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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
1. Clinical Anatomy
C HAPT E R
6
Open Flank Hernia Repair
Melissa S. Phillips, MD and Michael J. Rosen, MD, FACS
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2. Preoperative Considerations
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Flank hernias can be divided broadly by etiology into those that are congenital in nature
and those that are acquired, often after previous surgery or trauma. Congenital, or lumbar
hernias, are less common than the acquired type and can be subclassified into superior
triangle (Grynfeltt) or inferior triangle (Petit) defects. Acquired flank hernias can develop
after previous operations such as iliac bone harvest, trauma, retroperitoneal aortic surgery,
or nephrectomy. The anatomic proximity of flank hernias to bony prominences and major
neurovascular structures presents a challenge in the durable repair of these hernias. Spe-
cifically, the proximity of these lesions with the iliac crest and twelfth rib can often limit
the amount of tissue present for adequate mesh-tissue overlap.
When considering surgical repair of flank hernias, it is important to perform a computed
tomography (CT) scan of the abdomen and pelvis. First and foremost, this will distin-
guish a true hernia from a pseudohernia (e.g., abdominal wall laxity from denervation
after division of the lower thoracic nerves). In addition, a CT scan is not only essential to
understanding the patient’s specific anatomy but also for delineating the presence of previ-
ous mesh repairs. It also will show the structure of remaining bone, because there may be
alterations secondary to previous operations in this area. This information is important for
planning the appropriate location for prosthetic deployment and any fixation or overlap
issues that might arise.
Preoperative counseling detailing the risks of nerve injury leading to numbness, weakness,
or chronic pain, as well as the risks for vascular and intraabdominal injury is important.
Given the large incision and extent of dissection, these patients may benefit from the place-
ment of preoperative epidurals for postoperative pain management if no other contraindi-
cations exist. Routine preoperative antibiotics for skin flora should be administered.
97
98 Section III • Open Repairs
3. Operative Steps
1. Patient Positioning
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2. Operative Steps
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The patient is positioned in the full lateral decubitus position on a beanbag as seen in
Figure 6-1. A roll is placed in the axilla and the table is flexed to maximize the space
between the lower border of the costal margin and the anterior superior iliac spine to optimize exposure. The beanbag is then engaged for support and padding. The patient should
be secured to the table with padded tape to allow for full rotation of the bed during the
operation.
The following anatomic landmarks are prepped into the sterile field: costal margin and pel-
vic brim including the anterior superior iliac spine, inguinal ligament, pubic tubercle, and
umbilicus. The midline should be accessible as well if added exposure and mesh overlap
are necessary. The incision should be made preferably 3 cm above the iliac crest. As many
flank hernias are related to previous surgical interventions, the incision site will often be
dictated by the site of the previous incision.
Electrocautery is used to carry the dissection through the subcutaneous tissue including
Camper and Scarpa fasciae to identify the musculature of the lateral abdominal wall. If the
anatomic planes are intact, the external oblique, internal oblique, and transversus abdominis muscles will be divided. If the distinct muscle layers are obscured by the presence of
the hernia or prior prosthetic, blunt dissection is used to identify the hernia sac and follow
this down to the fascial edges, separating the hernia from the surrounding lateral abdominal wall musculature.
If possible, an attempt is made to avoid entry into the peritoneum. In many circumstances,
reduction of the hernia sac will lead to an inadvertent entry into the abdominal cavity. In
this circumstance, the edges of the hernia sac are left attached to the surrounding peritoneum, and the defect in the peritoneum will be closed at the completion of the dissection.
After division of the transversus abdominis muscle, the preperitoneal fat is encountered.
This plane is easier to identify laterally than medially. Care is taken to confirm entry into
the preperitoneal/retroperitoneal plane because this is the location to deploy the prosthetic
and optimize overlap. A Kittner dissector is useful to bluntly extend the preperitoneal dissection in all directions. Often the hernia sac is attenuated and cannot be separated from
the subcutaneous tissues safely. In these circumstances, we typically enter the abdominal
cavity and perform a complete adhesiolysis. Subsequently, the preperitoneal space can be
accessed at the border of the defect directly.
Chapter 6 • Open Flank Hernia Repair 99
Figure 6-1.
100 Section III • Open Repairs
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Establishing an area of overlap for mesh placement is essential in the repair of a flank
hernia. Superiorly, the dissection and overlap one can achieve can be limited by the costal
margin. However, the preperitoneal plane can be developed, separating the peritoneum off
the diaphragm obtaining 8 to 10 cm of overlap underneath the ribs in the cephalad direction as illustrated in Figure 6-2 and Figure 6-3. Posteriorly, the psoas muscle and spine
form an anatomic boundary. In this area, care is taken to identify and avoid injury to the
ureter, gonadal vessels, and iliac vessels as shown in Figure 6-4 and Figure 6-5. Additionally, the genitofemoral, ilioinguinal, iliohypogastric, and lateral femoral cutaneous nerves
are identified and avoided when securing the prosthetic. Medially, the peritoneum can be
adhered densely to the posterior rectus sheath. We prefer to transition the dissection plane
into the posterior rectus sheath just medial to the linea semilunaris (Fig. 6-6). This allows
the dissection to be carried all the way to the linea alba. Inferiorly, the Cooper ligament
and the pelvis are exposed by sweeping away the bladder. Care should be taken to avoid
injuring the spermatic cord structures as they are often encountered at this point.
Dissection between diaphragm
and peritoneum creating
8-10 cm overlap
Chapter 6 • Open Flank Hernia Repair 101
Diaphragm
Costal margin
Peritoneum
containing bowel
Psoas muscle
Costal margin
Ribs
Figure 6-2.
Diaphragm
SUPERIOR EXPOSURE
Figure 6-3.
102 Section III • Open Repairs
margin
Genito-femoral nerve
Common iliac vessels
Costal
Gonadal vessels
Ureter
Iliac wing
Internal and external obique muscles
Transversalis muscle and fascia
Psoas muscle
Lateral femoral cutaneous nerve
External iliac vessels
Ilioinguinal nerve
Iliohypogastric nerve
Inguinal ligament
Peritoneum
containing bowel
Pubic tubercle
POSTERIOR EXPOSURE
Figure 6-4.
Figure 6-5.
Chapter 6 • Open Flank Hernia Repair 103
Posterior rectus sheath
Ureter
Psoas
Peritoneum
Iliac crest
A. POSTERIOR MESH PLACEMENT
Posterior rectus sheath
Mesh placement in preperitoneal
and retrorectus space
Peritoneum
Ureter
Psoas
Iliac crest
B.FINAL MESH PLACEMENT
Figure 6-6.
104 Section III • Open Repairs
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If the peritoneum was entered during the hernia sac reduction or during the preperitoneal
dissection, it is closed with a #2-0 absorbable braided suture. If this layer is not completely
excluded, bowel can herniate through with a high strangulation risk or an internal hernia.
The hernia sac may be used to provide additional coverage of the viscera in larger defects.
If primary closure of this plane is not possible, the remaining defects may be buttressed
using omentum or with a piece of vicryl mesh. An adequately sized piece of mesh (Fig.
6-7) is used to cover the entire retroperitoneal space from the Cooper ligament to the psoas
muscle, under the costal margin, and to the midline. Since the mesh is placed extraperitoneally, an unprotected macroporous synthetic mesh is used.
The mesh is placed into the preperitoneal space, folded in a “taco” configuration The
mesh is initially fixed posteriorly (Fig. 6-8, A). The suture is placed off the edge of the
mesh to allow the mesh to drape over the psoas muscle to the ureter. The sutures can now
be passed with the Reverdin needle inferior to the lateral border of the psoas muscle to
avoid major vascular injury. Inferiorly, the mesh is fixated to the iliac crest in the following fashion, illustrated in Figure 6-8, B and Figure 6-9. A surgical cordless drill is used to
preplace the number of designated holes in the iliac crest. Mitek bone anchors (Mitek Surgical Products, Westwood, MA), which contain titanium anchors with double #2 braided
polyester sutures, are placed into the tracts. Each arm of the bone anchor suture is passed
through the mesh and tied, securing the mesh to the iliac crest. These sutures are not
placed at the edge of the mesh. Instead the suture is placed 8 to 10 cm off the edge of the
mesh. This allows the mesh to drape past the iliac crest for adequate overlap. A total of
8 to 10 fixation sutures are then placed The remaining transfascial sutures for mesh fixation are placed using a #1 polypropylene suture passed through the mesh and the needle
removed. Once in place, the mesh is pulled to recreate normal physiologic tension. We
recommend the circumferential fixation begin posteriorly, then medially, then inferiorly,
and finally superiorly. After the inferior edge of the mesh is fixated, the flex in the table is
removed and the patient is allowed to return to neutral position. It is important to return
the anatomic position to allow appropriate tensioning of the mesh and avoid buckling. It
is also critical to not overstretch the mesh excessively tight to limit lateral movements and
stretching to the contralateral side. The cross sectional images in Figure 6-6 illustrate the
location of mesh placement. At the completion of the mesh fixation, the boundaries of the
fascial defect should be relatively reapproximated before closure, as seen in Figure 6-8, C
and Figure 6-10. The fascia of the lateral abdominal wall is closed using a #1 absorbable
monofilament suture in a figure of eight fashion.
Figure 6-7.
Chapter 6 • Open Flank Hernia Repair 105
Reverdin needle
Psoas muscle
Figure 6-8.
POSTERIOR TRANSFASCIAL SUTURE FIXATIONS
106 Section III • Open Repairs
Posterior transfascial
Medial side of psoas muscle
Titanium bone anchors
Iliac wing
suture
Bone anchor sutures
placed 8-10 cm off edge
of mesh for adequate
overlap
Figure 6-8—Cont’d
ILIAC BRIM BONE ANCHOR PLACEMENT