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508
intact is made, and I try to limit the dissection
such that entry into the peritoneal cavity is
avoided. With incarcerated contents, this is not
usually feasible, however.
50.2.1 Tissue Repair
This option is usually applied to defects less than
2cm in thin patients. The tissue dissection is usually carried out with electrocautery. The hernia is
exposed easily (Fig.50.1). The dissection continues until the sac is reduced, and adequate preperitoneal dissection is performed to assure that the
neck of the sac is no longer attached underneath
(Fig.50.2). This aids in reduction of hernia recurrence. The use of a permanent suture is preferred
(Fig. 50.3). As shown, I use a CV-0 expanded
polytetrauoroethylene suture. This suture is preferred as it is not stiff and is not multilamented.
A running suture rather than interrupted sutures
is used. This minimizes the amount of suture
knots used in an effort to reduce the potential of
infection.
K. A. LeBlanc
Fig. 50.2 The hernia sac is reduced fascia exposed
Fig. 50.3 First throw of the stitch
50.2.2 Mesh Repair
As noted above, this is the repair that is most
commonly favored in the appropriate group of
patients. The initial approach to the procedure is
identical as that of the non-mesh repair. The dissection at the fascial level must be more extensive
to allow for the placement of the four cardinal
sutures described below. This exposure will Fig. 50.1 Supraumbilical incision exposing the hernia
50 Umbilical Hernia Repair
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depend upon the size of the mesh that is chosen,
which in turn will depend on the size of the fascial defect. The preperitoneal space must be dissected to the extent of that is required for the
placement of the chosen mesh product. This frequently results in the exposure of the intraabdominal contents. In some instances, this is not
recognized. It is for this possibility that a barriercoated product is chosen in this procedure.
The usual material chosen is that of a rounded
coated mesh. This must be placed so that it is
completely at against the anterior abdominal
wall (Fig.50.4). The tether in the gure allows
the surgeon to manipulate the mesh. Additionally,
this will be sewn into and below the fascial closure to xate the mesh in addition to the four cardinal sutures.
The most critical xation of the product occurs
with the four cardinal sutures [7]. Permanent
sutures are used in a “U” fashion with the knots
tied on the anterior surface of the fascia (Figs.50.5
and 50.6). The tether will be incorporated into the
transverse closure of the fascial defect in a
509
Fig. 50.5 Four cardinal ePTFE sutures in place prior to
closure of the fascial defect
Fig. 50.4 Ventralex ST mesh with tether outside of the
fascial defect
Fig. 50.6 Exposure of the tether prior to closure of the
defect
510
Three Port Placement
manner similar to the open repair above. The
umbilical skin will be grasped with the underlying suture to create an imbricated umbilicus at
the completion of the operation.
50.3 Minimally Invasive Repair
50.3.1 Laparoscopic Repair
As with the open repairs, the minimally invasive
repairs are very similar in many respects. They
require an entry into the abdominal cavity by
whatever method is selected by the surgeon. An
initial inspection of the structures will occur.
Notation of the presence of adhesions and incarcerated contents of the hernia will be the next
step. This will aid in the placement of the additional trocars. A total of three or four trocars will
be required. Depending on the choice of the surgeon, three can be placed on one side, and the
entire procedure can be done with these, or an
additional one can be placed on the opposite side
to aid in xation of the mesh (Fig. 50.7).
Alternatively, two trocars can be placed on both
sides (Fig.50.8). This will alleviate the problem
of “mirror-imaging.”
As with any laparoscopic procedure, any
adhesions must be lysed prior to inspection of the
operative area. For hernia repair, this is even
more critical because any fat on the abdominal
wall must be dissected free such that the applied
mesh will contact tissue other than adipose tissue. This will ensure that ingrowth will occur into
the mesh without the inhibition afforded by any
fatty tissue between the mesh and the fascia. In
many cases, intestinal adhesions or incarceration
will be associated with these hernias. These will
require release or reduction prior to mesh xation
(Fig.50.9).
After this has been completed, one may elect
to close the fascial defect. This has been reported
to improve results in incisional hernia repair [8].
This can be closed either transcutaneously or
K. A. LeBlanc
Fig. 50.7 The yellow port can be used instead of one of
the ports on the opposite side
intraperitoneally. The mesh is then inserted and
xed to the anterior abdominal wall with transfascial sutures and/or tacks that are either absorbable or permanent (Fig. 50.10). We prefer
permanent sutures to xate the mesh in addition
to absorbable tacks; the sutures are not seen in
gure. Generally, the tacks are placed rst followed by placement of the sutures. It is important
that the mesh is pulled taut so that there are no
wrinkles, which will predispose to the development of adhesions at these sites.
50.3.2 Robotic Repair
Usage of the robot to repair these hernias is a
matter of personal choice of the surgeon. This
Four Port Placement
50 Umbilical Hernia Repair
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511
Fig. 50.10 Permanent mesh xed with absorbable tacks
and transfascial sutures
Fig. 50.8 Two ports on either side of the abdomen
Fig. 50.9 Intestinal incarceration into an umbilical
hernia
approach is especially desirable for the larger
hernias in larger patients. One of the advantages
is that the defect can be close reliably without
Fig. 50.11 Trocar positions for robotic repair
the use of percutaneous sutures, which (at least
theoretically) will reduce the risk of infection.
The approach to the abdomen does not differ
from the laparoscopic approach above. The
need for a safe entry into the abdominal cavity
and the initial inspection do not differ. In these
cases, however, four trocars are used
(Fig.50.11).
For primary umbilical hernias, there are minimal adhesions usually (Fig. 50.12). The usual
instrumentation, as noted in the gure, is the
fenestrated bipolar in the left hand and scissors in
the right. After reduction of any incarcerated contents, an inspection of the tissues around the fascial defect will determine if there is a need to
dissect the adipose tissue from the fascia
(Fig.50.13). In most cases, this will be required
to allow for accurate measurement of the defect
and to allow mesh contact to fascia rather than
512
K. A. LeBlanc
Fig. 50.12 Incarcerated omentum in the umbilical hernia
Fig. 50.13 Preperitoneal fat surrounding the fascial defect
fat. This is critical to ensure tissue ingrowth into
the mesh (Fig. 50.14). The scissors will be
exchanged to the needle holder after all dissection has been performed (Fig.50.14).
Fig. 50.14 Exposed fascia after dissection allowing an
accurate measurement of the fascial defect
A ruler will be inserted into the abdominal cavity to measure the defect. To this measurement,
10cm will be added to select the appropriate size
of the mesh. As with the laparoscopic repair, a
5cm overlap of mesh is critical to decrease recurrence rates [9]. The mesh will be inserted through
the 12mm trocar under direct vision. A preplaced
central absorbable suture will be pulled through
the middle of the hernia defect (Fig.50.15). This
is important to assure that the mesh is placed
central to the defect and not malpositioned,
which would compromise the 5cm overlap.
After this, the defect will then be closed with
a permanent suture that is noted in Fig. 50.15.
The mesh lies below the defect and will be pulled
up by that suture (Fig.50.16). The mesh will be
sewn in place with another permanent suture
(Fig.50.17). It is preferred if the mesh is taut in
all directions.
50 Umbilical Hernia Repair
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513
Fig. 50.15 The central suture has been pulled through the
abdominal wall to assure central positioning of the mesh.
The permanent suture to close the defect is also seen
Fig. 50.16 Closed fascial defect
Conclusion
There are many options to repair umbilical
hernias. The method will be selected based
upon surgeon preference as it relates to the
comorbidities of the patient and the characteristics of the hernia. Surgeons should possess
the knowledge and skill to use more than one
type of repair to provide optimal care to the
patient.
Fig. 50.17 Completed repair with a barrier coated mesh
References
1. Arroyo A, Garcia P, Perez F, Andreu J, Candela F,
Calpena R. Randomized clinical trial comparing
suture and mesh repair of umbilical hernia in adults.
Br J Surg. 2001;88(10):1321–3.
2. Colavita PD, Belyansky I, Walters AL, Zemlyak AY,
Lincourt AE, Heniford BT, Augenstein VA.Umbilical
hernia repair with mesh: identifying effectors of ideal
outcomes. Am J Surg. 2014;208(3):342–9.
3. Nguyen MT, Berger RL, Hicks SC, Davila JA, Li LT,
Kao LS, Liang MK.Comparison of outcomes of syn-
thetic mesh vs suture repair of elective primary ventral
herniorrhaphy: a systematic review and meta-analysis.
JAMA Surg. 2014;149(5):415–21.
4. Mathes T, Walgenbach M, Siegel R. Suture versus
mesh repair in primary and incisional ventral hernias:
a systematic review and meta-analysis. World J Surg.
2016;40(4):826–35.
5. Berger RL, Li LT, Hicks SC, Liang MK. Suture ver-
sus preperitoneal polypropylene mesh for elective
umbilical hernia repairs. J Surg Res. 2014;192(2):
426–31.
6. Liang MK, Holihan JL, Itani K, Alawadi ZM, Gonzalez
JR, Askenasy EP, Ballecer C, Chong HS, Goldblatt
MI, Greenberg JA, Harvin JA, Keith JN, Martindale
RG, Orenstein S, Richmond B, Roth JS, Szotek P,
Towgh S, Tsuda S, Vaziri K, Berger DH.Ventral her-
nia management: expert consensus guided by system-
atic review. Ann Surg. 2017;265(1):80–9.
7. Martin DF, Williams RF, Mulrooney T, Voeller GR.
Ventralex mesh in umbilical/epigastric hernia
repairs: clinical outcomes and complications. Hernia.
2008;12(4):379–83.
514
K. A. LeBlanc
8. Clapp ML, Hicks SC, Awad SS, Liang MK. Transcutaneous Closure of Central Defects (TCCD) in laparoscopic ventral hernia repairs (LVHR). World J Surg.
2013;37:42–51.
9. LeBlanc KA. Mesh overlap is a key determinant of
hernia recurrence following laparoscopic ventral
and incisional hernia repair. Hernia. 2016;20(1):
85–9.
Endoscopically Assisted Mini
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orLess Open Sublay (MILOS) Mesh
Repair ofAbdominal Wall Hernias
W.Reinpold
51
51.1 Introduction
Primary abdominal wall and incisional hernia
repair gure among the most frequent operations
in surgery. The risk of incarceration is 1–2% per
year. The main cause seems to be genetically
determined insufcient cross-links between the
collagen molecules. Since the advent of synthetic
mesh [1], recurrence rates could be reduced from
25 to 60% to below 15%.
The open sublay mesh implantation based on
techniques of Jean Rives and René Stoppa and
the laparoscopic intraperitoneal onlay mesh
plasty (Lap IPOM) are the internationally leading
procedures for the treatment of incisional hernias
[2–8] (Fig.51.1a, b).
In open sublay repair, the alloplastic mesh is
inserted via a large skin incision between the
peritoneum/posterior rectus sheath and the
abdominal wall. Today, the sublay mesh position
is considered most advantageous because direct
contact of foreign material with bowel and other
viscera is omitted. Because the intra-abdominal
pressure pushes the alloplastic prosthesis against
the abdominal wall, in many cases, only no or
minimal atraumatic xation is necessary. The
disadvantages of the procedure are the more inva-
sive access trauma and, according to the literature, the higher infection rates.
Despite the advantages of the small skin incisions in Lap IPOM surgery, the pain level is not
low. A further concern is the implantation of a
foreign body in the abdominal cavity, which is a
risk factor for adhesion formation to the bowel
and injuries to the viscera. In addition, the mesh
has to be xated with many staples, clips, tacks,
or extensive sutures to the pain-sensitive peritoneum [6, 9–11] (Fig.51.1a). Expensive implants
with adhesion barriers on the area facing the
bowel have to be used. Reoperations have shown
that all IPOM prostheses can lead to massive
adhesions and do not provide secure protection of
the viscera. Another disadvantage of Lap IPOM
repair is the fact that the hernia defect is often not
fully closed but only bridged by the synthetic
prosthesis. This often leads to a persisting protrusion that frequently regresses slowly or not at all.
Current data from the German hernia register
“Herniamed” show signicantly more 1-year
recurrences after Lap IPOM hernia repair than
after open sublay operations.
51.2 The MILOS Technique
For the further reduction of complications and
W. Reinpold
Department of Surgery and Reference Hernia Center,
Gross Sand Hospital Hamburg Wilhelmsburg,
Hamburg, Germany
e-mail: w.reinpold@gross-sand.de
© Springer International Publishing AG, part of Springer Nature 2018
G. Campanelli (ed.), The Art of Hernia Surgery, https://doi.org/10.1007/978-3-319-72626-7_51
pain in abdominal wall hernia repair, we developed a new minimally invasive technique—the
mini or less open sublay (MILOS) repair. The
MILOS repair permits insertion of a large mesh
515
516
ab
ect
Fig. 51.1 (a) Extensive tack xation of Lap IPOM mesh (b) Large incision in open sublay surgery
W. Reinpold
in the retromuscular/preperitoneal space and anatomical reconstruction of the abdominal wall via
a small transhernial incision. Using the MILOS
technique, major trauma to the abdominal wall
and entering the abdominal cavity is avoided.
Skin incision
The MILOS operation can be performed mini
open with light-armed laparoscopic instruments
either under direct vision or endoscopically
assisted. Today, in our institution, all primary and
incisional abdominal wall hernias are operated
on with the MILOS technique. Exceptions are
small hernias with a hernia defect diameter
smaller than 2cm and extremely large hernias.
The MILOS operation starts with an incision of
2–6 cm directly above the center of the hernia
Fig. 51.2 eMILOS-TEP ventral hernia repair with stan-
dard trocars
defect. The abdominal wall is lifted with retractors. The preparation is carried out in “mini-open”
technique under direct vision or endoscopically
assisted. After transhernial mini-open preparation
of an extraperitoneal space of at least 8cm diameter and closing of the abdominal cavity, the procedure can be continued as total extraperitoneal
gas endoscopy (TEP of the abdominal wall) using
either standard trocars (Fig.51.2) or a transhernial
single port (Fig.51.3) [12].
The MILOS technique enables the extraperitoneal preparation of the whole rectus compartment and both lateral compartments. Very large
synthetic meshes can be implanted (Fig. 51.4)
minimal invasively if the size of the hernia
requires it. Posterior component separation can
be performed using the MILOS technique. Thus,
a total sublay repair of the abdominal wall is
possible.
prothesis
Hernia def
ab
51 Endoscopically Assisted Mini orLess Open Sublay (MILOS) Mesh Repair ofAbdominal Wall Hernias
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Fig. 51.3 eMILOS-
TEP ventral hernia
repair with single port
517
Fig. 51.4 MILOS operation of the fourth recurrence of an incisional hernia after open prostatectomy
The surgical steps of MILOS repair:
laparoscopic instruments armed with a light
tube specically designed by us and WOLF
1. Small incision directly above the center of the
hernia defect (Fig.51.5).
2. Hernia sac preparation.
3. Small incision of the peritoneum for diagnostic laparoscopy.
4. Resection of abundant peritoneum of the her-
Company (Endotorch TM, Figs.51.6a, b and
51.9). Via a 4 cm incision, the Endotorch
TM allows circumferential dissection of
the extraperitoneal plane with a radius of up
to 20cm from the fascial border of the hernia gap.
nia sac.
5. Complete and precise exposure of the fascial
edge of the hernia orice.
6. While the abdominal wall is lifted with rectangular retractors (Figs.51.6b, 51.7, 51.8),
transhernial extraperitoneal dissection
around the hernia gap is performed using
Transhernial longitudinal incision of the posterior rectus sheath is performed in all quadrants
to correspond with mesh size (Figs. 51.7 and
51.8). Figure51.10 depicts the endoscopic inci-
sion of the cranial section of the left posterior
rectus sheath.
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