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35 Laparoscopic and Robotic Repair of Parastomal Hernias
Fig. 35.14 Partial closure of the parastomal fascia defect
467
Fig. 35.17 The two lateral sutures are pulled tight to assess
placement
Fig. 35.15 Placement and fixation of the Bio-A. The tacking device on
the left is used with an undocked robotic trocar. The instrument on the
right is a robotic needle holder
Fig. 35.16 Lateral transfascial suture pulled through the abdominal
wall
is snug. Another barbed polypropylene suture (#2) is used
to secure one side of the mesh. This is a double-armed
suture. One will run adjacent to the intestine and the other
near the edge of the mesh. A separate suture will be used
to also suture next to the intestine and the other arm on the
lateral aspect of the mesh. This will create the tunnel for
the intestine to enter typical of the Sugarbaker repair
(Fig. 35.20). The final step will be to suture the mesh to
the intestine with a smaller barbed permanent suture
(Fig. 35.21).
Fig. 35.18 The white polyglactic suture is pulled through the abdomi-
nal wall to position the medial side of the mesh
Fig. 35.19 The DualMesh PLUS is drawn tight against the abdominal
wall
Postoperative Management
Abdominal binders are generally not used, as this seems to
interfere with ostomy function. The NGT and urinary catheter
are removed on postoperative day one. Meals are advanced as
appropriate. Patients are usually discharged on the third or
fourth postoperative day.
468
Fig. 35.20 Fixation with barbed suture to complete creation of a tube
for the intestine to pass
Fig. 35.21 Securing the intestine to the mesh with barbed suture
Most of these hernias will develop a seroma. Generally
they are small unless the hernia contents were long standing
and of large amount. Patients should be informed of such
preoperatively. Unless very symptomatic no treatment is
necessary. If needed, aspiration or drainage via interventional radiology could be done.
Results
To date, we have performed 16 parastomal hernias using the
robotic assistance. At the time of this writing, the follow-up
ranged from 2 to 36 months. One patient did have to be
returned to the operating room due to an obstruction that was
caused by too tight of a suture that fixed the mesh to the anterior abdominal wall. The mesh was slit and re-sutured to the
intestine. There have been no other adverse events or recurrence during this time frame.
K.A. LeBlanc
Conclusion
The laparoscopic repair of parastomal hernias is a preferred technique over the open method. This can be done
in a safe and effective manner with the Sugarbaker or this
modified Sugarbaker, as described here. The robotic
repair is an extension of that repair and should provide
similar, if not, superior results.
References
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J, Hansson B, Janes A, Miserez M, Mandala V, Montgomery A,
Morales Conde S, Muysoms F. European Hernia Society classification of parastomal hernias. Hernia. 2014;18(1):1–6.
2. Safadi B. Laparoscopic repair of parastomal hernias: early results.
Surg Endosc. 2004;18:676–80.
3. Hansson BME, Bleichrodt RP, DeHingh IH. Laparoscopic parastomal hernia repair using a keyhole technique results in a high recurrence rate. Surg Endosc. 2009;23:1456–9.
4. LeBlanc KA, Bellanger DE, Whitaker JM, Hausmann
MG. Laparoscopic parastomal hernia repair. Hernia. 2005;9:140–4.
5. LeBlanc KA. Mesh overlap is a key determinant of hernia recurrence following laparoscopic ventral and incisional hernia repair.
Hernia. 2016;20(1):85–9.
6. P W, Andersen LM. Long-term follow-up of laparoscopic repair
of parastomal hernia using a bilayer mesh with a slit. Surg Endosc.
2011;25(2):526–30.
7. Liu F, Li J, Wang S, Yao S, Zhu Y. Effectiveness analysis of laparoscopic repair of parastomal hernia using CK Parastomal patch.
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2011;25(6):681–4.
8. Mizrahi H, Bhattacharya P, Parker MC. Laparoscopic slit mesh
repair of parastomal hernia using a designated mesh: long-term
results. Surg Endosc. 2012;26(1):267–70.
9. Berger D, Bientzle M. Laparoscopic repair of parastomal hernias:
a single surgeon’s experience in 66 cases. Dis Colon Rectum.
2007;50(10):1668–73.
10. Berger D, Bientzle M. Polyvinylidene fluoride: a suitable mesh
material for incisional and parastomal hernia repair. A prospective
observational study of 344 patients. Hernia. 2009;13(2):167–72.
11. Mancini GJ, McClusky DA 3rd, Khaitan L, Goldenberg EA,
Heniford BT, Novitsky YW, et al. Laparoscopic parastomal
hernia repair using a nonslit mesh technique. Surg Endosc.
2007;21(9):1487–91.
12. McLemore EC, Harold KL, Efron JE, Laxa BU, Young-Fadok TM,
Heppell JP. Parastomal hernia: short-term outcome after laparoscopic and conventional repairs. Surg Innov. 2007;14(3):199–204.
13. Craft RO, Huguet KL, McLemore EC, Harrold KL. Laparoscopic
parastomal hernia repair. Hernia. 2008;12(2):137–40.
14. BM H, Slater NJ, van der Velden AS, Groenewoud HM, Buyne
OR, de Hingh IH, Bleichrodt RP. Surgical techniques for parastomal hernia repair. Ann Surg. 2012;255(4):685–95.
15. DeAsis FJ, Lapin B, Gitelis ME, Ujiki MB. Current state of
laparoscopic parastomal hernia repair: a meta-analysis. World J
Gastroenterol. 2015;21(28):8670–7.
35 Laparoscopic and Robotic Repair of Parastomal Hernias
469
16. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli G,
Fortelny R, Köckerling F, Kukleta J, LeBlanc K, Lomanto D,
Misra M, Morales-Conde S, Ramshaw B, Reinpold W, Rim S,
Rohr M, Schrittwieser R, Simon T, Smietanski M, Stechemesser
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2014;28(2):380–404.
Lumbar Hernia
Maciej Śmetański and Karl A. LeBlanc
36
Anatomy
The lumbar area is bounded above the 12th rib, below the
iliac crest, behind the erector spinae (sacrospinalis), and in
front the posterior border of the external oblique (a line passing from the tip of the 12th rib to the iliac crest). Within this
area two triangles are described: the superior lumbar triangle
(of Grynfeltt) and the inferior lumbar triangle (of Petit). The
superior lumbar triangle is an inverted triangle, its base is the
12th rib, its posterior border is the erector spinae and its anterior border the posterior margin of the external oblique, and
its apex is at the iliac crest 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 the superior triangle. Both the superior and the
inferior lumbar triangles vary in size depending on the
attachments of muscles to the iliac crest (Fig. 36.1). The
floor of both triangles is the thoracolumbar fascia incorporating the internal oblique and the transversus abdominis to a
variable degree.
The T12 and L1 nerves both cross the superior lumbar
triangle. The abdominal wall musculature (rectus abdominis,
external and internal oblique, and transversus abdominis)
and overlying skin are supplied by the 7th through 11th intercostal nerves and subcostal nerve (12th intercostal equivalent). It is described that the 11th intercostal nerve divides
into two branches (at the tip of the 11th rib). The posterior
M. Śmetański (*)
2nd Department of Radiology, Medical University of Gdańsk,
Gdańsk, Poland
Department of Surgery and Hernia Center, District Hospital in
Puck, Puck, Poland
e-mail: smietana@gumed.edu.pl
K.A. LeBlanc
Department of Surgery, Louisiana State University Health Sciences
Center, Baton Rouge, LA, USA
Minimally Invasive Surgery Institute, Baton Rouge, LA, USA
branch supplies motor innervation of the transversus abdominis and internal oblique muscles, and the anterior branch
supplies motor innervation of the external oblique and sensory innervation of the overlying skin [1]. This is important
to mention that if the nerve is injured proximal to its division
(e.g., intraoperatively), motor innervation for the entire segment of the muscles would be compromised.
The cutaneous sensory nerves of the abdomen overlap
with adjacent sensory nerves to provide the innervation in
the dermatomal distribution. In contrast, minimal overlap
exists between adjacent motor nerves. Segments of each
abdominal muscle are innervated by a single intercostal
nerve. So loss of a single spinal level of motor nerves results
in paralysis of a full-thickness segment of the abdominal
musculature, what can lead to postoperative flank bulging,
often diagnosed as a type of lumbar herniation [2].
Another important finding for the surgical anatomy is that
the segmental nerves and vessels are situated between the
internal oblique and transverse muscle. This is important to
understand because this layer should not be used for surgical
procedures to avoid possible nerve irritation or injury.
Surgical injury and/or division of the nerves in this layer can
potentially lead to pain and functional impairment of the lateral abdominal wall.
Clinical Features
Congenital lumbar hernia does occur and can be bilateral [3].
Such congenital hernias present as a bulge in the loin and
may be associated with intestinal symptoms. Lumbar hernias
may be acquired, following sepsis in the retroperitoneal tissues [4] as a result of osteomyelitis or tuberculosis of the
vertebral bodies or iliac crest which disrupts the lumbodorsal
fascia [5], or following surgical operations on the kidneys
[6], aortic aneurysm, and also iliac bone harvest and latissimus dorsi myocutaneous flap [7, 8]. Traumatic lumbar hernias occur following direct blunt trauma [9] and seat belt
injuries in vehicle accidents [10, 11]. During the vehicle
© Springer International Publishing AG, part of Springer Nature 2018
K.A. LeBlanc et al. (eds.), Management of Abdominal Hernias, https://doi.org/10.1007/978-3-319-63251-3_36
471
472
Superior (Grynfelt’s) triangle
Inferior (Petit’s) triangle
M. Śmetański and K .A. LeBlanc
Fig. 36.1 Dissection of the
lumbar region to illustrate the
anatomy of the inferior
lumbar triangle (left) and the
superior lumbar triangle
(right)
External oblique m.
Latissimus dorsi
crash, poorly applied seat belt tends to migrate above the
iliac crest exposing the full abdominal musculature to the
forces of deceleration. This results in anterior rotation of the
pelvis with a shearing action that predisposes the patient to
disruption of the musculofascial structures [12]. In some
cases even large disruption of the posterolateral abdominal
wall from the level of T12 vertebra to the iliac crest can
occur, causing large lumbar hernia involving sigmoid and
descending colon and/or the kidney [13].
Lumbar hernia is also described following the anterior
approach to the lumbar spine for vertebral interbody fusion
for lumbar disk disease or nephrectomy. These are usually
not true hernias as there is no true fascial defect. In some
cases a true fascial defect (i.e., hernia) may be demonstrable,
but, in the majority, this is not the case. These abdominal
wall deformities result from the injury to the nerves that
innervate the upper portions of the external oblique, internal
oblique, transversus abdominis, and rectus muscles. The
path of the T11 and T12 nerves can be traversed during the
dissection of open space for the above operation. The development of a permanent flank bulge as a consequence of flank
incision for radical nephrectomy is underestimated and can
occur in almost half of the patients [14]. The deformity can
be progressive as the protrusion of the upper portions of the
paralyzed muscles will cause an outward protrusion of the
normal portions of these muscles (Fig. 36.2). This bulge can
increase in the time causing pain and discomfort especially
during the Valsalva maneuver and walking [2].
Lumbar hernias may contain a variety of intra-abdominal
organs; hernias containing the colon are 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.
The differential diagnosis must include tumors of the
muscles, lipoma, hematoma associated with blunt trauma,
abscess, and adrenal tumors. Small fatty protrusions of retroperitoneal fat through the lumbodorsal fascia have been
implicated as a cause of low back pain [15, 16].
Back pain radiating to the groin, presumably due to irritation of lateral cutaneous branches of the 10th, 11th, and 12th
intercostal nerves, has been recorded. Tiny fatty hernias
along the tracks of cutaneous nerves through the lumbar fas-
Serratus posterior
12th rib
Internal oblique
External oblique
Fig. 36.2 Preoperative appearance of a “denervation hernia” after a
right nephrectomy
cia give rise to severe low back pain with radiation to the
buttocks and thigh. These hernias are palpable and tender.
They are similar to the fatty hernias that occur through the
linea alba and anterior aponeurosis. Local anesthetic infiltration abolishes the pain and confirms the diagnosis. Local
excision and closure of the defect cures the condition. The
diagnosis is made/confirmed by CT scan, which will delineate the defect [10, 17].
The patients that have the “denervation” injury that leads
to the protrusion of the flank will frequently complain of
back pain that is related to the defect. It is difficult to explain
the source of this complaint, as many of these patients will
have had a long preexisting complaint of back pain requiring
the disk surgery. The most common presentation is the
acknowledgment of the significant cosmetic deformity that
is caused by the musculature paralysis. This will cause asymmetry to the contour of the abdomen (Fig. 36.2).
The Operation
Operative treatment of lumbar hernia varies in abovementioned different clinical situations. Primary lumbar hernias
rarely extend over 7–10 cm, and many alternative operations
have been described giving positive results in short- and
Hernia
Bean bag
36 Lumbar Hernia
medium-term follow-up. Different methods and approaches
should be used in the “denervation” hernias. Acute traumatic
hernias with comorbid injures create many clinical situations, so the time and extension of the procedure should be
the point of consideration.
Elective treatment of primary lumbar hernia could be performed via open or laparoscopic approach. Small hernias
(diameter less than 5 cm) have been successfully treated
without synthetic implant using simple closure of the defect
with nonabsorbable sutures. In these cases open access parallel to the 12th rib was performed and the sac identified and
reduced. If only the preperitoneal fatty mass was found in the
hernia orifice, excision after ligature was performed to
reduce the content. No recurrences were found in this series
of patients in the mean 8-month follow-up [18]. While this
treatment option could be taken into consideration, most of
the authors believe that synthetic material implanted in the
sublay position will improve the results. Small hernia was
cured successfully with open implantation of a plug (Bard
Mesh Dart) in one described case [19]. In other series (ten
patients), an open approach was used (incision over the hernia typically in the parailiac location) to place the implant in
the preperitoneal space. Mesh should extend the defect with
an overlap of minimum 5 cm to secure the repair. In the area
of iliac crest when the overlap was not sufficient (hernia orifice extended to the bone), fixation to the bone with double
suture-arm bone anchor (Mitek GII titanium anchor) was
performed [20].
In the recent years, the laparoscopic approach seems to
dominate over open techniques due to better visualization of
the defect, its simplicity, and proven good results [8, 21, 22].
For incisional lumbar hernias, the transperitoneal approach
allows dissection of the omental adhesions from the previous
surgery, careful extraction of the hernia content, and exposure of the hernia orifice [8, 23]. Even if the open repair must
be performed due to the hernia size, laparoscopic exploration
of the abdominal cavity is advised to assess the clinical situation [13]. In this method the approach and technique is
similar to that of the incisional hernia repair (described in
Chapter on Ventral Hernias). A significant difference is that
the patient must be turned in the lateral decubitus position
(Fig. 36.3). The use of transfascial sutures and fixation
devices is identical to the incisional hernia operation. Mesh
could be placed intraperitoneally (composite tissue separating material) or retroperitoneally after hernia sac extraction
[24]. In these cases polypropylene or partially absorbable
lightweight mesh is used. The peritoneum is closed over the
mesh to avoid contact with the viscera [8, 23].
Moreno-Egea has reported on a prospective nonrandomized study of 16 patients, 15 of whom were post nephrectomy and 1 after trauma. Mesh was used in all of the repairs,
with seven done by the open method and nine by a laparoscopic approach. They found that the open repair was associ-
473
Fig. 36.3 Position of patient to repair a lumbar hernia of the left side.
This position is also used for the repair of the “denervation hernia.” The
three dark circles connote the approximate location of the trocar sites
ated with a longer operative time, a longer length of stay,
higher morbidity, and more recurrences. There were no
recurrences in the laparoscopic group compared to three in
the open group (p = 0.4). They concluded that the laparoscopic repair was “more efficient and profitable.” This level
2b evidence supports laparoscopic repair [25]. The
International Endohernia Society in 2014 has based its
guidelines mainly on this paper with a statement that:
“Laparoscopic repair of lumbar hernia (with mesh) is superior to open repair with mesh in terms of morbidity but not
recurrence rate” [26].
An interesting alternative was described in the series of
patients operated via laparoscopic approach with combined
intra- and extraperitoneal repair [TAPE—transabdominal
partially extraperitoneal]. For sufficient overlap in large lateral defects, the retroperitoneal space is dissected laterally
(behind the ascending or descending colon) to reach the
psoas muscle. A large prosthesis is fixed with tackers to the
abdominal wall and with the sutures to psoas muscle. At the
end of the procedure, the colon is restored to its natural anatomical position through interrupted sutures to the mesh,
making use of the preserved peritoneum above the white line
of Toldt [27].
One paper considered the totally extraperitoneal
approach and showed the possibility of that repair. The
authors believe that retroperitoneoscopy allows safer dissection of the space and tension free placement of the mesh.
However, only one case has been described to date, but this
method is very similar to the TEP in inguinal hernia repair.
While it could be a valuable alternative, it was never
followed by other authors [28].
In the acute traumatic situation, where full laparotomy
to exclude intraperitoneal bleeding is mandatory, the abdomen should be explored through a midline abdominal
incision.
Extensively damaged, ischemic colon in the hernia will
need resection with the formation of a stoma if indicated.
The defect in the lumbodorsal fascia should be sutured with
nonabsorbable sutures. The defect in the fascia is best
474
M. Śmetański and K .A. LeBlanc
reinforced with a prosthetic biomaterial in addition to primary closure. However, the acute repair of the traumatic
lumbar hernia is associated with a high recurrence rate. In
recently described series, 50% of patients developed a recurrence. Due to this data delayed repair was proposed. The
authors believe that even if the patient requires abdominal
exploration for other injuries, the repair of traumatic lumbar
hernia is not mandatory at that time and should be individualized. At that time, it may be best to defer to an expeditious,
elective repair once the other acute issues have resolved.
Repair in high-risk patients with associated injuries and contaminated wounds may lead to wound infection and, eventually, failure of the repair thereby making any subsequent
repair more difficult [13].
In the situation of the denervation injury, the repair is
more problematic. Because no fascial defect is present, many
surgeons are reluctant to repair what is reasonably believed
to be a cosmetic problem [29]. As mentioned, according to
the recent follow-up studies, the flank bulge leads very often
to persistent pain and limitation of daily activity [14].
Because of this many such patients have a strong desire to
undergo a reparative operation. The difficulty lies not only in
the decision to operate but also in the type of repair that can
be done in these patients. The data on any of these choices is
sparse. There are three basic options in which to approach
this problem. The first is seemingly a very simple procedure.
The involved flank muscles can be exposed and sutured in
the form of a plication. Several layers of these sutures can be
applied which will result in a very appreciable improvement
in the appearance of the contour of the abdomen at the time
of surgery and shortly thereafter. Unfortunately, the denervated muscle cannot be cured nor does the plication provide
a final solution. The muscle adjacent to the plication is still
paralyzed and will bulge as before within several months to
a few years. Because of this failure, the use of a prosthetic
material is recommended. The surgeon must provide for a
very wide overlap of the prosthetic to affect a positive longterm result. The prosthetic can be placed in the extraperitoneal position or over the external oblique muscle. The
muscles are divided and the extraperitoneal space is dissected. A large piece of material is placed in that location. It
is important to ensure that the mesh extends from above the
ribs to the level of the iliac crest. Only in this manner will all
of the denervated muscle be covered. The difficulties lie in
the dissection of the preperitoneal space, as this area will be
densely scarred.
There are two proposed approaches to the preperitoneal
space. A lateral approach through the previous incision or a
medial approach through an incision of the rectus sheath can
be done. Placement of the mesh should extend it onto the
unaffected site to overlap the defect. In a small series (7 lateral vs. 8 median), the lateral approach to the denervation
area did not provide satisfactory long-term results. Conversely
the median approach resulted in the maintenance of the
proper shape of the flank in long-term observation [30].
The results achieved can be even more satisfying when
plication of the muscles is performed concomitantly. Because
the fibers of the abdominal muscles are orientated in opposing directions, the forces that the muscles exert are in opposition. The anatomical repair restores these opposing forces
through plication of the lateral muscles transversally. In
these cases implanted mesh additionally reinforces the
strength of the repair [2].
Another, less favored, method is the prefascial (onlay)
method. In this case, the denervated muscles are plicated. A
large piece of a prosthetic material is then placed from above
the ribs to below the iliac crest. This can be sutured with
permanent sutures in an interrupted or continuous fashion.
The theoretical disadvantage of this approach is that the
denervated muscle is supported from above rather than
behind the fascia. Although this repair seems to be easier to
perform, it does not increase the possibility of intraabdominal injury due to the underlying adhesions.
Additionally recurrent hernias can occur in the previous scar
underneath the mesh [31]. Evidence favoring either the onlay
or extraperitoneal approach is still sparse due to the relatively infrequency of these hernias.
Laparoscopic/Robotic Repair
General Technique Comments
A nasogastric tube and urinary bladder catheter is placed
after the patient has undergone general anesthesia. The
patient will then be placed in a near lateral decubitus position. The use of a “bean-bag” or “jelly rolls” will greatly
assist in this task. It is important to maintain exposure from
below the midline of the contralateral side of the abdominal
wall to the spine. This is necessary to place trocars and transfascial sutures (if used). I sometimes mark the skin to identify the costal margin and the iliac crest. Flexing of the table
is avoided. Although this would facilitate placement of trocars, this would separate the fascial edges, making the hernia
larger and the repair more difficult.
The laparoscopic and robotic approaches do have different considerations that should be mentioned. The usual locations of the trocars when the laparoscopic technique is
employed are shown in Fig. 36.3. There is significant latitude
in the locations of them with this approach.
The use of the Intuitive Surgical (Sunnyvale, CA, USA)
robot influences the location of the trocars used depending
on the robot employed. The older Si places the camera trocar
slightly behind that of the other two trocars. The Xi version
requires that the trocars be aligned in a straight line. These
differences and the typical locations are shown in Fig. 36.4.
Port Placement - Left Lumbar Hernia
36 Lumbar Hernia
475
effective repair. This is the fundamental difference between
these methods. The following procedure description will
apply to both.
This repair will be similar to the traditional incisional hernia repair. If possible, the fascial defect can be closed with
either transfascial sutures or intracorporeal sutures. The latter option seems easiest if barbed sutures are utilized in the
closure (Fig. 36.5). If transfascial sutures are to be placed,
one must be careful not to inadvertently place them through
the chest if the hernia is adjacent to the thoracic cavity.
Closure of the defect becomes more difficult with larger
defects.
The mesh will be placed to cover the defect with at least a
Xi
Si
5-cm overlap of the fascial defect. It is preferred that the size
be selected on the measurement of the unclosed defect as one
cannot be assured that the closed defect will remain permanently closed [5]. If fixation to the diaphragm is necessary,
this should be sutured with either interrupted or running permanent sutures. If additional fixation with a device is needed,
one should only place them below the diaphragm (see
Chapter on Prosthetics).
Fig. 36.4 Robotic trocar positions for the left sided lumbar hernia
(shown in blue)
Undoubtedly there will be other surgical robots in the future,
but at the time of this writing, these are the only ones
available.
Repair of True Fascial Defects
These hernias can be repaired with either the preperitoneal
placement or intraperitoneal placement of mesh (IPOM). It
has been shown that the main consideration in the repair of
lumbar hernias is the placement of a prosthetic material [26].
The choice of mesh will be influenced by the location of its
final placement (see Chap. 7 on Prosthetics). The preperitoneal dissection will expose the fascia as part of the procedure
and covers it once the repair is complete. In that method, a
“non-coated” product may be used. A “coated” product is
required if the IPOM is performed. If the latter technique is
utilized, it is important to dissect the preperitoneal fat away
from the fascia so that the uncoated surface of the mesh contacts as little of the adipose tissue as possible to ensure an
Repair of “Denervation Hernias”
These are challenging hernias because there is no fascial
defect but paralyzed musculature. This represents a large
surface to be repaired. The repair is entirely dependent on the
placement of mesh. For these types of hernias, a hybrid
approach is recommended. Generally, the procedure is
started open, converted to either laparoscopic or robotic and
then returning back to open if not competed prior to that. In
most cases, I complete the open portion prior to beginning
the laparoscopic/robotic portion.
The skin incision of the prior procedure is utilized, and in
most cases, this must be extended. The initial dissection will
require the development of significant skin flaps in all directions. An onlay mesh will ultimately be placed, which
requires the overlap to extend above the ribs superiorly,
Fig. 36.5 The blue arrows indicate the closed fascial defect
476
below the iliac crest inferiorly, onto the rectus sheath medially, and near the spine posteriorly. This will provide coverage of the entire area of denervation.
At that point, the muscles are incised to enter the
abdominal cavity. Adhesiolysis is performed as necessary.
Again, this dissection must extend above the diaphragm
superiorly, into the pelvis inferiorly, to the midline medially, and to the paraspinus muscles posteriorly (Fig. 36.6).
The mesh should be large enough to cover all of these
areas. It will be inserted and sutured to the paraspinus and/
or psoas muscles initially. Transfascial sutures are also utilized. The superior portion of the mesh will then be sutured
to the diaphragm with interrupted sutures. Additionally,
transfascial sutures are added below the costal margin and
medially.
After this has been performed, three trocars are placed
where best located. This will vary slightly if the procedure
will be laparoscopic or robotic (see above). At this point the
divided muscles will be plicated in a “vest over pants” configuration (Fig. 36.7). These should be pulled a tight as feasible. One must account for this portion of the procedure
during placement of the subcostal transfascial sutures. One
may elect to place the onlay mesh at this time (Fig. 36.8). A
single closed suction drain is used. If one elects to not close
the subcutaneous tissue and skin after this, these muscles
M. Śmetański and K .A. LeBlanc
Fig. 36.7 “Vest over pants” plication of the flat muscles
Fig. 36.6 Completed intra-abdominal dissection
Fig. 36.8 Onlay of polypropylene mesh
will be then covered with either lap sponges or a towel.
Occasionally, it will be necessary to close the skin with towel
clips to maintain pneumoperitoneum but this is seldom
required.
If used, the robot will be docked and the laparoscopic
portion will commence. The goal of this portion of the procedure is to pull the inferior portion of the mesh taut and
fixate it firmly. This will be done with transfascial sutures
laparoscopically or running barbed sutures robotically. The
robotically placed sutures will also be run over the interior
of the mesh to firmly fixate all of it to the abdominal wall
(Fig. 36.9). This will be accomplished laparoscopically
36 Lumbar Hernia
Fig. 36.9 Completed robotic fixation of the intraperitoneal mesh
with a fixation device of either permanent or absorbable
tacks. Both options will aid in the prevention of a seroma,
while assuring firm attachment of the prosthesis. At this
point, the procedure returns to the open portion (if not competed). The subcutaneous tissue is closed in layers and the
skin closed.
Although not mentioned above, it is extremely beneficial to inject a long-acting local anesthetic into the tissues
during the first open portion of the operation. Liposomal
bupivacaine is preferred. This is a painful operation and
the addition of this drug aids in pain control posto
peratively.
477
a
b
Postoperative Management
The use of a patient-controlled analgesia pump is preferred. Additional medications such as intravenous acetaminophen or ketorolac are also helpful. The NGT and
urinary catheter are typically removed on postoperative
day 1. The timing of discharge will be usually determined
by the ability to control the pain. Most patients will remain
hospitalized for 2–4 days. The drain should be left in until
the output is less than 25cc per day.
There will be a prolonged asymmetry to the repaired side
in the hybrid cases that should be discussed with the patients
preoperatively. Although in many cases this will resolve
within a year, the majority will never be perfectly symmetric
due to the paralysis of the musculature and the sole reliance
on the mesh product. However, there is never a complaint by
the patient, as this will be vastly improved than their appearance preoperatively (Fig. 36.10a, b).
Fig. 36.10 Preoperative (a) and postoperative (b) appearance of a
right sided “denervation hernia”
Conclusions
• The incidence of lumbar hernias is low.
• The use of prosthetic reinforcement is recommended in
the light of evidence.
• Laparoscopic approach is beneficial for small- and
middle- sized hernias, feasible in large defects, and even
in the cases of open repair of the large hernias allows
better assessment of the clinical intra-abdominal
situation.
• The problem of the denervation flank bulge needs an
extended approach and complex repair. A large prosthesis should be used in these cases.