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433
PLATE
202
INDICATIONS Breast cancer patients undergoing a mastectomy or breast-
conserving procedure are candidates for axillary sentinel lymph node dissection (SNLD) if there is no palpable or clinical evidence of axillary lymph node
involvement. e nding of breast cancer metastases in axillary lymph nodes
changes the staging of the disease, predicts the rate of recurrence and survival,
and results in adjuvant treatment with chemotherapy, hormone therapy, or
radiation therapy. e standard axillary lymph node dissection of level I and
II nodes has signi cant morbidity, of which lifelong lymphedema is the most
feared by patients. Using a combination of radionuclide and dye injections,
the correlation of SLND and standard axillary lymph node dissection (ALND)
in nding positive lymph nodes is quite high ( percent) in the hands of an
experienced surgeon. However, sentinel lymph nodes are o en only identi ed in to percent of the dissections. Additionally, a false-negative nding occurs in to percent of the patients having SLND—that is to say, the
sentinel nodes are negative, but higher nodes are found to be positive. e
advantages of SLND are the fewer complications versus ALND and the ability to identify sentinel lymph nodes that are not in the traditional level I or II
areas. e identi cation of sentinel lymph nodes focuses the histiopathologic
examination, which may include immunohistochemical staining as well as the
traditional hematoxylin and eosin (H&E). e importance of a micrometastases (< mm) is under study; however, the total number of nodes involved
with metastases may in uence the adjuvant therapy that is o ered. Contraindications to SLND include locally advanced primary cancers (>-cm size);
suspicious, palpable axillary lymphadenopathy; multicentric primary breast
cancers; prior axillary surgery; and regional breast operations (e.g., breast
reduction) that alter normal lymphatic ow.
PREOPERATIVE PREPARATION e skin should be free of infection,
as should the preceding breast biopsy site. e preparation, delivery, and
monitoring of the radionuclide solution for injection must be coordinated
with the nuclear medicine sta .
ANESTHESIA General anesthesia with endotracheal intubation is preferred,
as many patients will also have ALND and may be having a concurrent reoperation upon the breast. Most surgeons prefer that the anesthesiologist use a
short-acting muscle paralyzing agent for placement of the endotracheal tube
such that the motor nerves can still be identi ed with mechanical stimulation during the ALND.
POSITION e patient is placed in a comfortable supine position with the
arm out at degrees on a padded arm board (figure 1). is position
allows easy access of the breast and the axilla.
S L N D, B
OPERATIVE PREPARATION Approximately minutes before the start
of the operation, the surgeon injects the radionuclide solution into the
breast, using sterile technique. A commercially available sulfur colloid
solution using a technetium-m tag is sterilized a er passage through a
.-μ m lter. Four -mL syringes are each loaded with mL of solution
containing about μC of radioactivity, for a total dose of about μC.
Shielding is not required, but the site is monitored with a radiation survey
meter. e breast is prepared with an antiseptic solution and sterile paper
drapes are applied. e four injection sites are anesthetized with an intradermal injection of local anesthetic. e pattern shown (figure 2a) allows
in ltration above, below, and at either end of the incision from a preceding
biopsy. A long ½-in. -gauge needle is used for this injection about the
biopsy site or the breast cancer. Many techniques are used for injection of
the radionuclide and the blue dye. e injections may be placed () deeply
about the tumor or biopsy cavity (figure 2), () super cially in the subdermal or intradermal site over the tumor or about the biopsy site scar, and
() super cially about the perimeter of the nipple in a subareolar manner.
Care must be taken not to inject into a biopsy cavity. e breast is washed
and the disposal items are surveyed and disposed of in a radiologically
safe manner. e patient proceeds to the operating room. A er induction
of anesthesia, the breast, chest, and upper arm are prepared and draped in
the usual manner.
INCISION AND EXPOSURE e same three techniques are available for
injection of about to mL of isosulfan blue vital dye (figure 3).
A er injection, the area is massaged for a few minutes. e dermal lymphatics may then manifest a faint blue blush streaming toward the axilla.
Using a hand-held gamma detector with a sterile cover, the surgeon
scans toward the axilla (figure 4) looking for the area with the high-
est count rate. is may be di cult to nd if the breast tumor or biopsy
site is high in the upper/outer quadrant, as a regional “shine through” of
the injection site radioactivity may create a very high background level.
e angled head of the gamma counter can be used to advantage, as it
allows more medial placement of the detector with an angled view that is
away from the injection site but yet still points into the axilla. If the hottest spot is near the base of the hair-bearing axilla, a transverse incision
is made directly over it (figure 5) in such a manner that the incision
can be extended later in a medial manner for a standard ALND. Sharp
dissection with a scalpel or electrocautery is made through the rst to
cm of fat. e probe explores the open incision to nd the hottest area
(figure 6).
CONTINUES
434
435
PLATE
203
DETAILS OF PROCEDURE Deeper dissection may reveal
some blue lymphatic channels (figure 7) owing toward the hot region
where a lymph node is palpable. e lymph node is dissected free along
with any neighboring lymph nodes that are blue or signi cantly hot
(figure 8). e de nition of “signi cant” is any lymph node that has a
radioactivity level greater than percent of the hottest sentinel node or a
level greater than two or three times the background level of the axillary tissue. Following removal of the sentinel nodal tissue, the incision is explored
with the gamma probe for any other lymph nodes with signi cant radioactivity. A basal background level (figure 9) should be present except when
the detector is pointed toward the tumor or biopsy injection site. Additionally, any rm or abnormal lymph nodes should be removed.
e nodal tissue removed is examined and the individual lymph nodes
are separated. One node, the sentinel node, should be quite hot, while its
neighbors are much less so (figure 10). In the example shown, lymph node
A is labeled as the principal sentinel lymph node. Lymph node B is labeled
as a sentinel node. Node C is not a sentinel node, as its counts are less than
percent of the principle sentinel node and it is not blue.
S L N D, B
CLOSURE If the sentinel lymph node is in the typical low axillary region,
careful hemostasis is obtained. A decision must be made as to whether to
proceed with a standard axillary node lymph dissection (ALND) through a
new incision or through extension of the existing incision. If a new incision
is required, then closure is performed. Scarpa’s fascia and the subcuticular
fat are closed with interrupted absorbable sutures. e skin is approximated with absorbable sutures.
POSTOPERATIVE CARE Most patients who have both SNLD and ALND
are observed overnight until the e ects of the general anesthesia have
cleared. Oral intake is resumed as tolerated and oral pain medications are
given. e serous output of the closed-suction Silastic drain is monitored.
O en it is removed before the patient is discharged or whenever the output
falls to less than mL per hours.
Patients with only an SLND are usually operated on in an ambulatory
setting. ey can be discharged home within a few hours when they are
alert and have stable vital signs according to the discharge protocol of the
surgical unit. ■
436
437
PLATE
204
INDICATIONS Ventral hernias in the anterior abdominal wall include
both spontaneous (e.g., umbilical, epigastric, and spigelian) and, most commonly, incisional hernias a er an abdominal operation. Small ventral hernias less than ½ cm in diameter are o en successfully closed with primary
tissue repairs. However, larger ones have a recurrence rate of up to or
percent when a tissue repair alone is performed. It is estimated that to
percent of all abdominal operations result in an incisional hernia. is
explains the predominance of such hernias. Fortunately, the use of mesh
has revolutionized the repair of abdominal wall hernias. Anterior placement of polypropylene mesh as an onlay to the primary repair is helpful
and a retrorectus muscle placement is even better. However, the development of dual-sided mesh has allowed for an improved placement of mesh
behind the abdominal wall and the hernial defect. ese meshes present
an intraperitoneal nonadherent surface (expanded polytetra uoroethylene,
or PTFE) to the bowel and an open polypropylene mesh grid or screen for
adherence and incorporation into the peritoneum and posterior abdominal wall fascia. e dual-sided meshes can be placed laparoscopically for
almost any ventral hernia, but extremely large hernias with loss of abdominal domain or those associated with extensive, dense intra-abdominal
adhesions (e.g., peritoneal dialysis, prior peritonitis) are relative contraindications. e meshes are very expensive; however, operating room time
and hospital length of stay are shortened. e laparoscopic incisions cause
less pain and there is a faster return to normal activities or work. Finally,
laparoscopic repair enables the detection and repair of multiple defects—a
common nding in midline incisional hernias.
PREOPERATIVE PREPARATION e patient must be free of infections,
especially in the skin. Respiratory function should be optimized with cessation of smoking and appropriate pulmonary function evaluation. If bowel
is contained with the hernia, endoscopic visualization, contrast studies, or
imaging may be performed and the patient may be given a bowel preparation with a liquid diet and cathartics for or days prior to surgery. e
major factors in the occurrence of this hernia, as well as the preceding operative note, should be reviewed.
ANESTHESIA General anesthesia with an endotracheal tube is required.
POSITION e patient is placed in a supine position with a pillow placed to
produce mild exion of the hips and knees. is helps to relax the abdominal wall. For ventral hernias that are not midline, the patient may be positioned with pillows for some lateral elevation of the chest, ank, and hips.
OPERATIVE PREPARATION e patient is given perioperative antibiotics.
An orogastric tube is passed for gastric decompression. A Foley catheter
is placed and pneumatic sequential stockings are applied. e skin is prepared in the routine manner.
INCISION AND EXPOSURE e -mm videoscope port () and the -mm
operating ports (X) are a function of the position of the hernial defect and
the preference of the surgeon (figure 1a). e general principle is that of
triangulation. e ports should be about a hand’s breadth or more apart
from each other and the two operating ports should be placed as widely
apart as possible. Typical hernias and the placement of ports are shown
(figure 1b to e). One of the operating ports should be mm in size if a
-mm videoscope is not available.
e videoscope port is placed rst, using the open Hasson technique
(Plate ). A er the abdomen is entered safely and the Hasson port secured
with the lateral stay sutures, the intraperitoneal space is in ated with carbon dioxide. e surgeon sets the gas ow rate and the maximum pressure
(≤ mmHg). e rising intra-abdominal pressure and total volume of gas
infused is observed as the abdomen and hernia distend. e videoscope is
white-balanced and focused. e optical end, usually a at or zero-degree
angle, is coated with antifog solution and the scope is advanced down the
port into the abdomen under direct vision. All four quadrants of the abdomen are explored visually. e hernia and its contents are evaluated and
additional unrecognized incisional hernial defects may be found, especially
in long midline incisions. Omental and other adhesions to the abdominal
and anterior abdominal wall about the hernial defect are visualized. A zone
R V H, L
of about to cm must be made clear about the rim of the hernial defect for
the wide attachment of the mesh beyond the borders of the actual defect.
Placement of the operating ports begins with the in ltration of the skin
with a long-acting local anesthetic. e local needle may be passed perpendicularly full-thickness through the abdominal wall and its entry site veri ed with the videoscope. e skin is incised and the subcutaneous tissues
are dilated with a small hemostat. e abdominal wall is transilluminated
with the videoscope to show any regional vessels within the abdominal
musculature. e -mm operating ports are placed, with visualization of
their clean entry into the intraperitoneal space.
DETAILS OF PROCEDURE In the typical ventral or incisional hernia, the
omentum will have formed some adhesions to the sac of the hernia. e
omentum is grasped near the abdominal wall with the forceps or the dissecting instrument and gentle traction is applied. Using laparoscopic scissors, the surgeon sharply incises the junction of the omentum with the
peritoneum of the abdominal wall (figure 2). A er each cut, a sweeping
motion in the same area will open up the next zone for cutting. Minimal
bleeding occurs. Electrocautery or other heat-generating coagulating systems should be used sparingly and only with full visualization so as to minimize the chance of thermal injury to the bowel. Extensive dense adhesions,
inability to reduce the hernial contents from the sac, or an enterotomy that
is not easily repaired all require conversion to an open laparotomy and
repair. A er the abdominal wall adhesions are taken down, the omentum
is removed from the hernial sac, which is le intact. A useful maneuver is
the inversion of the hernial sac using several ngers externally (figure 3).
is allows the sharp cutting to continue with the best visualization of the
junction of the omentum with the peritoneal sac. Again, gentle traction
is applied to the omentum while the surgeon spreads, cuts, and sweeps.
roughout this dissection, the surgeon must be vigilant for the appearance
of a loop of bowel hidden within these adhesions. Small and large bowel
may also be cautiously cut away from the abdominal wall and hernia sac,
but less sweeping and traction is applied lest an enterostomy occur. e
appearance of bile or succus demands a search for the source, which may be
repaired laparoscopically or a er conversion to and open laparotomy. Some
surgeons regard this complication as a contraindication to the placement
of mesh, which is porous and may harbor a chronic infection, requiring
eventual removal of the mesh.
A er careful inspection of the omentum and other adhesions that have
been removed from the abdominal wall, the surgeon makes a visual measurement about the perimeter of the defect to be certain there is an adequately clear zone for attachment of the mesh and its sutures. In general,
to cm is su cient. An important next step is to lower the intra-abdominal
CO
gas pressure to about or mmHg, which minimizes the stretching of
the abdominal wall and hernia. If measurements of the defect are made with
the abdomen fully in ated at mmHg, the mesh will be too large. It will
become very wrinkled and loose when the CO is removed at the end of the
operation. e size of the defect is measured. Some surgeons use an internal
measurement based upon a -cm spread, tip to tip, of the opened dissecting
instrument. Most perform an external measurement and marking maneuver
(figure 4). A long needle is passed perpendicularly at the edge of the fascial
defect in each of the four quadrants. e entrance site at the internal edge
of the hernial defect is veri ed with the videoscope and the external sites
are marked with indelible ink. e pattern of the defect is outlined so as to
determine the size and shape of the mesh. A - to -cm margin is drawn out
from this defect. is is marked and measured for choosing the mesh’s size
and shape (figure 4). e dual-sided mesh is prepared with placement of
four sutures, one in each quadrant (figure 5). e sutures are nonabsorbable in size and may be placed with parallel with or perpendicular to the
edge of the mesh. A useful maneuver is to use a pair of parallel sutures in
one axis ( and o’clock) and perpendicular sutures in the other axis ( and
o’clock). In this manner, the axis for internal attachment is identi ed when
the mesh is not round in shape. Each suture is tied in its midpoint and the
long tails are le intact. e mesh is rolled snugly with the expanded PTFE
surface on the inside and the polypropylene mesh on the outside, so as not to
create tension that may peel the two layers apart (figure 6).
CONTINUES
438
439
PLATE
205
DETAILS OF PROCEDURE In the hernia illustrated, the
-mm Hasson port for the videoscope was placed in the le lateral abdominal position. is large port site is needed for the di cult passage of the
rolled up mesh through the abdominal wall. A useful technique is to pass
a grasping forceps through an operating port and then out through the
Hasson port (figure 7). e port tube is removed and the rolled up mesh
is grasped with the forceps (figure 8) and drawn back into the abdomen.
e mesh is unrolled and oriented with the smooth expanded PTFE surface
down toward the bowel. Getting the mesh into the abdomen and unrolling
it in the correct orientation can be quite tedious. e mesh is rst secured
with one of the preattached sutures at the four quadrants. Most surgeons
begin with the or o’clock sutures. e four previously marked skin sites
are incised with a No. scalpel blade, which makes a -mm skin opening
(figure 9). A special suturing needle is passed perpendicularly through
the abdominal wall. e needle tip is opened and one of the suture ends is
grasped as it closes. e loose suture end is brought out through the abdominal wall and secured with a hemostat. A special suturing needle is passed
again through the abdominal incision, but this time it is aimed to enter the
abdominal space about cm away from the rst site. e other half of the
tied suture is grasped and brought out. e suture is tied down through
the skin incision, setting the knot deeply. is secures the mesh to the abdominal wall within (figure 9). is transabdominal suturing continues with
placement of the two lateral sutures and then, last, the opposite ( o’clock)
suture. In general, the mesh should be slightly loose but not wrinkled rather
than precisely tight. e exposed perimeter of the mesh is now secured with
an endoscopic stapling device. Spiral screws or tacks are preferred.
R V H, L
ese are placed cm apart. It is important that the perimeter be securely
attached with closely spaced tacks such that no bowel or omentum can get
under the edge of the mesh. Placement of the tacks is facilitated by having the surgeon apply external counterpressure with the hand while the
tacking instrument spreads out the mesh in a radial manner (figure 11).
ese two actions provide a little lip to the edge of the mesh, thus allowing
a more precise placement of each tack. Upon completion of the procedure,
the abdomen is lavaged with the suction irrigator. Careful inspection is
made for any bleeding sites and bile or succus. Each of the operating ports
is removed under direct vision to be certain that there are no bleeding sites
in the abdominal wall. As intra-abdominal gas is vented, the nal view of
the loosely applied mesh is seen (figure 12). e fascia of any -mm port
site is closed with delayed absorbable sutures. e skin is approximated
with ne subcuticular sutures. Adhesive skin strips and dry sterile dressings
are applied.
POSTOPERATIVE CARE e orogastric tube is removed before the patient
awakens and the Foley catheter is discontinued when the patient is alert
enough to void. He or she may experience a moderate amount of pain for a
day or so. Clear liquids are resumed within day and the diet is advanced as
tolerated. Some surgeons recommend the use of an abdominal binder for
month a er surgery. Hematomas and surgical-site infections can occur.
e latter may require eventual removal of the mesh if the infection becomes
chronic. Accumulation of serum in the old hernial sac occurs frequently
and may require aspiration. Last, some patients may experience chronic
pain at the sites of xation. ■
440
441
PLATE
206
INDICATIONS An umbilical hernia is usually a congenital defect, although
a variation may follow surgery such as the placement of an incision or laparoscopic port in this region. e increased susceptibility to strangulation
of an umbilical hernia in an adult necessitates repair as the patient’s condition permits.
Repair of an umbilical hernia in the very young child is rarely indicated,
since percent of these fascial defects will close by the age of years. In
addition, the incidence of incarceration and strangulation within an umbilical hernia in this age group is extremely low. However, if supportive measures such as the “keystone” type of strapping during infancy have failed
and the fascial ring is su ciently large to admit the index nger, the hernia
should be repaired before school age.
PREOPERATIVE PREPARATION is defect is usually seen in either chil-
dren or obese adults, and the preoperative preparation depends entirely
upon the patient’s general condition and age. Obese patients are placed on
a reducing diet. A general medical assessment is indicated. e patient may
be placed on a low-residue diet for a day or two and the bowels emptied
with a mild purgative. Repair is delayed in the presence of acute respiratory
infection, chronic cough, or infection about the navel. Special attention is
given to cleaning of the navel.
ANESTHESIA Spinal anesthesia may be preferred in large hernias because
of the excellent relaxation it provides; however, inhalation anesthesia can be
used if not contraindicated. Inhalation anesthesia is the method of choice for
children.
POSITION e patient is placed in a comfortable supine position.
OPERATIVE PREPARATION e skin is prepared in the usual manner a er
the umbilicus has been carefully cleaned. is may require cotton applicators saturated with antiseptic to reach any deep crevices.
INCISION AND EXPOSURE A curved incision placed superiorly or
inferiorly about the umbilicus is most commonly used (figure 1). A
vertical incision that curves around the umbilicus may be necessary for
very large hernias. e umbilicus proper should be retained in the skin
ap. e incision is made to the hernia sac. e sac is easily mobilized
except for its attachment to the back of the umbilical skin. is is dissected carefully so as not to create a buttonhole that may put the repair
at risk for infection. e neck of the herniated sac is then dissected from
adjacent tissues by a combination of blunt and sharp dissection, which
is carried down to the level of the linea alba and anterior sheaths of the
rectus muscle.
R U H
ADULTS
If an intermediate-sized defect in the range of to cm is found, many
surgeons prefer to repair it with the two layer “vest-over-trousers” (Mayo)
technique (figures 4, 5, and 6). e upper fascia is imbricated over the
lower fascia with a row of interrupted sutures. ese begin and end high
on the vest, while the trousers are secured in a horizontal manner at the
belt line (figure 4). When these sutures are secured, the free superior edge
(vest) overhangs the inferior fascia (trousers) and a second layer of interrupted sutures is used to secure the free edge (figure 5a). e technique is illustrated schematically in the cross-sectional view illustrated in
figure 6.
Many surgeons believe that a medium to large defect should be repaired
with mesh, as primary tissue repairs in large hernias have a signi cant
recurrence rate. e preferred site for placement of the mesh is posterior to
the defect and posterior rectus sheath. If the zone between the peritoneum
and posterior rectus sheath can be freely dissected, some surgeons use a
polypropylene mesh a er rst being certain that the omentum is directly
behind this region when the umbilical hernia sac is closed. Alternatively, if
this plane cannot be developed and the mesh must be placed in an intraperitoneal position, a dual-sided mesh is used wherein the smooth, nonadherent expanded polytetra uoroethylene (PTFE) surface is posterior
toward the omentum and bowel, while the polypropylene screen-like mesh
is anterior against the peritoneum and posterior fascia (figure 6a). e
mesh should be sized to extend to cm beyond the anticipated edges
of the closed defect. is mesh is secured with nonabsorbable mattress
sutures that are placed full-thickness through the linea alba at the and
o’clock positions and through the rectus sheaths and muscle at the and
o’clock positions. ese sutures should secure only the polypropylene
mesh and should not go full-thickness through the PTFE, as this may present a free intra-abdominal loop that may catch a loop of bowel. e anchoring sutures are tied and the defect is closed either vertically or transversely
using interrupted sutures.
CLOSURE A er careful hemostasis is obtained, the apex of the subcutaneous
tissue beneath the umbilicus is sutured down to the linea alba with absorbable sutures. is produces the desirable ingoing bellybutton. Further absorbable sutures are used to obliterate the subcutaneous dead space. A triple-bite
suture that secures Scarpa’s fascia to the deep fascia and then the Scarpa’s fascia
on the other side of the incision minimizes the space for a potential accumulation of serum or a hematoma. When the hernia is quite large, a closed-system
Silastic suction catheter may be placed through an adjacent stab wound.
POSTOPERATIVE CARE Special attention is given to the avoidance of abdom-
inal distention. An adhesive tape strip in. wide is liberally applied across the
abdomen, and the patient may use an abdominal binder for approximately
month. e patient is warned to avoid overly heavy li ing and straining.
DETAILS OF PROCEDURE Most commonly, omentum is contained within
the sac, but small and large bowel may also be present. Frequently the omentum will have formed adhesions to various areas of the sac, thus preventing
reduction of the hernia. Sharp dissection is required to detach hernial contents from the sac as well as from the peritoneum around the neck of the sac
as it joins the peritoneum. When there is a strong suspicion of gangrenous
intestine within the sac, the abdominal cavity should be entered through an
extended midline incision that enters either above or below the umbilicus.
is incision is extended to the fascial defect and up the side of the sac so
as to allow complete mobilization of the incarcerated bowel. e intestine is
either reduced or resected as indicated. In the majority of cases, omentum is
incarcerated within the sac.
In these patients, the sac may be opened (figure 2). If the omentum
cannot easily be freed and/or reduced, it is wise to resect it with sequential
clamping and suture ligature placement. When the contents of the sac have
been reduced and its neck has been well de ned, a decision is made as to
how to repair the fascial defect.
In general, when the defect is less than cm in diameter, the peritoneum
is closed and the excess sac excised. e perimeter of the fascial defect is
cleaned of fat both anteriorly and posteriorly, and a primary repair is performed using interrupted sutures that may be of a delayed absorbable or
nonabsorbable nature (figure 3). is primary repair is performed only
for small defects of . cm or less.
CHILDREN
DETAILS OF PROCEDURE A curved incision around the superior half
of the umbilical depression is made and the hernia sac is freed down to
the linea alba. is dissection extends laterally onto either rectus sheath.
e hernia sac is dissected free from the back of the umbilical skin, using
countertraction with skin hooks. e fascia is cleaned for a few centimeters
in all directions. In most patients, the sac can be reduced without being
opened. e edges of the fascial ring are grasped with Kocher clamps and
the posterior aspect of the fascia is cleaned for or cm. As most of these
fascial defects are small, a primary repair using interrupted sutures can
be performed in either a vertical or horizontal manner, depending upon the
shape of the defect.
CLOSURE e skin margins are approximated with interrupted subcutic-
ular absorbable suture. Skin strips are applied and the umbilicus is
packed with a small wad of gauze. A dry sterile dressing is applied.
POSTOPERATIVE CARE e routine postoperative care is performed.
Most patients are able to tolerate uid within a few hours and are discharged home within a day on a so diet. e skin of the umbilicus should
be observed for viability if an extensive dissection has been performed. In
most patients, the curved periumbilical incision becomes minimally visible
as the area heals. ■
442
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