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16
Types of repairs of inguinal and femoral hernias
L. Amodu et al.
Types of repairs
Laparoscopic
mesh repair
Totally
extraperitoneal
(TEP) repair
Transabdominal
preperitoneal
(TAPP) repair
A balloon dissector is used to create an
articial preperitoneal space
Hernia is reduced and mesh is placed to
cover all three potential hernia spaces
(direct, indirect, and femoral)
Avoid tacks inferior to the iliopubic tract to
avoid the risk of neurovascular injuries in
the triangles of doom and pain
Conventional laparoscopic access is
obtained
Identication of 4 anatomic landmarks
• Spermatic vessels
• Medial umbilical ligament
• Inferior epigastric vessels
• External iliac vessels
Creation of peritoneal aps
Dissection of hernia sac
• Re-identication of landmarks
• Mesh placement
Closure of peritoneum/fascia/skin
Key Steps
Complications and treatments of hernia repair
Complication
Recurrence
Patient factors include elevated
intra-abdominal pressure, chronic
cough, site infection, and collagen
disorders
Characteristics
Uses and limitations
• Reduces risk of complications
involving intra- abdominal
structures
• Maintains an intact peritoneal
layer between mesh and
abdominal cavity
TAPP has advantages with larger
hernias, and with previous lower
abdominal surgery
TAPP and TEP have similar
outcomes
One study demonstrated
minimally increased risk of
trocar site herniation and post-op
bowel obstruction with TAPP as
opposed to TEP
Management
Mesh repairs have a 60% reduction in the
recurrence rate compared with non-mesh
repairs
Recurrence is more common after repair
of direct hernia
Seromas and hematomas 5% of laparoscopic repairs: Most
Supercial wound infection Infected supercial wounds without
Deep infection Deep infection (with potential mesh
Mesh migration and
erosion
Urinary retention 2.2% after GA; 0.4% local May require catheterization
Bladder injury During trocar insertion/development of the
commonly of the epigastric artery or
vein
Hematomas may spontaneously
decompress through the wound
uid collection
contamination)
Primary due to inadequate xation or
external forces
Secondary due to chronic foreign body
reaction
peritoneal ap/result of mesh migration
Observation. Aspiration is not
recommended because of the risk of
infection
Antibiotic therapy for 10–14days
If no improvement➔surgical incision
and drainage
Surgical exploration with debridement and
mesh removal
Adequate xation and at mesh placement
may prevent. Treatment often requires
mesh explantation
Surgical repair/urologic intraoperative
consultation
1 Abdomen andHernia
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Complications and treatments of hernia repair
17
Complication
Testicular atrophy Thrombosis of veins supplying testicles Supportive measures
Chronic pain occurs in 10% of patients,
with 2% to 4% of patients having pain
that interferes with daily activities. Most
Groin pain and postherniorraphy neuralgia
Entrapment of the
ilioinguinal nerve
Entrapment of lateral
femoral cutaneous nerve
chronic pain is self-limited and resolves
within 6months
Pain >3months: Post-herniorraphy
neuralgia
MC complication (incidence as high as
53%)
After open repairs May require groin re-exploration
During laparoscopic repair, three nerves
are at risk: The lateral femoral
cutaneous, the femoral, and the femoral
branch of the genitofemoral nerve
The overall complication rate for hernia
repair is 10%. Complications include
infection (1–2%), chronic pain (5%),
ischemic orchitis (rare), injury to the vas
deferens (rare), recurrence (2–15%), and
death (rare)
Characteristics
Avoid exploration in the rst year
Best initial treatment is reassurance and
conservative therapy (NSAIDs and local
nerve blocks)➔ pain not controlled by
these measures may require operative
exploration, neurectomy, and mesh
removal
Dissection and tacks should be avoided
inferior to the inguinal ligament/iliopubic
tract
Management
Common case scenarios and best approach for management
Case scenario
Bilateral inguinal hernias Laparoscopic Decreased postoperative pain
Patient with medical comorbidities
who cannot tolerate general
anesthesia
Recurrent hernia after lap repair Open Operating in a virgin eld rather
Recurrent hernia after open repair Laparoscopic Operating in a virgin eld rather
Patients with prior? Surgery
involving preperitoneal space
(prostatectomy, hysterectomy)
Patients with ascites Open
Patients with large scrotal hernia Open (more surgeons are performing
Patients with incarcerated or
strangulated hernia
Preferred surgical approach
Open with local anesthesia Increased peri-operative risk with
general anesthesia
than through previous scar
than through previous scar
Open Operating in a virgin eld rather
than through previous scar
robotic repairs for this)
Open if strangulated intestine is
necrotic➔resection of intestine+tissuebased repair or use bioabsorbable mesh
Reason
18
Above arcuate line
s
e
artery
Aponeurosis of
inte
Rectus
Anterior
s
Ventral Hernia
Surgical anatomy of abdominal wall
L. Amodu et al.
Layers of
abdominal
wall
Blood supply
The layers of the abdominal wall
are: Skin, subcutaneous tissue,
Camper’s and Scarpa’s fasciae,
external oblique muscle, internal
oblique muscle, transversus
abdominis muscle and aponeuroses,
transversalis fascia, preperitoneal
fat, and peritoneum
Medially, the anteromedial
abdominal wall is composed of the
aponeurotic rectus sheath, rectus
abdominis muscle, and linea alba
The blood supply to the rectus
muscles comes from the superior
epigastric artery, the internal
thoracic artery, the inferior
epigastric artery, and the lower
intercostal arteries (T7–T12)
The lateral abdominal wall muscles
derive their arterial supply from the
lower three to four intercostal
arteries, the deep circumex iliac
artery, and the lumbar arteries. The
lower intercostal arteries travel
between the internal and external
oblique muscles
Aponeurosis of
internal oblique
muscle
Aponeurosis of
rnal oblique
muscle
Aponeurosis
of tranversus
muscle
Aponeurosis of
external oblique
muscle
transversus
muscle
external oblique muscle
Inf. Epigastric
vein
abdominis
Rectus
abdominis
muscle
Inf. Epigastric
vein
Aponeurosis of
Inf. Epigastric
Linea alba
Inf. Epigastric
artery
Below arcuate line
Rectus
abdominis
muscle
Umbilical prevesical
cutaneous
Anterior layer
of rectus sheath
Posterior
rectus
sheath
Anterior layer of
rectus sheath
fascia
nerve
External oblique
muscle
Internal oblique
Transversalis
fascia
Peritoneum
External oblique
muscle
Peritoneum
Tranversalis
fascia
External and Internal
oblique muscle
Transversus abdomini
muscle
Transversu
muscle
Internal obliqu
muscle
Tranversus
muscle
1 Abdomen andHernia
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Surgical anatomy of abdominal wall
The anterior abdominal wall is
largely innervated by the intercostal
nerves (T7–T11), the subcostal
nerve (T12), and the iliohypogastric
and ilioinguinal nerves (branches of
L1)
Innervation
The neurovascular bundles
supplying the anterior abdominal
wall travel between the internal
oblique and the transversus
abdominis muscle layers (also
known as the transversus abdominis
plane)
Transversus abdominis plane (TAP) block
Uses Administration of local anesthesia in the transversus abdominis plane (TAP) to serve as an
adjunct to postoperative pain control and limit the use of narcotic analgesia
Procedure Known as the transversus abdominis plane, the space between the internal oblique and
transversus abdominis is the space in which TAP blocks are administered. local anesthetics are
administered under sonographic guidance. Classically, a needle is inserted into the plane in
Petit’s triangle yielding a “double pop” sensation. The rst pop is due to the needle traversing
the EO, while the second pop is due to the needle traversing IO.Local anesthesia is
administered and allowed to diffuse throughout the TAP plane
19
Management of ventral hernia
Emergent surgery: Acute incarceration with inability to reduce hernia contents, strangulation of
hernia contents, bowel obstruction, leakage of ascites through the skin in a patient with
Indications for
repair
Complex hernia
cirrhosis
Elective surgery: Pain or discomfort, high risk of bowel obstruction, including chronic
incarceration or intermittent acute incarceration, interference with daily activities or affecting
the patient’s quality of life
Patient factors: BMI>35, smoking, DM, steroids, CHF, COPD
Hernia factors: Enterotomy or bowel resection, urgent procedure for incarceration or
obstruction, hernias that result from damage control laparotomies, recurrent hernias, hernias
with contaminated wounds, previous wound infection, presence of stoma or stula, previous
mesh
20
Management of ventral hernia
Hernia defects that are <1cm can be closed primarily with suture
For defects >1cm, mesh can be used. mesh signicantly reduces the recurrence rate for defects
of this size
L. Amodu et al.
Mesh vs no mesh
Laparoscopic vs
open repair
Nonoperative
management
Prevention A suture-to-wound length ratio of 4:1, and 0.5cm bites from the wound edge, 0.5cm apart
If ventral hernia is associated with signicant diastasis recti➔ hernia xation together with
re-approximation of the diastasis recti to restore the linea alba can be accomplished
5-cm overlap of mesh beyond the defect
Complex hernias ideally require mesh placement to help prevent recurrence
Laparoscopic repair has a lower wound infection rate than open repair
Factors that favor laparoscopic repair: Smaller defects, multiple defects, older age, obesity,
lower risk of wound complications, lack of need to reapproximate the linea alba
Factors that favor open repair: Larger defects, multiple prior operations with concern for dense
adhesions not amenable to laparoscopic lysis, loss of domain, abdominal skin grafts, need for
large mesh excision, small defect with large hernia sac, active enterocutaneous stula, inability
to tolerate pneumoperitoneum
Patients with reducible and asymptomatic ventral hernias can be safely observed, but there is
no denitive evidence that this is true
have been shown to reduce hernia formation compared to the traditional fascial closure of 1-cm
bites and 1-cm advancement (STITCH trial)
Open ventral hernia repair options
Repair
options
Mesh location Characteristics
Inlay mesh
Onlay
Sublay
Use of mesh as a
bridge between
fascial edges
Mesh placed above
fascia
Retrorectus,
preperitoneal, or
retromuscular
Should be avoided due
to its high recurrence
rate
Usually done after
approximation of the
fascia if possible
For larger hernias,
retrorectus placement
can be combined with
transversus abdominis
or external oblique
release to facilitate
midline reconstruction
1 Abdomen andHernia
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Open ventral hernia repair options
Repair
options
Underlay Intraperitoneal
Mesh location Characteristics
Mesh should have
adhesion barrier to
protect the viscera from
the prosthetic mesh
Research
Reference Findings
21
Holihan JL, Nguyen DH, Nguyen MT,
Mo J, Kao LS, Liang MK.Mesh
location in open ventral hernia repair:
a systematic review and network
meta-analysis. World J Surg.
2016;40(1):89–99
Kanters AE, Krpata DM, Blatnik JA,
Novitsky YM, Rosen MJ.Modied
hernia grading scale to stratify surgical
site occurrence after open ventral
hernia repairs. J Am Coll Surg.
2012;215(6):787–93
Sublay mesh placement had the highest probability of being the best
treatment to prevent recurrence compared with underlay and onlay
repairs. Sublay mesh also has a lower complication rate compared with
the other techniques
The Ventral Hernia Working Group grade helps determine the risk of
infection and surgical site occurrence. The grading scale includes factors
such as patient comorbidities (smoker, obesity, diabetes,
immunocompromised, COPD), and presence of wound contamination
Laparoscopic ventral hernia repair
Hernia defect should be measured intraperitoneally for the most accuracy
The mesh size selected should allow for 5-cm overlap on all sides
Key steps
Mesh is appropriately positioned
Transfascial sutures are brought up through the abdominal wall. this can cause increased pain
It may be used selectively in non-obese patients with smaller defects and still achieve good outcomes
Mesh is then tacked in place, using the “double crown” technique with tacks placed at 1-cm intervals
along the outside edge of the mesh to xate and prevent bowel from being trapped between mesh and
parietal peritoneum, and a second inner ring to help with xation
Desufate abdominal cavity to 5–8mmHg during mesh xation
22
Component separation
To relieve tension on midline fascial closure
L. Amodu et al.
Benets
Indications Hernias >7cm usually require a component separation
Contraindications Previously placed preperitoneal or retromuscular mesh (relative contraindication)
Facilitate retromuscular mesh placement
It enables reconstruction of the linea alba, the “central tendon of the abdominal wall” and
recreates the native anatomy
Patients who have had procedures involving the posterior abdominal wall, e.g. radical
cystectomy (relative contraindication)
Approaches to component separation
Approach
Anterior release
Bilateral retrorectus dissection is
performed rst
Up to 8cm of myofascial
advancement can be achieved by
releasing the rectus muscles from
the posterior sheath, allowing
closure of many defects
If sufcient advancement is not
achieved for closure of the hernia
defect, only then is the external
oblique release performed; division
of the external oblique aponeurosis
lateral to the semilunar line
Key steps
Development of the plane between
the external oblique aponeurosis
and the internal oblique muscle
laterally
Mesh reinforcement can then be
placed in an underlay or overlay
position
Anterior Component Separation
1 Abdomen andHernia
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Approaches to component separation
23
Approach
Posterior release/
transversus
abdominis
release (TAR)
Key steps
The rst key step is entry into the
retrorectus space as close as
possible to the linea alba and
creation of posterior plane between
rectus muscle and posterior rectus
sheath
Dissection is then continued
laterally in a retrorectus plane to
the linea semilunaris. Care is taken
to avoid injury to the deep
epigastric vessels
Posterior rectus sheath is then
incised again just medial to the
semilunaris to avoid injuring the
laterally perforating neurovascular
bundles classically, the dissection
is begun in the upper abdomen by
incising the posterior lamella of the
internal oblique and the underlying
transversus abdominis muscle to
expose the pre- transversalis fascia.
Dissection is then continued
laterally in a pre-transversalis or
preperitoneal plane until a wide
ap of posterior sheath, divided
transversalis, and peritoneum is
developed.
Posterior Component Separation
Posterior Component Separation With TA R
The posterior rectus sheath is
reapproximated
Sublay mesh placement in the
retromuscular space
The midline fascia is closed over
the mesh
Complications and treatment of ventral hernia repair
Complication
Seroma
Clinical examination ndings and diagnostic
maneuvers are required to differentiate between
infected and non-infected uid collections
Characteristics
Management
Usually resolve with observation alone
after laparoscopic repair
24
Complications and treatment of ventral hernia repair
L. Amodu et al.
Complication
Recurrence
Mesh infection
Characteristics
Range 0–30%
Risk factors: Smoking, obesity, diabetes,
immunosuppression, malnutrition,
corticosteroid therapy, chemotherapy, or
radiation therapy, connective tissue disorders,
postoperative wound infection, or chronic
seroma
Risk factors: Presence of infection prior to
surgery, skin ulceration over hernia, enterotomy
during hernia repair, presence of stoma, obesity,
and incarcerated or obstructed bowel within the
hernia
CT ndings: Fluid collection, with signs of
infection including rim enhancement and gas
Management
Recurrence rates for small primary
hernias <2cm repaired with primary
suture repair are as low as 5% to 7%
Recurrence rates for larger primary
hernias >2cm repaired with primary
suture repair can range between 10%
and 50%
Nonoperative management includes
antibiotics and local wound care.
Ongoing signs and symptoms of mesh
infection indicate failure of
nonoperative management
Local measures may be sufcient for
mesh infections involving macroporous
mesh made from polypropylene or
polyester, although mesh removal may
be required
Nonoperative strategies are unlikely to
be successful in treating microporous or
PTFE prosthetic infections
Most common pathogenic organisms
are Staphylococcus aureus and
Streptococcus spp.
Ileus, postoperative pain, sepsis, intestinal
Others
obstruction or stula formation, necrotizing soft
tissue infection
Research
Reference Findings
Petro CC, O’Rourke CP, Posielski NM,
etal. Designing a ventral hernia staging
system. Hernia. 2016;20(1):111–7
Itani KM, Hur K, Kim LT, etal.
Comparison of laparoscopic and open
repair with mesh for the treatment of
ventral incisional hernia: A randomized
trial. Arch Surg. 2010;145(4):322–8
Krpata DM, Haskins IN, Phillips S, etal.
Does preoperative bowel preparation
reduce surgical site infections during
elective ventral hernia repair? J Am Coll
Surg. 2017;224(2):204–11
For ventral hernia, width of hernia and contamination are the 2 most
signicant factors for recurrence
This is a multicenter VA study that prospectively randomized patients
with ventral hernias between open and laparoscopic repairs. The results
showed that laparoscopic repair had signicantly lower incidence of
SSI compared with open repair and the likelihood of developing
complications up to 8weeks postoperatively was approximately 50%
lower in patients whose hernias were repaired laparoscopically
This study evaluated the accrued data from the Americas Hernia
Society Quality Collaborative to evaluate whether bowel preparation
had a protective effect. This study showed patients with bowel
preparation were more likely to develop postoperative SSI
1 Abdomen andHernia
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Miscellaneous Hernias
Parastomal hernia
Risk factors Obesity, high intra-abdominal pressure, creation of an ostomy in the emergency
setting, using stoma site as specimen extraction site during laparoscopic procedure
Most common after colostomies and may develop in up to 50% of patients who
Presentation
undergo stoma formation
Patients present with bulging adjacent to the stoma
Rarely present with bowel obstruction
Consider observation if small and asymptomatic
25
Management
Risk factors for recurrence Obesity and tobacco and surgical site infections are associated with development of
Key steps
If possible, consider medical or surgical weight loss and smoking cessation prior to
surgery to optimize postoperative outcomes
Hernia repair with a permanent prosthetic mesh is associated with lowest rates of
recurrence. Suture repair or use of absorbable or biologic mesh is linked to higher
recurrence rates
recurrent hernia
• Reduction of the hernia contents
• Excision of the hernia sac
• Tension-free closure of the fascial defect (if possible)
• Possible mesh reinforcement
Mesh placement, in a retrorectus or intraperitoneal underlay position, reduces
recurrence rates
In emergent or contaminated cases, suture repair alone with or without absorbable/
biologic mesh placement may be the preferred option
Parastomal hernia repair options
Advantages and
Repair options
Keyhole mesh technique
Key steps
Intraperitoneal onlay position
Mesh is placed with a cutout allowing egress
of the ostomy while providing wide coverage
of the abdominal wall defect
Higher recurrence rate then
Sugarbaker technique
Does not require stoma relocation
disadvantages
Sugarbaker technique
Uses intra-abdominal placement of mesh over
the hernia with a ap valve created at the
edge of the mesh
Ostomy is lateralized using a noncircumferentially secured underlay mesh
Lowest recurrence rate
Mesh related complications (dense
adhesions, bowel erosion)
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