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Sublay
. Fig. 13.1 Schematic drawing of retromuscular meshplasty (sublay position). (After Schumpelick 2011)
13
Sublay Technique
5 Conventional standard care.
5 Incisional hernia repair in the sense of
abdominal wall reinforcement using a
textile mesh implant in the retromuscular
position (. Fig.13.1).
5 Pros:
– Extraperitoneal mesh position
– Restoration of fascia continuity= res-
toration of abdominal wall function.
Abdominal Wall Replacement
5 When tension-free fascial closure is impos-
sible.
5 Defect bridging by mesh.
! Caution
In both the sublay technique and abdominal wall replacement, care must be taken
to ensure sufcient overlap between the
mesh prosthesis and the tissue of at least
5cm in all directions.
Laparoscopic Procedures
5 IPOM (intraperitoneal onlay mesh)=stan-
dard laparoscopic treatment.
5 Advantage laparoscopic vs. open=reduced
rate of wound complications.
5 Basics:
– Visualization of the entire anterior
abdominal wall (= adhesiolysis).
– Mobilisation of the content of the her-
nia sac, display of the complete hernia
gap.
– Cover the entire scar with an overlap of
at least 5cm on all sides (of the hernia
gap and the scar; .
Fig.13.2).
– If necessary, cut through fatty tissue
structures such as the ligaments falciforme and teres hepatis or open up the
prevesical space in the lower abdomen.
IPOM mesh materials must achieve rapid and stable
incorporation on the parietal side and prevent adhesions
on the visceral side.
Special Procedures
Component Separation According
toRamirez
5 Mobilization technique of the fascia to
close large gaps of the median lines.
5 Useful in combination with mesh rein-
forcement for large defects.
Surgical Procedure
Component Separation According to Ramirez
5 Lateral: Longitudinal splitting of the
external aponeurosis (approx. 1–2 cm
lateral to the rectus sheath) = separation of the internal oblique muscle and
external oblique muscle.
5 Medial: Longitudinal splitting of the
rectus sheath on both sides from the
median line.
5 Medialization of the rectus sheath
blades = closure of the defect on the
median line.
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ba
13
. Fig. 13.2 Examples of mesh coverage. Trolar and Mesh placement in the case of: (a) Midline Incision Hernia;
(b) Subcostal Incision Hernia; (c) Transversal Incision Hernia
13.3.7 Guidelines
Bittner R, Bingener-Casey J, Dietz U, Fabian
M, Ferzli GS, Fortelny RH, Köckerling F,
Kukleta J, Leblanc K, Lomanto D, Misra
MC, Bansal VK, Morales-Conde S, Ramshaw
B, Reinpold W, Rim S, Rohr M, Schrittwieser
R, Simon T, Smietanski M, Stechemesser B,
Timoney M, Chowbey P, IEHS (2014)
Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias.
International Endohernia Society (IEHS) –
Part 1. Surg Endosc 28: 2–29.
Bittner R, Bingener-Casey J, Dietz U,
Fabian M, Ferzli GS, Fortelny RH, Köckerling
F, Kukleta J, Leblanc K, Lomanto D, Misra
MC, Bansal VK, Morales-Conde S, Ramshaw
B, Reinpold W, Rim S, Rohr M, Schrittwieser
R, Simon T, Smietanski M, Stechemesser B,
Timoney M, Chowbey P, IEHS (2014)
Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias.
International Endohernia Society (IEHS) –
Part 2. Surg Endosc 28: 353–379.
Bittner R, Bingener-Casey J, Dietz U,
Fabian M, Ferzli GS, Fortelny RH, Köckerling
F, Kukleta J, Leblanc K, Lomanto D, Misra
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MC, Bansal VK, Morales-Conde S, Ramshaw
B, Reinpold W, Rim S, Rohr M, Schrittwieser
R, Simon T, Smietanski M, Stechemesser B,
Timoney M, Chowbey P, IEHS (2014)
Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias.
International Endohernia Society (IEHS) –
Part 3. Surg Endosc 28: 380–404.
Dietz UA, Wiegering A, Germer CT
(2014) European Hernia Society guidelines on
the treatment of inguinal hernia in adult
patients; Hernia (2009) 13: 343–403; 7 https://
doi.org/10.1007/s10029- 009- 0529- 7 Surgeon
7 https://doi.org/10.1007/s00104- 014- 2814- y
13.4 Inguinal andFemoral Hernia
13.4.1 Anatomy, Denition
andClassication
Anatomy
5 Inguinal canal (= inguinal canal):
– Course from the inner, lateral (= Anulus
inguinalis profundus) to the outer,
medial (= Anulus inguinalis supercialis) inguinal ring.
– Contents: In the male spermatic cord +
vessels supplying the testis; in the female
Lig. rotundum.
– Anatomical border: anterior wall=apo-
neurosis of the obliquus externus muscle; posterior wall=fascia transversalis
and peritoneum; upper border = inferior border of the obliquus internus
muscle and the transversus muscle; inferior border=inguinal ligament.
5 Femoral canal (= thigh canal):
– Anulus femoralis: entrance into the
femoral canal; limited by V. femoralis,
Lig. inguinale, Lig. lacunare and Pecten
os pubis.
– Canalis femoralis: 3–4cm long canal in
the medial section of the lacuna vasorum (femoral vessels).
Denition
5 Inguinal hernia: abdominal wall hernia in
the area of the trigonum inguinale (immediately above the lig. inguinale).
5 Femoral hernia: abdominal wall hernia
below the lig. Inguinale through the femoral canal.
Division
5 Classication of hernias in relation to the
inguinal ligament:
– Inguinal hernia: hernial gap in regio
inguinale, cranial of the lig. Inguinale.
– Femoral hernia (= thigh hernia): Hernial
gap = annulus femoralis (caudal to the
inguinal ligament), hernial sac medial to
the femoral vein (always acquired).
5 Topographical classication of inguinal
hernia (in relation to the epigastric vessels):
– Medial (= direct) inguinal hernia (30–
40% of all inguinal hernias, always
acquired): Hernial gap directly in the
area of the medial inguinal fossa.
– Lateral (= indirect) inguinal hernia
(mostly congenital, can also be
acquired): Hernial gap=inner inguinal
ring, course through the inguinal canal.
13.4.2 Epidemiology
Inguinal Hernia
5 Incidence=25% of all men and 2% of all
women during their lifetime.
5 Peak of manifestation: childhood and
adolescence + older adulthood (>40years).
5 Bilateral ndings=15–30%.
5 220,000 interventions in Germany.
5 Men: Women=8: 1.
5 In children almost always indirect; in
adults 70% indirect.
Femoral Hernia
5 Incidence = 5–7% of all hernias (signi-
cantly less frequent than inguinal hernia).
5 Mostly women of advanced age (75%).
5 Association with simultaneous inguinal her-
nia: Up to 9% in women; up to 50% in men.
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13.4.3 Pathophysiology
5 Risk factors:
– Increased intra-abdominal pressure
(e.g. obesity, chronic cough, COPD,
prostatic hyperplasia or constipation).
– Connective tissue disorders (e.g. Ehlers-
Danlos syndrome, Marfan syndrome or
osteogenesis imperfecta).
– Change in collagen composition.
– Smoking.
13.4.4 Clinical Presentation
Asymptomatic Small Inguinal Hernia
5 Incidental nding in the course of a clini-
cal or sonographic examination.
5 Initially no indication for sur-
gery=“watchful waiting”.
Symptomatic Inguinal Hernia
5 Visible/palpable protrusion (= size pro-
gression).
5 Under stress (abdominal press, lifting
weights, etc.) Pain in the groin region.
5 Possibly swelling in the groin.
Complications
5 Intestinal incarveration: severe, persistent
pain + a palpable, turgid swelling of the
groin region.
5 Irreducibility: increase in symptoms →
vomiting + ileus symptoms → intestinal
perforation + peritonitis.
! Caution
Intestinal incarceration, ileus or perforation=indication for immediate emergency
surgery.
5 Entrapment of parts of the omentum
majus: often pressure-painful swelling.
Femoral Hernia
5 Typical hernial growth below the inguinal
ligament.
5 Mostly unspecic feeling of pressure.
5 Signs of incarceration.
5 Differential diagnoses: lymphadenopathy,
subsidence abscess, lymph node, lipoma.
– Exclusion by sonography.
13.4.5 Diagnostic Procedures
Palpation oftheInguinal Canal
5 Lying down + standing patient under
abdominal pressure (cough)=assessment
of potential hernia/hernial gap.
5 Clarication of reproducibility.
Sonography
5 In combination with palpation= reliable
statement on hernia size, position, content, reducibility and incarceration.
CT/MRI Examination
5 Only in exceptional cases (e.g. previous
operations/obesity).
13.4.6 Therapeutic Principles
Evidence-Based Strategy
(. Fig.13.3)
EHS (European Hernia Society)
Recommendation
5 All male adults aged 30years and older
with symptomatic inguinal hernia →
Surgical procedure with mesh implantation.
5 Open Lichtenstein surgery/minimally
invasive surgical procedures (TAPP and
TEP) = best evidence-based methods for
the treatment of a primary unilateral
inguinal hernia.
5 Suture procedure without mesh implanta-
tion (Shouldice procedure): Only in individual cases (e.g. young patient with a
small hernia gap and sufcient fascial conditions or young patient with a desire to
have children).
Principles
5 Surgery=therapy of choice.
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Inguinal hernia
incarceration symptomatic
Emergency Surgery
Elective Surgery
primary unilateral
inguinal hernia
Mesh Implantation:
Lichtenstein procedure
or TEP/TAPP
After open (anterior) procedur fter dorsal (posterior) procedur
primary bilateral
inguinal hernia
Mesh Implantation:
Lichtenstein
procedure or TEP/TAPP
asymptomatic or few
symptoms
"watchful waiting"
Recurrent inguinal hernia
e
13
Mesh Implantation: TAPP/TEP
. Fig. 13.3 Flowchart for the treatment of inguinal hernia (IH) in men aged 30years and older; TEP total extra-
peritoneal plasty, TAPP transabdominal preperitoneal plasty. (European Hernia Society Guidelines 2009)
5 Aim of the surgical procedures = rein-
forcement of the posterior wall of the
inguinal canal by means of a mesh implant.
5 Laparoscopic procedures (TAPP/TEP):
– Intraoperative decision option pro vs. contra
mesh (in case of strong fascia conditions and
small hernia gap = suture procedure without
mesh application, e.g. Shouldice possible).
Mesh Implantation:
Lichtenstein procedure
– Lower rate of wound infection/hema-
toma formation.
– Shorter convalescence time but longer
OP time.
In women (high rate of femoral hernias)=laparoscopic
repair procedures are more likely, since the possibility of
clarifying the treatment of the femoral hernia is better.
5 Open procedures:
– Surgery under local anesthesia possible.
Emergency Surgery
5 Incarceration + signs of mechanical
ileus=emergency surgery.
5 Acute hernia incarceration (<6h) = one
reduction attempt + inpatient monitoring.
5 Suspected bowel necrosis/acute abdo-
men=emergency surgery.
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Complications
5 Essential in preoperative education.
5 Inguinal hernia recurrence (1–10%).
5 Chronic groin pain:
– Denition: Groin pain that has been
present for 3months or more.
– Incidence: open procedure 18%; laparo-
scopic procedure 6%; however, after
approx. 2.5 years the incidence is the
same for both surgical procedures.
5 Injury to the spermatic cord = potential
infertility/testicular necrosis.
5 Intraoperative conversion to open surgical
technique, even median laparotomy in case
of emergency.
5 Injuries to the bowel, urinary bladder or
iliac vessels.
5 Wound infection (1–2%).
5 Seroma formation.
5 Bleeding (0.5%).
5 Injury or compression of the femoral
artery, femoral vein and femoral nerve
(1%), thromboembolism (1%).
5 Lethality <1%.
Surgical Technology
Inguinal Hernia
Operative Procedure
Shouldice Herniotomy
5 Opening of the inguinal canal, attachment
of the spermatic cord with appendages,
separation of the hernia sac.
5 Important=protection of the ilioinguinal
nerve, iliohypogastric nerve and the rami
genitales as well as femorales of the genitofemoral nerve.
5 2-row doubling of the fascia transversalis
(continuous Prolene suture) starting at the
tuberculum pubicum.
5 Narrowing of the inner inguinal ring.
5 Continuous suture of the transversus
abdominis and obliquus internus muscles
to the inguinal ligament (2-row).
5 Continuous closure of the external apo-
neurosis, skin suture.
! Caution
In case of incarceration with bowel resection: lethality up to 20%.
Intraoperative EHS Classication (2007)
5 Assessment of:
– Frequency of hernia (primary and
recurrent).
– Localization (medial, lateral, femoral,
combined).
– Size of hernial gap (1 = 1.5 cm corre-
sponding to ≤1 nger, 2=1.5–3cm cor-
responding to 1–2 ngers, 3 ≥ 3 cm
corresponding to 3 ngers and more).
5 Target:
– Standardization of the hernia descrip-
tion.
– Enabling large international compara-
tive studies.
Surgical Procedure
Herniotomy According to Lichtenstein
5 Opening of the inguinal canal, attach-
ment of the spermatic cord with
appendages, separation of the hernia
sac.
5 Important=protection of the ilioingui-
nal nerve, iliohypogastric nerve and the
rami genitales as well as femorales of
the genitofemoral nerve.
5 Treatment of the hernia, resection of
the preperitoneal lipoma if necessary;
repair of the posterior wall with nonabsorbable mesh (8× 12 cm); continuous mesh xation at the inguinal
ligament.
5 In the male, slit in the lateral part and
new formation of the inner inguinal
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ring around the spermatic cord and testicular vessels and subsequent closure
of the slit.
5 Externus aponeurosis closure.
Surgical Procedure
TAPP (= Transabdominal Preperitoneal
Plasty)
5 Only intubation anesthesia because of
capnoperitoneum.
5 Periumbilical camera trocar plus two
working trocars, creation of the capnoperitoneum.
5 Incision of the peritoneum + dissection
of the preperitoneal inguinal region
with visualization of the hernial gap,
inguinal ligament and inguinal canal
structures.
5 Dissection of the hernia back into the
peritoneal space.
5 Placement of a non-absorbable mesh
implant (mesh size at least 10×15cm);
xation only if necessary by means of
tissue adhesive, absorbable stapler –
more important is sufcient overlapping of the mesh in relation to the
fracture edge.
5 Closure of the peritoneum (continuous
suture).
Surgical Procedure
TEP (= Total Extraperitoneal Plasty)
5 Preparation in the preperitoneal space
by mechanical + CO2 insufation.
5 Intubation anesthesia only.
5 Subumbilical access to the preperito-
neal space; CO2 insufation.
5 Two additional working trocars in the
midline and suprasymphysary: preparation of the preperitoneal inguinal
region with visualization of the hernial
gap, inguinal ligament and inguinal
canal structures.
5 Placement of a non-absorbable mesh
implant (mesh size 10×15cm); xation
with tissue adhesive/no xation.
5 Relief CO2, fascial closure of the sub-
umbilical incision, skin suture.
Surgical Procedure
Recurrence of Inguinal Hernia
5 Supply principle depends on the previ-
ous operation.
5 After open hernia repair=laparoscopic
procedure recommended.
5 After laparoscopic hernia repair=open
procedure recommended.
Surgical Procedure
Femoral Hernia
5 Optimal treatment possible with
TAPP– Open surgery: visualization of
the femoral portal via inguinal access/
crural access.
5 Closure of the hernial gap:
5 Continuous suture of the pectineal liga-
ment to the inguinal ligament (according to Moschkowitz/Fabricius).
5 Single button sutures between M.
obliquus internus and M. transversus
abdominis and Lig. pectineale and Fascia transversalis (after Lotheissen/
McVay).
5 Closure of the hernial gap by mesh
(Gilbert prosthesis via inguinal; plug
from crural).
Aftercare
5 Rule of thumb: do not lift more than
10–15kg for 4–6weeks.
5 Immediately postoperative: pain-adapted
stress possible.
5 Refrain from heavy lifting/sporting activi-
ties for approx. 2–3 weeks, followed by
pain-adapted loading.
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13.4.7 Guidelines
European Hernia Society guidelines on the
treatment of inguinal hernia in adult patients;
Hernia (2009) 13: 343–403; 7 https://doi.
org/10.1007/s10029- 009- 0529- 7
Simons MP, Aufenacker T, Bay-Nielsen
M, Bouillot JL, Campanelli G, Conze J, de
Lange D, Fortelny R, Heikkinen T, Kingsnorth
A, Kukleta J, Morales-Conde S, Nordin P,
Schumpelick V, Smedberg S, Smietanski M,
Weber G, Miserez M (2009) European Hernia
Society guidelines on the treatment of inguinal hernia in adult patients. Hernia 13: 343–
403.
Bittner R, Arregui ME, Bisgaard T, Dudai
M, Ferzli GS, Fitzgibbons RJ, Fortelny RH,
Klinge U, Kockerling F, Kuhry E, Kukleta J,
Lomanto D, Misra MC, Montgomery A,
Morales-Conde S, Reinpold W, Rosenberg J,
Sauerland S, Schug-Pass C, Singh K, Timoney
M, Weyhe D, Chombey P (2011) Guidelines
for laparoscopic (TAPP) and endoscopic
(TEP) treatment of inguinal hernia
[International Endohernia Society (IEHS)].
Surg Endosc 25: 2773–2843.
13.5 Umbilical andEpigastric
Hernia
– Mostly paraumbilical hernia next to the
umbilical pillar.
– No spontaneous regression tendency at all.
– Risk factors: Obesity, liver cirrhosis or
ascites; in combination with rectus diastasis.
13.5.2 Epigastric Hernia
Denition
5 Fascia defect in the linea alba between
xyphoid and umbilicus.
5 Incidence=approx. 5.
5 Men>Women.
5 Overview: Clinical presentation, diagnosis
and indication for surgery is similar for
umbilical and epigastric hernia.
13.5.3 Clinical presentation
5 Unspecic abdominal pain.
5 Pain when stretching or tensing the
abdominal wall muscles.
5 protrusion of the abdominal wall.
5 Depending on the ndings, up to intestinal
obstruction, with ileus or strangulation.
13.5.4 Diagnosis
13.5.1 Umbilical Hernia
Denition
5 Hernia.
5 Incidence=approx. 5.
5 Women > Men.
5 Risk factors: Ascites, obesity, pregnancy…
Division
5 Infantile umbilical hernias:
– Hernia gap at the annulus umbilicalis.
– Spontaneous closure in the rst years of
life (98%) = no indication for surgery
before the age of 2years.
5 In adulthood:
5 Palpation.
5 Sonography: fascial gap, hernia contents.
13.5.5 Therapy
5 Small asymptomatic ndings=“watchful
waiting”.
5 Symptomatic ndings (e.g. increase in size,
incarcerations or also non-specic abdominal pain)=surgical therapy:
– Small fascial defects (<1 cm): continu-
ous sutureplasty (non- absorbable,
transverse), joint to joint.
– Fascia defects >1cm and/or a BMI of
>30: Additional mesh implant (alloplastic material).
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13.5.6 Guideline
Guidelines for treatment of umbilical and epigastric hernias from the European Hernia
Society and Americas Hernia Society N.A.
Henriksen, A. Montgomery, R. Kaufmann,
F. Berrevoet, B. East, J. Fischer,W. Hope,
D. Klassen, R. Lorenz, Y.Renard, M. A.
Garcia Urena and M.P. Simons5onbehalf of
the European and Americas Hernia Societies
(EHS and AHS).
Surgical Procedure
Umbilical Hernia
5 Semicircular left lateral umbilical inci-
sion (extendable to cranial and caudal).
5 Sharp detachment of the navel (cau-
tion: skin injury and blood circulation).
5 Preparation of the hernia sac up to
linea alba and hernia gap.
5 Repositioning the hernia sac.
5 Transverse hernia closure: Direct non-
absorbable or slow-absorbable suture
for small gaps less than 1 cm; mesh
implantation in preperitoneal position
(preperitoneal umbilical mesh
plasty = PUMP) with an overlap of
3cm for gaps of 1–4cm.
5 Rexation of the umbilicus and skin
closure.
Etiology andPathogenesis
5 Congenital rectus diastasis.
5 Acquired rectus diastasis.
Clinical Presentation
5 Protrusion in the area of the diastasis
when tightening the abdominal muscles
(or straightening).
5 Mostly only an aesthetic problem.
Therapy
5 In the absence of a fascial defect, no risk
of incarceration = primary conservative
therapy.
5 Only rarely (e.g. for cosmetic reasons) cor-
rection indicated= procedure as for incisional hernia = mesh implant in
retromuscular position (sublay).
5 High recurrence rate without mesh rein-
forcement.
13.6 Parastomal Hernia
13.6.1 Denition
5 Protrusion of any kind near a stoma.
13.6.2 Epidemiology
Surgical Procedure
Epigastric Hernia
5 Transverse skin incision.
5 Then procedure analogous to the
umbilical hernia.
13.5.7 Dierential Diagnosis:
Rectus Diastasis
Denition
5 Divergence of the rectus musculature in
the area of the linea alba.
5 No fascial defect: bulge-like protrusion.
5 Incidence depending on stomatal type:
– Terminal colostomy: 4–48%.
– Terminal ileostomy: 2–28%.
– Loop colostomy: 0–31%.
– Loop ileostomy: 0–6%.
– High recurrence rate after treatment.
13.6.3 Risk Factors andPrevention
Risk Factors
5 General risk factors (similar to the patho-
genesis of incisional hernias, 7 Sect.
13.3.3): Obesity, wound infections,
advanced age, immunosuppression,
COPD.
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5 Special risk factor=opening too large for
stoma passage (fascial passage should be
as narrow as possible).
Prevention
5 Expulsion of the stoma through rectus
muscle.
5 abdominal wall gap (fascia gap) as small as
possible.
5 Tunneling technique under peritoneum
(valve mechanism) (before abdominal wall
passage).
5 Prophylactic mesh implantation: Signi-
cant reduction in the rate of parastomal
hernias = recommended for open/laparo-
scopic creation of permanent terminal
small and large bowel stomas (Level 1 rec-
ommendation, Bittner etal. 2014).
13.6.4 Clinical Presentation
5 Often symptomatic
5 Especially supply problems with plate and
bag.
5 Voiding disorder, pain.
5 Incarceration, ileus.
13.6.5 Relevant Complications
5 Hernia incarceration.
5 Ileus.
5 Progressive voiding obstruction.
5 Chronic pain and subileus conditions.
13.6.6 Therapy
5 Mains supply=standard.
Open Procedures
5 Local suture procedures with only fascia
constriction (= recurrence rate 50 to
76%)=not recommended.
5 Stomal Relocation:
– Usually by means of relaparotomy.
– Relocation alone without prophylac-
tic mesh implantation = disappointing recurrence rates (30–45%
parastomal hernias at the newly created stoma site) (analogous to initial
placement).
– Treatment of the defect at the initial
stoma site in the sense of a scar hernia
(in 33% here recurrent scar hernia).
– A further disadvantage of relocation is
scar fractures in the relaparotomy area
in 10–20% of cases.
5 Repair by means of mesh implantation
(. Fig.13.4):
– Reduction of the fracture.
– Fascia constriction and reinforcement
using textile mesh implant;
– Reticular tunneling and lateralization
of the intestine (Sugarbaker technique).
Peritoneum
. Fig. 13.4 Mesh position in parastomal hernia repair. a Onlay, b Sublay, c Intraperitoneal mesh position
Rectus Sheath
Stoma
A
B
C
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