in making the diagnosis of delayed gastric emptying. Once the diagnosis is made, the patient is treated initially with endoscopic pneumatic dilation of the pylorus. If the patient responds favorably to this treatment, then the definitive treatment by laparoscopic pyloroplasty can be offered. Trocars are placed similarly as for laparoscopic fundoplication, although usually in a more caudad position on the abdominal wall. The duodenum is then mobilized (Kocher maneuver) utilizing the harmonic scalpel and blunt dissection. The pylorus is identified, and a longitudinal incision is made on the anterior surface of the duodenum, through the pylorus and then on to the stomach. This longitudinal incision is now closed transversely in one layer utilizing 0-Ethibond sutures. Following the completion of the pyloroplasty, intraoperative EGD is performed to check for air leaks, and additional sutures


are placed as necessary. The EGD is also valuable in determining the adequacy and patency of the pyloroplasty.

roles. Additionally, good-quality and well-maintained equipment makes for a better experience for the physician. The patient ultimately reaps the benefit from the smaller, more patient- and physician-friendly setting.

DISCUSSION The technical steps presented in this chapter represent the authors’ preferred methods of performing anti-reflux procedure. It should be emphasized that each patient should be treated individually. As surgeons, we love to adhere to rules, but we often forget the true intent of such rules. For example, the intent of dividing the short gastric vessels was to allow adequate mobilization of the fundus of the stomach. We now know that the fundus can be mobilized adequately and the patient can obtain a good result without division of the short gastric vessels, as discussed earlier. Certainly, one can mobilize the fundus posteriorly by dividing the posterior gastric attachments. What is important is that minimal tension be placed on the fundoplication. Much has been said about the results of preoperative esophageal motility. Again, by individualizing each patient, the history of possible dysphagia is much more important to us than the fact that they can generate a pressure of 30 mmHg in the body of the esophagus, as it relates to the decision to perform a complete or partial fundoplication. Lastly, our tendency as surgeons often to adhere rigidly to tradition has made the question of performing the above procedures in an ambulatory surgical center a controversial issue. However, the outpatient setting is our preference in performing anti-reflux procedures (including ‘redos’, para-esophageal hernias and Collis gastroplasties). Available data support the fact that this can be done with similar morbidity and mortality, as compared with the inpatient setting. We feel strongly that a dedicated team approach is the single most important factor to the success of any advanced laparoscopic procedure. The team must be composed of individuals who are both expertly trained and self-motivated in their respective

REFERENCES 1

2

3

4

5

6

7

8 9

10

11 12

Orlando RC. The pathogenesis of gastroesophageal reflux disease: the relationship between epithelial defense, dysmotility, and acid exposure. Am J Gastroenterol 1997; 92 (suppl 4): 3S–5S, 5S–7S. Stein HJ, Barlow AP, DeMeester TR, Hinder RA. Complications of gastroesophageal reflux disease: role of the lower esophageal sphincter, esophageal acid and acid/alkaline exposure, and duodenogastric reflux. Ann Surg 1992; 216: 35–43. Bowry, DJ, Peters JH. Current state, techniques, and results of laparoscopic antireflux surgery. Semin Laparosc Surg 1996; 6: 194–212. Dallemagne B, Weerts JM, Jeahes C, Markiewics S. Results of laparoscopic Nissen fundoplication. Hepatogastroenterology 1998; 45: 1338–43. Spechler SJ. Veterans Affairs Gastroesophageal Reflux Disease Study Group. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. N Engl J Med 1992; 326: 786–92. Triadafilopoulos G, Dibaise JK, Nostrant TT, et al. Radiofrequency energy delivery to the gastroesophageal junction for the treatment of GERD. Gastrointest Endosc 2001; 53: 407–15. Filipi CJ, Lehman GA, Rothstein RI, et al. Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial. Gastrointest Endosc 2001; 53: 416–22. Finley CR, McKernan JB. Laparoscopic antireflux surgery at an outpatient surgery center. Surg Endosc 2001; 15: 823–6. McKernan JB, Finley CR. Experience with optical trocar in performing laparoscopic procedures. Surg Laparosc Endosc Percutan Tech 2002; 12: 96–9. O’Boyle CJ, Watson KI, Jamieson GG, et al. Division of short gastric vessels at laparoscopic Nissen fundoplication. A prospective double-blind randomized trial with 5-year follow-up. Ann Surg 2002; 235: 165–70. Huntington TR. Laparoscopic mesh repair of the esophageal hiatus. J Am Coll Surg 1997; 184: 399–400. Thor KB, Silander T. A long-term randomized prospective trial of the Nissen procedure versus a modified Toupet technique. Ann Surg 1989; 210: 719–24.

27 Para-esophageal hernias HUGO BONATTI, BEATE NEUHAUSER AND RONALD A. HINDER

Treatment of para-esophageal hernias Preoperative management Surgical procedure

201 202 203

Hiatal hernias are common disorders in the western population.1 The overall incidence of hiatal hernias has been reported to lie between ten and over 20 per cent.2 Hiatal hernias are categorized into four groups, as determined by Hill and Tobias in 1968.3 Type I hiatal hernias, also known as sliding hiatal hernias, account for the most common group (⬎80 per cent) and are characterized by a sliding herniation of the gastroesophageal junction through the hiatus into the chest. Para-esophageal hernias (PEHs) account for the remaining three groups: type II represent a herniation of the fundus of the stomach through the hiatus with a fixed gastroesophageal junction in the normal position; type III are the most common PEHs, and represent a combination of type I and type II with a displaced gastroesophageal junction as well as herniation of parts of the stomach into the chest; type IV are composed of a large PEH combined with a large hiatal defect containing not only the stomach but also other intra-abdominal organs, such as colon or spleen. PEHs are observed more commonly in the elderly population. In our series of 117 patients undergoing laparoscopic PEH repair, the median age was 68 years (range 39–95); 12 patients were over the age of 80 years. Sixty per cent of patients were female.

TREATMENT OF PARA-ESOPHAGEAL HERNIAS The only curative treatment available for PEH is surgery. The principles are complete reduction of the hernia from the chest, repair of the hiatal defect, and fundoplication.

Postoperative management Conclusion References

207 208 208

Indications for surgical repair PEH may occur with or without symptoms. PEH can remain asymptomatic for long periods, but these patients require close observation.4 On closer examination, the patient may eventually report distinct symptoms, such as coughing, chest pain or epigastric pain, which the patient may relate to other causes.5 The more common complaints associated with symptomatic PEH are dysphagia, gastroesophageal reflux (GER), epigastric pain, chest pain, regurgitation and vomiting, shortness of breath, and coughing; there is also chronic anemia in up to 38 per cent of patients with PEH.6,7 Symptomatic PEH is always an indication for elective surgical repair in order to avoid the potentially serious complications, such as acute strangulation, volvulus, massive hemorrhage, and perforation.8,9

Contraindications to surgical repair Patients with PEH are usually of an older age than patients with type I hiatal hernias. A meticulous cardiopulmonary investigation is necessary in most cases. One must bear in mind that symptoms consistent with PEH in this population could also originate from cardiac or pulmonary disease.10 If these latter etiologies are excluded and the patient is fit for laparoscopy, then we do not see any major contraindications for the procedure, regardless of age. It has been shown that laparoscopic anti-reflux procedures can be performed safely in elderly patients.11 We recently published a series of 30 octo- and nonagenarian patients undergoing laparoscopic fundoplication, with zero mortality.12 Although considered by


some to be a contraindication to the procedure, we do not hesitate to use a laparoscopic approach for recurrent PEH or in patients with a history of previous abdominal surgery.13

Laparoscopic versus open approach A variety of studies have shown that the laparoscopic approach is as effective as the open approach in terms of recurrence rate and perioperative complications, if an experienced laparoscopic surgeon carries out the procedure.14–16 However, hospitalization was shorter after laparoscopy and patients experienced less pain.17 Recent studies based on symptomatic outcomes analyses have shown that the laparoscopic repair of large PEHs is safe, successful, and equivalent to open repair.18 A disturbingly high (42 per cent) prevalence of recurrent herniation following laparoscopic repair of type III hiatal hernias has been reported recently in a single study.19 However, more than half of such recurrences had few, if any, symptoms, and recurrence rates in other series were considerably lower.20 In our own series, we observed a recurrence rate of 15 per cent; there was no mortality.2 Other authors have also concluded that the laparoscopic approach is superior to a transthoracic approach due to less pain and shorter hospitalization.2,17 Gastrostomy or gastropexy, although suggested for high-risk patients, cannot provide results comparable to surgical PEH repair.21

(a)

PREOPERATIVE MANAGEMENT Anatomy/pathology Whereas GER symptoms are present in most patients with type I hiatal hernias, the presence of reflux in type II PEH is variable and dependent on the esophageal length and function. Type III hernias are usually accompanied by GER. The presence of dysphagia can be explained by the fact that the PEH tends to rotate along the long axis of the stomach, resulting in gastric volvulus, which can cause obstruction at the esophagogastric or gastroduodenal junction. In patients with a large type IV PEH, the likelihood of pulmonary symptoms is greatest. Coughing, shortness of breath, asthma-like symptoms, and lowerrespiratory-tract infections result not only from recurrent aspiration but also from compression of the lung by the intrathoracic mass.

Preoperative testing A substantial number of PEHs are diagnosed incidentally on thoracic radiography (Figure 27.1a). Usually, a gas bubble within the mediastinum – in most cases on the left side – can be observed. Preoperative evaluation includes a barium esophagogram (Figure 27.1b), upperintestinal endoscopy, esophageal manometry, and sometimes 24-hour ambulatory pH monitoring. The lower

(b)

Figure 27.1 (a) Thoracic radiograph showing gas bubble within the chest as a result of a giant PEH. (b) Barium esophagogram showing large PEH (type III). The fundus of the stomach and the gastroesophageal junction are positioned above the diaphragm.

Para-esophageal hernias 203

Figure 27.2 On CT scan, the PEH is seen in the posterior mediastinum anterior to the spine and to the right of the aorta.

esophageal sphincter (LES) is considered incompetent if any of the following criteria are met:

• • •

Figure 27.3 Trocar placement for laparoscopic PEH repair.

resting pressure less than 6 mmHg; overall sphincter length less than 2 cm; intra-abdominal sphincter length less than 1 cm.

A computerized tomography (CT) scan can be of value in some cases in order to obtain optimal imaging of the hernia (Figure 27.2).

SURGICAL PROCEDURE Operating room set-up The patient is placed supine in the lithotomy position in the steep reversed Trendelenburg position. Full muscle relaxation is of major importance in order to create a good intra-abdominal working space. The laparoscopic procedure is performed using 5–11-mm ports in similar positions to those used for Nissen fundoplication (Figure 27.3). Instrumentation includes a zero-degree laparoscope, atraumatic graspers, a liver retractor, a small hook attached to the electrocautery, the harmonic scalpel, and two needle-holders. A nasogastric tube is inserted only if there is excessive gas within the stomach.

Operative technique A transverse 1-cm incision is made above the umbilicus in the midline, the Veress needle is introduced, and a pneumoperitoneum is created. After placement of the other ports, the abdomen is inspected. The first step of PEH

Figure 27.4 After the ports are placed, the stomach is retracted to the left, exposing the large hiatal defect.

repair is to completely reduce the hernia contents (Figure 27.4). Dissection is commenced by dividing the gastrohepatic ligament at its flaccid part. The right crus is visualized, and the hernia sac is divided along the free edge of the hiatus. This is extended on to the left crus, ensuring that the sac is freed far posteriorly on the left (Figure 27.5). Thereafter, the peritoneum is completely mobilized within the mediastinum and the sac is pulled caudally (Figures 27.6 and 27.7). This can usually be achieved easily without the need to divide any adhesions within the mediastinum. Once the sac is reduced from the chest, it remains adherent to the anterior surface of the stomach. Dissection in this


Figure 27.5 The peritoneum along the edge of the right crus is divided.

Figure 27.6 The incision of the peritoneum along the crural edge allows access to adipose tissue in the posterior mediastinum, and the sac can be dissected easily out of the mediastinum.

Figure 27.7 The peritoneal incision is continued far posterior on the left crus. This allows access to the connective tissue behind the lower esophagus.

Figure 27.8 This dissection is continued from the right side behind the esophagus but inferior to the left crus of the diaphragm.

Figure 27.9 A window is created behind the esophagus, firstly inferior to the left crus and then superior to the left crus. This allows the esophagus to be separated completely from all of its crural attachments.

region should be carried out cautiously in order to avoid injury to the gastric or esophageal wall, blood vessels, or the left vagus nerve. The peritoneal sac may, however, be trimmed if it is very bulky. The esophagus can now be observed and elevated on a closed instrument (Figures 27.8 and 27.9). This allows for the creation of a window posterior to the esophagus, which can be freed further from its attachments in the mediastinum to achieve adequate length. Once there is sufficient esophageal length, the hiatus is reconstructed using two to ten interrupted nonabsorbable stitches, such as 0-Ethibond or Prolene (Ethicon, Inc.), depending on the size of the defect (Figure 27.10). The first stitch should be placed immediately above the point where the two crura join. Sufficient tissue should be included in the stitches to avoid


Figure 27.10 The hiatal defect is closed using interrupted nonabsorbable sutures. Figure 27.12 Fundic wrap being created using Prolene ‘U’stitch with Teflon pledgets.

Figure 27.11 The hiatal closure is continued posterior to the esophagus until an adequate defect remains to easily accommodate the esophagus and its contents.

tearing the muscle. A tension-free reconstruction should be achieved. Stenosis of the hiatus around the esophagus must be avoided (Figure 27.11). The hiatal defect can be reinforced with mesh, such as polypropylene, Marlex® (BARD), Gore-Tex®DualMesh (W.L. Gore & Associates), or denatured animal tissue (Surgisis ES® , Cook Surgical Inc.) fixed to the diaphragm using metallic staples or stitches. The mesh measures about 4 ⫻ 5 cm; it is cut with a keyhole to enclose the esophagus and is overlapped posteriorly. The mesh is placed on the hiatal musculature. We prefer to use Surgisis, which is absorbable and soft. It is less desirable to use a nonabsorbable material adjacent to the esophagus, which has the potential for erosion into the lumen or stricture formation. Following repair of the hiatal defect, the short gastric vessels are divided using the harmonic scalpel (Ethicon Endosurgery, Inc.). The procedure is completed by a fundoplication, which can be performed as a 360-degree Nissen or a 270-degree Toupet procedure

Figure 27.13 The completed fundoplication with an additional silk suture placed inferior to the ‘U’-stitch to secure it in position.

(Figures 27.12 and 27.13). The decision as to which procedure to perform is based on preoperative esophageal motility. If a severe motility disorder was diagnosed, then a Toupet fundoplication is indicated. With the Nissen repair, the fundoplication should be tacked to the diaphragm on either side to prevent recurrence of a sliding hernia. Gastrophrenic anchorage can be added by suturing the peritoneum of the hernia sac to the diaphragm.

Operative pitfalls Para-esophageal hernia repair in patients with previous abdominal surgery An increasing number of PEHs are seen in patients who have undergone previous surgery. As in other


laparoscopic procedures, insertion of ports can be difficult, and placement at non-standard sites might be necessary. If a previous midline incision is present, then the Veress needle can usually be placed safely in the left subcostal area. After division of adhesions between the parietal peritoneum and intra-abdominal organs, placement of the other trocars can be achieved. Occasionally, patients must undergo PEH repair following an unsuccessful antireflux operation. Dissection of the left liver lobe from the stomach and diaphragm can be particularly difficult in these cases. Nevertheless, in ‘redo’ operations, conversion to laparotomy is required rarely.22,23 Left accessory or replaced hepatic artery These arteries originate from the left gastric artery and are found in up to 25 per cent of patients. Some accessory arteries are small and can be divided without consequence; however, large vessels suggest that there is complete replacement of the arterial blood supply to the left lateral liver segments. If this is suspected, the vessel should be preserved intact in order to avoid ischemic damage of the biliary tree.24

Large defects at the hiatus In some patients, the defect at the hiatus is too large to be closed primarily. This occurs most frequently in type IV hernias. In other cases, the fibrous tissue at the hiatus in this elderly patient population is not compliant and cannot be approximated adequately. This can result in large dissecting tears in the crura, which must be managed by the use of mesh (Figures 27.14–27.16). These patches should be cut with a keyhole defect and positioned to lie circumferentially around the esophagus. The keyhole technique allows for overlapping of the mesh posteriorly. There is the risk of erosion of the mesh into the esophagus if nonabsorbable materials are used. They must be attached to the diaphragm using staples or interrupted sutures. Some authors suggest the universal use of such patches to allow for tension-free repair.25 Diaphragmatic stitches placed anterior to the esophagus have been suggested to close large defects; however, tension is usually even greater in this area. Others have used a relaxing incision made lateral

Tearing and perforation of stomach and esophagus This is best avoided by gentle handling of tissues in these elderly patients. However, surrounding tissues can be rather fibrotic and sharp dissection might be necessary. Small serosal tears can be oversewn and should be included in the fundoplication site whenever possible. Transmural injuries of the esophagus and stomach can be repaired laparoscopically using a stapling device. Intraoperative endoscopy can be helpful to make sure that the defect is closed completely. Type IV hernias These hernias can contain colon or the spleen. Injuries to the spleen may result in major hemorrhage. Closure of the defect can be particularly difficult in these patients. Postoperative use of incentive spirometry is of importance to avoid atelectasis and pneumonia.

Figure 27.14 Giant hiatal defect with a tear in the right crus after failed primary closure.

Pneumothorax This occurs more frequently on the left side and can result in a symptomatic pneumothorax. When this occurs, the intra-abdominal gas pressure should be decreased to avoid a tension pneumothorax. Should the latter occur, conversion to an open procedure may be necessary. A chest tube can be used to alleviate the tension in the pneumothorax if necessary. Generally, however, most cases do not require a chest tube, as the gas in the pleural space may be expelled by forceful lung inflation at the time of release of the pneumoperitoneum.

Figure 27.15 Closure of the large defect using a Gore-Tex patch.


to the esophageal hiatus with primary closure of the hiatus and mesh repair of the relieving incision. Hernia sac Some controversy exists as to whether to excise the sac or mobilize it fully with complete excision.26 We feel that a remnant of the sac in the mediastinum might cause an effusion or lead to recurrent herniation. We always mobilize the sac completely from the mediastinum. On dissection, care must be taken not to injure the esophagus, stomach, vagus nerve, or blood vessels. The sac is left anterior and to the left of the cardia and can be used as a plug to help avoid recurrent herniation of the stomach. Division of short gastric vessels It is our preference that the short gastric vessels are divided along the upper 10 cm of the greater curvature of the stomach to allow for a tension-free wrap. In most cases, these vessels have been stretched by the gastric herniation, allowing the fundus to be brought behind the esophagus easily and without tension. Possible kinking of the esophagus Following the posterior approximation of the crura, the esophagus might be forced anteriorly, causing kinking and obstruction as it rides up and into the hiatus. This has been observed occasionally as a kink on a barium esophagogram, but there are seldom any observed symptoms related to such a kink in the follow-up of our patients. Short esophagus In type III hernias, insufficient intra-abdominal length of the esophagus has been reported following attempted

Figure 27.16 Closure of a large defect using a polypropylene mesh.

mobilization.6 In most cases, dissection of the esophagus far up into the mediastinum allows for adequate mobilization. Dissection can be performed as high as the bronchial bifurcation. If adequate intra-abdominal length of the esophagus without tension cannot be obtained, then an esophageal-lengthening procedure, such as Collis gastroplasty, followed by a fundoplication should be performed. This can be achieved laparoscopically, but in our opinion the best approach for this procedure is through the chest. Hashemi and colleagues have reported the need for thoracotomy in over 33 per cent of cases.27 A novel approach for esophagus lengthening has been suggested by Champion and coworkers (personal communication, 2002): they laparoscopically flap the fundus of the stomach to the right and then carry out a stapled fundectomy to a point 3 cm inferior to the angle of His. This is then stapled off along the left side of the esophagus, achieving a Collis gastroplasty (see Chapter 26). Para-esophageal hernia repair in obese patients In obese patients there may be excessive fat in the operative field, and/or the left lateral liver segments may be very large. This might hinder retraction of the liver. Such fatty livers are rigid and the capsule can be injured easily, resulting in hemorrhage. Local appliance of argon-beam coagulation or electrocautery may be used, followed by insertion of a collagen plug to control such hemorrhage.

POSTOPERATIVE MANAGEMENT In general, we do not place a nasogastric tube. For the majority of patients, this represents an unnecessary inconvenience and is tolerated poorly. Patients are encouraged to ambulate early and to use incentive spirometry. A gastrografin esophagogram is performed only if the dissection was difficult and in the presence of symptoms such as excessive pain, vomiting or fever. During the first 24 hours after surgery, pain control is achieved satisfactorily using oral analgesics. We prefer to use paracetamol (acetaminophen) elixir; however, any synthetic opioid, tramadol or non-steroidal anti-inflammatory drug can be used. Metoclopramide or ondansetron are our preferred antiemetic drugs. Retching and vomiting must be suppressed in order to avoid stress on the repaired hiatus and the fundoplication. Patients are started on a liquid diet on the night following surgery and advanced to a pureed diet, as tolerated. Fresh bread and meat should be avoided for about three weeks. A normal diet is usually achieved within six weeks following surgery. We have now completed 120 laparoscopic repairs of large PEH with zero mortality and a 15 per cent recurrence rate. These recurrences are usually asymptomatic type I hernias. Others reported higher rates of mortality (three per cent28) and


morbidity (30 per cent29). Dahlberg and colleagues28 and Trus and colleagues29 also report the need for conversion to an open procedure in 1.3–5.4 per cent of cases. We feel, however, that with adequate experience, these rates of morbidity and mortality should be reduced.

7

8

9

CONCLUSION 10

Currently, the only effective treatment available for PEH is surgery. This is successful in most cases if appropriate principles of operative therapy are followed. Surgical reduction of the hernia results in the relief of dysphagia in 91 per cent of patients. The principles of PEH repair include reducing the stomach, mobilizing the hernia sac from the mediastinum, effectively closing the hiatus, and achieving a sufficient gastropexy. Open repair using laparotomy or thoracotomy was the standard procedure a decade ago. The development of laparoscopic anti-reflux surgery has stimulated interest in laparoscopic paraesophageal hiatal hernia repair. Minimally invasive techniques today offer a better treatment option with lower risk. Laparoscopic repair of PEH is safe, technically feasible, and well tolerated, with rapid relief of symptoms. The laparoscopic approach allows for excellent visualization of the hiatus and superior esophageal mobilization, with significantly less surgical insult to this often aged and debilitated patient population. PEH repair remains a challenging surgical procedure. We feel that an anti-reflux procedure is necessary because the LES is mobilized extensively during the dissection and is likely to be incompetent as a result. This does not add significantly to the time required for this operation, and it provides an excellent anchoring mechanism for the stomach on to the diaphragm. We consider laparoscopic PEH repair with Nissen fundoplication to be the procedure of choice in appropriately selected patients with PEH.

REFERENCES 1

Ilves R. Hiatus hernia. The condition. Chest Surg Clin N Am 1998; 8: 401–9. 2 Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal hernia repair. Arch Surg 1997; 132: 586–9, 590–1. 3 Hill LD, Tobias JA. Paraesophageal hernia. Arch Surg 1968; 96: 735–44. 4 Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic stomach. Presentation and results of operation. J Thorac Cardiovasc Surg 1993; 105: 253–8, 258–9. 5 Akdemir I, Davutoglu V, Aktaran S. Giant hiatal hernia presenting with stable angina pectoris and syncope – a case report. Angiology 2001; 52: 863–5. 6 Hashemi M, Sillin LF, Peters JH. Current concepts in the management of paraesophageal hiatal hernia. J Clin Gastroenterol 1999; 29: 8–13.

11

12

13 14 15 16

17

18

19

20

21

22

23

24 25 26 27

28

29

Moskovitz M, Fadden R, Min T, et al. Large hiatal hernias, anemia, and linear gastric erosion: studies of etiology and medical therapy. Am J Gastroenterol 1992; 87: 622–6. Maruyama T, Fukue M, Imamura F, Nozue M. Incarcerated paraesophageal hernia associated with perforation of the fundus of the stomach: report of a case. Surg Today 2001; 31: 454–7. Nattakom T, Schuerer D, Batra S, et al. Emergency laparoscopic repair of a paraesophageal hernia. Surg Endosc 1999; 13: 75–6. Richter JE. Noncardiac (unexplained) chest pain. Curr Treat Options Gastroenterol 2000; 3: 329–34. Kamolz T, Bammer T, Granderath FA, et al. Quality of life and surgical outcome after laparoscopic antireflux surgery in the elderly gastroesophageal reflux disease patient. Scand J Gastroenterol 2001; 36: 116–20. Bammer T, Hinder RA, Klaus A, et al. Safety and long term outcome of laparoscopic antireflux surgery in patients in their eighties and older. Surg Endosc 2002; 16: 40–42. Neuhauser B, Hinder RA. Laparoscopic reoperation after failed antireflux surgery. Semin Laparosc Surg 2001; 8: 281–6. Freeman ME, Hinder RA. Laparoscopic paraesophageal hernia repair. Semin Laparosc Surg 2001; 8: 240–5. Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000; 80: 1243–52. Buenaventura PO, Schauer PR, Keenan RJ, Luketich JD. Laparoscopic repair of giant paraesophageal hernia. Semin Thorac Cardiovasc Surg 2000; 12: 179–85. Oelschlager BK, Pellegrini CA. Paraesophageal hernias: open, laparoscopic, or thoracic repair? Chest Surg Clin North Am 2001; 11: 589–603. Basso N, Rosato P, De Leo A, et al. ‘Tension-free’ hiatoplasty, gastrophrenic anchorage, and 360 degrees fundoplication in the laparoscopic treatment of paraesophageal hernia. Surg Laparosc Endosc Percutan Tech 1999; 9: 257–62. Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 2000; 190: 553–60, 560–1. Edye MB, Canin-Endres J, Gattorno F, Salky BA. Durability of laparoscopic repair of paraesophageal hernia. Ann Surg 1998; 228: 528–35. Kercher KW, Matthews BD, Ponsky JL, et al. Minimally invasive management of paraesophageal herniation in the high-risk surgical patient. Am J Surg 2001; 182: 510–14. Seelig MH, Hinder RA, Klingler PJ, et al. Paraesophageal herniation as a complication following laparoscopic antireflux surgery. J Gastrointest Surg 1999; 3: 95–9. Floch NR, Hinder RA, Klingler PJ, et al. Is laparoscopic reoperation for failed antireflux surgery feasible? Arch Surg 1999; 134: 733–7. Edoga JK, Willekes CL. Laparoscopic fundoplication and the aberrant left hepatic artery. Arch Surg 1997; 132: 448–9. Hui TT, David T, Spyrou M, Phillips EH. Mesh crural repair of large paraesophageal hiatal hernias. Am Surg 2001; 67: 1170–4. Athanasakis H, Tzortzinis A, Tsiaoussis J, et al. Laparoscopic repair of paraesophageal hernia. Endoscopy 2001; 33: 590–4. Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective follow-up reveals high recurrence rate. J Am Coll Surg 2000; 190: 553–60. Dahlberg PS, Deschamps C, Miller DL, et al. Laparoscopic repair of large paraesophageal hiatal hernia. Ann Thorac Surg 2001; 72: 1125–9. Trus TL, Bax T, Richardson WS, et al. Complications of laparoscopic paraesophageal hernia repair. J Gastrointest Surg 1997; 1: 221–8.

28 Traumatic and unusual herniation SERGIO G. SUSMALLIAN AND ILAN CHARUZI

Diaphragmatic injuries Acute diaphragmatic herniation Surgical treatment of acute diaphragmatic injuries Chronic diaphragmatic hernia

209 210 211 212

The diaphragm is a thin muscle with a full-time job. It is innervated by the ipsilateral phrenic nerve and has an abundant blood supply.1 The anatomical role of the diaphragm consists of dividing the two large cavities of the human body and maintaining its different pressures.2 Its presence separates and contains the viscera of the abdominal and thoracic cavities. The symptoms related to diaphragmatic injuries are caused by the incapacity to contain the abdominal viscera in the cavity favored by the pressure gradient.1 During inspiration, the diaphragm contracts physiologically, acquiring a flat shape. During expiration, it relaxes passively and acquires a dome shape. This concept is important for understanding and diagnosing diaphragmatic injury in the various chest and abdominal levels of penetrating trauma. Diaphragmatic injury is not common, but its incidence has increased over the past few years, probably because of the increased frequency of high-speed motorvehicle accidents.3–5 Additionally, early recognition has become more feasible with the diagnostic procedures that are now available. It is also conceivable that early recognition of signs and symptoms of a possible diaphragmatic injury can result in the correct treatment being given, so avoiding chronic injuries. The diagnosis of diaphragmatic injury is influenced strongly by the severity of the associated lesions.6–8 Sennertus in 1541 was the first to report a diaphragmatic injury, in a postmortem examination.9 He described a strangulated stomach herniated through a left diaphragmatic defect seven months after a stab wound. In 1579, Paré described the consequences of diaphragmatic herniation in blunt and penetrating injuries.10 He found a strangulated

Surgical treatment of chronic diaphragmatic injuries Conclusion References

213 214 215

colon through a small defect in the diaphragm. In 1853, Bowditch became the first physician to diagnose a posttraumatic diaphragmatic hernia in vivo.11 In 1886, Riolfi performed the first repair of a diaphragmatic herniation after a stab wound,12 while Walker in 1900 was the first surgeon to repair a diaphragmatic hernia after blunt trauma.13 The aim of this chapter is to provide a clear concept of the various diaphragmatic lesions and the approaches for successful diagnosis and treatment.

DIAPHRAGMATIC INJURIES Injuries of the diaphragm can be classified into two groups: acute and chronic. Acute injuries (from blunt or penetrating trauma) detected in the first 24 hours are called ‘early diagnosed’; after the first 24 hours, they are called ‘delayed diagnosed’. If the diaphragmatic lesion was missed in the acute phase, then the second latent phase occurs. In this variable time (months to years), the injury may be asymptomatic. The chronic phase begins with the appearance of symptoms related to the herniation of the abdominal viscera into the thoracic cavity. This, in turn, will affect respiratory patterns or cardiovascular performance or cause digestive symptoms, such as gastric distention, gastric or colonic obstruction, volvulus, and perforation.14–17 Each of the three phases of diaphragmatic injury has a relevant importance in the operative strategy decision. The early-diagnosed acute phase accounts for about 90 per cent of diaphragmatic injuries. These patients will typically have associated injuries and are treated by the


open approach.18 Delayed-diagnosed acute injuries differ from early-diagnosed injuries in that patients with the former are generally more stable and have fewer severely associated injuries. In this subgroup of acute patients, laparoscopic approach and repair can be achieved.19–21 Laparoscopic treatment for chronic diaphragmatic herniation is quickly becoming widely accepted and performed.

ACUTE DIAPHRAGMATIC HERNIATION The etiology of diaphragmatic injuries can be classified as penetrating or blunt trauma. Diaphragmatic injury in trauma patients is not uncommon: its incidence is 0.8 per cent of all trauma patients admitted, 5 per cent of all blunt abdominal traumatic admissions, and 9.5 per cent of all thoracoabdominal penetrating trauma admissions.8,22,23 Penetrating diaphragmatic hernia during thoracoabdominal trauma, such as in shotgun wounds, has a different incidence of severity. This massive destructive effect requires laparotomy or thoracotomy and laparotomy to repair visceral or vascular damage. Stab wounds and iatrogenic diaphragmatic injuries are usually less severe, and if vascular penetration is ruled out laparoscopic repair is feasible. Blunt trauma is more common in motor-vehicle accidents, especially during high-speed impact.7,24 The physiological pressure of the abdominal cavity varies from 4 to 20 cm of water, and it can climb to 100 cm of water during a forced inspiration. Elevation of the abdominal pressure up to 400 cm of water occurring during motor-vehicle accidents can explain the rupture of the diaphragm and the herniation of the viscera into the thorax, which has a negative pressure (⫺2 to ⫺10 cm of water). Blunt diaphragmatic injury is seen more frequently after motor-vehicle accidents than after pedestrian or motorcycle accidents or falls from great heights. During blunt trauma, the rupture of the diaphragm can occur in the right, left or both sides, the central tendinous area (opening into the pericardium), or into the posterior area, thereby compromising the hiatus. Diaphragmatic injury is an indicator of an impact with high-energy transmission. Each of the affected areas demonstrates differing characteristic features. In 80 per cent of cases the trauma results in herniation through the left side of the diaphragm, 15 per cent affect the right side, and in five per cent both sides are affected.18 Rupture of the diaphragm is effected, generally, by an impact that occurs on the ipsilateral side of the injury.25 An associated injury has been reported in 90 per cent of patients with diaphragmatic tear. Mortality varies between three and 30 per cent, and depends upon the severity of the trauma and associated injuries. The differences between right and left side on admission were well defined in the literature.26–28

Abdominal contents were found to invade the thorax in 58 per cent of patients with a left-sided diaphragmatic tear and in 19 per cent with a right-sided defect. These findings can be explained by the presence of the liver in the upper right abdominal cavity, thereby protecting the passage of the viscera. Because of this anatomical difference, patients with a right-sided tear are generally injured more severely than those with a tear on the left side.18 Boulanger and colleagues showed that the mean Glasgow Coma Scale was 8 for patients with right diaphragmatic tear compared with 11 for those with left diaphragmatic tear.18 Patients with a right diaphragmatic injury had more significant amounts of blood loss than patients with injuries elsewhere in the diaphragm. The injuries associated with blunt diaphragmatic trauma are shown in Table 28.1.29–31 The figures shown in this table indicate that hemothorax occurs in 78.5 per cent of patients with blunt trauma. Table 28.2 outlines the overall rate of abdominal injuries associated with blunt trauma. The overall mortality rate in the blunt diaphragmatic injuries group of patients is 16–20 per cent, depending on the associated injuries. Bilateral rupture of the diaphragm is associated with the highest rate of mortality, followed by traumatic rupture of the right hemidiaphragm. Intrapericardial diaphragmatic rupture is a rare condition that can mimic cardiac tamponade during the acute diagnosed phase of herniation; most commonly, it is the stomach that protrudes into the pericardium.32–34 Posterior rupture of the diaphragm is an infrequent lesion that can compromise the crura and the hiatus.35 Recently, we had the opportunity to treat a patient with a known hiatal hernia after a motor-vehicle accident. He presented with a posterior transverse rupture of the Table 28.1 Injuries associated with blunt trauma Injury

Percentage

Hemothorax Rib fracture Pelvic fracture Extremity fracture Pneumothorax Spinal fracture Thoracic aortic tear

78.5 51 46 40 28 16.5 7

Table 28.2 Overall rate of abdominal injuries in blunt trauma Abdominal injury

Percentage

Liver Spleen Hollow viscus Kidney Bladder Pancreas

63.5 51 25.5 11 9 6.5

Traumatic and unusual herniation 211

diaphragm, which included a total avulsion of the right crura. A primary repair by open approach was performed, and the crura was sutured with non-absorbable sutures. In these cases, esophageal perforation must be ruled out either before (with preoperative testing) or during operation by irrigation with saline solution or methylene blue solution through a nasogastric tube. Manifestations of diaphragmatic injury during the acute phase depend upon the severity of pulmonary compromise and the associated clinical manifestations. The symptoms of thoracic pain referred to the scapula, dyspnea, and decreased breath sounds are present in more than 70 per cent of these patients. Specific symptoms of diaphragmatic rupture may be absent in 25–37 per cent of the patients.36 Abdominal tenderness, distension and rebound can also be present. Almost half of the victims are admitted to the emergency room with symptoms of shock. Following historical and physical examination, the initial assessment of a trauma patient with suspected diaphragmatic injury should be a chest radiograph. However, the ability of the chest X-ray to demonstrate a diaphragmatic injury varies from 37 to 50 per cent.37 Direct signs of diaphragmatic rupture on chest X-ray are visceral herniation, indistinct diaphragmatic lines, elevation of the diaphragm, and position of a nasogastric tube within the thorax (Figure 28.1). Indirect signs of diaphragmatic injury on chest X-ray are rib fractures, sternal fracture, pneumothorax, hemothorax, lung contusion, atelectasis, gastric dilation, and subcutaneous air. Ultrasonography can demonstrate diaphragmatic rupture by the presence of fluids above and below the

diaphragm and discontinuity of the diaphragmatic edge. On the right side, ultrasonography can be sensitive to detection of diaphragmatic rupture with liver herniation. Spiral computerized tomography (CT) and magnetic resonance imaging (MRI) are the most accurate diagnostic methods for finding diaphragmatic ruptures.38,39 Diagnostic peritoneal lavage (DPL) is a controversial tool for diagnosing diaphragmatic injury.1 DPL in the presence of isolated diaphragmatic injury may be falsely negative, and the positive results depend upon the status of the abdominal viscera. Laparoscopy and thoracoscopy are the best invasive techniques for diagnosing diaphragmatic lesions and eventual treatment of the rupture.40–42 However, the diagnosis and treatment of this problem can also be accomplished with the use of a thoracotomy and/or laparotomy when necessary.

SURGICAL TREATMENT OF ACUTE DIAPHRAGMATIC INJURIES When diaphragmatic injuries are diagnosed, repair is mandatory. If, during the acute phase, early diagnosis is confirmed, then the approach to the repair must be dictated by any associated injuries. Generally in this case, laparotomy will be the preferred method to treat additional visceral injuries. The repair of the diaphragm will usually be accomplished with simple suturing of the defect with nonabsorbable sutures in one or two layers.43 If the diaphragmatic injury is isolated or the associated damages allow a laparoscopic approach, then the repair can be performed easily with the advantage of good visualization, even in the posterior areas.

Operative technique

Figure 28.1 Chest X-ray, showing nasogastric tube in the left thorax after trauma.

The patient is placed in lithotomy and Fowler’s position. Some surgeons prefer to stand on the right side of the patient, with the patient supine. In the former approach, the surgeon stands between the legs of the patient. The first assistant is positioned on the left side of the patient and the second assistant is on the right of the patient. A pneumoperitoneum using carbon dioxide is obtained by introducing a Veress needle in the left subcostal midclavicular line at low pressure, such as 12 mmHg. The use of high-pressure insufflation (15 mmHg or higher) must be avoided in trauma patients. High abdominal pressure can reduce the venous return by 30 per cent, and the patient could became hemodynamically unstable. One 10-mm trocar is introduced supraumbilically where a 30-degree laparoscope is placed. It is important to remember that in obese patients, this first trocar must be introduced in a slightly higher position between the


10 mm trocar 5 mm trocar

Figure 28.2 Schematic position of trocars for laparoscopic treatment of diaphragmatic herniation.

umbilicus and the xiphoid process. Another 11- or 12-mm trocar is introduced in the left upper quadrant, higher than the first one, in the midclavicular line, with direct visualization with the laparoscope. A third trocar (5 mm) is placed in the left upper quadrant subcostally. The placement of two more trocars is optional, one for liver retraction in the subxiphoid area and one in the left flank for retraction (Figure 28.2). The herniated abdominal viscera are returned gently into the abdominal cavity using atraumatic graspers. Any devitalized tissue that is found along the edge of the laceration should be debrided. The defect is then sutured with endo-stitches. These can be made free-hand or placed with a device designed to suture laparoscopically. If the defect is greater than 4 cm in diameter, then a reinforcement of the suture line can be done with an onlay of absorbable mesh, such as braided Dexon®(U.S. Surgical Corp.) or Vicryl®knitted mesh (Ethicon, Inc.), fixing it to the diaphragm with endo-staplers. We believe that the placement of such prostheses can help to relieve any excessive tension on the suture line if the patient develops high abdominal pressure or abdominal compartment syndrome in the immediate postoperative period. Treatment of diaphragmatic rupture when diagnosis is delayed (more than 24 hours) differs from treatment during the early diagnosis phase because of the greater possibility of failure of primary repair due to tension on the suture line. In this condition, the fibers of the diaphragm are contracted. Primary suture of the defect will be performed under tension, thereby increasing the possibility of recurrence. We prefer to treat these defects with nonabsorbable material, such as an expanded polytetrafluoroethylene

(ePTFE) prosthetic biomaterial. Polypropylene mesh can also be used to close these defects, but severe adhesions to the adjacent viscera can develop, especially to the splenic flexure of the colon. Additionally, polypropylene mesh should be used carefully when it is fixed in the proximity of the esophagus due to the possibility of erosion. If contaminated fluids are found in the abdominal cavity, then the use of nonabsorbable material is not advised. In these cases, an absorbable material such as Dexon or Vicryl mesh is preferred. Another unusual type of diaphragmatic injury is that of posterior rupture, which can compromise the hiatus. We recommend that this injury is repaired with a procedure that restores the normal anatomy, such as restoration of the crura by nonabsorbable sutures. The area of repair is then reinforced by placing an ePTFE mesh around the esophagus in either a ‘U’- or ‘O’-shape, depending on the size of the defect. The ePTFE patch is then attached to the diaphragm with titanium spiral tacks posterior to the esophagus and to the crura (using special care not to injure the aorta). Lateral and anterior to the esophagus, the fixation of biomaterial should be performed with sutures or an endo-stapler. Regardless of the method of choice, one must be careful in the tendinous area to avoid penetration of the myocardium. In our experience, we have demonstrated by echocardiogram one case of pericardial effusion after laparoscopic repair of a diaphragmatic hernia induced by a stapler in the pericardial area. Intrapericardial rupture of the diaphragm is rare, with fewer than 60 cases having been reported in the literature.32–34 Generally, these were long, transverse wounds that occurred during blunt abdominal trauma. CT and echocardiography were used for diagnosis.44 Primary suture is recommended in these cases. The myocardium must be protected from injury, which could occur at the time of repair.

CHRONIC DIAPHRAGMATIC HERNIA Diaphragmatic injury represents one of the most commonly missed pathologies in trauma patients.1 Undetected acute diaphragmatic injuries begin as small lacerations without associated serious damage. During the posttraumatic phase, the positive abdominal pressure causes the viscera to herniate into the pleural space, resulting in an increase in the size of the diaphragmatic defect.6,45,46 Because of a delay in diagnosis, only ten per cent of diaphragmatic hernias are diagnosed in the acute phase. Consequently, 90 per cent of these injuries become chronic.47 The time interval to diagnosis varies from months to years and depends upon the appearance of symptoms after the latent phase. The size of the original disruption, localization (left, right, central or posterior), and content can influence the development of pulmonary

Traumatic and unusual herniation 213

Figure 28.3 Left chronic diaphragmatic hernia after stab wound three years previously.

Figure 28.4 Right chronic hernia: the entire liver, stomach and hepatic flexure of the colon were reduced from the right thorax.

or abdominal symptoms. An acute presentation with signs and symptoms of incarceration or obstruction can be the initiating event for the patient (Figure 28.3).17,48 Perforation or necrosis are serious complications that make the emergency repair of these diaphragmatic hernias a life-saving procedure. In such cases, two-stage repairs should be considered. Work-up should include a simple chest X-ray, which can make a diagnosis in 73 per cent of cases with chronic herniation on the left side. Spiral CT is most useful for diagnosis of right-sided herniation in which an indirect sign of herniation can be identified by an abnormal position of the liver. CT can also help to identify the content of the herniation. MRI is the preferred and the most sensitive diagnostic method for identifying missed diaphragmatic injuries.49

SURGICAL TREATMENT OF CHRONIC DIAPHRAGMATIC INJURIES The diaphragm is a muscle, and its insertions are around the inferior chest wall. Physiologically, the injured muscle experiences eccentric retraction, with a tendency to increase the diameter of the edges. The muscle can also undergo atrophy. Therefore, primary repair in chronic defects has a high index of failure, with subsequent recurrence of the hernia. Additionally, the diaphragmatic hernia does not have a sac, unlike the classical concept of the more commonly seen hernias (Figures 28.4 and 28.5). The choice between the two methods of repair, thoracoscopic or laparoscopic, is the object of debate.50–53 We strongly recommend an abdominal approach, which provides for better management of the adhesions and abdominal viscera. The technique includes placing the patient in the lithotomy position and carrying out abdominal insufflation through a Veress needle with carbon dioxide at a

Figure 28.5 Diaphragmatic hernia repair with ePTFE mesh by laparoscopy.

pressure of 15 mmHg. Some surgeons prefer a lateral position of the surgeon and the use of one of the optical viewing trocars. A supraumbilical trocar is inserted for the introduction of a 30-degree scope (5- or 10-mm). One 11-mm trocar is then inserted in the left upper quadrant at the lateral border of the rectus abdominis muscle under vision to avoid injury to the epigastric vessels. Two more 5-mm trocars are used, one on the right abdominal side subcostally, and one in the left flank for the assistant. One more 5-mm trocar can be inserted in the epigastrium for liver retraction if this is necessary. Meticulous adhesiolysis is the first step in the repair, avoiding injury to any viscus. Careful reduction of the hernia contents from the pleural space to the abdominal cavity is performed during this dissection. A complication, such as a perforation, during these procedures can


can be performed using ePTFE mesh fixed by nonabsorbable sutures alone to avoid injury to the myocardium. The complicated diaphragmatic hernia is an emergency and is associated with high mortality and morbidity rates. The herniorrhaphy can be a life-saving procedure. Complicated cases, such as those associated with bowel injury or severe bleeding in an unstable patient, can be treated in relation with the affected viscous, such as primary suture or exteriorization of the injured bowel, and the definitive repair delayed. Contamination is a contraindication for definitive repair. Treatment during an acute presentation consists of the management of the compromised viscera (reduction, resection, colostomy, etc.). The defect in the diaphragm is closed by primary suture if possible or (in our experience) with absorbable mesh if there is a devitalized area of the diaphragm. In the latter case, definitive treatment is delayed for three months and then performed laparoscopically. Figure 28.6 Chronic diaphragmatic hernia, showing part of the stomach in the left chest. The presentation of this patient was incarceration of the stomach.

contaminate the operative field. The retracted edges of the laceration must be identified and cleared from the adhesions. The definitive repair is then performed with nonabsorbable mesh materials. We use either ePTFE mesh as the sole prosthesis or polypropylene mesh placed on to the diaphragm, which is then covered by an ePTFE mesh to avoid contact between the polypropylene and the viscera (Figure 28.6). We recommend an overlap of the mesh size of at least 3 cm. The mesh is folded into a cylindrical shape and introduced into the abdominal cavity through the lumen of the 11-mm trocar. After unfolding the mesh in the abdominal cavity, fixation commences in the posterior muscular diaphragm with titanium spiral tacks. In the lateral, central and anterior portions, we use several interrupted nonabsorbable sutures and EMS staples. For a posterior laceration mimicking a para-esophageal hernia, the repair consists of a total reduction of the stomach and dissection of the crura. In these cases, a sac may be present if the patient had a hiatal hernia before the injury; removal of the sac, if present, is recommended. The hiatus is repaired by closure of the crura posterior to the esophagus with endoscopic sutures. After completion of the sutured repair, we reinforce the site with mesh. In the proximity of the esophagus, the use of ePTFE mesh is recommended. Because a repair in this area of the diaphragm must include the esophagus, the ePTFE mesh must be cut into either an ‘O’- or a ‘U’-shape. If an intrapericardial hernia is present in the tendinous area of the diaphragm, then a meticulous repair

CONCLUSION Traumatic diaphragmatic hernia is an indicator of the severity of injury in blunt trauma patients, who have high rates of mortality and morbidity. Penetrating trauma of the diaphragm is generally a smaller injury of the diaphragm but is usually associated with injury of vital organs of the chest and abdomen. During blunt trauma of the diaphragm, the injury is a long tear caused by the high pressure of the forces originated. Preoperative diagnosis of diaphragmatic injuries in trauma patients is low (39 per cent) and missed injuries are seen in ten per cent. Acute repair can be performed by laparoscopy in stable patients without severe associated injuries. The technique includes primary repair with separate stitches using a nonabsorbable material. Delayed diagnosis (more than 24 hours) and chronic diaphragmatic hernias require prosthetic repair with nonabsorbable mesh, fixed to the diaphragm with titanium spiral tacks, sutures and/or EMS staples. If incarceration is present without contamination and the reduction can be performed without complication, then the repair will be similar to that seen in chronic diaphragmatic hernia. During strangulation, life-saving procedures must be performed, such as resection, colostomy, or feeding tubes. In this situation, absorbable materials are recommended as a means to effect a temporary repair until definitive repair is possible.

REFERENCES 1

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29 Etiology of recurrent gastroesophageal reflux disease ZIAD T. AWAD AND CHARLES J. FILIPI

Clinical presentation Mechanisms of failure Wrong operation

217 219 221

Gastroesophageal reflux disease (GERD) is a common disease that accounts for approximately 75 per cent of the pathology of the esophagus. Forty per cent of the adults in the USA have occasional heartburn, and ten per cent experience heartburn daily.1,2 It is estimated that 20 per cent of patients with GERD develop serious complications, such as ulceration, stricture, and Barrett’s metaplasia. Although medical therapy may be effective, it is often required for a protracted period of time. In addition, prolonged therapy often requires escalated dosages, and discontinuation of medications may result in an early recurrence of symptoms. Surgery has improved because of a better understanding of the underlying pathophysiology of GERD and technical refinements of operative techniques.3,4 A controlled, randomized trial showed superiority of surgical therapy for the treatment of severe GERD, with less frequent side effects than with non-surgical management.5 Other investigators have provided evidence to favor antireflux surgery over medical treatment.6,7 The advent of minimally invasive surgery has revolutionized the surgical treatment of GERD, leading to a significant increase in the number of cases performed. Studies have shown that the functional results of laparoscopic anti-reflux procedures are equal to those of open surgery, but with significantly less postoperative morbidity and a shorter hospital stay.8–10 The surgical management of GERD sometimes fails, whether performed open or laparoscopically, and may require reoperation for optimal results. Failure of open fundoplication occurs in 9–30 per cent of patients,3,11,12 whereas published failure rates of laparoscopic Nissen fundoplication are 2–17 per cent.6,13–16 The lower published rates for laparoscopic surgery probably

Wrong diagnosis Discussion References

221 222 224

reflect the fact that laparoscopic fundoplication is a relatively new technique rather than it being intrinsically better. However, the early adopters of the laparoscopic approach were usually more skillful individuals who were likely to be quite compulsive in the indications and techniques of these operations. Therefore, it is hoped that with longer follow-up this procedure will reveal its superiority. Reoperations for failed or recurrent GERD are technically more demanding due to adhesions from previous surgery and obscured anatomy. The relatively fragile walls of the esophagus, gastric cardia, and fundus are easily damaged or breached, leading to postoperative leak with potentially lethal complications. In addition, the recognized and repaired injury may impair the precise reconstruction required to obtain a good functional result. Reoperative anti-reflux surgery has a morbidity and mortality of 4–40 per cent and 0–4.9 per cent, respectively.17 The overall clinical results after reoperation – even those obtained by experienced surgeons – are significantly less favorable than outcomes for first-time repairs. The incidence of unsatisfactory results is at least doubled after reoperation. Furthermore, the greater the number of previous failed repairs, the greater the incidence of poor results.

CLINICAL PRESENTATION Dysphagia Approximately 30–40 per cent of patients suffer from some form of dysphagia in the early postoperative period. This, however, decreases to approximately five


per cent at long-term follow-up. It is believed that early short-term dysphagia is due to distal esophageal edema and transient esophageal dysmotility. We generally recommend that the patient stays on a liquid diet for two days after surgery and then maintains a soft diet for three weeks following surgery. If the patient has difficulty in swallowing liquids and/or there is significant weight loss, then intervention may be necessary. This includes esophageal dilation and, in extreme cases, placement of a gastrointestinal feeding tube. Postoperative gastrografin or barium esophagogram helps to define acute postoperative events, such as para-esophageal herniation of the stomach producing obstruction at the lower esophagus. This finding warrants emergency surgical intervention. Patients with dysphagia that persists past three months represent a complex problem that warrants careful analysis and interpretation. Common causes include slipped fundoplication, para-esophageal hernia formation, tight or fibrotic fundoplication, hiatal stenosis, twisted fundoplication, missed tumors at the gastroesophageal junction, lowamplitude esophageal waves, incomplete propagation of contractile waves, and undiagnosed achalasia. A barium esophagram with a 12.5-mm barium pill will differentiate anatomical abnormalities at the gastroesophageal junction (slipped or para-esophageal hernia) from other causes of dysphagia, such as esophageal dysmotility. The latter diagnosis is confirmed by an esophageal motility study. Patients who are still confined to liquids at three months postoperatively, and patients who are losing weight because of dysphagia, should be offered reoperation. If the solid dysphagia is mild or moderate with few dietary restrictions, and there is little or no weight loss, then conservative management is a viable option.

Recurrent reflux This occurs in up to eight to ten per cent of patients followed for ten years after the open procedure.3 Common causes of recurrent reflux are slipped fundoplication, intrathoracic fundoplication with partial disruption, and fundoplication that is too loose. Barium esophagogram, esophageal manometry, endoscopy, and 24-hour pH monitoring studies are valuable adjuncts in the evaluation of these patients.

Abdominal bloating This frequent entity is believed to be due to the trapping of swallowed air, which may not be belched easily in the presence of a competent fundoplication. Many patients after anti-reflux surgery complain of increased epigastric discomfort and flatulence.18 It is likely that patients who undergo anti-reflux surgery habitually swallow air to clear the esophagus of refluxed acid. This habit continues

after the anti-reflux surgery, resulting in the so-called ‘gas-bloat syndrome’. The symptoms can be treated with gas-binding agents or prokinetics. Very rarely, it is necessary to take down the fundoplication or convert it to a partial fundoplication.

Pain Some patients complain of pain, mainly in the lower thoracic region, the epigastrium or the left shoulder, following fundoplication. This is believed to be due to suture placement in the diaphragmatic hiatus, producing referred pain; it may also be the result of esophageal muscle spasm. These symptoms can be treated expectantly, and occasionally they respond to a calcium-channel blocker such as nifedipine or diltiazem.

Diarrhea After fundoplication, approximately eight per cent of patients have diarrhea. The reason for this may be increased gastric emptying, excessive liquid intake, or a post-vagotomy effect. In those cases in which the cause is not clear, gastric-emptying studies or, for completeness of vagotomy, a sham feeding pancreatic polypeptide test may help to resolve the question.19 A pyloroplasty is appropriate when the gastric-emptying study has a halftime of more than 150 minutes. Most patients can be treated effectively with anti-diarrhea medication; only rarely is surgical intervention, such as the reversal of a 10-cm jejunal loop, necessary.

Alkaline reflux gastritis Some patients complain of epigastric discomfort in conjunction with their preoperative complaints of heartburn and acid regurgitation. Careful evaluation of these patients may identify excessive bile in the stomach at endoscopy and on testing with the Bilitec probe. Twentyfour-hour gastric pH monitoring and hepatobiliary scanning with technetium 99 m-labeled derivatives of iminodiacetic acid to show the presence of radioactive material in the stomach help to define the problem further. In carefully selected patients, bile-diversion surgery is useful. The duodenal switch consists of division of the duodenum at the juncture of the first and second portion with a roux-en-Y jejunal loop anastomosed to the proximal duodenum in addition to a highly selective vagotomy. Medical management using a prokinetic and a binding agent such as cholestyramine, however, usually suffices. It is important that the patient is advised preoperatively of the probability of continued gastric symptoms after fundoplication.

Etiology of recurrent gastroesophageal reflux disease 219

MECHANISMS OF FAILURE Failed repairs requiring reoperation may be the result of technical errors, selection of the wrong operation, or incorrect primary diagnosis. Technical failure undoubtedly relates to the inexperience of the individual surgeon. The restoration of a functional acid barrier while avoiding dysphagia and side effects, such as diarrhea and gastroparesis, requires precise surgical technique and careful preoperative assessment.

Crural disruption This disorder results in an intrathoracic migration of the wrap or a para-esophageal hernia and is particularly common after laparoscopic anti-reflux procedures for large hiatal hernias.20,21 Contributing factors, in theory, include operator inexperience, short esophagus, inadequate mobilization of the esophagus, and physiological factors that would increase pressure or tension at the diaphragmatic hiatus.21 This is particularly true if the patient vomits or retches during the early postoperative period or encounters excessive intra-abdominal pressure secondary to a fall, heavy lifting, or a car accident. We advise inclusion of the overlying crural peritoneum when closing the hiatus. The subdiaphragmatic fascia, which is identified easily on the left limb of the right crus, is included in our crural repair. Although some surgeons advocate an anterior crural closure and others recommend a prosthetic reinforcement,22,23 we prefer to place deep 0-Ethibond sutures 1 cm apart that include the peritoneum and subdiaphragmatic fascia. A concerted effort is made to preserve the fascia and avoid a muscle-to-muscle closure. In addition, patients are placed on an antiemetic regimen intraoperatively, which is continued during the first 48 postoperative hours. Restricted activity and lifelong avoidance of weight-lifting are advised.

Missed short esophagus Pathological acid reflux initially produces an inflammatory reaction and edema in the lamina propria. However, in long-standing cases, it results in destruction of the muscularis mucosae, forming a stricture down to and including the circular muscle level. Eventually, transmural inflammation causes fibrosis of the outer longitudinal muscle, creating a shortening effect and, in some cases, an inability to reduce the gastroesophageal junction to its normal subdiaphragmatic position. A foreshortened esophagus may also be found in patients with a failed anti-reflux procedure and in those with type III (mixed) hiatal hernias. Between three and 14 per cent of patients undergoing anti-reflux surgery have the so-called short esophagus.24,25

Preoperative diagnosis of the short esophagus, although not standardized, is currently based on demonstrating a non-reducing 5-cm or larger hiatal hernia on an upright barium esophagram, endoscopic demonstration of stricture formation or Barrett esophagus, or short esophageal length as measured by manometry. Awad and colleagues showed that neither a single preoperative test nor any combination of tests was completely accurate.26 When each of the preoperative tests was evaluated individually, endoscopy had the highest sensitivity (61 per cent) and a positive predictability rate of 26.6 per cent; manometric length measurement had the highest specificity rate (78 per cent) and a positive predictability rate of 36.3 per cent. The combination of two or more tests resulted in a specificity ranging from 63 to 100 per cent but a low sensitivity (28–42 per cent). The only reliable way to confirm or exclude esophageal shortening is to demonstrate intraoperatively that the gastroesophageal junction rests in the abdominal environment allowing for a tension-free repair. If this precaution is not observed, then an anti-reflux repair has a failure rate of approximately 25 per cent.27 The most effective treatment for the shortened esophagus is a lengthening procedure using a Collis gastroplasty. This operation can be done by an open transthoracic approach; alternatively, a totally laparoscopic or a combined laparoscopic and thoracoscopically assisted approach can be used. Currently, the primary problem with laparoscopic esophageal mobilization is exposure, as only 6–8 cm of distal esophagus can be freed easily when using the laparoscopic approach. The use of longer instruments, an incision of the arch of the diaphragm to allow a mediastinal retractor, and division of the vagal branches to the left lung aid in circumferential esophageal dissection up to the aortic arch. All patients with a possible short esophagus undergo circumferential esophageal mobilization followed by intraoperative endoscopic evaluation of the distance between the gastroesophageal junction and the arch of the crus. Initially, we required a 2-cm intra-abdominal segment of the esophagus without tension, but after experiencing one recurrent slipped Nissen we subsequently have used a 3-cm intraperitoneal length requirement.

Two-compartment stomach A partitioned stomach is unique to laparoscopic antireflux surgery and occurs when a point too low on the anterior greater curvature of the stomach is used as the anterior wing or a point too distal on the posterior wing of the fundoplication is selected. This creates a pouch of fundus that is isolated from the corpus, created by a partitioning line of tension. There is a characteristic X-ray picture at esophagography (Figure 29.1) and


Twisted fundoplication This disorder may be associated with the Nissen–Rosseti repair and results from failure to mobilize the greater curvature of the stomach from the spleen, diaphragm and pancreas. A lead point on the anterior wall of the stomach is used for the posterior wing and is sutured to another level of the anterior stomach wall. If the proximal distal axis lead point levels are sufficiently different, then a twist results and a spiral-type deformity is seen on retroflexion at endoscopy. This deformity is associated with dysphagia; a manometric evaluation will show a hypertensive and, sometimes, poorly relaxing fundoplication. The twisted fundoplication is often resistant to esophageal dilation and requires reoperation.

Hiatal stenosis

Figure 29.1 The proximal compartment is filled with barium and the distal compartment is filled with air.

This phenomenon is associated only with laparoscopic Nissen fundoplication. It has been reported infrequently and must be differentiated from an excessively tight closure. Hiatal stenosis is due to excessive scar formation, which in turn constricts the esophagus at the hiatal level. It is easily recognized at reoperation by intraoperative endoscopy, after taking down the gastric-hepatic adhesions. It can be corrected by incising the hiatus anteriorly. We also inject the hiatoplasty with dexamethasone. The cause may be due to cautery dissection of the right crura.

Missed neoplasm A small submucosal tumor causing dysphagia may go unnoticed at endoscopy. Endoscopic ultrasound is a useful adjunct in these circumstances, especially in patients who exhibit weight loss and are suspected to have a benign disorder. All patients with Barrett’s esophagus should undergo a biopsy protocol before operation. At laparoscopic reoperation, one should suspect a malignancy if the dissection is difficult and the tissue is excessively hard.

Figure 29.2 A retroflexed view of the stomach with two compartments separated by a fold/partition of tissue.

the endoscopy is diagnostic (Figure 29.2). Patients with this deformity often have dysphagia, and manometric evaluation shows a hypertensive fundoplication with incomplete relaxation. The gastric body does not relax with swallowing, thus dysphagia results when the gastric body is used for the fundoplication. Reoperation is required.

Slipped Nissen This well-known problem occurs after protrusion of the gastric fundus through the fundoplication. It may be the result of esophageal foreshortening, failure to anchor the fundoplication to the esophagus, or incorrect positioning of the fundoplication on to the stomach rather than the lower esophagus. Esophageal mobilization to achieve a sufficient intra-abdominal length of esophagus allowing for a tension-free repair is essential to minimize the occurrence of this complication.

Etiology of recurrent gastroesophageal reflux disease 221

Vagal-nerve disruption

Fundoplication disruption

Injury to both vagus nerves can lead to a marked delay in gastric emptying, which in turn may in turn require a pyloroplasty. Familiarity with the anatomy and careful dissection of the arch of the right crus will minimize the risk of anterior nerve injury. Posterior nerve injury is probably more common when the nerve is displaced from the posterior esophagus and is unrecognized as such. Single-nerve injury or excessive nerve stretching to make an ample window behind the gastroesophageal junction may create transient gastroparesis. A gastricemptying study should be performed; our criteria for pyloroplasty is a half-time of more than 150 minutes for solids or liquids. Vagal-nerve injury is the reason for legal consultation and action more frequently than any other post-Nissen problem.

This is the Achilles heal of Nissen fundoplication and may not be avoidable. Disruption may be the incorrect term in many instances. Clearly, the fundoplication folds and tucks are lost with time in some patients and recurrent reflux disease occurs, but this is based on the retroflexed endoscopic view. In fact, at reoperation many patients have a seemingly intact fundoplication with sutures still holding the right and the left wing serosal surfaces in continuity. Apparently, the suture has pulled out of the full thickness of the stomach wall in one or both of the wings, and an effective barrier has been lost. Tissue attenuation may also be responsible for this phenomenon. Consequently, Tom DeMeester has recommended a pledgeted repair, which the main author (CJF) of this chapter incorporates with every Nissen fundoplication he performs.

Too loose, too tight, or too long fundoplication If the wrap is too floppy, then the pressure created in the distal esophagus is low, favoring recurrent reflux symptoms. Conversely, if the fundoplication is too tight, dysphagia may occur. Calibration of the fundoplication has been standardized and shown to prevent long-term dysphagia.3 A 60F bougie should be introduced, and the right and left wing lead points should be chosen with the dilator in place. We prefer to overlap the lead points by 3 cm to create a floppy Nissen fundoplication (Figure 29.3).

Posterior Anterior

3 cm

WRONG OPERATION Selection of the optimal operation may be influenced by the presence of esophageal foreshortening, defective esophageal motility, or gastric-outlet or duodenal obstruction. The acquired short esophagus is an indication for an esophageal-lengthening procedure to reduce undue tension on the repair. Significant impairment of esophageal peristaltic amplitude of contraction, propagation, or abnormal peristaltic waves necessitates a floppy Nissen fundoplication to avoid the complication of dysphagia from a functional obstruction. Gastric-outlet obstruction warrants a gastric resection, while an obstructing duodenal stricture is best treated by gastrojejunostomy and vagotomy.

WRONG DIAGNOSIS

Anterior

Posterior

Figure 29.3 An end-on view of the gastric fundus wings overlapped to assure a floppy Nissen fundoplication.

Failure to identify an underlying primary motor disorder, such as achalasia or diffuse esophageal spasm, results in a repair that inevitably fails to relieve and may exacerbate the clinical problem. In such cases, dismantling the fundoplication and adding myotomy is required. Preoperative manometry is imperative in this case but is often forgotten by the casual esophageal surgeon. Esophageal cancer or a malignancy at the gastroesophageal junction can be missed at endoscopy. Care in obtaining a good retroflexed view of the squamocolumnar junction is necessary. This may be difficult if the patient is unable to hold the air in the stomach. A smaller scope, however, can almost always be placed in the hiatal hernia to obtain the view needed. Any suspicion of a neoplasm warrants biopsy. If the patient is combative when


the endoscope is retroflexed within the hernia, then esophageal perforation can occur. Improved sedation or repeat endoscopy at another session is warranted. We have discovered four patients with malignancy who had been endoscoped recently by an experienced physician and referred for anti-reflux surgery. Endoscopy by the operating surgeon is a must in our opinion.

DISCUSSION The reasons for poorer outcomes after repeat surgery are hypothetical and perhaps uncorrectable (Table 29.1). A specific classification of mechanisms of failure has not been agreed upon, and the best method of correction for each mechanism has yet to be determined. Many failures are the result of technical errors, whereas others result from deteriorating foregut motility or wear and tear on the fundoplication. The best approach for reoperative anti-reflux surgery is debatable. Currently, we prefer the transthoracic approach for patients with two or more failed anti-reflux procedures, for any patient with an irreducible hiatal hernia more than 2 cm in size, and for patients with a suspected short esophagus (short esophageal manometric length, stricture formation, or Barrett’s esophagus). The left transthoracic approach provides maximum exposure of the hiatus and makes dissection of the esophagus from the surrounding tissues safer; with a circumlinear incision of the diaphragm near its rib attachment, excellent exposure of the abdominal contents is

possible. More importantly, the esophagus can be mobilized up to the aortic arch and a lengthening procedure, if needed, can be performed easily. A disrupted fundoplication, a repair that is too tight, or a patient with crus closure failure and an intrathoracic fundoplication more than 2 cm above the diaphragmatic crus and without additional risk factors for a short esophagus are our primary indications for laparoscopic reoperative surgery. The patient’s symptoms must be uncontrollable despite aggressive medical therapy (including dilations) to warrant reoperative surgery. Satisfactory results have been shown with laparoscopic reoperative surgery (Table 29.2). Detractors of the laparoscopic approach for reoperative surgery are concerned primarily about incomplete dismantling of the fundoplication. This can be difficult, as the posterior wing is often densely adherent to the crural closure and retroperitoneum. Safe dissection in this area is not possible for inexperienced surgeons. However, after mobilization, an intraoperative endoscopy with full insufflation and the J-maneuver can prove or disprove complete dismantling. If blood is seen within the lumen, one should check carefully for a perforation. Obviously, if the stomach cannot be inflated fully then a larger perforation may be present. Vagal-nerve injury is also a concern, as the nerve is not palpated so easily during laparoscopic surgery. Attention to detail and sharp dissection immediately adjacent to identifiable structures will usually prevent this complication. If there is suspicion of a vagal nerve injury, then percutaneous endoscopic gastrostomy placement is appropriate at the end of the operation.

Table 29.1 Reported series of reoperations with more than 30 cases Reference

a

Cases (n)

More than one prior repair

Skinner (1967)28 Orringer (1972)29

43 45

0 0

Hill (1971)30 Polk (1980)31

63 36

12 28

Henderson and Marryatt (1981)32 Maher et al. (1984)33 Little et al. (1986)34 Stirling and Orringer35

121 55 61 87

0 6 27 25

Pearson et al. (1987)36 Low et al. (1989)37 Siewert et al. (1995)38 Stein et al. (1996)39 Ellis et al. (1996)40 Deschamps et al. (1997)41

118 116 50 71 101 185

22 9 11 43

Mortality (%) 3 0 3 4 0 0 4 5 3 0 0 3 2 1 1 0.5

Good/excellenta (%)

Satisfactoryb (%)

73 85 81 80 50 94 80 72 67 76 80 86 70 86 80 88

Combined total of excellent and good results; bcombined total of excellent, good and fair results; fair results imply significant symptoms.

Table 29.2 All published series of laparoscopic reoperation anti-reflux repairs Reference

Repairs (n)

DePaula et al. (1995)17

19

5

9 8

0 25

Watson et al. (1999)43

27

22

Alexander et al. (1996)44 Croce et al. (1997)45 Schauer et al. (1999)46

2 5 22

0 20 4.5

Gastric strangulation preventing safe mobilization of the distal esophagus – Dense adhesions between left lobe of liver and stomach Intra-abdominal adhesions, perihiatal adhesions – Intrathoracic cuff and short esophagus Not mentioned

Curet et al. (1999)47

27

3.7

Poor visualization, gastric perforation

Soper et al. (1999)21 Floch et al. (1999)48

6 46

16.6 20

Szwerc et al.(1999)49

15

0

Pointner et al. (1999)50

30

7

Hunter et al. (1999)51

75

8

Awad et al. (2001)52

38

13

Serafini et al. (2001)53

28

7

Frantzides and Carlson (1997)8 O’Reilly et al. (1997)42

PEH, para-esophageal hernia.

Conversion (%)

Cause

Dense mediastinal adhesions Adhesions, bleeding, perforation, tension pneumothorax – Bleeding from the spleen, gastric perforation Adhesion, gastric perforation Adhesions, bleeding, big PEH, calcified Angelchik prosthesis Dense adhesions

Complications (%)

Results (%)

Follow-up (months)

Intraoperative, 15.8; postoperative, 21 Postoperative, 100 Intraoperative, 33; postoperative, 16.6 0

Excellent (84.3)

Mean 13 (range 1–26)

Excellent (100) Excellent (100)

Range 4–14 Range 12–42

Good (92.6)

Median 12 (range 3–48)

Excellent (100) Excellent (100) Excellent (73); fair (27)

Not clear Range 6–20 Mean 5.7 (range 0–14)

Excellent (96); fair (4)

Mean 22 (range 1–60)

Excellent (75); poor (25) Significant improvement in wellbeing score Significant improvement in symptom score Significant improvement in quality of life Excellent/good (87); fair/poor (13) Excellent (65); fair (21.5); poor (13.5) Excellent (89); fair (11)

Not mentioned 17.1 ⫾ 11.8

0 0 Intraoperative, 13.6; postoperative, 4.5 Intraoperative, 44.4; postoperative, 44.4 0 Intraoperative, 30.4; postoperative, 20 0 Intraoperative, 18 Intraoperative, 2.6; postoperative, 5 Intraoperative, 16; postoperative, 38 Intraoperative, 46; postoperative, 21

⬎3 Median 29 (range 12–45) Not clear Mean 26.5 (range 4–101) Mean 20 ⫾ 14


As more series of reoperative laparoscopic surgery become available for review, a consensus concerning treatment for the various mechanisms of failure should result. Until that time, careful attention to preoperative evaluation, intraoperative technical detail, and postoperative care are necessary to minimize the morbidity of anti-reflux surgery.

20

21 22

23

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3

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6

7

8 9

10

11 12

13

14

15 16

17

18 19

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sensory function of the proximal stomach. Br J Surg 2000; 87: 338–43. Dallemagne B, Weerts JM, Jehaes C, Markiewicz S. Causes of failures of laparoscopic antireflux operations. Surg Endosc 1996; 10: 305–10. Soper NJ, Dunnegan D. Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–76. Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc 1997; 11: 769–71. Paul MG, DeRosa RP, Petrucci PE. Laparoscopic tension-free repair of large paraesophageal hernias. Surg Endosc 1997; 11: 303–7. Johnson AB, Oddsodottir M, Hunter JG, et al. Laparoscopic Collis gastroplasty and Nissen fundoplication. A new technique for the management of esophageal foreshortening. Surg Endosc 1998; 12: 1055–60. Ritter MP, Peters JH, DeMeester TR, et al. Treatment of advanced gastroesophageal reflux disease with Collis gastroplasty and Belsey partial fundoplication. Arch Surg 1998; 133: 523–9. Awad ZT, Mittal SK, Roth TA, et al. Esophageal shortening during the era of laparoscopic surgery. World J Surg 2001; 25: 558–61. Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and fundoplication for complex reflux problems. Ann Surg 1987; 206: 473–81. Skinner DB. Surgical management of esophageal reflux and hiatal hernia: long term results with 1,030 patients. J Thorac Cardiovasc Surg 1967; 53: 33–54. Orringer MB. Long-term results of the Mark IV operation for hiatal hernia and analyses of recurrences and their treatment. J Thorac Cardiovasc Surg 1972; 63: 25–33. Hill LD. Management of recurrent hiatal hernia. Arch Surg 1971; 102: 296. Polk HC. Jejunal interposition for reflux esophagitis and esophageal stricture unresponsive to valvuloplasty. World J Surg 1980; 4: 731. Henderson RD, Marryatt G. Recurrent hiatal hernia. Management by thoracoabdominal total fundoplication gastroplasty. Can J Surg 1981; 24: 151–7. Maher JW, Hocking MP, Woodward ER. Reoperation for esophagitis following failed antireflux procedures. Ann Surg 1984; 201: 723–7. Little AG, Ferguson MK, Skinner DB. Reoperation for failed antireflux operations. J Thorac Cardiovasc Surg 1986; 91: 511–17. Stirling MC, Orringer MB. Surgical treatment after the failed antireflux operation. J Thorac Cardiovasc Surg 1986; 92: 667–72. Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and fundoplication for complex reflux problems. Ann Surg 1987; 206: 473–81. Low DE, Anderson RP, Ilves R, Hill LD. 15 to 20 year results after the Hill operation. J Thorac Cardiovasc Surg 1989; 98: 444. Siewert JR, Stein HJ, Feussner H. Reoperations after failed antireflux procedures. Ann Chir Gynaecol 1995; 84: 122. Stein HJ, Feussner H, Siewert JR. Failure of antireflux surgery: causes and management strategies. Am J Surg 1996; 171: 36–40. Ellis FH, Gibb SP, Heatley GJ. Reoperation after failed antireflux surgery: review of 101 cases. Eur J Cardiothorac Surg 1996; 10: 225–33. Deschamps C, Trastek VF, Allen MS, et al. Long term results after reoperation for railed antireflux procedures. J Thorac Cardiovasc Surg 1997; 113: 545–51. O’Reilly MJ, Mullins S, Reddick EJ. Laparoscopic management of failed antireflux surgery. Surg Laparosc Endosc 1997; 7: 90–3. Watson DI, Jamieson GG, Game PA, et al. Laparoscopic reoperation following failed antireflux surgery. Br J Surg 1999; 86: 98–101.

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Alexander HC, Hendler RS. Laparoscopic reoperation on failed antireflux procedures: report of two patients. Surg Laparosc Endosc 1996; 6: 147–9. Croce E, Azzola M, Russo R, et al. Laparoscopic re-operation from gastro-oesophageal reflux. Hepatogastroenterology 1997; 44: 912–17. Schauer PR, Ikramuddin S, Piskun G, et al. Reoperative laparoscopic antireflux surgery. Surg Endosc 1999; 13: S40. Curet MJ, Josloff RK, Schoeb O, Zucker KA. Laparoscopic reoperation for failed antireflux procedures. Arch Surg 1999; 134: 559–63. Floch NR, Hinder RA, Klingler PJ, et al. Is laparoscopic reoperation for failed antireflux surgery feasible? Arch Surg 1999; 134: 733–7.

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Szwerc MF, Wiechmann RJ, Maley RH, et al. Reoperative laparoscopic antireflux surgery. Surgery 1999; 126: 723–8. 50 Pointner R, Bammer T, Then P, Kamolz T. Laparoscopic refundoplications after failed antireflux surgery. Am J Surg 1999; 178: 541–4. 51 Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 1999; 230: 595–604. 52 Awad ZT, Anderson PI, Sato K, et al. The laparoscopic reoperative antireflux surgery. Surg Endosc 2001; 15: 1401–7. 53 Serafini FM, Bloomston M, Zervos E, et al. Laparoscopic revision of failed antireflux operations. J Surg Res 2001; 95: 13–18.


30 Reoperation for recurrent gastroesophageal reflux disease THOMAS R. EUBANKS

Characterizing failure Patient selection Operative strategy

227 230 230

Successful reoperative anti-reflux procedures are based on three principles: precise characterization of the original procedure’s failure, appropriate patient selection, and operative intervention capable of repairing the failure. More than 30 000 anti-reflux procedures were performed in the USA in 1998, with the number expected to go well above 50 000 annually in the early 2000s. Symptomatic failure rates of operative intervention range between seven and 15 per cent. Reoperation is required in 1–3.5 per cent of patients,1–3 thus 500–1750 patients will undergo reoperative anti-reflux surgery each year. Symptoms of failed anti-reflux procedures can be divided into three categories: those that are too tight, those that are too loose, and those that are malpositioned. The first are characterized by dysphagia and regurgitation of undigested material, the second by recurrent heartburn and regurgitation, and the third by chest pain, abdominal pain and, occasionally, dysphagia. Although symptoms provide a clue to the etiology of the failed initial procedure, objective assessment is required before planning any further operative intervention.


234 234

Esophagitis confirms uncontrolled acid reflux. A tortuous path of the distal esophagus implies abnormalities of fundoplication position. In some cases, a large paraesophageal hernia can be documented (Figure 30.1).

CHARACTERIZING FAILURE The objective assessment of a patient being considered for reoperative treatment should include endoscopy, esophagography, esophageal physiological studies, and, when indicated, solid-phase gastric-emptying studies. Endoscopy is useful to assess the state of the esophageal mucosa and the orientation of the fundoplication.

Figure 30.1 Retroflexed view of the gastroesophageal junction at endoscopy. The lesser curve is at the bottom of the photograph. The bulging mucosa above the crus is caused by extrinsic compression of the heart on the herniated stomach. This is a large para-esophageal hernia after an anti-reflux operation.


However, a twisted fundoplication or two-compartment stomach can also be identified as causes for failure during endoscopy.3 Contrast esophagography is undoubtedly the most valuable anatomical study for evaluating symptoms after anti-reflux surgery. This study shows the positional

Figure 30.2 Early phase of an esophagogram in the same patient as in Figure 30.1. The contrast is flowing through the esophagus, which is slightly distorted by the large para-esophageal hernia. Air in the herniated stomach can be seen in the mediastinum. Note the location of the diaphragm. The gastroesophageal junction appears to be in the abdomen.

relationships between the esophagus, hiatus, stomach and fundoplication. Figure 30.2 shows early images of contrast flowing past the cardia of the stomach and into the body. An air-filled fundus can be seen in the posterior mediastinum, well above the hiatus. Figure 30.3 demonstrates later images of the same study with contrast in the fundus, confirming its position in the mediastinum. The most common reasons for failure of anti-reflux procedures can be identified on contrast

Figure 30.3 Later images in the study shown in Figure 30.2. The contrast has been cleared from the esophagus and is now present in the herniated portion of the stomach. The compression of the stomach caused by the hiatus is evident.

Figure 30.4 Esophageal manometry tracing, demonstrating normal propagation of peristalsis along the esophageal body. The patient had occasional decreased amplitudes in the distal esophagus (⬍60 mmHg).

Reoperation for recurrent gastroesophageal reflux disease 229

esophagography: transdiaphragmatic herniation, slipped fundoplication, twisted fundoplication, and tight fundoplication. The addition of a marshmallow swallowed during the study also gives a good impression of lower esophageal relaxation. Esophageal manometry is essential in all patients being evaluated for postoperative symptoms. In patients with dysphagia and chest pain, manometry identifies motility (physiological) abnormalities. Manometry will also help in planning the operative strategy to correct the failed procedure. A patient with poor motility may not be a candidate for a ‘redo’ 360-degree fundoplication. Figure 30.4 shows a typical esophageal body tracing, with occasional decreased amplitudes of peristalsis in the distal esophagus, but confirms the presence of peristalsis, a feature required to proceed with an anti-reflux procedure.

The lower esophageal sphincter (LES) pressure also provides helpful information. A defective sphincter supports the diagnosis of a loose fundoplication in patients with symptoms of recurrent reflux. A non-relaxing sphincter or a sphincter with extremely high pressures confirms a fundoplication that is too tight. Figure 30.5 demonstrates normal LES pressure and relaxation in a patient with symptoms of chest pain after a fundoplication, but no symptoms of reflux. Twenty-four-hour pH monitoring is important in all patients (Figure 30.6). Although the symptom of heartburn would seem to be an accurate predictor of postoperative acid exposure, 50 per cent of patients who complain of heartburn after a fundoplication will have normal acid exposure on pH testing.4 Half of the patients who complain of heartburn but have normal acid exposure will have other etiologies identified as a cause of

Figure 30.5 Manometry tracing showing a normal LES pressure (17–18 mmHg) with complete relaxation during deglutition.

Figure 30.6 Twenty-four-hour pH testing, showing normal amounts of acid reflux in both proximal and distal channels.


their symptoms (esophageal motility abnormalities, cardiac dysrhythmia, irritable bowel syndrome). In those patients who do not complain of heartburn, the study is useful in documenting subclinical, abnormal acid exposure, which can be present in 20 per cent of cases.4 Solid-phase gastric-emptying studies are helpful in patients who complain of bloating. These studies do not document vagal injury at the previous operation but they do raise the suspicion of this. Many surgeons will add a pyloroplasty to the reoperation if the study is abnormal; however, dumping syndrome may occur in up 30 per cent of patients.5 If the stomach is atonic, then the patient may not be amenable to reoperative anti-reflux surgery but instead may require gastrectomy. Objective testing helps to confirm the clinical suspicion of failure of the previous operation and can influence the strategy of the planned corrective procedure. The objective findings should support the clinical suspicion. A patient with symptoms of reflux (heart burn and regurgitation) will have different objective findings compared with a patient with dysphagia and postprandial chest pain.

PATIENT SELECTION Laparoscopic revision of anti-reflux procedures is becoming more common, regardless of whether the original procedure was performed via laparotomy or laparoscopy.1–3,6,7 The surgeon should be comfortable with the laparoscopic approach in its use for the initial anti-reflux procedures before proceeding with ‘redo’ operations. The selection process in a case with an obvious anatomical defect is straightforward. With such distorted anatomy, the patient and surgeon can be confident that the repair of the defect will improve symptoms. Less subtle defects, such as a small posterior herniation, are unlikely to be the cause of significant symptoms, and reoperation is indicated rarely in these cases. In patients with recurrent symptoms of reflux and a fundoplication that is too loose, the decision to reoperate is difficult. Symptom control after reoperative therapy is significantly less than after the initial operation.7 Furthermore, reoperative anti-reflux surgery normalizes acid exposure in 74 per cent of patients compared with 83 per cent in primary operations.4 The medical management of such a patient is often successful and obviates the need for operative intervention. Patients with obstructive symptoms caused by a tight fundoplication (not malposition) may benefit from endoscopic dilation. Early dilation (two to six weeks postoperatively) can reduce the need for operative intervention when symptoms are severe. Up to four per cent of all patients undergoing anti-reflux procedures will require endoscopic dilation, but only one per cent will need operative revision for dysphagia alone.7

Regardless of the reason for reoperation, the complication rates are significantly higher for ‘redo’ procedures. Major operative complications, such as visceral injury, and postoperative problems, such as dysphagia requiring dilation, occur twice as often during or following reoperations compared with primary procedures.8

OPERATIVE STRATEGY The patient is placed in the low lithotomy position. The surgeon stands between the patient’s legs. The assistant stands on the patient’s left. A static liver retractor (endoscope holder) is attached to the right side of the operating table. A single monitor may be placed at the right shoulder of the patient. Electrocautery (thin avascular tissues) and ultrasonic (thick vascular tissues) dissection capabilities are required. Five laparoscopic ports are used. The equipment available dictates the size of the ports. If a high-quality, 5-mm laparoscope, a flexible 5-mm liver retractor, and a 5-mm ultrasonic dissector are available, then all five ports may be 5 mm in size; otherwise, several of the ports may need to be larger. Although each case is unique, the operative strategy is based on complete restoration of the anatomy prior to the repair of the hernia. The procedure can be divided into three steps: initial dissection, unwrapping, and rewrapping.

Initial dissection The first objective is to free the viscera from the hiatus. Often, this requires mobilization of the inferior aspect of the left lobe of the liver from the fundoplication. The two most common planes encountered during this dissection are the subcapsular plane of the liver and the subserosal plane of the stomach. Neither is desired, and both are characterized by the presence of unexpected bleeding. Anterior traction of the liver edge and counter traction on the stomach facilitate the dissection. Infusing saline irrigant under modest pressure (hydrodissection) can help to develop the proper plane. After the liver is freed, the next move is to separate the crura from the fundus/esophagus complex. The dissection can be initiated at any point in which the anatomy is discernable. In Figure 30.7, the intraoperative view demonstrates a large para-esophageal hernia with relatively few adhesions to the liver. The left crus and omental attachments to the greater curve could be discerned easily. The adhesions between the omentum and proximal greater curve are divided with electrocautery. Since the short gastric vessels were divided at the original operation, this plane was avascular (Figure 30.8). The para-esophageal hernia allowed a clear view of the anterior aspect of the


Figure 30.7 Initial intraoperative view of the esophageal hiatus, demonstrating the large para-esophageal hernia. The liver is out of view to the left, the spleen to the right. Note the adhesions to the pericardium at the top of the photograph, which correspond with the endoscopy images in Figure 30.1.

Figure 30.9 Dissection of right crus. The lesser omentum has already been divided (caudate lobe is visible) and adhesions of subhiatal fat and greater omentum are being freed.

mobilization of the esophagus allows identification of the anterior and posterior vagii. If the esophagus is difficult to identify due to adhesions, then a lighted bougie may be passed into the lumen via the mouth. With the anterior esophageal wall exposed in the mediastinum and the anterior surface of the stomach identified, the surgeon can visualize the relative depth of the dissection required to undo the fundoplication.

Unwrapping

Figure 30.8 Division of the adhesions between the omentum and the greater curve of the stomach. This plane is usually avascular if the short gastric vessels are divided at the original operation.

crural arch, thus the dissection is carried out from left to right. The plane between the right crus and the portion of herniated stomach is shown in Figure 30.9. In paraesophageal hernias occurring after previous anti-reflux surgery, no hernia sac will be encountered. Freeing the fundoplication/esophageal complex from the crura is an extremely important step for two reasons: it provides visual confirmation of the course of the esophagus as it travels into the fundoplication and it is a safe step, as the fundoplication provides a buffer for errant dissection and thus aids in the avoidance of esophageal injury. Once the fundoplication/esophageal complex is circumscribed by surgical tubing, further mediastinal

The anterior portion of the fundoplication can usually be elevated from the body of the stomach lateral to the sutures forming the fundoplication. The surgeon then locates the inferior extent of the fundoplication and places traction on the right portion of the fundus while the assistant places traction on the left. A bougie placed in the esophagus provides a detectable firmness to the esophagus. The surgeon and the assistant elevate their respective aspects of the fundus anteriorly and inferiorly. Electrocautery, ultrasonic or sharp dissection is then carried out from the inferior aspect of the fundoplication to the superior aspect. This plane is avascular and the sutures used to construct the prior fundoplication are encountered (Figure 30.10). Esophageal and vagal injury can be avoided at this step if the surgeon and assistant focus on proper traction upon the fundoplication. When the sutures have been divided and the dissection plane is continued to the previously dissected mediastinal esophagus, the fundus should be freed from the cardioesophageal junction. With the bougie still in place, the surgeon elevates the right aspect of the fundoplication while the assistant provides counter-traction on the cardia and the anterior vagus. The right portion of the


(a)

Figure 30.10 Close view of the sutures used to create the fundoplication at the original operation. The grasper is used to retract the suture while it is dissected. Encountering sutures is reassuring during this part of the dissection as it confirms the proper dissection plane.

(b)

Figure 30.11 Mobilization of the right portion of the fundoplication. This is an essential step required to restore the original anatomy. The anterior vagus is at risk during this portion of the operation. (c)

fundus is freed from the anterior aspect of the cardia and esophagus, preserving the anterior vagus (Figure 30.11). This dissection is carried as far posteriorly as possible. The ideal dissection would extend just to the left of the posterior vagus. As the right aspect of the fundus is passed from right to left, through the retro-esophageal space, the entire fundus and gastric body are freed from the hiatal defect (Figure 30.12). Dissection of the left aspect of the fundoplication does not involve as much work as the right aspect, but it is just as important. The assistant provides the traction on the fundus and the surgeon provides the traction on the

Figure 30.12 Series of photographs demonstrating the extent of stomach herniation. The grasper in (a) remains attached to the same portion of stomach throughout the series. The hiatal defect can be appreciated in (c).

cardia. Once the fundus is restored to its anatomical position, the cardiac notch should be clearly identifiable, as should the smooth transition from the right edge of the esophagus to the lesser curve of the stomach. Hopefully, the anterior and posterior vagii are visible and intact. With traction applied to the esophagus using surgical tubing, the esophagus is mobilized from its mediastinal


Figure 30.13 The esophagus has been mobilized from the mediastinum until 3 cm of intra-abdominal esophagus rests in the abdomen without tension.

Figure 30.14 Closure of the hiatal defect. The first suture has been placed and is about to be cut.

attachments (Figure 30.13). This allows the gastroesophageal junction to return to an intra-abdominal position. Although it is often tempting to avoid complete dissection of the esophagus and stomach during a ‘redo’ operation, the surgeon should recall that the best opportunity for success lies in the first ‘redo’ procedure. Subsequent procedures have lower success rates and higher complication rates.

Rewrapping The ‘redo’ fundoplication is performed similarly to a primary operation. Techniques to prevent recurrent herniation should be emphasized. These include adequate esophageal mobilization, hiatal closure, and anchoring the fundoplication to the crura. The crura are re-approximated to decrease the hiatal opening (Figure 30.14). The fundoplication is re-created by passing the posterior aspect of the fundus from left to right through the retro-esophageal space and approximating it to the anterior aspect of the fundus (Figure 30.15). Figure 30.16 shows the completed fundoplication, which is 3 cm long. The fundoplication is then anchored to the hiatus to help prevent recurrent herniation (Figure 30.17). Figure 30.18 shows the completed fundoplication with the crural closure sutures, fundoplication sutures, and anchoring sutures visible. Intraoperative endoscopy showed an intact flap valve, a symmetric fundoplication, and the absence of the para-esophageal hernia (Figure 30.19). The anchoring sutures help to secure the fundoplication to the hiatus. Since herniation is the most common cause of reoperative hiatal hernia surgery, these sutures may also be important for initial operations. Four to six sutures are placed between the fundoplication and the crura. The extreme

Figure 30.15 Re-creating the fundoplication using the posterior (left) and anterior (right) portions of the fundus. The esophagus and subhiatal fat are in the center, encircled by the surgical tubing.

Figure 30.16 The fundoplication is complete. Four sutures placed 1 cm apart are shown securing the right and left portions of the fundoplication.


Figure 30.17 The left portion of the fundoplication is being anchored to the anterior portion of the left crus.

Figure 30.19 Intraoperative endoscopy shows the corrected flap valve and the repaired para-esophageal hernia.

consisting of liquids the first week and advancing to regular food by the fourth week is prescribed.

CONCLUSION Effective reoperative anti-reflux surgery can be expected if the reason for failure of the previous operation is known, if it correlates with the patient’s symptoms, and if it is correctable. Figure 30.18 Completed procedure. This view demonstrates the hiatal closure sutures, several of the anchor sutures (fundoplication to hiatus), and the fundoplication sutures.

REFERENCES 1

right and left sutures can incorporate the muscular wall of the esophagus if it is not too ragged from the previous dissection. The anterior and posterior sutures should not incorporate the esophagus, to avoid injuring the vagii. Postoperative care for reoperative anti-reflux procedures is the same as that for patients undergoing primary repairs. Gastric decompression tubes are not used. Patients are allowed liquids by mouth on the day of the operation. Pharmacological agents are used to suppress nausea and emesis. Once the patient is ambulating and oral elixirs are controlling postoperative pain, the patient is discharged from hospital. Patients are instructed to limit exertion (lifting ⬍7 kg) to minimize intra-abdominal pressure. A graduated diet

2 3

4 5 6 7

8

Horgan S, Pohl D, Bogetti, D, et al. Failed anti-reflux surgery: what have we learned from reoperations? Arch Surg 1999; 134: 809–17. Soper NJ, Dunnegan D. Anatomic fundoplication failure after laparoscopic anti-reflux surgery. Ann Surg 1999; 229: 669–77. Hunter JG, Smith D, Branum GD, et al. Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 1999; 230: 595–606. Eubanks TR, Omelanczuk P, Richards C, et al. Outcomes of laparoscopic anti-reflux procedures. Am J Surg 2000; 179: 391–5. Rieger NA, Jamieson GG, Britten-Jones R, Tew S. Reoperation after failed anti-reflux surgery. Br J Surg 1994; 81: 1159–61. Watson DI, Jamieson GG, Game PA, et al. Laparoscopic reoperation following failed anti-reflux surgery. Br J Surg 1999; 86: 98–101. Hinder RA, Klingler PJ, Perdikis G, Smith SL. Management of the failed anti-reflux operation. Surg Clin North Am 1997; 77: 1083–1098. Pohl D, Eubanks TR, Omelanczuk PE, Pellegrini CA. Management and outcome of complications after laparoscopic anti-reflux operations. Arch Surg 2001; 136: 399–404.

31 Results of laparoscopic treatment of hiatal hernias PATRICK R. REARDON AND STIRLING E. CRAIG

Type I hiatal hernia repair Types II, III and IV hiatal hernia repair

235 236

Four types of hiatal hernias exist. With type I or sliding hiatal hernias, the most common type, the gastroesophageal junction is displaced cranially into the chest. Type II and type III hiatal hernias are para-esophageal hernias. In type II hiatal hernias, the gastroesophageal junction is in its native position, inferior to the diaphragm. The fundus, and sometimes the body and antrum of the stomach, have rolled cranially into the mediastinum. Type III hiatal hernias are mixed para-esophageal hernias. In these hiatal hernias, both the gastroesophageal junction and a large portion of the stomach have rolled into the mediastinum. Type IV hiatal hernias include the spleen, the colon, or some other intra-abdominal organ within the hernia. When discussing outcomes for laparoscopic repair of hiatal hernias, the results should focus on two groups of patients. The first group comprises patients with type I hiatal hernias, which account for 90–95 per cent of all hiatal hernias. These hernias are generally asymptomatic and do not require repair. They are repaired primarily as part of a fundoplication to treat gastroesophageal reflux disease. Most surgeons mobilize the distal esophagus in order to achieve intra-abdominal esophageal length. This process destroys the phreno-esophageal ligament. At this point, the anatomy resembles the anatomy in the repair of a small type I hiatal hernia. Therefore, the outcomes for the repair of these hernias are essentially the same as outcomes for laparoscopic 360-degree fundoplication. The second group comprises patients with types II, III or IV hiatal hernias. These tend to be larger hernias occurring in an older patient population and have different outcomes. In an online PubMed literature search using the keywords ‘hiatal hernia’ and ‘laparoscopic’, 220 citations

References

237

were returned. There were no results that dealt specifically with type I hiatal hernias. There were multiple articles on type II, type III, and giant hiatal hernias.

TYPE I HIATAL HERNIA REPAIR Intraoperative complications reported during laparoscopic 360-degree fundoplication include esophageal perforation,1–3 gastric perforation,1,2 pneumothorax,2 bleeding,2 and conversion to open procedure.2–4 These complications should not be affected by small hiatal hernias. The intraoperative complications of type I hiatal hernia repair are outlined in Table 31.1. Postoperative complications include atelectasis, gastric perforations,4 dysphagia,3,4 substernal chest pain,3,4 heartburn,3,4 regurgitation,3,4 early satiety,3 death,2 and recurrent hiatal hernia.4 The likelihood of a recurrent hiatal hernia following a laparoscopic 360-degree fundoplication with a small hiatal hernia or no hiatal hernia is affected by whether the crura are closed. Crural closure has been documented to reduce the occurrence of recurrent hiatal hernias.4–7 Larger hiatal hernias are also Table 31.1 Type I laparoscopic hiatal hernia repair Intraoperative complications

Percentage

Esophageal perforation Gastric perforations Pneumothorax Bleeding

0.2–3.03,1 1.61 ?2 ?,2 1.030

Superscript figures indicate references. ? ⫽ reported without a percentage.

236 Laparoscopic treatment of diaphragmatic herniation Table 31.2 Type I laparoscopic hiatal hernia repair Postoperative complications

Percentage

Gastric perforation Dysphagia Substernal chest pain Heartburn Regurgitation Early satiety Atelectasis Pneumothorax Wound infection Postoperative herniation Death

0.3,4 1.06 7.2,4 4.9,6 4.8,3 9.031 16.9,4 8.0,3 22.031 5.2,4 2.8,3 12.031 3.5,4 5.43 15.63 ?31 16 130 6.2,4 1.0,6 3.4,31, 5.030 0.31

Superscript figures indicate references. ? ⫽ reported without a percentage.

associated with an increased likelihood of recurrent hiatal hernia.5 Most larger hiatal hernias, however, are type II, III or IV. The postoperative complications of type I hiatal hernia repair are outlined in Table 31.2.

TYPES II, III AND IV HIATAL HERNIA REPAIR Laparoscopic repair of a large para-esophageal hernia is a technically difficult operation and should be performed only by a surgeon with significant experience of performing standard laparoscopic 360-degree fundoplications in patients with no or small type I hiatal hernias. Large hiatal hernias tend to occur in older patients with significant associated comorbidities, which make them higher operative risks. In addition, because of the rotation of the stomach up into the mediastinum, identification of the anatomy is difficult. The larger hernia sacs may obscure the location of the esophagus and vagus nerves, and these structures are injured more easily in the repair of large or para-esophageal hernias. The intraoperative complications of types II, III and IV hiatal hernias are outlined in Table 31.3. Intraoperative complications include esophageal perforations,8–12 enterotomy,8 gastric perforations,8,9,13–15 pneumothorax,9,13 hypercarbia,13 vagus nerve injury,13 bleeding,11 tearing of the right crus,15 gastric leak,16 myocardial infarction,8 cardiac arrest, pulmonary embolism,8 and death due to pulmonary embolism. When recognized and repaired intraoperatively, perforations of the esophagus, stomach and intestine add very little morbidity.5 Delayed recognition of a perforation of a hollow viscus is associated with significant morbidity and a prolonged hospital stay.1,2 Most cases of pneumothorax do not involve an actual lung injury. Most are due to inadvertent injuries to the mediastinal pleura during dissection in the chest. Most contain only carbon dioxide. Whenever possible, a recognized pleural injury should be oversewn. Positive-pressure ventilation using a positive end expiratory pressure (PEEP)

Table 31.3 Types II, III and IV laparoscopic hiatal hernia repair Intraoperative complications Esophageal perforation Gastric perforations Enterotomy Pneumothorax Hypercarbia Vagus nerve injury Bleeding Tear of the right crus Cardiac arrest Death (due to a pulmonary embolism)

Percentage 4.0,32 1.9,8 5.0,9 2.3,10 8.3,11 0.512 1.6,32 10.0,14 1.8,13 3.09 3.88 3.6,13 4.0,9 0.832 1.813 1.8,13 1.210 2.715 0.832 1.813

Superscript figures indicate references.

valve during the operation and high-volume ventilation during desufflation of the abdomen will usually obviate the need for any treatment. Hypercarbia is more common in the repair of these large hiatal hernias due to the extensive dissection within the mediastinum leading to increased absorption of carbon dioxide. The problem may be exacerbated by the frequent occurrence of emphysema or chronic obstructive pulmonary disease in these elderly patients. During dissection of the large sac associated with these hernias, bleeding may occur.5,11 Vagus nerve injuries may occur secondary to failure to recognize the esophagus and vagus nerves within the sac.13 Cardiac arrest, and death due to pulmonary embolism or other causes are rare occurrences intraoperatively.13 Numerous postoperative complications have been reported following laparoscopic repair of para-esophageal hernias. Some of these complications are minor, but many of them are severe. Many of these complications are related to the fact that these patients present in the sixth and seventh decades of life. Frequently, the patients are frail and present with significant other diseases. Some of the complications may be related to failure to perform an anti-reflux procedure at the time of the hernia repair. The postoperative complications are outlined in Table 31.4. The need to perform anti-reflux procedures at the same time remains a controversial issue. Some of the most common symptoms reported after these procedures, such as dysphagia, are related directly to the performance of an anti-reflux procedure. Hernia recurrence remains a problem in laparoscopic hiatal hernia repair. Symptomatic hernias represent only a fraction of the total number of recurrences,5,17,18 and therefore, recurrences in many series may be underreported. Hernia recurrence is more common in paraesophageal hernias than in type I hernias. The larger the hernia, the more likely is the recurrence.4 Factors associated with increased recurrence include a failure to excise the hernia sac,10,15,19 breakdown of the crural repair,20 shortened esophagus, and large hiatal defects with an inability to

Results of laparoscopic traeatment of hiatal hernias 237 Table 31.4 Types II, III and IV laparoscopic hiatal hernia repair Postoperative complication

Percentage

Esophageal perforation Gastric perforations Esophageal stricture Gastric obstruction Acute gastric dilation Delayed gastric emptying Prolonged gastric atony Mesh erosion into stomach Prolonged ileus Small-bowel obstruction Dysphagia

1.333 0.8,32 1.98 2.633 1.210 1.3,33 8.337 1.813 2.6,33 16.737 2.321 1.0,9 2.715 1.536 3.6,13 20.0,14 6.0,8 21.0,10 8.3,11 1.612 1.8,13 20.0,14 10.0,8 41.7,11 3.712 19.08 1.112 29.08 10.014 37.5,39 48.834 8.337 3.210 10.0,24 8.3,37 10.0,38 3.718 3.5,10 8.311 1.09 0.8,32 4.09 1.813 2.0,9 1.210 1.8,13 1.9,8 3.0,9 1.210 1.6,32 1.9,8 1.09 6.0,9 16.711 1.813 1.3,33 1.836 3.718 1.09 1.09 3.718 8.311 3.718 0.512 1.8,36 2.923 1.09 7.4,18 2.321 0.8,32 0.512 2.0,9 0.512 4.621 1.09 1.333 2.715 3.6,13 10.0,14 8.0,8 1.0,9 3.5,10 1.112 2.4,32 0.512

GERD symptoms Early satiety Gas bloat Hyperflatulence Mediastinal seroma Transient cervical emphysema Breast mastalgia Pneumothorax Atelectasis Pneumonia ARDS Pleural effusion Respiratory failure Deep vein thrombosis Pulmonary embolus Myocardial infarction Atrial fibrillation Cardiac arrhythmia Congestive heart failure Cardiac tamponade Stroke Hematoma Hemothorax Bleeding Retroperitoneal bleeding Need for transfusion Urinary retention Transient renal failure Urinary-tract infection Mediastinal abscess Intra-abdominal abscess Wound infection Clostridium difficile colitis Fever of unknown origin Incisional hernia Postoperative herniation Death Superscript figures indicate references.

achieve a tension-free repair. Recently, there have been increasing reports in the literature of the use of mesh in an attempt to decrease the recurrence rate following repairs of hiatal hernias.16,20–28 The mesh may be placed centrally as a bolster to an already closed hiatus.16,23,26,28 The mesh may be used to span the hiatal defect to create a truly tensionfree repair.16,20,29 The mesh may also be used to close a relaxing incision placed laterally in the tendinous diaphragm. Overall, the surgical literature supports the belief that the laparoscopic repair of para-esophageal and hiatal hernias is technically feasible, safe and effective. Given the age and condition of the patients, the morbidity and mortality rates are acceptably low. However, the recurrence rates in some series have been unacceptably high.18 Recent reports utilizing mesh to reduce the recurrence rate are promising and may help reduce the relatively high recurrence rate that has been the Achilles heel of laparoscopic hiatal hernia repair.

REFERENCES 1

2 3 4 5 6

7

8

9

10

11

12

13

14

Schauer PR, Meyers WC, Eubanks S, et al. Mechanisms of gastric and esophageal perforations during laparoscopic Nissen fundoplication. Ann Surg 1996; 223: 43–52. Bowrey DJ, Peters JH. Laparoscopic esophageal surgery. Surg Clin North Am 2000; 80: 1213–42, vii. Granderath FA, Kamolz T, Schweiger UM, et al. Long-term results of laparoscopic antireflux surgery. Surg Endosc 2002; 16: 753–7. Soper NJ, Dunnegan D. Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–76, 676–7. Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000; 80: 1243–52. Watson DI, Jamieson GG, Devitt PG, et al. A prospective randomized trial of laparoscopic Nissen fundoplication with anterior vs posterior hiatal repair. Arch Surg 2001; 136: 745–51. Seelig MH, Hinder RA, Klingler PJ, et al. Paraesophageal herniation as a complication following laparoscopic antireflux surgery. J Gastrointest Surg 1999; 3: 95–9. Swanstrom LL, Jobe BA, Kinzie LR, Horvath KD. Esophageal motility and outcomes following laparoscopic paraesophageal hernia repair and fundoplication. Am J Surg 1999; 177: 359–63. Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair of giant paraesophageal hernia: 100 consecutive cases. Ann Surg 2000; 232: 608–18. Watson DI, Davies N, Devitt PG, Jamieson GG. Importance of dissection of the hernial sac in laparoscopic surgery for large hiatal hernias. Arch Surg 1999; 134: 1069–73. Behrns KE, Schlinkert RT. Laparoscopic management of paraesophageal hernia: early results. J Laparoendosc Surg 1996; 6: 311–17. Livingston CD, Jones HL, Jr, Askew RE, Jr, et al. Laparoscopic hiatal hernia repair in patients with poor esophageal motility or paraesophageal herniation. Am Surg 2001; 67: 987–91. Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of paraesophageal hiatal hernias. J Am Coll Surg 1998; 186: 428–32, 432–3. Oddsdottir M, Franco AL, Laycock WS, et al. Laparoscopic repair of paraesophageal hernia. New access, old technique. Surg Endosc 1995; 9: 164–8.

238 Laparoscopic treatment of diaphragmatic herniation 15

16 17

18

19

20

21 22 23

Wu JS, Dunnegan DL, Soper NJ. Clinical and radiologic assessment of laparoscopic paraesophageal hernia repair. Surg Endosc 1999; 13: 497–502. Hui TT, Thoman DS, Spyrou M, et al. Mesh crural repair of large paraesophageal hiatal hernias. Am Surg 2001; 67: 1170–74. Velanovich V, Karmy-Jones R. Surgical management of paraesophageal hernias: outcome and quality of life analysis. Dig Surg 2001; 18: 432–7. Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of large type III hiatal hernia: objective followup reveals high recurrence rate. J Am Coll Surg 2000; 190: 553–60, 560–61. Edye M, Salky B, Posner A, Fierer A. Sac excision is essential to adequate laparoscopic repair of paraesophageal hernia. Surg Endosc 1998; 12: 1259–63. Basso N, Rosato P, De Leo A, et al. ‘Tension-free’ hiatoplasty, gastrophrenic anchorage, and 360 degrees fundoplication in the laparoscopic treatment of paraesophageal hernia. Surg Laparosc Endosc Percutan Tech 1999; 9: 257–62. Carlson MA, Richards CG, Frantzides CT. Laparoscopic prosthetic reinforcement of hiatal herniorrhaphy. Dig Surg 1999; 16: 407–10. Huntington TR. Laparoscopic mesh repair of the esophageal hiatus. J Am Coll Surg 1997; 184: 399–400. Frantzides CT, Richards CG, Carlson MA. Laparoscopic repair of large hiatal hernia with polytetrafluoroethylene. Surg Endosc 1999; 13: 906–8.

24 25

26

27

28

29 30 31

32

Athanasakis H, Tzortzinis A, Tsiaoussis J, et al. Laparoscopic repair of paraesophageal hernia. Endoscopy 2001; 33: 590–4. Casaccia M, Torelli P, Panaro F, et al. Laparoscopic physiological hiatoplasty for hiatal hernia: new composite ‘A’-shaped mesh. Surg Endosc 2002; 27: 27. Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc 1997; 11: 769–71. Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. A prospective, randomized trial of laparoscopic polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty for large hiatal hernia. Arch Surg 2002; 137: 649–52. Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic antireflux surgery with routine mesh-hiatoplasty in the treatment of gastroesophageal reflux disease. J Gastrointest Surg 2002; 6: 347–53. Paul MG, DeRosa RP, Petrucci PE, et al. Laparoscopic tension-free repair of large paraesophageal hernias. Surg Endosc 1997; 11: 303–7. Zornig C, Strate U, Fibbe C, et al. Nissen vs Toupet laparoscopic fundoplication. Surg Endosc 2002; 16: 758–66. Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg 1999; 230: 595–604, 595–604. Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of laparoscopic repair of paraesophageal hernia. Surg Endosc 2002; 16: 745–9.

32 Complications and their management SANTIAGO HORGAN AND ROBERT BERGER

Intraoperative complications Postoperative complications

239 243

Numerous reports detail the benefits of laparoscopic fundoplication, including decreased pain, quicker return to normal daily activities, and shorter hospital stay. However, there are also complications related to the treatment of gastroesophageal reflux disease (GERD). Mortality reports range from zero to two per cent for initial repairs, increasing to five per cent for second operations.1,2 The morbidity, and likewise failure, of laparoscopic fundoplication is dependent on its definition and length of follow-up. Most large, single-institution studies report morbidities of two to 26 per cent, with specific identification of failed surgery occurring in four to eight per cent.2–4 Table 32.1 displays the reported causes and frequencies of these failures (see also Chapter 29). This chapter discusses the more common intraoperative and postoperative complications associated with laparoscopic fundoplication, their prevention, the appropriate work-up for their diagnosis, and the appropriate course of action. In addition, any reoperation, whether laparoscopic or open, is known to have a higher incidence of complications as well as a higher risk of recurrence.5–7 It should be stressed that conversion from a laparoscopic to open surgery for patient safety should not be considered a complication if performed at the appropriate time.

INTRAOPERATIVE COMPLICATIONS The ability to adequately visualize and identify the anatomy required for performance of a Nissen fundoplication cannot be overemphasized. These concepts are discussed elsewhere and will not be re-addressed here. It is prudent, however, to state that our typical fundoplication is performed using a left crus approach, as described by Horgan


247 247

and Pellegrini.8 The left crus is initially identified, and the short gastric vessels are divided using an ultrasonic shears. A no-touch technique for esophageal dissection is used to minimize traumatic manipulation of the esophagus. This requires the crura to be separated from the esophagus, and not vice versa. After visualizing the right crura, circumferential dissection of the esophagus proceeds cephalad while using a Penrose drain to manipulate the esophagus. The posterior crura should be re-approximated with interrupted, nonabsorbable sutures to create a snug fit over a 56 French Maloney bougie placed within the esophagus. A short, floppy, 2-cm fundoplication with three sutures is created and secured to the esophagus but not to the crura or diaphragm. Table 32.1 Commonly reported complications and various case reports following laparoscopic Nissen fundoplication Complication

Incidence (%)

Case report

Failed Nissen Para-esophageal hernia Reoperation Dysphagia Heartburn/reflux Pneumothorax

4–8 0–7

Pneumomediastinum Pulmonary embolism

2–6 1–7 1–5 ⬍2

Gastric perforation

1.5

Delayed gastric emptying Splenectomy

1

Mesenteric thrombosis Hiatal stenosis Bowel perforation Delayed gastric perforation Cardiac laceration/tamponade Injury to major vessels

⬍1

Hemorrhage

0.5

Late diaphragmatic rupture Necrotizing fasciitis


Possible intraoperative complications are discussed below. This is followed by a discussion on ways to avoid encountering these problems initially and what to do if they are encountered.

Posterior esophageal dissection Factors causing increasingly difficult dissection of the esophagus include prior foregut surgery, extensive history of Barrett’s esophagus causing peri-esophagitis, and prior dilation treatments (in which microperforations may have occurred). Meticulous dissection and use of the Penrose drain will help to minimize this complication. In addition, the use of an angled scope (30 or 45 degrees) will assist in visualizing the posterior aspect of the esophagus. The ultrasonic shears are well suited for the lysis of adhesions, whereas monopolar cautery devices can allow for lateral thermal injury and potential delayed esophageal perforation. In addition, obese patients often have significant adipose tissue along the greater curve of the stomach. In these instances, it is best to place the patient in a steep reverse Trendelenburg position and place a 4 ⫻ 4 gauze within the abdomen, just medial to the superior tip of the spleen (Figure 32.1). This will assist in lateral retraction of the adipose for improved exposure of the left lateral and posterior aspects of the esophagus. Should perforation of the esophagus be suspected, then the anesthesiologist should be asked to place an orogastric or nasogastric tube and instill 60 cc of methylene blue to help localize any injury. If the surgeon cannot visualize the posterior esophagus adequately, a clean 4 ⫻ 4 gauze may be placed behind the esophagus before the instillation of the methylene blue. The gauze is then withdrawn and inspected for any evidence suggestive of a leak. If methylene blue is not available, then the patient could be placed in a level position while the upper abdomen is

Figure 32.1 Placing a gauze sponge at the superior splenic pole assists in exposure.

filled with saline. The esophagus should then be insufflated with air while observing for bubbles as evidence of a perforation.

Bougie perforation Perforation with a bougie or dilator is a feared complication. The best safeguard is to ensure active communication between the person passing the bougie and the surgeon observing the process. This alone will not guarantee elimination of the risk of perforation, but it will diminish the risk when both parties involved actively assist each other. If any resistance is encountered with the passage of the bougie, then force should not be applied. Either a more experienced person should attempt to pass the bougie and/or re-examination within the abdominal cavity via the laparoscope should occur. First, verify that the appropriate bougie size is being used (48–60 French are most common, depending on the patient’s body habitus and any history of prior dilations or strictures), and ensure adequate lubrication of the bougie with a water-soluble jelly. The Penrose drain, typically used to manipulate the gastroesophageal junction, should not be manipulated in any way while advancing the bougie. It is critical that no tension is placed on the gastroesophageal junction to ensure a straight and unobstructed path from the esophagus into the stomach. Using a blunt grasper, palpation along the greater curve of the stomach and anterior gastric wall will inform the surgeon when the bougie has entered the stomach. The surgeon also needs to be attentive to an overly aggressive and easy passage of the bougie to ensure it does not pass too far distally, creating a perforation along the greater curve or near the pylorus. Infrequently, the use of the bougie is impossible because it cannot be passed easily. It is safer to avoid the use of force for advancement than to do so and produce a perforation. With experience, the looseness of the wrap and the crural closure will rarely result in postoperative dysphagia. If perforation of either the intrathoracic or intraabdominal esophageal occurs, it is critical to recognize and treat the injury early. If recognized immediately, the injury may usually be treated with primary closure using interrupted sutures with placement of the fundoplication over the injury to reinforce the repair. It is also considered safe to place a closed suction drain at the level of the injury for postoperative monitoring. A drain is not mandatory but is dependent on the level of comfort of the surgeon with repairing this type of injury. The drain is removed easily once the patient has shown no significant morbidity after adequate time to heal and there is no evidence of leakage. We recommend removing the drain at least five days after surgery after a normal esophagogram is performed. The patient can be fed after this point.


Pneumothorax

Hemorrhage

The incidence of pneumothorax occurring during esophageal dissection is almost 2 per cent.4 Contributing factors are peri-esophagitis from severe Barrett’s disease, prior endoscopic therapy, large hiatal hernias, and prior operations upon this area (i.e. prior fundoplication). There is little to prevent this complication other than careful, meticulous dissection. Pneumothorax may present in two ways: the first, and most common, is visualization of an opening in the pleura by the operating team. Usually, the patient has no immediate respiratory compromise, such as increasing end tidal carbon dioxide or increased peak airway pressures. Should a rent in the pleura occur, then it might be closed using a stitch or clip, in order to avert ventilatory compromise. The anesthesiologist may also ventilate the patient manually with several large tidal volume breaths to expel carbon dioxide trapped in the pleural space. The operation may then continue while using a lower insufflation pressure (8–10 mmHg). Postoperatively, a chest X-ray can be obtained. The majority of patients will not require a thoracostomy tube, as the carbon dioxide is readily absorbed and a repeat chest X-ray will document resolution of any pneumothorax. Should the chest radiograph in the postanesthesia unit reveal a large pneumothorax (⭓50 per cent), then a small chest tube may be necessary, especially if the patient appears symptomatic. The second presentation of pneumothorax may be more dramatic. In this scenario, the anesthesiologist will suddenly comment on increasing end-tidal carbon dioxide, increased peak airway pressures, or decreasing hemodynamics. If the presentation is limited to endtidal carbon dioxide, then the surgeon should decrease the intra-abdominal pneumoperitoneum pressure after safely removing the instruments from the abdomen. The anesthesiologist should then ventilate the patient manually to clear any intrapleural collection of trapped carbon dioxide. If the patient is experiencing elevated peak airway pressures or decreased hemodynamics, then the same initial approach of lowering the intra-abdominal pressure and manual ventilation of the patient should occur. If peak airway pressures do not decrease or if the hemodynamics continue to deteriorate, then tension pneumothorax is likely. The decision to place a thoracostomy tube should not be delayed. If a chest tube is not available immediately, then a 14-gauge angiocatheter needle should be placed in the second intercostal space at the midclavicular line. To determine the appropriate side, one should auscultate the chest or attempt to visualize the pleural tear. However, the placement of an angiocatheter needle is only a temporary measure. This should be followed by the introduction of a 28–32 French chest tube connected to a closed suction drain. A postoperative chest X-ray should confirm the proper location.

The development of bleeding is always an unnerving experience, especially as it is visually magnified when performing laparoscopic surgery. Laparoscopic procedures have the additional complexity of requiring the judgment necessary to know when to convert to an open operation to obtain control. This question has as many answers as there are operative cases. In general, there are three specific situations in which excessive hemorrhage occurs during the performance of laparoscopic fundoplications: retraction of the left liver lobe, division of the short gastric vessels, and dissection of the superior gastrosplenic ligament. The position and type of the liver retractor vary with the surgeon performing the operation. Preventing injury is preferable to treating injury, so adequacy and clarity of optics are mandatory. This allows identification of any adhesions from prior surgeries or inflammation, and then allows the selective division of them with cautery or an ultrasonic scalpel. If a laceration or puncture occurs, several options are available. First, place a 4 ⫻ 4 gauze into the abdomen and apply direct pressure to the injury. If the bleeding is controlled, the gauze may be held in place under the liver retractor while the surgery proceeds. At the end of surgery, careful removal of the gauze and visualization of the injury will confirm whether the bleeding has stopped. This will be sufficient for the majority of liver injuries. It is also recommended that the intra-abdominal pressure is decreased at the time of this inspection to ensure that the pneumoperitoneum is not creating a tamponade effect. If bleeding continues, then one should try the placement of one of the many available hemostatic agents, either liquid or solid, at the site. Other therapies include electrocautery and the argon-beam coagulator. Only rarely have we found cases of hepatic bleeding that could not be controlled with one or more of these modalities. Division of the short gastric vessels is another step that potentially can result in a hemorrhagic complication. The majority of surgeons performing fundoplications today use ultrasonic scalpels. Other possible techniques include the use of clips followed by their division or bipolar coagulation. Regardless of the instrument employed, the standard warning of careful visualization and maintaining patience is applicable. The surgeon should elevate the greater curve of the stomach while the assistant elevates the omentum. The initial opening of the greater sac is usually uncomplicated. The greatest occurrence of bleeding is seen when approaching the superior aspect of the greater curve. In this area are the most superior and posterior short gastric vessels. At this level, the assistant should use a blunt grasper to push the greater curve of the stomach medially and inferiorly. This will allow the surgeon to gently retract the redundant portion


Figure 32.2 Exposure of the most superior-posteriorly located short gastric vessel requires careful dissection and transection.

of the fundus in an inferior and medial direction to expose the last short gastric vessel. Once identified, the surgeon should bluntly create an opening posteriorly to the vessel to allow complete visualization of the occlusion of the vessel by the instrument of choice for division (Figure 32.2). Finally, the spleen is in close approximation to this dissection. Again, only careful progression of the surgery will ensure prevention. Multiple reports have shown a decreased incidence of splenic injury with the increasing performance of laparoscopic fundoplication.2,9,10 One frequent precipitating factor is multiple adhesions from the gastric wall to the spleen. In this situation, a quick remedy is to use an endoscopic linear stapler to transect across the greater curve of the stomach and leave a small gastric remnant attached to the splenic hilum. This is a better alternative to incurring uncontrollable bleeding from a tear of splenic capsule and does not exert any significant impact on the patient. Again, depending on the degree of injury, direct pressure to the injury is the best initial approach if the bleeding is minimal. If bleeding is profuse, then one should be comfortable in performing laparoscopic splenectomy or have a low threshold for conversion to an open surgery to ensure the patient’s safety first and foremost. The latter is preferred.

Shortened esophagus The concept of a shortened esophagus generates much controversy. If appropriate preoperative work-up was performed, then the barium swallow and esophageal manometry should indicate the length of intra-abdominal esophagus, ideally 2–3 cm. Patients with severe or longstanding esophagitis and long-segment Barrett’s esophagus are at increased risk of esophageal shortening. If identified preoperatively, the patient should be informed

Figure 32.3 Short esophagus: The gastroesophageal junction can be seen easily above the diaphragm. The esophagus does not show folds, which is usually a sign of a short esophagus. When the esophagus appears tortuous, the chances of being able to reach the abdomen are very high.

of the potential need for a Collis gastroplasty, either laparoscopically or via a thoracic approach. In our experience, however, preoperative identification of a shortened esophagus is not always correlated with intraoperative findings (Figure 32.3). Should the esophagus be found to not have the necessary 2–3-cm length within the abdomen, then proximal circumferential dissection of the esophagus will free up more thoracic esophagus to reach further into the abdomen. The surgeon should not settle for less than the minimum intra-abdominal length, as this will likely lead to slippage of the fundoplication, migration of the wrap into the thoracic cavity, or improper placement of the wrap on to the upper stomach rather than the esophagus.

Large hiatal hernia This should be identified preoperatively by barium swallow, esophageal manometry, or esophagogastroduodenoscopy (EGD). If the hernia is no larger than 4 cm, then it


can be repaired primarily with standard crural closure, using interrupted nonabsorbable sutures. If the hernia is large or if the diaphragm is thinned, then closure of the hernia primarily without undue tension may not be possible. Reinforcement of the repair using pledgets made of expanded polytetrafluoroethylene (ePTFE; W. L. Gore & Associates) can be attempted. These should be cut into small rectangular shapes and placed perpendicular to the fibers of the crura to buttress the repair. If the closure remains under tension or if the surgeon is still unable to close the hiatus completely, then a prosthetic patch should be placed. Previously, polypropylene mesh was used, but this led to migration and erosion into the stomach and/or esophagus. Currently, most surgeons prefer the use of ePTFE mesh because of the markedly decreased risk of erosion. We use the technique described by Huntington.11 A relaxing incision is made to the right of the right crus to allow a tension-free primary closure of the hiatus. This allows the crura to be in direct contact with the esophagus rather than the mesh. The ePTFE patch is then placed over the relaxing incision in order to cover the defect, and is secured with either sutures or tacks. It is critical that the placement of these tacks or sutures is not into the esophagus, pericardium, inferior vena cava, or aorta.

Gastric necrosis/perforation Injury to the gastric fundus is most likely to occur during the manipulation of the tissues to provide exposure, during passage of the wrap, or during the division of the short gastric vessels and causing thermal injury. If identified, a primary closure of the perforation is required. This may be accomplished by over-sewing the perforation in a two-layered fashion using an inner absorbable suture and a nonabsorbable outer suture. This requires the ability to perform intracorporeal suturing. The surgeon performing the laparoscopic fundoplication should possess this skill. The second option is to use an endoscopic linear stapler. An endoscopic Babcock grasper can be used to approximate both edges of the defect and incorporate them into the stapler line. If one is unsure of the security of the repair, then a closed suction drain may be placed near the site of perforation at the end of the case.

POSTOPERATIVE COMPLICATIONS Following laparoscopic fundoplication, patients generally present with complaints in either the early (⬍30 days) or late (⬎30 days) timeframe. Early complaints of dysphagia, nausea, bloating, and early satiety are reported by 20–40 per cent of patients.12,13 A large portion of these patients will do well after careful questioning

and verbal reassurance, as these complaints drop to five per cent after three months.12 The surgeon must question patients about their diet and activity in the immediate postoperative period to differentiate between patients who require radiographic studies and patients who require only reassurance. Instructing patients preoperatively about necessary diet restrictions and activity limitations will avert many from overzealous eating or exercising. During questioning, often the surgeon can identify whether the patient has eaten certain foods (breads, meats, raw vegetables) at too early a time and may be experiencing obstruction, or whether they have overexerted themselves (weight-lifting, heavy manual labor, etc.) too early (before two months). For patients who complain of these symptoms, the easiest and most prudent study to obtain is a barium swallow. This reveals the anatomy responsible for the majority of early complications. If the barium swallow study is equivocal, then it is reasonable to undertake an EGD examination if the symptoms persist after six to eight weeks. Repeat studies of 24-hour pH monitoring and esophageal manometry may be pursued if the symptoms of reflux, asthma, cough or hoarseness persist after a trial of antisecretory medication. Finally, persistent gastric bloating may necessitate gastric emptying studies.

Bloating/nausea/epigastric pain/increased flatulence A majority of patients will return to the clinic with specific complaints of feeling bloated, occasional nausea, epigastric pain, and generally an increased incidence of flatulence. This is due to the patient’s habit of swallowing saliva and air to neutralize the presence of acid in the esophagus. Once a fundoplication is performed, this air progresses through the bowel rather than retrograde through the esophagus, as before surgery. This is an expected event postoperatively. Because of this, it is important to inform the patient in preoperative counseling to decrease anxiety levels when it does occur. Most patients will have significant improvement in these symptoms with just several weeks of expectant management, which includes a critical review of their current diet. One important question to ask patients postoperatively is whether their symptoms of reflux have been treated. Often, reflux patients are of the anxious type and tend to concentrate on a new type of problem once the reflux has been treated. If the patient is unable to tolerate liquids at any time or the patient has persistent nausea and vomiting, then the surgeon should obtain a barium swallow as an initial diagnostic test to evaluate the post-surgical anatomy. If no gross abnormality is seen, an EGD may be warranted. Some patients will self-medicate with previous antacids or proton-pump inhibitors as they are almost dependent


upon them. If the barium study shows no anatomical defect and the patient feels better with medical therapy, then one can continue to follow the patient and treat on an as-needed basis.

Para-esophageal herniation An occurrence of para-esophageal hernias of up to seven per cent was noted when laparoscopic fundoplication was initially performed.9,14 Patients present with persistent nausea, vomiting, and intolerance of solids. This may occur at any time following surgery, but usually it is early (within one to two weeks) and generally it follows a report of sustained coughing and/or straining associated with heavy lifting or Valsalva-type maneuvers. The best initial workup is to obtain a barium swallow. Abnormal anatomy is revealed in 90 per cent of patients (Figure 32.4). This radiographic finding alone, with a symptomatic patient, is justification enough to return to the operating room for urgent repair before strangulation of the herniated viscera occurs. The incidence of para-esophageal hernia has decreased as more surgeons are routinely performing

careful re-approximation of the posterior crura. Careful attention to ensure the closure is tension-free is also paramount. We generally close the crura, beginning at the most inferior portion, using interrupted 0-Silk sutures placed 0.5 cm apart. After two or three sutures are placed, a 56 French Maloney dilator is passed, and the tightness of the crura closure is assessed. Closure is then tailored to ensure that it is snug, with no obvious gaps, but not overly restrictive. If a para-esophageal hernia develops postoperatively, then the wrap should be taken down completely to assist in visualizing any technical complications that may have contributed to the early failure of the wrap. In addition, this allows better visualization in the repair and reapproximation of the crura while assessing the possibility that an overlooked shortened esophagus was present at the initial surgery.

Slipped Nissen The term ‘slipped Nissen’ refers to one of several anatomical complications following laparoscopic fundoplication. It is most often discovered by a barium swallow study after complaints of dysphagia, early satiety, or symptomatic complaints of recurrent reflux type symptoms. The barium swallow may display one of the following anatomic failures (see Figures 32.5–32.8.):

• • • •

gastroesophageal junction and wrap above the diaphragm; gastroesophageal junction only above the diaphragm; para-esophageal herniation; malformation of the wrap.

Regardless of the type of failure, the patient will require the fundoplication to be redone. If none of these anatomical failures are seen on the initial radiographic

Figure 32.4 Para-esophageal herniation following fundoplication. Note the position of a portion of the stomach above the diaphragm.

Figure 32.5 Type IA hernia.


Figure 32.6 Type IB hernia.

study, then an EGD should be performed. This may show that the wrap was performed too tightly, placed too low on the stomach, or placed at an increased angulation, causing the lower esophagus to twist. Treatment for these complications requires advanced laparoscopic skills if the repair is to be attempted laparoscopically. Success rates at tertiary centers with advanced laparoscopic training programs are reported to be as high as 85–91 per cent.7,13 If one is to undertake such an effort, then keep in mind that the best time to attempt this is within the first week, before numerous dense adhesions are encountered. The ideal approach is to undo the initial fundoplication completely. This entails careful and deliberate dissection of the wrap from the anterior stomach wall, removal of the posterior crural sutures, and mobilization of the esophagus. This will ensure that there is sufficient esophageal length within the abdomen and that it is not under significant tension. If the esophagus does not allow for at least 2 cm of intra-abdominal length, then further circumferential mobilization of the esophagus is required. If this does not obtain more length, then the patient may require a Collis gastroplasty. Also, it is advisable to ensure sufficient mobilization of the fundus and greater curve of the stomach so that no tension or torque exists after creation of the wrap. After completely mobilizing the previous wrap, then the cause of the patient’s complaint is generally evident.

Vagal nerve injury

Figure 32.7 Type II hernia.

Figure 32.8 Type III hernia.

Identification of the vagus nerves is paramount in performing laparoscopic fundoplication. It is generally agreed that the magnification afforded by the laparoscope enhances the ability of the surgeon to visualize these structures. The left vagus will be seen as it progresses from its lateral to anterior position on the gastric wall. It may be obscured by the anterior fat pad just inferior to the gastroesophageal junction. The right vagus will course posteriorly behind the stomach. Meticulous dissection and a bloodless field are critical at this point of dissection. It is best to visualize, but not dissect, both vagi at their normal anatomical positions. This will decrease the possibility of retraction, thermal injury from cauterization, or transection of the nerve. A no-touch technique avoids directly grasping or manipulating the vagi and esophagus. This will decrease injury and irritation of the nerves and ultimately decrease complaints of postoperative dysphagia secondary to postoperative edema. If a patient suffers a vagal nerve injury, then symptoms of delayed gastric emptying may include bloating, early satiety, regurgitation, and diarrhea.15 Most patients are not studied preoperatively with a gastric-emptying test. However, if these symptoms are present during the initial clinical visit, then it is prudent to obtain a


baseline measurement. Some authors advocate performance of a pyloroplasty at the time of fundoplication if the patient has evidence of delayed gastric emptying. However, most authors do not advocate this, as studies have shown that gastric emptying times generally improve following fundoplication. In addition, a symptomatic patient may be tried on several prokinetic medications (e.g. metoclopramide, erythromycin) before undertaking surgery. Patients who return with complaints of postprandial weakness, palpitations, diaphoresis, and feelings of anxiety may be experiencing postprandial hypoglycemia. This was reported in several cases and confirmed with the performance of an oral glucose tolerance test.16 Postprandial hypoglycemia may be associated with a vagal nerve injury, thus causing early dumping and a hyperinsulin response to the glucose load. This probably represents a neuropraxic injury because it resolves with time and does not require treatment.

Ileus Ileus following laparoscopic fundoplication is usually mild due to the short time of the operation and minimal manipulation of the bowel. Most surgeons will not place a nasogastric tube postoperatively as it is rarely required and most patients start a liquid diet the same night as surgery. If a patient does experience intolerance of liquids, then placement of a nasogastric tube and decompression of the stomach is required. In addition, a low threshold for obtaining a barium swallow with small bowel follow-through can rule out any anatomical reason for ileus. Any treatment will be dictated by the clinical condition and results of testing of the patient.

Dysphagia Immediate postoperative dysphagia is attributed to postoperative edema from the surgical dissection. Late dysphagia may be from scarring at the hiatus, missed or new onset of achalasia, increasing dysmotility, worsening Barrett’s esophagus, esophagitis, or new development of esophageal carcinoma. At the time of diagnostic workup, barium swallow should be the first test performed. Anatomical deviations from standard surgical results will usually be identified. Occasionally, retained food is noted on the study. Whether the dysphagia occurs early or late will play a role in the determination of how quickly a patient should be taken back to the operating room for reconstruction. If it occurs early on, then it is most likely that a technical error has occurred. If it occurs late, then a trial with antisecretory medications may be warranted, as the success of repeat fundoplications decreases with each attempt at surgical repair.12,13

Diagnosis of achalasia is best confirmed with esophageal manometric studies. The lower esophageal sphincter should be identifiable and demonstrate a nonrelaxing and hypertensive pressure value. Development of achalasia after a fundoplication has been reported, but most cases are probably the result of inadequate preoperative evaluation. Treatment for achalasia is dilation, botulism toxin injection, or cardiomyotomy. If a surgical cure is undertaken, then the fundoplication will need to be taken down completely, cardiomyotomy performed, and a partial fundoplication carried out. Radiographic evidence of a wrap that is too tight is best appreciated with a barium marshmallow-swallow study. Liquids may pass easily through the wrap, but foods with thicker consistency may become lodged above the wrap. The best therapy is an initial attempt at dilation using either pneumatic dilatation or bougies of an increasing diameter. Most frequently, this will be successful if the complaint of dysphagia presents within the first three months. If the complaint of dysphagia arises more than three months after surgery, then dilation may be attempted but it is less likely to be successful. Finally, the hiatal opening may be the source of dysphagia following fundoplication. If the crura are approximated too tightly, then complaints will be almost immediate following surgery. Several authors have reported scarring at the hiatal opening, causing a stricture seen on postoperative barium swallow.17 It is suspected that the use of diathermy near the diaphragm is the source of injury. Treatment involves surgical incision of the scarred diaphragm to release the tension at this site. Complications arising more than 30 days after successful fundoplication may originate from anatomical failure or from functional problems. Anatomical failures include essentially the same difficulties listed above, in the ‘early’ categories. Regardless of the timing of presentation, a barium swallow should be the first test obtained, followed by esophageal manometry, 24-hour pH studies, or EGD, depending upon the symptoms of the patient. The management of these problems is similar to those presented above.

Recurrent reflux Patients who return with complaints of persistent or unrelenting reflux warrant a thorough work-up to ensure adequate anatomical integrity and functional success of the fundoplication. Again, start with a barium swallow study to assess anatomical changes and any evidence of herniation of the stomach or the wrap itself. If this appears normal, then a 24-hour pH study may show objective data relative to a functional failure of the fundoplication. Finally, EGD may show persistent irritation of the esophagus from refluxate as well as confirm proper


placement of the wrap. If these studies all appear normal and show no definitive pathology, then it is reasonable to give the patient a trial of antisecretory medications. If symptomatic relief is obtained from these, then it is best to medicate the patient. Little is to be gained by attempting further surgery if the initial fundoplication is seen to be anatomically correct and providing a mechanical barrier towards reflux.

2 3 4 5

6

CONCLUSION

7

Laparoscopic fundoplication affords a good to excellent result in more than 90 per cent of patients with refractory and chronic GERD. There is a 1.3 per cent chance of complications.1,9 However, the majority of complications are minor and can be limited in occurrence if careful attention to preoperative symptoms, diagnostic work-up, and appropriate intraoperative techniques are followed. The use of careful laparoscopic technique will help minimize intraoperative complications. Postoperative complications should always be studied with X-ray, endoscopy, 24-hour pH study, and manometry if an early solution and explanation cannot be found. As more surgeons acquire advanced laparoscopic techniques, the general surgeon’s scope of advanced laparoscopic procedures will also continue to broaden. Fundamentals, however, will not change; therefore, solid, practical judgment should always be used with the patient’s safety and outcome at the forefront of the surgeon’s considerations.

8 9

10

11 12

13 14

15

16

REFERENCES 17 1

Rantanen T, Salo J, Sipponen J. Fatal and life-threatening complications in antireflux surgery: analysis of 5,502 operations. Br J Surg 1999; 86: 1573–7.

Evans S, Jackson P, Czerniach D, et al. A stepwise approach to laparoscopic Nissen fundoplication. Arch Surg 2000; 135: 723–8. Soper N, Dunnegan D. Anatomic fundoplication failure after laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–77. Watson D, de Beaux A. Complications of laparoscopic antireflux surgery. Surg Endosc 2001; 15: 344–52. Pohl D, Eubanks T, Omelanczuk P, Pellegrini C. Management and outcome of complications after laparoscopic antireflux operations. Arch Surg 2001; 136: 399–404. Hunter J, Smith D, Branum G, et al. Laparoscopic fundoplication failures. Patterns of failure and response to fundoplication revision. Ann Surg 1999; 230: 595–606. Horgan S, Pohl D, Bogetti D, et al. Failed antireflux surgery. What have we learned from reoperations? Arch Surg 1999; 134: 809–17. Horgan S, Pellegrini, C. Surgical treatment of gastroesophageal reflux disease. Surg Clin North Am 1997; 77: 1063–82. Carlson M, Frantzides C. Complications and results of primary minimally invasive antireflux procedures: a review of 10735 reported cases. J Am Coll Surg 2001; 193: 428–39. Collet D, Cadiere G. Conversions and complications of laparoscopic treatment of gastroesophageal reflux disease. Am J Surg 1995; 169: 622–6. Huntington T. Laparoscopic mesh repair of the esophageal hiatus. J Am Coll Surg 1997; 184: 399–400. Perdikis G, Hinder R, Wetscher G. Nissen fundoplication for gastroesophageal reflux disease: laparoscopic Nissen fundoplication – technique and results. Dis Esophagus 1996; 9: 272–7. Hinder R, Klinger P, Perdikis G, Smith, S. Management of the failed antireflux operation. Surg Clin North Am 1997; 77: 1083–98. Watson D, Jamieson G, Devitt P, et al. Paraoesophageal hiatus hernia: an important complication of laparoscopic Nissen fundoplication. Br J Surg 1995; 82: 521–3. Hunter R, Metz D, Morris J, Rothstein R. Gastroparesis: a potential pitfall of laparoscopic Nissen fundoplication. Am J Gastroenterol 1996; 91: 2617–18. Zaloga G, Chernow B. Postprandial hypoglycemia after Nissen fundoplication for reflux esophagitis. Gastroenterology 1983; 84: 840–2. Watson D, Jamieson G, Mitchell P, et al. Stenosis of the esophageal hiatus following laparoscopic fundoplication. Arch Surg 1995; 130: 1014–16.


PART

5

Laparoscopy in the pediatric hernia patient

33 History 34 Anatomy and physiology

251 255

35 Diaphragmatic herniation 36 Complications and their management

257 261


33 History RAJEEV PRASAD AND THOM E. LOBE

Pediatric laparoscopy Laparoscopic exploration of the contralateral groin

251 251

Laparoscopy in pediatric hernia patients has undergone a rapid, albeit delayed, evolution. While laparoscopic herniorrhaphy was being popularized in adults, the approach was considered to be cumbersome, unnecessary, and even contraindicated in children. The perception that a child would outgrow the repair, particularly one involving mesh, dominated early thoughts about the laparoscopic approach. Other considerations, such as the physiological stress of laparoscopy in infants and children and the size and availability of appropriate instruments, initially precluded pediatric laparoscopic herniorrhaphy. However, once these barriers were overcome in other pediatric surgical maladies, it was inevitable that herniorrhaphy would be revisited. With steady progress, pediatric surgeons have applied their endoscopic skills to pediatric hernia patients, and today many surgeons prefer this approach for the repair of inguinal, ventral and diaphragmatic hernias in infants and children.

PEDIATRIC LAPAROSCOPY Gans and Berci were among the first to describe laparoscopy in pediatric patients when they published their experience with ‘visualization of the contents of the peritoneal cavity by means of a small telescope introduced through the anterior abdominal wall after establishment of pneumoperitoneum’.1 Since then, this approach has been rediscovered. New instruments and techniques have been developed, and there is a greater understanding of the physiological impact of pneumoperitoneum in infants and children. Laparoscopy in general has experienced a huge growth in its application in pediatric surgery. This is a

Laparoscopic inguinal herniorrhaphy References

252 254

relatively recent advance. While initially used solely for diagnosis, its use has expanded. It is now used routinely for cholecystectomy, appendectomy and pyloromyotomy, as well as more complex procedures, including fundoplication, colectomy, and pull-through procedures for Hirschsprung’s disease and high imperforate anus. Initially, herniorrhaphy was not considered an appropriate laparoscopic procedure in infants and children. Pediatric surgeons believed that a child would outgrow herniorrhaphy as it was applied in adults because the child had not reached its full development and size. Also, the physiological impact of the procedure in infants and children was unknown and initially overestimated.

LAPAROSCOPIC EXPLORATION OF THE CONTRALATERAL GROIN Routine open exploration of an asymptomatic contralateral groin during surgery for a clinically apparent unilateral hernia is common practice among pediatric surgeons. Supporters of this approach base their view on the reported 29 per cent incidence of the future development of a symptomatic hernia on the unexplored side.2 Others cite a lower incidence of bilateral hernia and feel that the increased cost and risk of damage to cord structures in males precludes the safe exploration of a clinically asymptomatic groin.3 Many alternative methods of detecting a contralateral hernia have been described, including simple pneumoperitoneum and external inspection of the inguinal canal, herniography, ultrasonography, and the passage of dilators across the lower abdomen through the open hernia sac.4–7 Lobe and Schropp first introduced laparoscopy to aid in

252 Laparoscopy in the pediatric hernia patient

the recognition of a patent processus vaginalis in the contralateral asymptomatic groin during open unilateral inguinal herniorrhaphy in 1992.8 In this initial series of 22 patients, an infra-umbilical 3-mm port was placed and a 2-mm, zero-degree telescope was used to visually inspect the contralateral groin. Fifty per cent of the patients with a clinically negative groin had an occult hernia, and the technique was 96 per cent accurate in detecting such hernias. Wolf and Hopkins used the same method in 38 boys and noted a 52.6 per cent incidence of bilateral hernia.9 Chu and colleagues were the first to perform both insufflation and laparoscopy through the open hernia sac to visualize the contralateral groin, thus introducing nonpuncture laparoscopy;10 in their series of 74 children, 29 per cent had a second hernia, and there were no false positives or false negatives. Fuenfer and coworkers described an improved technique in 1996 in which a 14-gauge angiocath was introduced through the open hernia sac for intraperitoneal insufflation. A second 14-gauge catheter was inserted through the abdominal wall on the contralateral side of the abdomen, and a 1.2-mm laparoscope was passed through this port for direct, in-line visualization of the contralateral groin.11 They noted a 21 per cent incidence of bilaterality in 110 children. Another technique described in 1996 employed a 5-mm, 30-degree or 70degree telescope through the open hernia sac.12 This report, which stratified patients by age, noted that patients older than 24 months had only a five per cent incidence of bilaterality, whereas patients younger than 24 months had a 42.9 per cent incidence of a contralateral hernia. Thus, they were able to identify patients who might benefit from contralateral surgery as well as those in whom surgery and its possible complications could be avoided. Other techniques have since been described, including the use of a 30-degree rigid bronchoscope with a working channel through which a catheter can be introduced and used to probe a suspected patent processus vaginalis, providing even better diagnostic accuracy.13

LAPAROSCOPIC INGUINAL HERNIORRHAPHY As laparoscopy evolved in children, pediatric surgeons began to investigate the feasibility of laparoscopic repair of inguinal hernias. Theoretical advantages included excellent visual exposure, minimal dissection (and thus less trauma to the inguinal canal and spermatic cord), and an improved cosmetic result as compared with the traditional open approach. In 1997, El-Gohary reported a series of 28 girls in whom herniorrhaphy was accomplished laparoscopically using one or more endoscopic loops placed at the base of the inverted hernia sac.14 He reported that this was an expeditious, effective, and cosmetically superior operation. However, he recommended

that this operation should not be carried out in boys as it was not possible to exclude the cord structures from the endoscopic loop ligature. In 1998, Schier described his technique of placing two to three Z-sutures laparoscopically using intracorporeal suturing and knot-tying techniques to close the neck of the hernia sac.15 Again, the procedure was limited to girls to avoid the risk of possible damage to the spermatic cord in boys. Montupet and Esposito were the first to report successful laparoscopic herniorrhaphy in boys.16 They specifically applied the laparoscopic approach to boys to avoid the risks of inadvertent removal of a segment of the vas deferens, as well as the possible risk of testicular damage (atrophy or high position in the scrotum), which can occur with the traditional open repair. In their series, 45 boys underwent laparoscopic repair in which an intracorporeal purse-string suture was placed around the neck of the hernia sac. There were no intraoperative or post-surgical complications, but two patients developed a recurrent hernia that required a second laparoscopic repair. Schier reported his further experience of laparoscopic hernia repair in 2000, concluding that the technique was simple for the experienced laparoscopist, that cosmesis was superb, and that the procedure was safe in both sexes.17 Other reports have described the utility of laparoscopy for direct inguinal hernias and suspected recurrent hernias.18,19 Schier reported that the laparoscopic approach allowed for easier detection of direct hernias as compared with the traditional open approach. Out of 109 patients, five (4.5 per cent) had a direct inguinal hernia. Most of these hernias were in boys and were on the right side. The prevalence of direct hernias was higher in this series as compared with the traditionally accepted rate (0.2–0.9 per cent) based on two large series of open hernia repairs,20,21 suggesting that direct hernias may go unrecognized during open repair, and that these cases may represent some of the recurrences after prior repair for indirect inguinal hernia. The conclusion was that laparoscopic repair for direct inguinal hernias is more reliable than open surgery as it is unlikely that an incorrect diagnosis will be made using laparoscopy. Regarding recurrent hernias, Perlstein and Du Bois noted that 44 per cent of children undergoing laparoscopy for recurrent inguinal hernias were found to have unsuspected findings, including indirect (missed sacs and true recurrences), direct (unilateral and bilateral), and femoral (all bilateral) defects.19 Innovative techniques have recently been described for use in pediatric laparoscopic inguinal hernia surgery. Endo and Ukiyama introduced the endo-needle, a 19-gauge hollow needle with a notched tip and pre-attached suture designed specifically for laparoscopic extraperitoneal closure of the patent processus vaginalis.22 They used this instrument in 61 girls and reported no complications or

History 253

Figure 33.1 Demonstration of the positions of the telescope, the lateral port for the grasper, and the site for insertion of the ligature passer during laparoscopic inguinal herniorrhaphy in children. Figure 33.3 Intraoperative photograph of the nonabsorbable ligature having been passed around the lateral half of the hernia sac.

Figure 33.2 Close-up view of the ligature-passer used in laparoscopic herniorrhaphy.

recurrences. Lee and Liang performed micro-laparoscopic high ligation in 450 patients, with good results.23 They reported no complications of the surgery and a remarkably low recurrence rate (0.88 per cent). In 2001, we began to use a unique technique using miniature laparoscopic equipment in which a curved stainless steel awl is used to pass a ligature circumferentially around the neck of the hernia sac. A 1.7-mm needle scope is introduced through a 2-mm port in or near the umbilicus, and the abdomen is insufflated with carbon dioxide gas to 12 mmHg (Figure 33.1). We place a second 2-mm port in the right lateral abdomen. We find this position to be the most useful for traction for both right- and left-sided hernias. A 1.7-mm laparoscopic grasper, placed through this second port, is used to manipulate the peritoneum near the hernia defect (right and/or left sides). The suture-passer (Figure 33.2), introduced through a stab incision anterolateral to the internal ring, is used to place a 2-0 nonabsorbable ligature circumferentially at the neck of the hernia sac. To accomplish this, the suturepasser, with the tie in place through its eyelet, is passed

through the stab incision and the muscle layers to the level of the peritoneum, or hernia sac. Once the lateral half of the hernia sac is encircled, the suture-passer pierces the peritoneum. The ligature is drawn intraperitoneally with the grasper as the passer is withdrawn (Figure 33.3). The empty suture-passer is then passed medially around the hernia sac (again just superficial to the peritoneum), and the peritoneal cavity is entered at the same point as before. The ligature is then passed through the eyelet of the instrument using the grasper so that it can be withdrawn externally. The ligature is tied extracorporeally, completing an extraperitoneal high ligation of the sac (Figure 33.4). The vas deferens and spermatic vessels are seen easily during the ligature placement in males, and it is a relatively straightforward task to find the tissue plane between these structures and the hernia sac, ensuring that they are not included in the ligature. After cutting the excess suture, the knot retracts subcutaneously. Steri-Strips (3M Healthcare) are all that are required for skin closure. The technique adheres to the essential principles of hernia surgery. We reliably identify and ligate the hernia sac at the level of the internal ring. Additionally, there is no disruption of the tissues of the inguinal canal. In males, the spermatic vessels and vas deferens are well visualized during the circumferential passage of the suture, ensuring that they are excluded from the repair. The contralateral inguinal canal is also easily inspected for the presence of a hernia, which is repaired if present. Our patients have had minimal postoperative discomfort, and all resume normal activities immediately after surgery. There is no longitudinal skin incision in the abdominal wall (only three to four stab incisions), so the cosmetic result is superior and the risk of infection is less

254 Laparoscopy in the pediatric hernia patient 4

5

6

7 8

9

10

Figure 33.4 Intraoperative photograph of the closed indirect hernia defect after laparoscopic high ligation of the hernia sac.

11

12

than that of the open approach. In our experience, we have not noted a single infection in any of the 2-mm stab incisions. Finally, there have been no major complications and only one recurrence in our patients. We believe that this technique, as well as others that utilize a circumferential high-ligation of the hernia sac, as opposed to simple suture closure of the defect with either a pursestring or similar suture, is the most effective means of repair. There are no gaps in the closure, particularly medially, where recurrences might occur. Early data in the literature suggest a lower recurrence rate with these extraperitoneal, high-ligation techniques.22,23

13

14 15 16 17 18 19

REFERENCES 1 2

3

Gans SL, Berci G. Peritoneoscopy in infants and children. J Pediatr Surg 1973; 8: 399–405. McGregor DB, Halverson K, McVay CB. The unilateral pediatric inguinal hernia. Should the contralateral side be explored? J Pediatr Surg 1980; 15: 313–17. Given JP, Rubin SZ. Occurrence of contralateral inguinal hernia following unilateral repair in a pediatric hospital. J Pediatr Surg 1989; 24: 963–5.

20 21 22

23

Powell RW. Intraoperative diagnostic pneumoperitoneum in pediatric patients with unilateral inguinal hernias: the Goldstein test. J Pediatr Surg 1985; 20: 418–21. Ducharme JC, Bertrand R, Chacar R. Is it possible to diagnose inguinal hernia by X-ray? A preliminary report on herniography. J Can Assoc Radiol 1967; 18: 448–51. Evez I, Kovalivker M, Schneider N, et al. Elective sonographic evaluation of inguinal hernia in children – an effective alternative to routine contralateral exploration. Pediatr Surg Int 1993; 8: 415–18. Brown RK. Hernia diagnosis by transperitoneal probing of the contralateral groin. Surg Gynecol Obstet 1964; 118: 123. Lobe TE, Schropp KP. Inguinal hernias in pediatrics: initial experience with laparoscopic inguinal exploration of the asymptomatic contralateral side. J Laparoendosc Surg 1992; 2: 135–40. Wolf SA, Hopkins JW. Laparoscopic incidence of patent processus vaginalis in boys with clinical unilateral inguinal hernias. J Pediatr Surg 1994; 29: 1118–21. Chu C, Chou C, Hsu T, et al. Intraoperative laparoscopy in unilateral hernia repair to detect a contralateral patent processus vaginalis. Pediatr Surg Int 1993; 8: 385–8. Feunfer MM, Pitts RM, Georgeson KE. Laparoscopic exploration of the contralateral groin in children: an improved technique. J Laparoendosc Surg 1996; 6 (suppl 1): S1–4. Zitsman JL. Transinguinal diagnostic laparoscopy in pediatric inguinal hernia. J Laparoendosc Surg 1996; 6 (suppl 1): S15–20. Saad SA, Goldfarb MA, Danikas D. Groin laparoscopy in pediatric patients with clinical unilateral hernia: an improved technique using the bronchoscope. Pediatr Endosurg Innov Tech 1999; 3: 59–65. El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls. Pediatr Endosurg Innov Tech 1997; 1: 185–8. Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998; 33: 1495–7. Montupet P, Esposito C. Laparoscopic treatment of congenital inguinal hernia in children. J Pediatr Surg 1999; 34: 420–3. Schier F. Laparoscopic surgery of inguinal hernias in children – initial experience. J Pediatr Surg 2000; 35: 1331–5. Schier F. Direct inguinal hernias in children: laparoscopic aspects. Pediatr Surg Int 2000; 16: 562–4. Perlstein J, Du Bois JJ. The role of laparoscopy in the management of suspected recurrent pediatric hernias. J Pediatr Surg 2000; 35: 1205–8. Fonkalsrud EW, de Lorimier AA, Clatworthy HW. Femoral and direct hernias in infants and children. JAMA 1965; 192: 101–3. Wright JE. Direct inguinal hernia in infancy and childhood. Pediatr Surg Int 1994; 9: 161–3. Endo M, Ukiyama E. Laparoscopic closure of patent processus vaginalis in girls with inguinal hernia using specially devised suture needle. Pediatr Endosurg Innov Tech 2001; 5: 187–91. Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic herniotomy in infants and children. Pediatr Endosurg Innov Tech 2002; 6: 25–8.

34 Anatomy and physiology RAJEEV PRASAD AND THOM E. LOBE

Anatomy Physiology

255 255

ANATOMY A comprehensive review of the anatomy of the inguinal canal is beyond the scope of this chapter. Chapter 6 describes this anatomy, which does not differ significantly from the adult patient. However, certain aspects of the anatomy of the abdominal wall should be considered in the context of laparoscopy. The layers of the abdominal wall must be traversed during port placement. The initial port that we place is the infra-umbilical port through which the 1.7-mm telescope is placed. We choose to place this in an infra-umbilical position to reduce the risk of infection. Ideally, the port traverses the midline. The fascia of the external abdominal oblique, internal abdominal oblique, and transversus abdominus muscles, which join anterior to the rectus muscles inferior to the arcuate line, are penetrated. The urachus, or median umbilical ligament, is in this area and should be avoided. The lateral port, through which a grasper is placed for traction, traverses the same muscles. Structures near the internal inguinal ring, where the hernia sac is ligated, must be considered. In our technique, the suture is passed through all layers of the abdominal wall that are superficial to the peritoneum or hernia sac. In males, the spermatic vessels, the genital branch of the genitofemoral nerve, and the vas deferens pass superficial to the sac, and great care is taken not to include these structures in the ligature. The external iliac vessels are near but deep to the ligature. They should be visualized and, obviously, avoided. Similarly, the inferior epigastric vessels, which are branches of the external iliac vessels, are easily identified and avoided. Once tied and cut, the permanent suture that we use to perform the high ligation of the sac retracts into the subcutaneous

References

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tissue and has not caused any wound complications in our experience.

PHYSIOLOGY Physiological factors to consider during pediatric laparoscopic hernia surgery are essentially identical to those for any other intra-abdominal laparoscopic procedures performed in children. The cardiovascular and respiratory effects of pneumoperitoneum are the issues that most often raise interest for the surgeon and anesthesiologist alike. The extremes of patient positioning, postoperative pain management, and postoperative nausea and vomiting also deserve consideration. Insufflation of carbon dioxide gas is essential for proper visualization during pediatric laparoscopic hernia surgery. In general, lower volumes and pressures (6–12 mmHg) are required than in adult patients. We use a Veress needle inferior to the umbilicus for insufflation and placement of the telescope. In our hands, the risks of visceral injury and pre-peritoneal insufflation are low with this technique. Carbon dioxide approaches the ideal insufflating gas, and is the gas used most often.1 It does not support combustion, and residual intraperitoneal gas is absorbed rapidly and subsequently excreted. The major drawback of carbon dioxide is its rapid intravascular absorption across the peritoneal lining, which can lead to hypercapnea during long procedures. This is generally not of concern in pediatric laparoscopic inguinal hernia surgery, as the procedures are relatively short. The pneumoperitoneum itself creates cardiovascular, respiratory and neurological effects in infants and

256 Laparascopy in the pediatric hernia patient

children. In an investigation involving 12 healthy infants, a pressure of 10 mmHg resulted in a decrease in aortic blood flow and cardiac stroke volume and an increase in systemic vascular resistance, when compared with controls.2 These changes, however, were reversed after peritoneal exsufflation and caused no clinically deleterious effects in healthy infants. In a study of the effects of pneumoperitoneum in pediatric hernia patients, a pressure between 6 and 12 mmHg did not cause clinically significant changes in cardiac index or systemic vascular resistance.3 These cardiac effects may be exaggerated by patient positioning during laparoscopy, particularly with the reverse Trendelenburg position when venous return and cardiac output are further decreased.4 However, in the Trendelenburg position, as may be used for laparoscopic hernia surgery, venous return is augmented and blood pressure returns to normal or supranormal levels. Other potential sources of cardiovascular compromise during laparoscopic hernia surgery include vasovagal reflex, myocardial sensitization by halothane, hypovolemia, and venous gas embolism.1 Deleterious respiratory effects during laparoscopy are the result of upward displacement of the diaphragm. This may result in early closure of small airways, an increase in peak airway pressure, and a reduction in functional residual capacity.1 These effects may be accentuated with positive-pressure ventilation and Trendelenburg positioning in herniorrhaphy. Tobias and colleagues demonstrated that an intra-abdominal pressure of 15 mmHg in children during inguinal laparoscopy increased the airway pressure by a mean of 3 cm water, and end-tidal carbon dioxide increased by a mean of 3 cm water.5 These values returned to normal within ten minutes of the completion of surgery. Increased intra-abdominal pressure can also result in increased intracranial pressure and, thus, a decrease in cerebral perfusion pressure.6 Consequently, it may be inadvisable to perform laparoscopic hernia surgery in patients with the potential for neurological complications. Control of pain and anxiety in the perioperative period is no different for laparoscopic hernia surgery than for other laparoscopic operations, except for certain adjuncts that may be useful specifically for the pediatric hernia patient. Premedication is a matter of routine surgical care. Atropine is useful to prevent some of the possible deleterious cardiorespiratory events that may occur, such as the vasovagal reflex. Intraoperatively, general endotracheal

anesthesia is our choice. Conversely, Tobias and colleagues have suggested that general face-mask anesthesia plus spontaneous ventilation with concurrent caudal block may be useful for short diagnostic procedures.7 However, this would likely be cumbersome for actual herniorrhaphy, which occasionally can be a difficult and long procedure. Postoperative pain management is less of a concern for laparoscopic herniorrhaphy compared with open inguinal hernia repair. In our experience, patients seem to have less discomfort and very rarely require a narcotic analgesic. Stretching of the peritoneum and phrenic nerves secondary to peritoneal insufflation, which can result in shoulder pain, has not occurred in our experience. Complete exsufflation is important in avoiding this postoperative complaint. Local anesthetic infiltration at the puncture sites as well as perioperative caudal block may be useful adjuncts to ameliorate postoperative pain. In the vast majority of cases, our patients have required only paracetamol (acetaminophen) for pain control. They are all able to return to immediate unrestricted activity. Postoperative nausea and vomiting, which can be problematic after laparoscopy, has not occurred in our experience with pediatric laparoscopic herniorrhaphy.

REFERENCES 1 2

3

4 5 6

7

Pennant JH. Anesthesia for laparoscopy in the pediatric patient. Anesthesiol Clin North Am 2001; 19: 69–88. Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic effects of pneumoperitoneum during laparoscopic surgery in healthy infants: assessment by continuous esophageal aortic blood flow echo-Doppler. Anesth Analg 1998; 88: 468–9. Sakka SG, Huettemann E, Petrat G, et al. Transoesophageal echocardiographic assessment of haemodynamic changes during laparoscopic herniorrhaphy in small children. Br J Anaesth 2000; 84: 330–4. Joris JN, Noirot DP, Legrand MJ, et al. Hemodynamic changes during laparoscopic cholecystectomy. Anesth Analg 1993; 76: 1067. Tobias JD, Holcomb GW, Brock JW, et al. Cardiorespiratory changes in children during laparoscopy. J Pediat Surg 1995; 30: 33. Bloomfield GL, Ridings PC, Blocher CR, et al. Effects of increased intra-abdominal pressure upon intracranial and cerebral perfusion pressure before and after volume expansion. J Trauma 1996; 40: 936. Tobias JD, Holcomb GW, Brock JW, et al. General anesthesia by mask with spontaneous ventilation during brief laparoscopic inspection of the peritoneum in children. J Laparoendosc Surg 1994; 3: 379.

35 Diaphragmatic herniation RAJEEV PRASAD AND THOM E. LOBE

History Patient selection Surgical technique: Bochdalek hernia

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HISTORY In 1848, the anatomist Vincent Bochdalek described two postmortem cases of diaphragmatic hernia. In 1902, Heidenhaim was the first to successfully repair such a defect in a child. Four decades later, Ladd and Gross described the repair of a diaphragmatic hernia in an infant. Thereafter, there was a steady increase in the success of repair of diaphragmatic hernias up to the 1970s, when survival reached a plateau and the physiological effects of persistent pulmonary hypertension and bilateral pulmonary hypoplasia were better appreciated. Since then, there has been slower progress in the surgical approach to this disease. The greatest advance has been with the application of extracorporeal membrane oxygenation (ECMO). The most significant change in the postnatal management of diaphragmatic hernias since ECMO has been the advent of minimally invasive techniques of repair. In 1995, van der Zee and Bax described the laparoscopic repair of a posterolateral diaphragmatic hernia in a six-month old infant.1 Since then, anterior Morgagni and posterolateral Bochdalek defects have been treated with minimally invasive techniques by experienced laparoscopists in stable, less critically ill infants.

PATIENT SELECTION The minimally invasive approach to diaphragmatic hernias should be considered only in infants who are hemodynamically stable, who are without signs of pulmonary

Surgical technique: Morgagni hernia Results References

258 259 259

hypertension, and who are on either oxygen by nasal cannula or minimal conventional ventilator settings. Older children who present either incidentally or with minimal symptoms are also suitable candidates.2

SURGICAL TECHNIQUE: BOCHDALEK HERNIA Posterolateral Bochdalek hernias may be approached through either the chest or the abdomen, depending on the preference of the surgeon. Supporters of the thoracoscopic route state that the herniated viscera are reduced easily with carbon dioxide insufflation.3,4 Those who support the laparoscopic approach state that the instruments are manipulated more easily and that the reduced viscera can be inspected easily for possible injury.5 For thoracoscopic repair, at least three ports are necessary: two 3-mm working ports and a 5-mm port for the camera (Figure 35.1). Carbon dioxide insufflation, as stated above, helps to reduce the herniated viscera. A hernia sac, if present, is resected as the defect is sutured (Figure 35.2).2 If a hypoplastic lung is present, as is often the case, then visualization is actually easier. Following completion of the repair, a pleural catheter is placed through the 5-mm port site. For laparoscopic repair, three to five ports are needed. An umbilical port is used to pass a 5-mm, 30-degree telescope. Two working ports (one 3 mm, one 5 mm) are essential. Additionally, a port for a liver retractor and an extra port for retraction by an assistant are useful.

258 Laparascopy in the pediatric hernia patient

Figure 35.1 Port placement for the thoracoscopic repair of a Bochdalek hernia.

Figure 35.3 Port placement for Morgagni hernia repair.

Figure 35.4 Laparoscopic view of a Morgagni hernia repair using nitinol clips and a porcine submucosal patch. Figure 35.2 Endoscopic view of a thoracoscopic Bochdalek hernia repair.

The viscera are reduced into the abdominal cavity, and the sac, if present, is resected first. We close the defect with 2-0 Ethibond (Ethicon, Inc.) sutures placed in an interrupted fashion. The viscera are inspected for injury at the completion of the repair.

SURGICAL TECHNIQUE: MORGAGNI HERNIA Morgagni hernias occur as anterior retrosternal or parasternal defects. Embryologically, they occur where the septum transversum joins the chest wall in the area where the mammary vessels pass from the chest to the abdomen. These defects are rare, accounting for only one to two per cent of congenital diaphragmatic defects. Associated anomalies can occur, particularly heart defects, as this type of hernia is one component of the

pentalogy of Cantrell. These defects are often asymptomatic. They may not be diagnosed until well after the neonatal period, either as an incidental finding on chest radiography or during the work-up of respiratory symptoms in an older child. Morgagni hernias are repaired through the abdomen. Three ports are necessary. A 5-mm port at the umbilicus is used to place a 30-degree telescope, and a 3-mm right abdominal port and a 5-mm left abdominal port are placed for instruments (Figure 35.3). The hernia contents are then reduced. The sac is resected, and the hernia defect is closed using 2-0 Ethibond sutures placed in an interrupted fashion. More recently, we have repaired a Morgagni hernia laparoscopically using an alternative closure device. In this case, we used clips of nitinol, a shape-memory metal (U-CLIP, Coalescent), to secure a prosthetic patch over the defect (Figure 35.4). Alternatively, a running suture of barbed Prolene (Ethicon, Inc.) is used by some surgeons to complete the repair in order to prevent slippage of the suture.4

Diaphragmatic herniation 259

Morgagni hernias, as well as Bochdalek hernias that are large, may require the insertion of a prosthetic patch, as stated above, for adequate closure. Expanded polytetrafluoroethylene (ePTFE) (Gore-Tex™, W. L. Gore & Associates, Inc.) or porcine small-intestinal submucosal (Surgisis™, Cook Surgical) patches are both suitable. A potential advantage of the latter is that the tissue collagen replaces the collagen of the Surgisis, which may enhance the strength and longevity of the closure.

patients who are asymptomatic before the discovery of the defect. Often, feeding can be initiated in the immediate postoperative period, and the patient can be discharged 24–48 hours following operation.

REFERENCES 1

RESULTS The results of Bochdalek and Morgagni herniorrhaphy are similar. The postoperative course of the patient is highly dependent on the preoperative condition of the patient.2 In patients who do not require mechanical ventilation or are weaned from it preoperatively, the postoperative course is usually straightforward. Postoperative pain is minimal, and the recovery is often rapid, particularly in

Van der Zee DC, Bax NM. Laparoscopic repair of congenital diaphragmatic hernia in a 6-month old child. Surg Endosc 1995; 60: 448–50. 2 Ferro MM. Video-assisted repair of diaphragmatic defects. In: Lobe TE, ed. Pediatric Laparoscopy. Georgetown, TX: Landes Bioscience, 2002, in press. 3 Farmer DL, Sydorak R, Harrison MR, et al. Thoracoscopic repair of neonatal congenital diaphragmatic hernia. Pediatr Endosurg Innov Tech 2000; 4: 98. 4 Berchi FJ, Allal H, Cano I, et al. Diaphragmatic conditions in infants and children: endosurgery repair perspectives. Pediatr Endosurg Innov Tech 2001; 4: 65. 5 Smith J, Ghani AJ. Morgagni hernia: incidental repair during laparoscopic cholecystectomy. Laparoendosc Surg 1995; 5: 123–5.


36 Complications and their management RAJEEV PRASAD AND THOM E. LOBE

Anesthetic complications Surgical complications Recurrence

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ANESTHETIC COMPLICATIONS Anesthetic complications include deleterious cardiovascular and respiratory effects, such as decreased cardiac output, hypercapnea, shunting and atelectasis due to peritoneal insufflation, and the extremes of patient positioning.1 Premedication, which includes the use of atropine, may alleviate these effects. The choice of anesthetic agent may differ in laparoscopic hernia surgery. For instance, nitrous oxide is avoided due to the increased incidence of bowel distention, which will obscure the view during laparoscopy. A balanced anesthetic technique using controlled ventilation with inhalation agents (sevoflurane, desflurane or isoflurane), intravenous opioids, and nondepolarizing muscle relaxants is preferred.2 Patient selection is important, and those patients at greater risk than usual for the above complications, such as premature infants or children with cardiopulmonary disease, should not be considered for laparoscopic herniorrhaphy.

SURGICAL COMPLICATIONS Adherence to meticulous technique is the best way to prevent surgical complications. The laparoscopist should consider their experience and level of comfort before embarking on or continuing difficult operations. One should attempt more complex operations only after simpler operations are mastered. Also, one should always consider the option to open when difficulty is encountered. Of course, this possibility should always be presented to the patient and family preoperatively.

Hydrocele and testicular atrophy References

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Chen and colleagues reviewed the surgical complications that occurred in all patients undergoing laparoscopy or thoracoscopy over a five-year period.3 Thoracoscopy was performed in 62 children, with a 13 per cent rate of conversion to thoracotomy, and laparoscopy was performed in 574 children, with a 2.6 per cent rate of conversion to laparotomy. The reasons for conversion to laparotomy included hemorrhage, esophagotomy during fundoplication, and malpositioned fundoplication. A case of a gastric volvulus after fundoplication and gastrostomy required a laparotomy in the postoperative period and was the result of a malpositioned gastrostomy tube. Other complications in the postoperative period included two children who developed hernias at the umbilical trocar sites used for contralateral groin exploration. Trocarsite cellulitis developed in three patients after laparoscopic gastrostomy in which the tube was brought out through the left upper quadrant port site. Other complications following laparoscopy included five instances of pelvic abscess after appendectomy, small-bowel obstruction after jejunostomy as well as after combined appendectomy/cholecystectomy, one case of enterocolitis after pull-through for Hirschsprung’s disease, and one case of pneumonia after splenectomy. There were no deaths, and complications were noted to decline with increased experience. Thus far, we, and others who perform laparoscopic herniorrhaphy, have experienced very few surgical complications. In their series of 450 patients undergoing laparoscopic herniorrhaphy, Lee and Liang had no operative complications.4 Schier and coworkers reported a series of 933 laparoscopic herniorrhaphies in boys and girls in whom no intraoperative complications occurred

262 Laparoscopy in the pediatric hernia patient

other than minor bleeding from peritoneal vessels in three patients.5 We have had one conversion to open herniorrhaphy following pre-peritoneal insufflation. This resulted in distortion of the pre-peritoneal plane through which the ligature and passer must be directed. The subsequent open procedure was completed uneventfully. There have been no cases of hemorrhage or visceral injury in our series of patients.

RECURRENCE The reported recurrence rate after traditional open inguinal herniorrhaphy is 0.9 per cent. In their multicenter experience, Schier and colleagues had a recurrence rate of 3.4 per cent, higher than that for open repair.5 Their technique of closure with either a purse-string suture or a Z-suture potentially left a gap in the herniorrhaphy medially, because they noted that all recurrences occurred at the medial margin between the suture and the epigastric vessels. Other reported series with smaller numbers of patients have had recurrence rates between zero and 4.4 per cent.6–9 Lee and Liang used a circumferential closure as their herniorrhaphy technique, and their recurrence rate in 450 cases was only 0.88 per cent.4 In our experience in approximately 50 patients with a follow-up of ten to 15 months, there have been no recurrences. We also use a circumferential ligature placed at the neck of the hernia sac, which leaves no gap. This may be a more effective means of closure of the hernia defect. Perlstein and Du Bois used diagnostic laparoscopy in 19 patients with recurrent inguinal hernias.10 Seventeen indirect hernias and one femoral hernia were repaired at the original procedure. One child had no hernia identified during the primary procedure. Overall, 11 recurrences were indirect hernias, four were direct hernias, and four were found to be femoral hernias. Forty-four per cent of these patients had unsuspected findings at diagnostic laparoscopy (contralateral indirect, direct or femoral hernias). Recurrent hernias themselves can be managed effectively with laparoscopy and laparoscopic repair.11 Direct hernias can be detected at the time of repair of recurrences, suggesting that they might have been missed at the initial operation.

HYDROCELE AND TESTICULAR ATROPHY We consider a non-communicating hydrocele that is present preoperatively, alone or in conjunction with an

ipsilateral hernia, to be a relative contraindication for laparoscopic hernia repair in infants and children. Others, however, repair these defects laparoscopically. Postoperative hydrocele as a complication of laparoscopic herniorrhaphy is a different entity. We have not yet seen any postoperative hydroceles in our series of patients. In their large series, Schier and colleagues reported a 0.4 per cent incidence of postoperative hydroceles.5 Testicular atrophy, presumably from damage to the spermatic vessels or a high-riding testis (iatrogenic cryptorchidism), are also concerns, but these seem to occur only rarely. We have not encountered either of these complications, and Schier and colleagues have had only one patient with a highriding testis postoperatively.5 It is difficult to predict which patients will develop either of these complications postoperatively. Again, meticulous technique is likely to be the best measure for preventing these rare but real complications.

REFERENCES 1 2 3 4

5

6 7 8 9 10

11

Pennant JH. Anesthesia for laparoscopy in the pediatric patient. Anesthesiol Clin North Am 2001; 19: 69–88. Tobias JD. Anesthetic considerations for laparoscopy in children. Semin Laparosc Surg 1998; 5: 60. Chen MK, Schropp KP, Lobe TE. Complications of minimal access surgery in children. J Pediatr Surg 1996; 31: 1161–5. Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic herniotomy in infants and children. Pediatr Endosurg Innov Tech 2002; 6: 25–8. Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children: a three center experience with 933 repairs. J Pediatr Surg 2002; 37: 395–7. El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls. Pediatr Endosurg Innov Tech 1997; 1: 185–8. Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998; 33: 1495–7. Montupet P, Esposito C. Laparoscopic treatment of congenital inguinal hernia in children. J Pediatr Surg 1999; 34: 420–23. Schier F. Laparoscopic surgery of inguinal hernias in children – initial experience. J Pediatr Surg 2000; 35: 1331–5. Perlstein J, Du Bois JJ. The role of laparoscopy in the management of suspected recurrent pediatric hernias. J Pediatr Surg 2000; 35: 1205–8. Schier F. Direct inguinal hernias in children: laparoscopic aspects. Pediatr Surg Int 2000; 16: 562–4.

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38 Socioeconomic issues

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37 Robotics and hernia surgery AMIT TRIVEDI AND GARTH H. BALLANTYNE

AESOP robotic arm Da Vinci and Zeus tele-robotic systems Tele-robotic laparoscopic ventral and incisional hernia repair

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Over the past several years, there has been an ever-increasing presence of robotics in the operating room. These devices have been designed to help the surgeon overcome the limitations of conventional open surgery and laparoscopic surgery. These limitations range from the decreasing availability of qualified surgical assistants, through the limited dexterity offered by conventional laparoscopic instruments, to the lack of a three-dimensional operating field.1 The potential advantages of such systems set the stage for the next major change in the field of surgery. As availability increases and costs decline, proficiency with such devices will be required by all future generations of surgeons. Additionally, the demands of patients for a robotic operation are expected to increase as more media attention is placed on this technology. Currently there are three Food and Drug Administration (FDA)-approved devices on the market that facilitate surgery: the AESOP robotic arm (Computer Motion, Inc.), the da Vinci tele-robotic system (Intuitive Surgical), and the Zeus tele-robotic system (Computer Motion Inc.). The use of these devices has a definite learning curve that often deters busy surgeons from investing the time required to become proficient in this technology.2 This chapter aims to serve as an introduction to the use of robotic devices in laparoscopic hernia surgery by outlining the potential advantages of the technology. The aforementioned devices have been used in inguinal, ventral and diaphragmatic hernias. The frequency with which these cases are encountered by the general surgeon makes hernia surgery an ideal platform on which to develop and

refine the skills needed to perform more challenging cases with the use of robotics.

AESOP ROBOTIC ARM The AESOP robotic arm uses proprietary speechrecognition technology as the interface between the surgeon and the robotic arm. Simple voice commands are used to direct the field of view of the laparoscope. The advantages of this technology include 24-hour availability, thereby eliminating the need for an assistant to hold the camera for a wide variety of laparoscopic operations, including inguinal hernia procedures. Additionally, the field of view is controlled by the surgeon and is completely free of tremor and straying.

AESOP solo-surgeon laparoscopic hernia repair Since 1995, over 500 laparoscopic totally extraperitoneal (TEP) and transabdominal pre-peritoneal (TAPP) patch hernia repairs have been performed at our institution using the AESOP robotic arm. The majority of these have been TEP repairs performed by a single practitioner as a solo surgeon operation.3 Because AESOP uses voice recognition as the interface between surgeon and the robotic arm, before using AESOP for the first time each surgeon must create a voice card that recognizes his or her individual voice. Frequent

266 Future considerations

use at our institution allows AESOP to be set up in less than ten minutes. Technique After bilateral pneumatic compression boots are placed on the patient, general anesthesia is induced and a Foley catheter is placed to decompress the bladder. A single dose of preoperative antibiotics is given approximately one hour before incision. The surgeon puts on the voice-control headset before scrubbing and performs the operation from the side opposite to the hernia. Laparoscopic monitors are placed at the foot of the bed (Figure 37.1). The AESOP robotic arm is mounted on the table before prepping the patient. The central articulated arm of AESOP is positioned over the patient’s umbilicus. Once the patient is draped, a sterile plastic sleeve is placed over the robotic arm and the arm is positioned manually over the operative field. A 1-cm vertical para-umbilical incision is made on the ipsilateral side of the hernia. The incision is made approximately 0.75 cm lateral to the umbilicus. The incision is carried down through the fat until the anterior rectus sheath is identified clearly. A 0.75-cm vertical incision is then made through the anterior rectus sheath, exposing the underlying rectus fibers. The medial edge of the rectus muscle is identified and the fibers are then pushed laterally

Figure 37.1 Set-up of the operating room for a solo-surgeon laparoscopic inguinal hernia repair. An electronically integrated operating room facilitates advanced laparoscopic operations. The laparoscopic equipment is suspended from the ceiling by booms, allowing easy movement. The laparoscopic equipment can be controlled either by the scrub nurse via a touch screen (not draped in this photograph) or by the surgeon via voice. An array of flat-screened digital and analog monitors are distributed around the feet of the patient. This ensures that the surgeon can view the laparoscopic video image in an ergonomically comfortable position throughout the operation.

by the use of an ‘S’-retractor. This maneuver exposes the posterior rectus sheath. Using blunt finger dissection, the space between the rectus muscle anteriorly and the posterior rectus sheath is developed. A stay suture is placed, which encompasses the anterior rectus sheath laterally and the midline fascia. The patient is dropped into a Trendelenburg position (Figure 37.2). An Origin Medsystems balloon dissector is then inserted into the space between the rectus muscle and the posterior rectus sheath. It is passed down gently parallel to the midline until the tip reaches the pubic bone. Care is taken during this step to keep a slightly upward slant to the balloon dissector tip, so as to avoid inadvertent entry into the peritoneal space and possible bowel injury. A 10-mm, zero-degree telescope is inserted through the trocar, and the balloon is inflated according to the manufacturer’s specifications under direct visualization. The balloon is kept inflated for approximately five minutes to allow for hemostasis. Next, the balloon is withdrawn and the pre-peritoneal space is insufflated to a pressure of 12 mmHg. Once the pre-peritoneal space is insufflated, a 5-mm trocar is placed in the suprapubic position and another 5-mm trocar is placed in the midline between the umbilical port and the suprapubic port. At this point, the laparoscope is changed to a 45-degree, 10-mm telescope. Trial and error have established that this angled telescope offers the best field of view and the least interference with the working ports. The telescope is premounted with a coupler that enables the telescope to be attached to the AESOP robotic arm via a strong magnet. The telescope is positioned such that the angle is looking upwards and the operative horizon is horizontal. Once positioned, the AESOP robotic arm will maintain these

Figure 37.2 Position of the patient and the surgeon for solosurgeon robot-assisted laparoscopic hernia repair. The patient is in a mild Trendelenburg position. A three-trocar technique is used: one port for the video-telescope and two ports for the surgeon’s right and left hands. A voice-controlled robot, AESOP, holds the video-telescope.

Robotics and hernia surgery 267

preset angles as it is directed to move the camera anywhere in the operative field. It has been our consistent experience that the camera does not have to be removed or manipulated until the placement of the mesh. The constant need to remove the camera for cleaning is reduced considerably with AESOP compared with the use of surgical assistants. Additionally, the surgeon’s anatomical orientation is maintained much better when using an angled camera in a confined space with the use of AESOP. Lastly, the operative surgeon retains control over the now tremor-free field of view.4 The simple voice commands available to the surgeon with AESOP include ‘move in’, ‘move out’, ‘move left’, ‘move right’, ‘move up’, and ‘move down’. In the TEP method, the hernia sac is bluntly dissected free from the surrounding fat and cord structures. Once this is done, the camera is disconnected from the robotic arm and removed. A large piece of Prolene mesh is passed through the umbilical port and into the pre-peritoneal space. The camera is reinserted, and the mesh is positioned to cover the direct, indirect and femoral spaces. A minimal number of spiral tacks is used to secure the mesh in place.5 The pre-peritoneal space is deflated and the ports are withdrawn. The fascia is closed at the umbilical port and a subcutaneous suture of the ports is preformed after 0.25 per cent bupivacaine infiltration.

Moreover, the need to connect and disconnect sophisticated equipment for each operation leads to equipment malfunction. Electronic integration of operating rooms facilitates advanced laparoscopic operations, improves turnover times, and provides a more pleasant working environment. Computer Motion first introduced voice control for AESOP and then extended it to other laparoscopic electronic equipment with HERMES. Storz Endoscopy has recently introduced a similar system – SESEM – that uses both touch-control panels and voice control (Figure 37.1). These integrated control systems facilitate advanced laparoscopic operations by permitting the surgeon to control most aspects of the operating room. AESOP decreases the ‘footprint’ of the camera holder. In many laparoscopic operations, the camera holder interferes with the excursion arcs of the surgeon’s arms. The surgeon and the camera holder often stand in uncomfortable positions. In contrast, AESOP permits the surgeon to stand erect in an ergonomically comfortable position (Figure 37.3). There is no crossing of arms with the camera holder. AESOP decreases the fatigue of the surgeon in these solo operations.

Advantages The advantages of using the AESOP robotic arm in this setting are clear. The use of the arm facilitates a solo-surgeon operation, provides a stable camera platform, further integrates the surgeon’s control of the operating room, and promotes an ergonomically advantageous posture. Solo-surgeon operations have been also reported for laparoscopic cholecystectomy, laparoscopic Nissen fundoplication, and laparoscopic colectomy.4,6 In our hospital, the number of surgical residents available to assist in operations is dropping. As a result, we frequently perform these operations with the assistance of only a scrub nurse or technician. The use of AESOP keeps both of the assistant’s hands free to pass instruments, prepare the mesh, and maintain surgical counts. AESOP provides a stable camera platform. The video image remains properly oriented to the horizon. This avoids motion sickness in the operating-room staff and helps to maintain the surgeon’s orientation within the operative field. Telephone calls, conversations with the nurses, and boredom do not distract from AESOP. The video image does not wander off the operative field, and the number of times the telescope requires cleaning is decreased.6 Advanced laparoscopic operations increase the complexity of the operating-room environment. The need to roll various electronic towers and auxiliary equipment into the operating room slows turnover of operations.

Figure 37.3 The surgeon wears a microphone through which he or she controls the robotic camera-holder and laparoscopic equipment. The voice-controlled robotic camera holder works unobtrusively, without interfering with the stance or arm movements of the surgeon. The overhead surgical light supports a video camera in its center for telecasting outside views of the operation.


The use of AESOP for laparoscopic hernia operations allows for the steady flow of the operation without breaking the momentum with distractions such as camera cleaning or a moving operative field. Additionally, the consistency of the dissection required in laparoscopic hernia repairs aids in the learning curve of the robot. After more than 500 laparoscopic hernia repairs by a single surgeon at our institution, operative times are now typically 45 minutes for a unilateral hernia repair and 60 minutes for a bilateral repair.

DA VINCI AND ZEUS TELE-ROBOTIC SYSTEMS The FDA has approved two tele-robotic surgical systems for use in general surgical operations within the USA: the da Vinci (Intuitive Surgical) and the Zeus (Computer Motion, Inc.). The two tele-robots differ in certain features (see below). In tele-robotic surgery, the surgeon sits at a computer console remote from the patient (Figure 37.4). The computer controls robotic surgical instruments that perform the operation. The computer translates the motions of the surgeon’s hands into motions of the robotic instruments and refines the motion by eliminating tremor and allowing for motion scaling. The FDA currently requires the surgeon who performs the operation to be in the same operating room as the patient; however, the technology permits the surgeon to sit thousands of miles away from the patient. Marescaux performed a tele-robotic laparoscopic cholecystectomy on a patient in Strasbourg, France while sitting at a Zeus surgeon’s console in New York City.7

Figure 37.4 Surgeon’s console and hand masters for da Vinci tele-robotic surgery. The surgeon views a virtual threedimensional operative field through binoculars in the surgeon’s console. The surgeon places his or her hands into the masters, which translate the motions of the surgeon’s hands into motions of the robotic instruments (insert).

Da Vinci The da Vinci tele-robotic surgical system was designed from scratch to perform tele-robotic operations within a virtual operative field. Da Vinci telecasts a true threedimensional field of view. This is accomplished with a special 12-mm laparoscope that has two smaller 5-mm telescopes within it. The video images from the two 5-mm telescopes remain separate and are projected on to two separate monitors within the surgeon’s console. The surgeon sees the left console with their left eye and the right monitor with their right eye, much like using field binoculars (Figure 37.4). This telecast system purposely isolates the surgeon’s field of view. The surgeon gets the sense of immersion within a virtual three-dimensional operative field. This helps the surgeon to maintain their orientation within the operative field despite their remote location. The surgeon controls the robotic instruments by placing their hands within the masters (Figure 37.4 insert). A foot pedal determines whether the masters are controlling the camera or two robotic surgical instruments. The da Vinci robotic instruments offer hand-like motions. The robotic instruments move with seven degrees of freedom, like the human wrist. These hand-like motions overcome the limitations of traditional straight laparoscopic instruments. Da Vinci also offers motion scaling. The computer translates coarse movements of the surgeon’s hands into finer motions of the robotic instruments. Buttons on the surgeon’s console set the motion scaling to one-, three- or five-to-one scales. The computer also performs a fast Fourier transform (FFT) on the hand motions. This allows identification and filtering of periodic motions such as tremors. This adds to the precision of robotic surgical instruments. The da Vinci robotic tower holds three robotic arms (Figure 37.5). The robotic arms are attached to laparoscopic trocars. The tower does not attach to the operating table. The robotic arms must be separated

Figure 37.5 The da Vinci electronics tower and four robotic arms. The electronics tower holds the video and electronics equipment for the stereoscopic telescope. In this prototype, the robotic tower holds four robotic arms. One arm holds the camera and the other three hold robotic laparoscopic surgical instruments.


from the trocars whenever the surgical table is repositioned. The FDA has recently approved use of a fourth arm with the da Vinci system, which became available commercially in 2003.

Zeus Zeus evolved from AESOP. Zeus consists of a surgeon’s console and three modified AESOPs that attach directly to the surgical table. The surgeon sits at a computer console with an open architecture (Figure 37.6). The surgeon maintains direct visual contact with the patient and the operative field. The surgeon controls movements of the camera with voice commands and controls the robotic instruments with the two hand interfaces (Figure 37.6 insert). This permits simultaneous control of all three robotic arms. The voice-control system, Hermes, can also control other electronics equipment in the operating room. Zeus offers a three-dimensional image but with a technology that is different to that of da Vinci. In the Zeus system, alternating images from the left and right video cameras are projected on to the main monitor. Polarizing filters permit the surgeon’s right eye to see only the right image and the left eye the left image. This causes a three-dimensional image to project out from the two-dimensional monitor. Zeus provides hand-like motions for the robotic instruments. The Zeus instruments move with six degrees of freedom, compared with the seven of da Vinci. This means that the surgeon must compensate for one less degree of freedom by moving the robotic arm in various directions.

Figure 37.6 Zeus surgeon’s console and hand device. The surgeon sits at a computer console with an open architecture. The surgeon sees the operative field in a three-dimensional video projection from the main monitor. Other flat-screen monitors display controls for the surgical instruments. The insert shows the Zeus hand interface.

The three modified AESOP arms attach directly to the surgical table (Figure 37.7). The surgical instruments are inserted into the abdomen through standard laparoscopic trocars. Movements of the surgical table do not require repositioning of the AESOP arms. This is advantageous in advanced laparoscopic procedures, such as colectomy, in which the patient is repositioned several times during the course of the operation. We believe that these tele-robotic surgical systems offer specific technologic solutions to specific limitations of traditional laparoscopic surgery. Both Zeus and da Vinci project three-dimensional operative fields. This helps the surgeon to maintain their orientation and also helps to avoid complications generated by past pointing. The hand-like motions of the robotic instruments replace the extreme limitations of straight laparoscopic instruments. Motion-scaling and tremor-filtration increase significantly the precision of laparoscopic tasks such as suturing. The surgeon sits in an ergonomically comfortable position at the computer console. Surgeons face a learning curve before mastering tele-robotic surgery. Before the use of these devices, surgeons and operating-room staff must attend an FDA-approved training course. After completion of this

Figure 37.7 Zeus robotic arms. The three robotic arms attach directly to the surgical table. The camera holder is a modified AESOP that is voice-controlled by the surgeon. The two other arms are AESOPs that have been modified to hold robotic surgical instruments.


course, individual hospitals may have specific requirements for granting privileges towards the use of this emerging technology.8 In our hospital, we require that surgeons practice tele-robotic operations in live animal models, act as a first assistant in five to ten operations, and are then observed by a proctor for an additional five to ten operations. This process for granting clinical privileges has successfully introduced tele-robotic surgery safely into clinical practice at our hospital.

TELE-ROBOTIC LAPAROSCOPIC VENTRAL AND INCISIONAL HERNIA REPAIR We obtained two da Vinci systems in November 2000. We initiated our clinical experience with da Vinci by performing a series of tele-robotic laparoscopic cholecystectomies.9 After demonstrating that we could perform cholecystectomies with outcomes similar to our standard laparoscopic cholecystectomy, we used the da Vinci system for Nissen fundoplication, colectomy, and incisional ventral hernia repair. The use of tele-robotic systems for a wide range of general, urology and cardiac surgery procedures has been described elsewhere.10–14 We have found that the da Vinci tele-robotic surgery system facilitates the performance of a laparoscopic Stoppa ventral hernia repair.

placed on the anterior axillary line above and below the camera port (Figure 37.8). This operation begins by using a solo-surgeon technique. The scrub technician changes the instruments as needed. The first assistant, although scrubbed, is used only when a fourth port is placed or for emergency laparotomy. At the end of the procedure, the assistant surgeon is required to help pass the fixation sutures through the abdominal wall. The surgeon is seated comfortably at the operative console and views the operation through the three-dimensional imaging system within the console. At this point, the surgeon has full control over the operative field. Foot pedals are used to control the camera movements, and ergonomically positioned fingertip controls are used to manipulate the surgical instruments in real time within the patient.

Technique for laparoscopic repair of incisional or ventral hernias with the use of the da Vinci tele-robotic system The tele-robotic team at our institution consists of a nurse, a scrub technician, a scrubbed laparoscopic fellow who serves as first assistant, and an attending surgeon.15 Each member of the team has completed the FDA-approved training session. The patient is positioned supine on the table. Bilateral pneumatic compression boots wrap both legs. After the induction of general anesthesia, an orogastric tube and urinary catheter are inserted. The patient is shaved and prepared with an iodine-containing solution. The abdominal wall skin is covered with an impermeable plastic drape. A single dose of antibiotics is given one hour before surgery. A sterile plastic covering is placed over the three robotic arms (two arms for the surgeon’s right and left hands, one arm for the laparoscope). Trocar placement varies somewhat with the location of the incisional hernia. The trocars are inserted as far away as possible from the defect. We select the side of the patient away from the previous operation for trocar insertion. If the patient had previously undergone sigmoid colectomy, for example, we would insert our trocars on the patient’s right side. For a midline hernia, three incisions are used: the camera port is placed at the level of the umbilicus in the mid-axillary line and the remaining two ports are

(a)

8mm 12mm 8mm

(b)

Figure 37.8 (a) Trocar placement for a tele-robotic Stoppa repair of an incisional ventral hernia. (b) A three-trocar technique is used. The 12-mm stereoscopic telescope is inserted through the 12-mm trocar. The two robotic surgical instruments are inserted through the 8-mm trocars.


The first part of the operation involves reducing the hernia and lysis of any adhesions to the anterior abdominal wall. A 30-degree telescope is used. Angulation of the telescope upwards improves visualization of the anterior abdominal wall. The hernia can usually be reduced with the use of two graspers and a hand-over-hand technique with gentle downward pressure to avoid tearing or injuring the hernia contents. Once this is done, any adhesions to the anterior abdominal wall can be lysed easily, using the electrocautery hook, harmonic scalpel scissors, or surgical scissors (Figure 37.9). Working on the underside of the abdominal wall is facilitated greatly by the dexterous instruments. After adequate lysis of adhesions, the fascial defect is usually evident. The limits of the defect are marked on the abdominal wall and measured. We like to overlap the mesh at least 2.2 cm beyond the perimeter of the hernia defect. DualMesh Plus (W. L. Gore & Associates) is fashioned so that a degree of overlap is achieved. We place Gore-Tex sutures every two inches around the perimeter of the mesh. The sutures are tied with two throws to the mesh and the ends are left long. The head, foot, and left and right sides of the mesh are marked on the light side of the mesh with a marking pen. The pneumoperitoneum is deflated. The perimeter of the mesh is traced on to the plastic drape that covers the hernia defect. The position of the sutures is also marked. The mesh is rolled tightly into a cylinder, with the tails of the sutures rolled within. The mesh is inserted into the abdominal cavity through the 12-mm trocar and unfurled maintaining the proper orientation. The pneumoperitoneum is maintained at this point at a pressure of 10 mmHg. The labels on the light side of the mesh are visualized easily with the video camera. Small stab incisions are made in the skin at the positions of the sutures.

A Storz suture-passer is inserted through the abdominal wall at each of the stab incisions and used to retrieve the ends of the Gore-Tex sutures (Figure 37.10). Once all of the suture ends are retrieved, they are tied. The edge of the mesh is inspected. The mesh needs to sit firmly against the anterior abdominal wall. Pleats between the sutures are flattened out with 5-mm surgical tacks (Autosuture). The abdomen is deflated and the trocars are removed. The fascial defect of the 12-mm trocar is closed with an absorbable suture. The skin edges of the three trocar sites are closed with absorbable subcutaneous sutures. All wounds are covered with impermeable dressings. Advantages We have found that the da Vinci facilitates laparoscopic repair of ventral and incisional hernias. The da Vinci provides a stable camera platform, permits a solo-surgeon approach to the lysis of adhesions, helps to maintain the surgeon’s orientation within the operative field, promotes dissection on the anterior abdominal wall, and simplifies

(a)

(b)

Figure 37.9 Robotic scissors and atraumatic Cadierre grasper. The adhesions are divided with robotic instruments. The Cadiere grasper retracts the bowel, and the adhesions to the abdominal wall are divided with scissors.

Figure 37.10 Passing sutures through the abdominal wall to fix the dual-sided mesh in place. The da Vinci’s stereoscopic view facilitates passing the sutures. A suture-passer drags the sutures through the abdominal wall (a). Two robotic graspers are used to hand the sutures to and from the suture-passer (b).


the passage of the fixation sutures through the abdominal wall. The da Vinci holds the video camera. The robot does not tire and does not wander from the operative field. This stable camera platform avoids the eye fatigue generated by a constantly moving, human-held video camera. Although all laparoscopic surgeons have been trained to operate from a two-dimensional monitor, the true three-dimensional virtual operative field provides immediate advantages and rapidly became our preferred field of view. The surgeon comprehends more easily the threedimensional virtual operative field. Our impression is that this makes it easier for us to maintain our orientation and helps to avoid past pointing injuries. Straight laparoscopic instruments often fail to reach the anterior abdominal wall. The wrist-like motion generated by seven degrees of freedom overcomes this shortcoming and simplifies lysis of the adhesions to the anterior abdominal wall. This maneuver is awkward at best with conventional straight laparoscopic instruments because of their anterior position. Straight laparoscopic instruments are often limited from reaching the anterior abdominal wall by the point of fixation of the trocar at the abdominal wall. The angulated movements of the robotic instrument tips permit the attack of the adhesions from a wide variety of angles. Three-dimensional imaging also assists in the passage of the fixation stitches through the abdominal wall. Although this process can be accomplished with twodimensional video cameras, novice laparoscopic surgeons accomplish this task more quickly in a three-dimensional operative field.

CONCLUSION

Tele-robotic surgery remains in a period of rapid evolution. Newer generations of both da Vinci and Zeus continue to be developed rapidly. Whether tele-robotics will become the standard of care in the near future remains uncertain. Nonetheless, even at this early juncture, telerobotic surgical systems address some of the specific limitations of standard laparoscopic surgery. Tele-robotic surgical systems maintain a stable camera platform, immerse the surgeon in a three-dimensional virtual operative field, move the surgical instruments with six or seven degrees of freedom, and further improve the ergonomics for the surgeon. Tele-robotics also have the potential usage in very remote settings, such as the battlefield and outer space.

REFERENCES 1

2 3 4

5

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7 8

Many surgeons perform advanced laparoscopic operations with standard twentieth-century technologies. Nonetheless, standard laparoscopy presents certain limitations that impede the learning of advanced skills and prevent many surgeons from performing advanced laparoscopic operations. Robotics offers technological solutions to some of these shortcomings. We have found that AESOP provides a stable camera platform, maintains a stable relationship with the horizon, adequately replaces a human camera-holder, and lets the surgeon stand in an ergonomically comfortable position. Voice-control systems help to integrate the operating room and to keep the surgeon in control of an ever more complicated operating environment. In our hospital, robot-assisted laparoscopic pre-peritoneal inguinal hernia repair in an integrated operating room is our standard of care. We believe that this technique permits the surgeon the best opportunity to replicate the operation in a high-volume mode with excellent clinical outcomes.

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10

11

12 13

14

15

Ballantyne GH. The pitfalls of laparoscopic surgery: challenges for robotics and telerobotic surgery. Surg Laparosc Endosc Percutan Tech 2002; 12: 1–5. Talamini MA. Surgery in the 21 century [editorial]. Ann Surg 2001; 234: 8–9. Fan P. Surgical grand rounds presentation: laparoscopic hernia repair. Hackensack University Medical Center, April 3, 2001. Merola S, Weber P, Wasielewski A, Ballantyne GH. Comparison of laparoscopic colectomy with and without the aid of a robotic camera holder. Surg Laparosc Endosc Percutan Tech 2002; 12: 46–51. Felix EL. Laparoscopic extraperitoneal hernia repair. In: Eubanks SW, ed. Mastery of Endoscopic and Laparoscopic Surgery. Philadelphia: Lippincott Williams & Wilkins, 2000: 443–55. Geis WP, Kim HC, Brennan EJ, Jr, et al. Robotic arm enhancement to accommodate improved efficiency and decreased resource utilization in complex minimally invasive surgery procedures. Stud Health Technol Inform 1996; 29: 471–81. Marescaux J, Leroy J, Gagner M, et al. Transatlantic robot-assisted telesurgery. Nature 2001; 413: 379–80. Ballantyne GH, Kelley WE, Jr. Granting clinical privileges for telerobotic surgery. Surg Laparosc Endosc Percutan Tech 2002; 12: 17–25. Hourmont K, Pereira S, Wasielewski A, et al. Robotic versus telerobotic laparoscopic cholecystectomy: duration of surgery and outcomes. Surg Clin North Am 2003; in press. Cadiere GB, Himpens J, Vertruyen M, Favretti F. The world’s first obesity surgery performed by a surgeon at a distance. Obes Surg 1999; 9: 206–9. Cadiere GB, Himpens J, Vertruyen M, et al. Evaluation of telesurgical (robotic) Nissen fundoplication. Surg Endosc 2001; 15: 918–23. Gould JC, Melvin WS. Computer-assisted robotic antireflux surgery. Surg Laparosc Endosc Percutan Tech 2002; 12: 26–9. Shah J, Rockall T, Darzi A. Robot-assisted laparoscopic Heller’s cardiomyotomy. Surg Laparosc Endosc Percutan Tech 2002; 12: 30–32. Horgan S, Vanuno D, Benedetti E. Early experience with robotically assisted laparoscopic donor nephrectomy. Surg Laparosc Endosc Percutan Tech 2002; 12: 64–70. Ballantyne GH, Hourmont K, Wasielewski A. Telerobotic laparoscopic repair of incisional ventral hernias using intraperitoneal prosthetic mesh (Stoppa technique): report of two cases. J Soc Laparoendosc Surg 2003; in press.

38 Socioeconomic issues KARL A. LEBLANC, ANDREW N. KINGSNORTH AND ZINDA Z. LEBLANC

Economics of hernia repair Economics of day-case surgery Incentives and day-case hernioplasty Return to normal activity and work

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Economic evaluations of new and existing healthcare interventions are an essential input into decision-making. Healthcare systems around the world face steady increases in expenditure as a result of demographic change and improvements in medical technology. Increasingly, payers must choose which interventions will be provided and which will not be reimbursed from limited public or private funds. This creates difficult choices, as systems are no longer limited by what is technically possible to improve the health of patients but by what is practically possible given resource constraints. In a situation where resources are scarce, all choices about who will be treated have an opportunity cost – the value of the benefit foregone. Health economics and the techniques of economic evaluation aim to maximize the amount of health that is produced within the scarce resources available. In the UK, the National Institute for Clinical Excellence (NICE) synthesizes evidence and reaches a judgment as to whether on balance the intervention can be recommended as a cost-effective use of National Health Service (NHS) resources.1 In 2000, NICE published recommendations for the use of laparoscopic hernia surgery. It recommended its use outside centers of expertise only in cases of bilateral inguinal hernia or recurrent inguinal hernia. In the UK in 1996, approximately ten per cent of hernia repairs were carried out laparoscopically.2 Since the publication of the NICE guidelines, this figure has decreased dramatically and supports the concept that the application of clinical pathways can reduce costs. Such measures are important in the UK, where the numbers of medical staff and the annual NHS budget are well below those in other European countries, Organization for

Economics of laparoscopic surgery Payment changes Conclusion References

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Economic Cooperation and Development (OECD) countries, and the USA.3 It is no longer sufficient to consider the clinical or therapeutic effects of healthcare interventions: purchasing choices will be predicated on studies that identify, measure and value what is given up when an intervention is used (the cost) and what is gained (improved patient health outcomes). This requires explicit economic evaluation of healthcare interventions. Purchasers have a fixed budget and are aware of the opportunity costs of interventions. Increasingly, they are likely to require evidence of effectiveness and cost-effectiveness, and they may develop contracts and enforce protocols to ensure this. Economic evaluation values both inputs (costs) and outcomes (consequences) of an intervention, comparing more than one alternative. This builds upon clinical evaluations that assess efficacy (can an intervention work in experimental circumstances?) and effectiveness (does it work in normal clinical practice?) to assess efficiency (does it provide the greatest benefit at least cost?). The type of economic evaluation depends upon the outcome measure chosen:

•

•

Cost-minimization analysis is appropriate only when the outcomes of two or more interventions have been demonstrated to be equivalent, in which case the least costly alternative is the most efficient, and only cost analysis is required. Cost-effectiveness analysis includes both costs and outcomes using a single outcome measure, usually a natural unit. This allows comparisons between


•

•

treatments in a particular therapeutic area where effectiveness is unequal, but not between therapeutic areas where natural outcome measures differ. Cost-utility analysis combines multiple outcomes into a single measure of utility (e.g. a qualityadjusted life year, QALY). This allows comparisons between alternatives in different therapeutic categories with different natural outcomes. Cost-benefit analysis links costs and outcomes by expressing both in monetary units, forcing an explicit decision about whether an intervention is worth its cost. Various techniques have been used to attach monetary values to health outcomes, but the technique remains rare in health economics.

Considerations in cost-effectiveness are particularly relevant at a time when healthcare costs are escalating disproportionately in relation to gross national product in many westernized countries.4 The value of any indicated treatment is directly proportional to treatment outcome and inversely proportional to treatment cost. Evaluation of both the numerator (outcome quality) and the denominator (cost) of the equation are subject to many methodological limitations. The value depends on whether it is viewed from the perspective of the patient, surgeon, hospital, employer, payer or industry. Moreover, cost does not equate with charge. In hernia surgery, the total cost includes pretreatment (diagnostics), treatment, post-treatment medical care including complications and recurrence, and societal and employer costs, which include insurance, worker’s disability compensation, worker replacement costs, and loss of productivity. Each sector of the treatment process has variable fixed and semi-fixed costs. The trends to eliminate general anesthesia and to perform conventional herniorrhaphy in an ambulatory setting have been cost-beneficial. Ideally, cost containment could be achieved by performing all elective inguinal hernia repairs at ambulatory surgical centers for a standardized charge. Technological innovation in surgery and in other areas (e.g. diagnostic innovation) is not regulated in the same way as innovative pharmaceutical therapies. A new pharmaceutical product is subjected to rigorous clinical trials to identify evidence of safety and efficacy, before licensing for public use. Increasingly, new and existing pharmaceutical products are also subjected to well-defined economic evaluation to show evidence of effectiveness and efficiency. Guidelines issued by the UK Department of Health state that ‘the economic evaluation of pharmaceuticals should become part of taking decisions about treatment’, and set out clear guidelines regarding how a high-quality economic evaluation should be carried out.5 The careful procedures that control the introduction of innovative pharmaceutical products are essential for innovative surgical and diagnostic therapies. How, then,

should technological innovations such as laparoscopic surgery be introduced? All such pioneering innovations should be evaluated in well-designed trials. There are difficulties in implementing randomized controlled trials of surgical techniques due to the difficulties of blinding, but a carefully designed trial can mitigate these problems. Clinical trials protect the safety of patients and ensure that new technologies produce effective healthcare. Economic evaluations ensure that such health gains are purchased at least cost. The guidelines applied to pharmaceutical products, intended to protect society’s health and scarce resources, should also be applied to surgical innovations, but this is a difficult task to institute. The principle of evaluating innovative surgical interventions was accepted by the Department of Health in the UK in a press release in 1995, which announced that major innovations were to be ‘scrutinised, evaluated and then, if approved, fast tracked throughout the health service’.6 A major advance should, under a new system, be subjected to clinical trials, and a central register would give information on approved operations. Purchasers could then consult the register as a measure of the effectiveness of various operations and procedures. This register, the Safety and Efficacy Register of New Interventional Procedures (SERNIP), is managed by the Academy of Medical Royal Colleges and funded by the Department of Health. Doctors are asked to register new techniques that they intend to pilot, and to check the register to discover the current status of new invasive procedures.7 An advisory committee convened by SERNIP will then assess all known data and assign the procedure to one of four categories: 1 Safety and efficacy unsatisfactory – procedure must not be used. 2 Safety and efficacy established – procedure can be used. 3 The procedure is sufficiently similar to one of established safety and efficacy to raise no reasonable doubts and can be used. 4 Safety and efficacy are not established – controlled evaluation is needed. The proposed system is voluntary and controlled clinically. In time, economic evaluation of innovative invasive procedures will be required, as is the case for pharmaceutical products. In the majority of other countries, including the USA, such a system does not exist at any level.

ECONOMICS OF HERNIA REPAIR Hernia repair is an established and effective procedure. Its relatively fixed cost and high volume among surgical procedures mean that economic evaluation of the procedure itself has become a priority. Hernias create pain and discomfort for patients and limit their ability to work or

Socioeconomic issues 275

carry out other productive activities. While the increased risk of surgical procedures in elderly people means that repair of some small direct hernias may not be mandatory, there would seem to be clear clinical and economic arguments in favor of carrying out hernia repairs among the majority of the working population.8 J.W. Hurst, a health economist, has compared the benefits and costs of hernia repair with the benefits and costs of home dialysis for renal failure, and with the benefits and costs of a successful renal transplant.9 Drawing on a measure of health status that measures two dimensions of health (disability and distress), and using Department of Health and Social Security (DHSS) cost data, Hurst calculated the health status yield per pound sterling for the three selected treatments. Using this cost-benefit equation, uncomplicated hernia repair comes out better than a successful renal transplant, and a renal transplant is better value than continuous home hemodialysis. Memories of Cecil Wakeley’s aphorism crowd in to confirm that refined clinical judgment may well be as valuable in evaluating the benefits of clinical care as the statistical gymnastics of contemporary health economists.10 Innovations in the procedure of hernia repair and the management of patients should, however, be subject to economic evaluation, ideally based upon a randomized controlled trial. The recent developments in hernia repair, such as the expansion of day-case surgery in Europe, require a clinical and economic base. However, the experience from the Shouldice clinic in Canada and the results from the USA support the use of limited hospitalization for the repair of hernias. Laparoscopic inguinal hernia surgery has not been proven to represent an economic benefit for the unilateral primary hernia. There may be some benefit for the patient with bilateral and/or recurrent herniation. Other laparoscopic hernia surgeries, such as hiatal and incisional hernia repair, have reduced the length of hospitalization significantly.

ECONOMICS OF DAY-CASE SURGERY Reductions in length of stay for many surgical and other inpatient procedures result from improvements in surgical procedures reducing recovery time, changing preferences of patients, and financial and political pressures on hospitals to reduce costs. Day-case surgery is often preferred by patients, and it may encourage early mobilization and reduce the risk of hospital-acquired infection.11 Day-case treatment for hernia repair may result in good outcomes for lower costs than other organizational forms of care.12,13 The Royal College of Surgeons recommends that at least 30 per cent of elective hernioplasties should be performed on a day-case basis.14 In the USA, however, all but the most ill or infirm individuals with inguinal hernias are operated

on as outpatients. Additionally, because of the increasing trend of incisional herniorrhaphy by the laparoscopic method, many incisional and ventral hernias are performed with a length of stay of 23 hours or less.15,16 Economic appraisal is unlike surgical decisionmaking. Economists analyze the results of their interventions by comparing them within different scenarios: as the scenarios change – employment prospects, labor relations, etc. – the economics change too. Surgeons are used to evaluating their outcomes over time with the scenario held constant. For instance, with day-case surgery and a constant surgeon-related scenario, one impact of shortening the patients’ stay will be empty beds, which the surgeon will perceive as the currency of an ‘efficiency saving’. The economist would not call this a saving; the concept of opportunity cost means that no benefit has accrued until the empty beds (resources) are put to some alternative use. Benefit is thus not necessarily the same to the surgeon as to the economist. Any economic appraisal of day-case surgery must, therefore, first address the crucial issue of the term ‘benefit’. Are the benefits to be:

• • •

more surgery, using the freed resources to undertake a greater volume of surgery or more complex innovative surgery? a redeployment of the freed resources towards a different client group, e.g. elderly or mentally ill people? a reduction in overall health service expenditure by the amount saved?

A day-case surgery policy will need to be appraised in the short run and in the long run. Short-run benefits may be very difficult to gain; for instance, a reduction in surgical bed requirements by 15 may confer no benefit since one cannot eliminate half a 30-bed ward and reduce staff costs by 50 per cent overnight. While there may be no short-term gains, the long-term gains could be substantial and allow explicit alterations to existing surgical and nursing practice. Consequently, new hospital provision could include fewer traditional inpatient surgical wards and instead have dedicated day-case units. In the USA, there are, in fact, many centers that are free-standing and dedicated to day-case surgery or short-stay procedures. Stepping through the looking-glass, more day-case surgery will need less capital expenditure on surgical inpatient facilities, and fewer nursing staff will need to be employed for the same volume of work in the long term. The quantification of savings accruing from a day-case policy is difficult; four approaches have been advanced:

• •

Comparing the bills paid by patients in private practice.17 The analytical device of holding the level of service constant and estimating the benefits that could be bought with the now unused resources.18


• •

The technique of comparing average per diem inpatient and outpatient costs.19 Farquharson produced the seminal paper advocating this type of economic evaluation.20 Comparing and computing the one-year costs of a day-care facility with the one-year costs of a traditional in-patient unit.21

Bailey, an economist from the Audit Commission in the UK, has proposed an alternative strategy to determine the resources that might be released as a result of a change from inpatient to day-case while treating an equivalent patient.22 He states that the costs of day surgery are substantially less than inpatient care, but it is misleading to interpret such measures as savings. The resource implications of more day surgery should be estimated directly by looking at precisely what changes are planned to take place. In conclusion, there is evidence that the unit costs of day-case surgery are much lower than inpatient care: of the order of 40–75 per cent per treatment episode, however calculated. These lower unit costs will free up resources to carry out more surgery or for alternative uses. Day-case surgery has been found to be superior to inpatient surgery in terms of wound infection and return to work, although this finding is not statistically significant.23 Day-case surgery is also becoming increasingly acceptable to patients. A dedicated five-day care unit allows more resources to be saved compared with day cases in a traditional theater suite and ward, where all the resources cannot be redeployed easily, particularly in the short run. This is consistent with the conclusions of a US review of costeffectiveness of management of hernia by Millikan and Deziel.4 These authors concluded that the most costeffective approach to hernia repair would use an ambulatory surgical center with open-mesh repair for primary inguinal hernia and failed primary suture repair.

INCENTIVES AND DAY-CASE HERNIOPLASTY To date, resource savings from day-case surgery in the NHS have been used largely to expand surgical services either quantitatively or qualitatively. Every hospital experienced this phenomenon in the 1970s. It has been quantified and shown that as resources are liberated by day-case work, they are used up in other surgical endeavors. This extra work sucks in further resources, and the overall surgical budget becomes larger. Increasing the proportion of day cases in the surgical unit mix will lead to a fall in the average cost of each patient treated. This may enable more cases to be operated upon; even though the marginal costs of doing each extra case within normal working hours are low, the aggregated cost to the hospital will be higher, although

greater demand will initially be met and the queue reduced. If there is no queue and no excess demand, then reducing costs should allow premises to be closed and staff made redundant, with considerable reduction in fixed and variable costs. The cost of doing an extra case after hours in a day-case unit, when staff must be paid overtime, is a very high marginal price – a fact to be remembered when case-scheduling is considered. If day-case surgery is used to cut unit costs and increase the overall volume of surgery, then this extra burden of rising productivity will fall on the surgeons and nurses. There are reports of the proportion of day cases rising to close to 40 per cent in some units, with consequent increases in surgical throughputs. Ultimately, the increased output may demand an alteration on the supply side of the equation, and more doctors and nurses may then need to be employed to cope with increased demand.24 While the relationship between demand and output of a surgical service is elastic in the short term, in the longer term supply inevitably must be increased to allow greater output. This is particularly evident in many areas in the USA, where there are nursing and anesthesia staff shortages. It must be apparent that there is no economic incentive for surgeons and other hospital employees to expand day-case surgery. Substantial savings can be achieved only by maintaining constant the quantity of surgery carried out, by not allowing day cases to increase the output, and by closing premises and dismissing redundant staff. The development of free-standing centers, however, will transfer these cases to these centers and allow more efficient use of the hospital staff and/or relocate these employees.

RETURN TO NORMAL ACTIVITY AND WORK There is enormous variation in reported times for return to normal activity and work. For instance, in a socialized system of healthcare where patients’ expectations and the insurance system still favor hospitalization, length of hospital stay after hernia surgery may be in excess of eight days.25 Even in the USA, where ambulatory surgery units are quite commonplace, the length of stay may be several days in institutions where reimbursement is not controlled as strictly as the private sector, although this is rapidly becoming uncommon. Customers of the Metropolitan Life Insurance Company surveyed by a nationwide claims questionnaire revealed a length of stay that averaged 2.9 days.26 In the US army, average hospital stay for hernia surgery is 4.6 days.27 In reality, housing conditions, the distance from home to hospital, and the availability of home nursing care (spouse, relative, friend) are the major factors affecting early discharge after hernia repair.28 These societal issues are more frequently problematic with


other larger procedures. Payers, however, seldom provide consideration for these important matters that involve patient care. The technique adopted has little predictive value for early postoperative pain and analgesic consumption. Kawji and colleagues, in a study of 240 patients who had been treated with Lichtenstein under general anesthesia, Lichtenstein under local anesthesia, laparoscopic transabdominal pre-peritoneal (TAPP), Shouldice operation, or pre-peritoneal Wantz procedure, found that the only technical factor significantly reducing analgesic requirement during the first three perioperative days was the use of intraoperative local anesthesia.29 Lau and Lee studied postoperative pain by linear analogue scores in 239 patients having inguinal herniorrhaphy with a variety of techniques.30 With multiple regression analysis, older patient age was the only independent factor of pain, a finding in keeping with anecdotal experience of surgeons used to operating on patients under local anesthesia. The French Association for Surgical Research investigated the feasibility of discharge within 48 hours of inguinal hernia repair in 500 consecutive men with unilateral, uncomplicated non-recurrent inguinal hernias. Of 411 patients suitable for early discharge, 107 (26 per cent) eventually stayed for more than 48 hours, early discharge was declined by 84, and early discharge was contraindicated in 42 (these patients had local or general complications), which finally resulted in one-day surgery being performed in only 51 (ten per cent) of the patients. These results emphasize the need for careful preoperative evaluation, which includes not only the hernia and the patient’s general medical condition, but also any social conditions, such as isolation, flights of stairs, or lack of a telephone, that may limit the ability to discharge a patient soon after surgery. Advice concerning return to normal activity has been managed poorly by surgeons. Recent studies indicate that factors limiting a patient’s return to activity and work are governed principally by the perceived amount of postoperative pain. Socioeconomic factors strongly influence this perception over and above the actual procedure performed or the anatomy involved.31 In a casecontrolled comparison of patients receiving workers’ compensation compared with patients having commercial insurance, seven surgeons from a single clinic compared 22 consecutive workers’ compensation patients with 22 commercial insurance patients. All patients had received open hernioplasty, and the duration of postoperative pain and the days off work were compared. The differences between the two groups were striking: the median duration of postoperative pain in the workers’ compensation group was 27 days, with 36.5 days off work. In the commercial insurance patients, the duration of postoperative pain was 7.5 days and they went back to work after only 8.5 days. Personal motivation, therefore,

appears to be the most important factor affecting clinical outcome and return to activities. Callesen and coworkers have demonstrated that well-defined recommendations and improved pain management can shorten convalescence.32 One hundred patients having elective herniorrhaphy under local anesthesia and managed analgesia were recommended to have one day of convalescence for light/moderate work and three weeks of abstinence from strenuous physical activity. The overall median absence from work was six days; unemployed patients returned to activities in just one day, those in light/moderate work returned in six days, and those in heavy jobs returned by 25 days. A more detailed prospective study of return to work after inguinal hernia repair has been undertaken by Jones and colleagues.33 Data were collected by personal interviews, written surveys, and medical record reviews in 235 patients, the main outcome measures being actual and expected return to work. Age, educational level, income level, occupation, symptoms of depression, and the expected day of return to work (ten days) accounted for 61 per cent of the variation in actual (12 days) return to work. Advice given in the UK on driving after groin-hernia surgery varies widely because there is no evidence-based information.34 In a postal questionnaire sent to 200 surgeons, the advice ranged from it being acceptable to drive on the same day of surgery (three per cent of respondents) to suggesting that patients wait six to eight weeks before driving (nine per cent of respondents); the most common response was that patients should wait two weeks (37 per cent of respondents). Amid has stated that the recovery period is dependent solely on the amount of postoperative discomfort, which should be minimal and should not usually require narcotic analgesia.35 Amid recommends that patients can resume driving as early as one week or less after surgery, depending on their comfort and whether they are using narcotic analgesics. Those who drive different types of vehicles need different advice. An additional consideration should be the complexity of the operative procedure. Intra-abdominal procedures will require longer periods of convalescence than inguinal hernia repair. It must be apparent that there is no economic incentive for surgeons and other hospital employees to expand day-case surgery. Substantial savings can be achieved only by maintaining constant the quantity of surgery carried out, by not allowing day cases to increase the output, and by closing premises and dismissing redundant staff. Such a policy is unlikely to make surgeons who take up day-case surgery popular. However, the experience in the USA, where day surgery is quite commonplace, has proven that the patients and their surgeons are quite satisfied with these economics. In fact, many patients are dismayed when they are told that their medical condition dictates a hospital stay of even one night.


ECONOMICS OF LAPAROSCOPIC SURGERY Since the pioneering laparoscopic removal of a gall bladder by French surgeon Phillippe Mouret in 1987, the introduction and rapid diffusion of laparoscopic surgical techniques was accepted with unbridled enthusiasm, and often without question, by many surgeons, the media and the general public. The years that have passed since then have allowed a more rational approach to many of these procedures. The majority of laparoscopic adaptations of the general surgical operations have proven to be cost-effective due to the diminution in the length of hospital stay. The great exception is laparoscopic repair of inguinal hernias, which is always more costly. Some economic arguments have been used to support the rapid diffusion of laparoscopic surgery. Studies often quote reductions in the length of inpatient hospital stay in comparison with standard surgical procedures and imply that this will necessarily save hospitals money. This is, however, not necessarily the case, and hospital managers are increasingly questioning the appropriateness of procedures that involve purchase of sophisticated and expensive capital equipment and considerably increased operative time, resulting in lower patient throughput for surgical procedures. Available time in the operating theatre is a scarce resource, and although operating time in laparoscopic surgery declines as experience increases, Cuschieri estimated that on average it will continue to take about one-third longer than the corresponding conventional operation, with the excess of time over open surgery the higher the more complicated the basic operation.36 Time, however, has proven that once past the learning curve, many of these operations are only as long as or are shorter than that of the open method. Many of these comparisons may be flawed because there are ‘slow operators’ and ‘quick operators.’ Many of the operations discussed in this book are commonly performed with less operative time than their open counterparts in centers with surgeons skilled in these procedures. The effect of length of inpatient stay on health service resource use is an important issue in many studies. Cuschieri estimates that discharge may, on average, be expected to be within less than 48 hours.36 This is thought to result in cost-savings from earlier discharge and earlier return to normal activities, including work. However, economists such as Sculpher note that this may not always be the case.37 First, a reduction in the demand for hospital beds may not result in cash-savings unless it allows ward closures. At one time, this was felt to be unlikely as laparoscopic surgery represented a small proportion of all hospital procedures. Other arguments were that laparoscopy did not release other resources used for surgical procedures, particularly theater time, and that some laparoscopic procedures replaced non-invasive

therapies rather than open surgery. It is important to remember that lengths of inpatient stay were falling for many years, and the additional savings from laparoscopic surgery may be lower than anticipated. History, however, has proven that many of these worries have not resulted in a decline in the use of laparoscopic surgery. In most procedures, except for inguinal hernia repair, the trend is upward. Complication rates are important determinants of the overall costs of any surgical procedure. Complications with laparoscopic surgery procedures, such as bile-duct injuries with laparoscopic cholecystectomy, have been well documented (see Table 1 in Soper et al.38). Most bileduct injuries occur early in a surgeon’s experience, highlighting the need for careful training and accreditation of surgeons, and clinical practice guidelines.39 The rate of conversions from laparoscopic operations to open operations ranges from 1.8 to 8.5 per cent, and tends to be highest early in a surgeon’s experience.38 The cost implications of complication rates include increased operating time, increased length of inpatient stay, increased care burden on families or other caregivers, and increased time for the patient to return to work or normal activities. The current rates of complications, however, have now established the laparoscopic cholecystectomy as the standard of care for gallbladder disease because they are comparable, whether open or laparoscopic. A recent systematic review of the effectiveness and safety of laparoscopic cholecystectomy showed that effectiveness of this procedure is similar to that of open and mini-cholecystectomy.40 Complete alleviation of symptoms was achieved in 60–70 per cent of patients. However, safety profiles differ, with more technical support and specialized surgical equipment required for the laparoscopic procedure. Differences in complication rates were difficult to assess because of methodological problems and differences between studies. In particular, studies often do not have sufficient statistical power to identify clinically important differences in outcomes, particularly bile-duct injury, because the rate of adverse events is low. Sculpher argues that laparoscopic surgery has a different ‘production function’ to conventional surgical techniques, i.e. it requires a different mix of inputs to the production process, more inputs of theater and medical staff time, more sophisticated equipment, and fewer inputs of inpatient bed days.37 The overall effect on hospital costs and on overall costs to society is unclear and requires economic evaluation. Evaluation should be long-term in order to include any effects of different re-admission rates, and should include not only hospital costs and effects but also the burden on communitybased services, patients and carers, which may change due to earlier discharge. The ‘production function’ description of surgery is useful in considering other issues. The appropriate level


of individual and center specialization should be determined by evidence of economies of scale. If a center specializes in laparoscopic surgery, then this may influence costs per patient, as theater time may be reduced as familiarity with the procedure increases. In addition, outcomes may be improved, particularly by reduced complication rates. However, the appropriate level of individual and center specialization requires careful evaluation: could the alleged benefits of centralization be matched by careful training and treatment protocols at local levels? Identification of the conditions necessary for the production of efficient laparoscopic procedures is absent but inhibits neither unsubstantiated assertions by policymakers nor significant investments in new facilities. The repair of inguinal hernias with the laparoscopic method continues to raise many questions, particularly regarding economics. Whereas it is generally accepted that this technique is effective for these hernias, the costs associated with this method causes many surgeons to question the usefulness of this technique. In 1996, the benefits were unclear.41 In 2003, the clinical efficacy is not generally questioned. The cost issues have been resolved for the most part. It is more expensive to perform the minimally invasive method except in a very few areas that have managed to eliminate the use of disposable instruments and tissue-expansion balloons. Evidenced-based studies have definitely revealed that the levels of pain and subsequent convalescence after laparoscopic repair are decreased when compared with open repair.42 This is particularly true with the comparison of pure tissue repairs, but it has also been found with open prosthetic repairs. However, some studies have reported that while these patients experience less pain postoperatively, the return to work interval was not different after TAPP repair. The opinion of these authors was that the increase in costs did not justify the operation unless the operative costs could be reduced.43 Another study found that laparoscopically repaired patients returned to their usual activities seven days earlier than those of the open group. The incremental cost for this time frame was £55 548 per QALY over the open method. This report showed that there might be specific situations in which this laparoscopic repair may be a viable alternative, particularly when reusable rather than disposable instruments were used because these costs were decreased significantly.44 The operative costs that are increased with the laparoscopic approach are the use of disposable instruments, balloon dissection devices, balloon trocars, additional personnel, and the length of the operation. These costs can be reduced to the extent that the cost of the operation can approach that of the open procedure. Lorenz has shown that by the deliberate attempt to decrease costs, the laparoscopic approach can be less expensive to the hospital.45 Beets and Dirksen found that the open approach can

be more expensive than the laparoscopic approach (open, US$1150; laparoscopic, US$1179).46 In many centers, however, this has been a stimulus for surgeons to abandon the procedure altogether (willingly or unwillingly). The insurance industry has refused to reimburse hospitals and surgeons for the procedure, leading to the rapid demise of the procedure. Medicare in the USA actually pays surgeons less to perform these operations laparoscopically than through the open technique (see below). These realities have resulted in the trend of many centers to utilize this operation only in the bilateral situation and for recurrent hernias. The success for this diagnosis is proven.47,48 The ongoing studies of the Medical Research Council (MRC) Laparoscopic Groin Hernia Trial Group support the move to specialist surgeons to perform this operation.49 Based upon the experience in the USA, this appears to be the trend. Data comparing open versus laparoscopic repair of inguinal hernias are now voluminous, and a detailed analysis of all the factors is beyond the scope of this chapter. Suffice to say that the vast majority of reports have identified the same findings that are commonly known. That is, in general the laparoscopic operation is more expensive but postoperative pain is diminished and the return to work is notably shorter. The learning curve and the payors of these operations will force this procedure into the hands of a few skilled surgeons with excellent outcomes. Even in this case, this will be for bilateral and recurrent hernias. Studies such as that by Lawrence and coworkers used a UK randomized controlled trial as the basis of an economic evaluation of laparoscopic versus open inguinal hernia repair, on data collected from 104 day-case patients.41 The mean total health service cost of laparoscopic repair was £1074, compared with £489 for open repair. Linking this additional cost with the additional pain-free days in the laparoscopic group showed an additional cost per pain-free day of £109 (95 per cent confidence interval, £41–393). The authors concluded that there were strong arguments against the introduction of laparoscopic hernia repair until evidence on long-term outcomes becomes available. Such studies, although important, are few. Hekkinnen and colleagues conversely proved that the overall societal costs are less with the laparoscopic method.50 Regardless, the cost– benefit structure of the insurance industry does not appreciate the societal costs as do the individual patient and surgeon. Therefore, this limited use of the laparoscope to repair inguinal hernias will probably be permanent in the USA. In other countries, such as those in Europe, a more critical look at these issues may be possible because of the public nature of the healthcare system. This is needed. Unlike those of laparoscopic inguinal herniorrhaphy, the clinical and economic benefits are clearer with the laparoscopic repair of incisional and ventral hernias.


Open repair Operative time, range (min)

Operative time, average (min)

Length of hospital stay, range (days)

Length of hospital stay, average (days)

Complication rate (%)

Recurrence rate (%)

Cost, range (US$)

Cost, average (US$)

45–259* 27–148 60–180 25–220 N/A 97.6* 78.5 111.5 82 N/A N/A 2–26* 3–21* N/A 0.5–14* 4.9 6.5* 9.06* 2.8 4.4* 31 36.7* ? 36 N/A 12.5 34.7 2 20.7 0 1987–12 611* N/A N/A N/A 6574–18 448 7299* N/A N/A N/A 12 461

*Statistically significant difference.

Laparoscopic repair 70–211* 45–170 30–180 18–225 N/A 128.5* 95.4 87 58 N/A N/A 1–17* 1–15* N/A 0.5–3* 1.6 3.4* 2.23* 1.7 0.8* 15 17.9* 10 N/A 1 11 0 2.5 4.8 3555–5235* N/A N/A N/A 5323–11 223 4395* N/A N/A N/A 8273

Ref. 54 55 53 56 16 54 55 53 56 16 54 55 53 56 16 54 55 53 56 16 54 55 53 56 16 54 55 53 56 16 54 55 53 56 16 54 55 53 56 16

PAYMENT CHANGES Despite the points discussed above, the financial realities of governmental reimbursement in the USA have declined continuously. We selected the comparison of the payments from Medicare in the USA since 1993 for four hernia operations (Figure 38.1). Unless noted otherwise, all of these are inguinal hernia repairs. It is readily apparent that these levels of payment have not changed significantly in nine years. These payments do not reflect the inflationary increases in office overheads and the enormous elevations in the cost of medical liability insurance. Additionally, the payment for the repair of bilateral inguinal hernias is 1.5 times the payment for the repair of a single hernia. Because of this, some surgeons simply cannot afford to repair bilateral hernias at the same time. Instead, these are repaired sequentially in two separate procedures. It is particularly disturbing that payment for the repair of an incisional hernia (US$636.69) is less than the repair of a recurrent incarcerated inguinal hernia (US$644.07). The differences

US dollars

Table 38.1 Results of comparative analysis of open and laparoscopic incisional and ventral herniorrhaphy

evaluated the cost of the repair.16,54 In both papers, the laparoscopic method was associated with less cost than the open repair. This is based primarily upon the decreased length of stay of laparoscopically repaired patients. This occurred even when the additional costs of any re-admissions were included in the overall determination. Interestingly, the work by DeMarie and colleagues evaluated the costs based upon open repair using a polypropylene product versus the laparoscopic repair using an expanded polytetrafluoroethylene (ePTFE) patch.16 Therefore, based upon the limited study that has been done on this operation, it appears that laparoscopic herniorrhaphy for incisional and ventral hernia is the economically preferred choice. These issues are discussed more frequently with the repair of inguinal and incisional hernias. The use of the laparoscope to repair the other hernias discussed in this textbook appears to compare favorably with open repair. Decreased length of stay, decreased morbidity, and a more rapid return to normal activity have been shown.

800 700 600 500 400 300 200 100 0 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02

Many papers in the literature have demonstrated the short period of hospitalization seen with this approach to this problem.15,16,51,52 It is generally believed by surgeons proficient in this technique that this method lessens the length of hospitalization for the patients. Five publications have compared open and laparoscopic repair of incisional and ventral hernias (Table 38.1).16,53–56 In all of these series, laparoscopic repair was associated with fewer complications and fewer days of hospitalization than those of open method. Only two of these papers

Open Recurrent Recurrent incarcerated Incisional Laparoscopic inguinal Laparoscopic recurrent inguinal

Figure 38.1 Medicare reimbursement in real dollar values from 1993 to 2002.


in the complexity of the operations, potential morbidity, and length of postoperative care are obvious to every surgeon. The financial realities of the practice of surgery in the USA are subtly affecting the ethics of surgery. Laparoscopic repair of primary inguinal hernias is reimbursed less than that of the open repair. There is no consideration given to the extra level of expertise and training that is required to perform that operation. One could postulate that the financial disincentive is placed to discourage the use of the procedure in these patients because of the extra cost associated with the operation. This is especially troubling, as this will inhibit its use in patients who might benefit from that method of repair. At the time of writing, there is no code in which to bill for the laparoscopic incisional hernia repair, although one should be available soon. In the USA, access to healthcare by the recipients of governmental healthcare is being affected adversely. Many people cannot find physicians who will accept these low levels of payment. Some surgeons no longer repair bilateral hernias simultaneously. Because of the costs of doing business, the ethics of medicine are being impacted. There does not appear to be hope of any meaningful relief in the near term. In fact, there may be less reimbursement by Medicare to the surgeon to perform any operation laparoscopically rather than by the open technique. Further government intervention may avert this unfortunate event, but politics are part of the medical landscape in all countries. Unless changes are forthcoming, few surgeons will adopt these newer techniques.

CONCLUSION It is no longer sufficient to consider only the clinical and therapeutic effects of healthcare: purchasing choices require explicit economic evaluation to identify, measure and value costs and patient health outcomes. Surgical interventions are no exception to this business principle. Hernia repair is an established and effective procedure for most patient groups, and its relatively low cost among surgical procedures means that economic evaluation of the procedure itself is not a priority. However, innovations in the procedure of hernia repair and the management of patients, such as day-case and laparoscopic repair of the different hernias, should be subject to economic evaluation. The unit costs of day-case surgery are lower than those of traditional in-hospital care. Any money saved will enable more operations to be carried out and more patients to be treated. Alternatively, savings generated could be used to develop other services. Laparoscopic surgery has spread rapidly through many surgical specialties, but there are still major knowledge

gaps about its clinical and economic attributes. The potential clinical and economic benefits of laparoscopic inguinal hernia repair are particularly unclear given the need for general anesthesia and the possibility of rare but serious injuries to intra-abdominal organs. This procedure benefitted from large-scale clinical trials and economic evaluations for inguinal hernia repair. The use of laparoscopy in the repair of many of the other hernias of the abdominal wall seems to have a strong economic benefit, however. The future development of advanced techniques and even the availability of even the simplest of hernia repairs may become more difficult due to the negative financial consequences of governmental payment schedules.

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Downs SH, Black NA, Devlin HB, et al. Systematic review of the effectiveness and safety of laparoscopic cholecystectomy. Ann R Coll Surg Engl 1996; 78: part II. Lawrence K, McWhinnie D, Goodwin A, et al. An economic evaluation of laparoscopic vs open inguinal hernia repair. J Public Health Med 1996; 18: 41–8. EU Hernia Trialists Collaboration. Laparoscopic compared with open methods of groin hernia repair: systematic review of randomized controlled trials. Br J Surg 2000; 87: 860–67. Pananini AM, Lezoche E, Carle F, et al. A randomized, controlled, clinical study of laparoscopic vs open tension-free inguinal hernia repair. Surg Endosc 1998; 12: 979–86. MRC Laparoscopic Groin Hernia Trial Group. Cost-utility analysis of open versus laparoscopic groin hernia repair: results from a multicentre randomized clinical trial. Br J Surg 2001; 88: 653–61. Lorenz D, Stark E, Oestreich K, Richter A. Laparoscopic hernioplasty versus conventional hernioplasty (Shouldice): results of a prospective randomized trial. World J Surg 2000; 24: 739–45. Beets GL, Dirksen CD, Go PM, et al. Open or laparoscopic preperitoneal mesh repair for recurrent inguinal hernia: a randomized controlled trial. Surg Endosc 1999; 13: 323–7. Sarli L, Iusco DR, Sansebastiano G, Costi R. Simultaneous repair of bilateral inguinal hernias. Surg Laparosc Endosc Percutan Tech 2001; 11: 262–7. Schmedt C-G, Däubler P, Leibl BJ, et al. Simultaneous bilateral laparoscopic inguinal hernia repair. Surg Endosc 2002; 16: 240–44. MRC Laparoscopic Groin Hernia Trial Group. Laparoscopic versus open repair of groin hernia: a randomised comparison. Lancet 1999; 354: 185–90. Heikkinen TJ, Haukipuro K, Hulkko A. A cost and outcome comparison between laparoscopic and Lichtenstein hernia operations in a day-case unit. Surg Endosc 1998; 12: 1199–8. Costanza MJ, Heniford BT, Area MJ, et al. Laparoscopic repair of recurrent ventral hernias. Am Surg 1998; 64: 1121–7. Kochler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: a personal series and review of literature. J Soc Laparoendosc Surg 1999; 3: 293–304. 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 1999; 13: 250–52. Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and incisional hernioplasty. Surg Endosc 1997; 11: 32–5. Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998; 124: 816–22. Ramshaw BJ, Escartia P, Schwab J, et al. Comparison of laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65: 827–32.

Index

Note: References to figures are indicated by ‘f ’ and references to tables are indicated by ‘t’ when they fall on a page not covered by the text reference. abdominal bloating, after fundoplication 218, 243–4 abdominal wall, anterior anatomy see anterior abdominal wall anatomy achalasia 198–9 adhesiolysis, and bowel injury 163 adhesives 11–12 AESOP robotic arm 266–8 alkaline reflux gastritis 218 Allison’s procedure 174–5 Alloderm prosthetic material 22–4 Anatomical Mesh 21 anatomy anterior abdominal wall see anterior abdominal wall anatomy in children 255 diaphragm 179–83 inguinal/femoral region see inguinal/femoral anatomy peritoneal cavity 41–2 pre-peritoneal space 42–3 and total extraperitoneal (TEP) patch technique 66–7, 68f anesthetic complications 89 in children 261 Angimesh prosthetic material 17–18 anterior abdominal wall anatomy 104–5 and cosmetic results 109 and functional outcomes 109–10 and hernia formation 105–6 and hernia repair methods 106–7 and prosthetic biomaterial fixation 107–8 and scar healing 108–9 arcuate line 42f, 44 balloon trocars 9 barium swallow 188, 190 Bassini, E 34 bilateral hernia 62 in children 251–2 bioadhesives 11–12 biochemical changes, and hernia formation 36 biological prosthetic materials 22–4 Biomesh prosthetic materials 17–18 bladder injury 92 Bochdalek hernia 257–8 bone complications 93 bowel injury 161–3 bowel obstruction 92–3 laparoscopic repair 111–13 calcitonin gene-related peptide (CGRP) 45–6 Cheatle, GL 34 children

anatomy 255 complications in 261–2 diaphragmatic hernia repair history 257 patient selection 257 surgical technique Bochdalek hernia 257–8 Morgagni hernia 258–9 history of laparoscopy in 251–4 physiology 255–6 cigarette smoking, and hernia formation 36 clinical studies, ventral/incisional hernioplasty comparative studies 157–9 series comparisons 155–7 collagen defects 46 Collis gastroplasty 198 colostomy, parastomal hernias see parastomal hernias compartmented stomach, after fundoplication 219–20 complication rates laparoscopic method comparisons 83–4 laparoscopic vs open methods 84–6 complications in children 255–6, 261–2 diaphragmatic hernia repair 235–7 economic evaluation 278 fundoplication intraoperative 239–40 bougie perforation 240–1 esophageal perforation 240 gastric injury 243 hemorrhage 241–2 large hernia 243 pneumothorax 241 short esophagus 242–3 postoperative dysphagia 246 gastrointestinal symptoms 243–4 ileus 246 para-esophageal hernia 244 recurrent reflux 247 slipped Nissen 244–5 symptom assessment 243 vagal nerve injury 245–6 inguinal/femoral hernioplasty anesthesia 89 hydrocele 90 laparoscopic access 89–90 nerve injury 91–2 organ complications 90 prosthetic mesh problems 93 recurrence rates 93–4 seroma 90–1

vascular injury 91 visceral injury 92–3 laparoscopic assisted ventral hernia repair 163–4 para-esophageal hernia repair 206–7 with prosthetic biomaterials 17–21 and recurrent gastroesophageal reflux disease 217–22 and return to work 276–7 with transfascial sutures 134–5 ventral/incisional hernioplasty bowel injury 161–3 comparative studies 157–9 gastrointestinal complications 166 postoperative pain 166 prosthetic mesh fixation 107–8 prosthetic mesh infection 164–5 recurrence rates 166–8 series comparisons 156t, 157 seroma 165–6 see also recurrence rates Composix prosthetic biomaterials 21–2 congenital hernias 257–9 connective tissue damage and hernia formation 36 and pathophysiology 46 convalescence after surgery 276–7 Cooper’s ligament 42–3 cosmetic outcomes, ventral/incisional hernioplasty 109 crural disruption, after fundoplication 219 cyanoacrylate fixation 12 da Vinci tele-robotic system 268–9 ventral/incisional hernioplasty 270–2 day-case surgery, economic evaluation 275–6 denervation hernias anatomy 151, 152f formation of 105–6 surgical repair indications/contraindications 152 operative technique 152–3 outcomes 153 diaphragm anatomy 179–83 and hernia surgery 184–5 physiology 183–4 diaphragmatic hernia in children 257 fundoplication see fundoplication history of surgery for Allison, P 174–5 in children 257 early surgery 173 laparoscopic approach 175–6

284 Index diaphragmatic hernia (Contd) Nissen fundoplication 175 short esophagus 174 outcomes of surgery 235–7 para-esophageal hernias see para-esophageal hernias from traumatic injury 209–10 acute herniation 210–12 chronic herniation 212–14 types of hiatal hernia 235 see also gastroesophageal reflux disease (GERD) diarrhea, after fundoplication 218 diffuse esophageal spasm 198–9 disposable instruments 7–8 dissecting instruments 8 double-crown technique indications/contraindications 133–4 instrumentation 135–6 operating room set-up 137 outcomes 141 postoperative management 141 preoperative management 135–6 prosthetic biomaterials 136–7 surgical technique 137–41 transfascial suture comparison 134–5 driving, after surgery 277 DualMesh prosthetic biomaterials 18–21 in ventral/incisional hernioplasty double-crown technique 136–7 parastomal hernias 146–7 series comparisons 156t, 157 transfascial suture technique 117–18 Dulex prosthetic biomaterial 18–21 dysphagia, after fundoplication 217–18, 246 economic evaluation 273–4 day-case surgery 275–6 hernia repair 274–5 laparoscopic surgery 278–80 payment methods 280–1 return to work 276–7 electrosurgery 10 employment, return to after surgery 276–7 EMS stapler 25–6 EndoAnchor fixation device 27–8 Endopath EMS stapler 26 endoscopy 188, 190, 227–8 endosopic gastroplasty 194 enterotomy 161–3 epigastric hernia 106 ergonomics 13 esophageal hiatus 181–3 esophageal manometry 188–9, 190, 228f, 229 esophageal perforation, with fundoplication 240–1 esophagography 228–9 esophagomytomy 198–9 expanded polytetrafluoroethylene (ePTFE) products composite products 21–2 flat, single-component products 18–21 in ventral/incisional hernioplasty 126 double-crown technique 136–7 fixation 108 obstructed/incarcerated bowel 112–13 parastomal hernias 146–7 and scar healing 108–9 series comparisons 156t, 157 transfascial suture technique 117–18 external oblique muscle 44, 104

fascia transversalis 42–4 pathophysiology 46 femoral canal 45 femoral hernioplasty history 76 incidence of femoral hernias 75–6 postoperative management 77 surgical technique 76–7 femoral nerve 45 femoral sheath 45 fibrin adhesive agents 11–12 fixation devices 11–12 EndoAnchor device 27–8 helical coil devices 27 Salute device 27, 28f staple devices 25–7 Fortagen prosthetic material 22–4 Fortaperm prosthetic material 22–4 fundoplication 194 anatomical considerations 184–5 complications intraoperative 239–40 bougie perforation 240–1 esophageal perforation 240 gastric injury 243 hemorrhage 241–2 large hernia 243 pneumothorax 241 postoperative dysphagia 246 gastrointestinal symptoms 243–4 ileus 246 para-esophageal hernia 244 recurrent reflux 247 slipped Nissen 244–5 symptom assessment 243 vagal nerve injury 245–6 short esophagus 242–3 failure of clinical presentation 217–18 mechanisms of failure 219–21 history 175–6 Nissen fundoplication see Nissen fundoplication operative technique Collis gastroplasty 197–8 crural closure 195–6 esophagomytomy 198–9 mobilization 194–5 modified Toupet 196–7 pyloroplasty 199 outcomes of surgery 235–6 preoperative evaluation esophageal manometry 188–9 pH monitoring 189–90 symptom assessment 187–91 for recurrent disease patient selection 230 preoperative evaluation 227–30 surgical technique 230–4 gastric blood vessel injury 241–2 gastric emptying studies 230 gastric injury 243 gastroesophageal reflux disease (GERD) diaphragmatic anatomy 179–83 and surgical repair 184–5 diaphragmatic physiology 183–4 fundoplication see fundoplication non-surgical treatment 193–4 preoperative evaluation esophageal manometry 188–9 pH monitoring 189–90

symptom assessment 187–8 recurrent disease 217 clinical presentation 217–18 evaluation after failed surgery 190–1 incorrect diagnosis 221–2 incorrect surgery 221 mechanisms of failure 219–21 surgery for indications 222–4 patient selection 230 preoperative evaluation 227–30 surgical technique 230–4 surgical treatment individualization of therapy 199–200 operative technique Collis gastroplasty 197–8 crural closure 195–6 esophagomytomy 198–9 mobilization 194–5 modified Toupet 196–7 Nissen fundoplication 196 pyloroplasty 199 patient preparation 194 see also diaphragmatic hernia gastrointestinal complications after fundoplication 243–4 after ventral/incisional hernioplasty 166 recurrent gastroesophageal disease 217–19 genitofemoral nerve 45 injury to 91–2 giant prosthetic reinforcement of the visceral sac (GPRVS), history 36 Glucamesh prosthetic biomaterial 21–2 Glucatex 3D prosthetic biomaterial 21–2 grasping instruments 8 hand-assisted laparoscopy (HAL) 12–13 Hasson trocar 8–9 health economics day-case surgery 275–6 economic evaluation 273–4 hernia repair surgery 274–5 laparoscopic surgery 278–80 payment methods 280–1 and return to work 276–7 helical coil fixation devices 11, 27 hemorrhage with fundoplication 241–2 with inguinal/femoral hernioplasty 91 Henry, AK 34 hepatocyte growth factor/scatter factor (HGF/SF) 45–6 Hermesh prosthetic biomaterials 17–18 Hertra prosthetic biomaterials 17–18 Hesselbach’s triangle 43 Hessert’s triangle 46 hiatal hernia see diaphragmatic hernia hiatal stenosis 220 history diaphragmatic hernia in children 257 diaphragmatic hernia surgery Allison, P 174–5 early surgery 173 laparoscopic approach 175–6 Nissen fundoplication 175 early surgery 33 femoral hernioplasty 76 fixation devices 25–8 intraperitoneal onlay of mesh (IPOM) procedure 47–8 laparoscopic general surgery 3–5 laparoscopic hernia repair 37–9

Index 285 nonoperative management 33 obturator hernioplasty 76 open hernia repair 33–6 ventral/incisional hernioplasty 99–100 hydrocele 90 in children 262 hypertensive lower-esophageal sphincter 198–9 ileostomy, parastomal hernias see parastomal hernias ileus 246 ilio-hypogastric nerve 45 ilio-inguinal nerve 45 iliopubic tract 42–3 imaging systems 12 see also robotic devices incarcerated bowel repair 111–13 incarcerated inguinal hernia 63 incisional hernias diagnosis 125 incidence 125 pre-peritoneal hernioplasty see pre-peritoneal hernioplasty repair methods 125–7, 129–30 risk factors 125 see also ventral/incisional hernioplasty infants see children infection, with prosthetic biomaterials 93, 113, 164–5 inferior epigastric vessels 41 injury to 91 infertility, and prosthetic mesh 93 inguinal canal 44 inguinal/femoral anatomy femoral canal 45 femoral sheath 45 inguinal canal 44 myopectineal orifice 44–5 nerves 45 oblique muscles 44 peritoneal cavity 41–2 pre-peritoneal space 42–3 spermatic cord 44 transversalis fascia 43–4 inguinal/femoral hernioplasty complications anesthesia 89 hydrocele 90 laparoscopic access 89–90 nerve injury 91–2 organ complications 90 prosthetic mesh problems 93 recurrence rates 93–4 seroma 90–1 vascular injury 91 visceral injury 92–3 economic evaluation 279 femoral hernioplasty history 76 incidence of femoral hernias 75–6 postoperative management 77 surgical technique 76–7 history in children 252–4 early surgery 33 nonoperative management 33 open hernia repair 33–6 intraperitoneal onlay of mesh (IPOM) procedure see intraperitoneal onlay of mesh (IPOM) procedure lipomas 80–1 low Spigelian hernia 81

obturator hernioplasty see obturator hernioplasty outcomes laparoscopic method comparisons 83–4 laparoscopic vs open methods 83–6 perineal hernia 79–80 prevascular hernia 80 sciatic hernia 77–9 supravesical hernia 79 total extraperitoneal (TEP) patch technique see total extraperitoneal (TEP) patch technique transabdominal pre-peritoneal (TAPP) patch technique see transabdominal pre-peritoneal (TAPP) patch technique injuries from laparoscopic access 89–90 traumatic diaphragmatic injuries see traumatic diaphragmatic injuries from trocars 8–10 see also complications instrumentation disposable 7–8 dissecting and grasping instruments 8 energy sources 10–11 ergonomics 13 fixation devices 11–12, 25–8 hand-assisted laparoscopy 12–13 robotic devices see robotic devices trocars 8–10 videoendoscopy systems 12 internal inguinal ring 41–2 internal oblique muscle 44, 104 intestinal complications 92–3, 161–3 intestinal stomas, parastomal hernias see parastomal hernias Intramesh prosthetic biomaterials 17–18 intraperitoneal onlay of mesh (IPOM) procedure advantages and disadvantages 51 history 37, 47–8 operating room set-up 48–9 patient selection 48 postoperative management 51 surgical technique 49–51 irreducible inguinal hernia 63 ischemic orchitis 90 laparoscopic assisted ventral hernia repair 163–4 laparoscopic hernia repair history 37–9 open method comparison 84–6 laparoscopic surgery economic evaluation 278–80 history 3–5 lateral cutaneous nerve of thigh 45 Lichtenstein repair history 35–6 laparoscopic method comparison 84–5 lipomas 80–1 liver injuries 241 low Spigelian hernia 81 lower-esophageal sphincter 183–4 lumbar hernias anatomy 151, 152f surgical repair indications/contraindications 152 operative technique 152–3 outcomes 153

Marcy, HO 33–4 Marlex prosthetic biomaterial 17–18 history 34–5 Mersilene prosthetic biomaterial 18 mesh prosthetics see prosthetic biomaterials modified Toupet fundoplication 196–7 Morgagni hernia 258–9 muscular denervation see denervation hernias Mycromesh prosthetic biomaterials 18–21 myopectineal orifice 35, 36f, 44–5 Nanticoke Hernia Stapler 26 National Institute for Clinical Excellence (NICE) 273 needle drivers 11 neoplasia, and recurrent gastroesophageal reflux disease 220, 221–2 nerves anatomy 45 injury to 91–2 with prosthetic biomaterial fixation 108 and recurrent gastroesophageal reflux disease 221, 245–6 Nissen fundoplication anatomical considerations 184–5 complications 220, 244–5 history 175 preoperative evaluation 187–91 surgical technique 196 non-cutting trocar 10 nutcracker esophagus 198–9 Nyhus, LM 34 oblique muscles 44 obstructed bowel repair 111–13 obturator artery, injury to 91 obturator hernioplasty history 76 incidence of obturator hernias 76 postoperative management 77 surgical technique 76–7 Omni-Tack 26–7 open hernia repair and anterior abdominal wall anatomy 106–7 history 33–6 for incisional hernias 126–7 laparoscopic method comparison economic evaluation 279–80 outcomes of surgery 84–6 for ventral/incisional hernias 129–30, 157–9 for para-esophageal hernias 202 optical view trocar 9 Origin tacker 27 outcome of surgery inguinal/femoral hernioplasty laparoscopic method comparisons 83–4 laparoscopic vs open methods 84–6 ventral/incisional hernioplasty comparative studies 157–9 cosmetic results 109 denervation hernias 153 double-crown technique 141 functional outcomes 109–10 lumbar hernias 153 parastomal hernias 148–9 pre-peritoneal hernioplasty 129–30 series comparisons 155–7

286 Index pain after fundoplication 218 after ventral/incisional hernioplasty 166 management in children 256 and return to work 277 para-esophageal hernias after fundoplication 244 outcomes of surgery 236–7 surgical repair anatomical considerations 202 indications/contraindications 201–2 laparoscopic vs open methods 202 operating room set-up 203 operative technique 203–7 postoperative management 207–8 preoperative evaluation 202–3 types of 201 parastomal hernias assessment 144 outcomes 148–9 postoperative management 147–8 surgical repair indications/contraindications 144–5 methods 144 preoperative preparation 145 surgical technique 145–7 types of 143–4 Parietene prosthetic biomaterial 17–18 Paritex prosthetic biomaterials 18, 21–2 partitioned stomach, after fundoplication 219–20 pathophysiology 36, 45–6 pectineal ligament 42–3 pediatric hernia anatomical considerations 255 complications anesthesia 261 hydrocele 262 recurrence rates 262 surgical complications 261–2 testicular complications 262 diaphragmatic hernia repair history 257 patient selection 257 surgical technique Bochdalek hernia 257–8 Morgagni hernia 258–9 pathophysiology 44, 45–6 physiological considerations 255–6 pediatric laparoscopy, history 251–4 pelvic anatomy anterior abdominal wall see anterior abdominal wall anatomy inguinal/femoral region see inguinal/femoral anatomy pelvic hernia repair see femoral hernioplasty; obturator hernioplasty perineal hernioplasty 79–80 peritoneal cavity, anatomy 41–2 pH monitoring 189–90, 190–1, 229–30 phreno-esophageal ligament 181 physiology in children 255–6 diaphragm 183–4 inguinal region 45–6 plug-and-patch technique, history 37 pneumothorax 206, 241 polyester biomaterials composite products 21–2 flat, single-component products 18, 19f preformed products 21 in ventral/incisional hernioplasty 126 polypropylene mesh (PPM) products

composite products 21–2 flat, single-component products 17–18 history 34–5 preformed products 21 in ventral/incisional hernioplasty 108, 126 double-crown technique 136–7 obstructed/incarcerated bowel 112–13 and scar healing 108–10 postoperative complications see complications pre-peritoneal hernioplasty comparison with other techniques 129–30 indications 127 laparoscopic vs open methods 129–30 operating room set-up 127 outcomes 129 patient preparation 127 postoperative management 129 surgical technique 127–9 tele-robotic systems 270–2 see also total extraperitoneal (TEP) patch technique pre-peritoneal space, anatomy 42–3 prevascular hernioplasty 80 processus vaginalis anatomy 44 pathophysiology 45–6 Prolene prosthetic biomaterials 17–18 Prolite prosthetic biomaterial 17–18 prosthetic biomaterials history 34–5, 37–9 infection 93, 164–5 non-synthetic materials 22–4 and outcome of surgery, laparoscopic vs open methods 85–6 synthetic materials composite products 21–2 flat, single-component products 17–21 preformed products 21 see also individual surgical procedures Protack device 27 protease/antiprotease imbalance, and hernia formation 36 pyloroplasty 199 radially expanding trocar 10 Reconix prosthetic biomaterial 18–21 rectus abdominus muscle 104 recurrence rates gastroesophageal reflux disease (GERD) see gastroesophageal reflux disease (GERD), recurrent disease hiatal hernia repair 235–7 inguinal/femoral hernioplasty 93–4 laparoscopic vs open methods 84–6 pediatric hernia 262 total extraperitoneal (TEP) patch technique 84 transabdominal pre-peritoneal (TAPP) patch repair 62–3, 84 ventral/incisional hernioplasty 166–8 comparative studies 158t, 159 series comparisons 156t, 157 reflux esophagitis see gastroesophageal reflux disease (GERD) respiration and incisional hernias 106 and laparoscopy in children 256 robotic devices 13

AESOP robotic arm 266–8 tele-robotic systems 268 da Vinci system 268–9 in ventral/incisional hernioplasty 270–2 Zeus system 269–70 round ligament, lipoma 80–1 Safety and Efficacy Register of New Interventional Procedures (SERNIP) 274 Salute fixation device 11, 27, 28f scar healing 108–9 sciatic hernioplasty 77–9 scrotal hernioplasty 63 Sepramesh prosthetic biomaterial 21–2 seroma 90–1, 165–6 shielded trocar 9–10 short esophagus Collis gastroplasty 197–8 and fundoplication 242–3 history of surgery for 173–4 and recurrent gastroesophageal reflux disease 219 Shouldice technique 84–5 skin complications 93 cosmetic outcomes 109 smoking, and hernia formation 36 socioeconomic issues day-case surgery 275–6 economic evaluation 273–4 hernia repair 274–5 laparoscopic surgery 278–80 and payment methods 280–1 and return to work 276–7 Soft Tissue Patch prosthetic biomaterial 18–21 spastic disorders of esophagus 198–9 spermatic blood vessels, injury to 91 spermatic cord anatomy 44 lipoma 80–1 Spigelian hernia 81 spiral tack fixation devices 11, 27 splenic injury 242 staple fixation devices 11, 25–7 stomach complications, after fundoplication 219–20 Stoppa procedure 36 strangulated bowel repair 113 Stretta Procedure 193–4 supravesical hernioplasty 78 surgical ergonomics 13 Surgipro prosthetic materials 17–18 Surgisis prosthetic materials 22–4 suture passers 11 synthetic biomaterials composite products 21–2 flat, single-component products 17–21 preformed products 21 see also prosthetic biomaterials tack fixation devices 11, 27 TAPP technique see transabdominal pre-peritoneal (TAPP) patch technique tele-robotic systems 268 da Vinci system 268–9 ventral/incisional hernioplasty 270–2 Zeus system 269–70 TEP technique see total extraperitoneal (TEP) patch technique

Index 287 testicular complications in children 262 inguinal/femoral hernioplasty 90 thermal energy sources 10 3D Max prosthetic biomaterial 21 total extraperitoneal (TEP) patch technique AESOP robotic arm 266–8 anatomical considerations 66–7, 68f complications anesthesia 89 hydrocele 90 laparoscopic access 89–90 nerve injury 91–2 organ complications 90 with prosthetic mesh 93 seroma 90–1 vascular injury 91 visceral injury 92–3 history 38 indications/contraindications 65–6 instrumentation 68 open method comparison 84–5 postoperative management 73 preoperative evaluation 68 recurrence rates 93–4 surgical technique 69–73 transabdominal pre-peritoneal (TAPP) comparison 83–4 transabdominal pre-peritoneal (TAPP) patch technique AESOP robotic arm 266–8 for bilateral hernia 62 complications anesthesia 89 hydrocele 90 laparoscopic access 89–90 nerve injury 91–2 organ complications 90 prosthetic mesh 93 seroma 90–1 vascular injury 91 visceral injury 92–3 history 37–8 indications/contraindications 53–4 instrumentation 55 open method comparison 54, 84–5

operating room set-up 55, 56f postoperative management 63 preoperative evaluation 54–5 recurrence rates 93–4 for recurrent hernia 62–3 for scrotal hernia 63 surgical technique 56–61 transfascial suture technique adhesiolysis 120–1 advantages/disadvantages 134–5 indications/contraindications 115–16 instrumentation 118–19 patient preparation 118 postoperative management 123–4 preoperative evaluation 116–17 prosthetic biomaterials 117–18 insertion/fixation 122–3 surgical technique 120 trocar placement 119–20 trocar selection 119 transversalis fascia 42–4 transversus abdominus muscle 104–5 traumatic diaphragmatic injuries 209–10 acute herniation 210–12 chronic herniation 212–14 Trelex prosthetic biomaterial 17–18 trocars design of 8–10 injury from 89–90 tumors, and recurrent gastroesophageal reflux disease 220 twisted fundoplication 220 ultrasonic dissection 10–11 ultrasonically activated trocar 10 umbilical hernia 106 urinary bladder injury 92 US Surgical Corporation stapler 26 Usher, FC 34–5 vagal nerve injury 221, 245–6 vas deferens complications 90, 93 vascular injury 89–90, 91 with fundoplication 241–2 with prosthetic biomaterial fixation 107–8 and trocar design 8–10

ventral/incisional hernioplasty anterior abdominal wall anatomy 104–5 and hernia formation 105–6 and repair methods 106–7 complications bowel injury 161–3 gastrointestinal complications 166 postoperative pain 166 prosthetic mesh infection 164–5 seroma 165–6 denervation hernias see denervation hernias double-crown technique see double-crown technique economic evaluation 279–80 history 99–100 laparoscopic assisted hernia repair 163–4 lumbar hernias see lumbar hernias obstructed/incarcerated bowel 111–13 outcomes comparative studies 157–9 cosmetic 109 functional 109–10 series comparisons 155–7 parastomal hernias see parastomal hernias pre-peritoneal hernioplasty see pre-peritoneal hernioplasty prosthetic biomaterial fixation 107–8 recurrence rates 166–8 scar healing 108–9 transfascial suture technique see transfascial suture technique Zeus tele-robotic system 268–9, 270–2 videoendoscopy systems 12 da Vinci tele-robotic system 268–9 ventral/incisional hernioplasty 270–2 visceral injury 89–90, 92–3, 243 with fundoplication 241–2 with para-esophageal hernia repair 206 and trocar design 8–10 work, return to after surgery 276–7 Zeus tele-robotic system 269–70

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Heart Valve Surgery: An Illustrated Guide

Mastery of Endoscopic and Laparoscopic Surgery, 3rd edition

Advanced Laparoscopic Surgery: Techniques and Tips, Second Edition

Laparoscopic Hernia Surgery: An Operative Guide