Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
Superior
mesh overlap
Chapter 6 • Open Flank Hernia Repair 107
Inferior mesh secured
to iliac brim with overlap
Posterior transfascial
mesh fixation
Inferior transfascial
mesh fixation
Psoas muscle
behind mesh
Kidney
Ureter
Anterior mesh
transfascial fixation
Figure 6-8—Cont’d
FINAL MESH PLACEMENT
(Taco shape)
108 Section III • Open Repairs
4. Postoperative Care
s
5. Pearls and Pitfalls
s
s
s
s
Abdominal distention should be avoided following this repair. If an extensive lysis of adhe-
sions was required, oral intake should be delayed until there is evidence bowel function
has returned. Patients should be kept in an abdominal binder following this operation for
6 weeks. Antibiotics are continued for 24 hours unless otherwise indicated. A drain is typically placed intraoperatively and removed within 3 days postoperatively.
Knowledge of the anatomy is particularly important in this type of hernia because dissec-
tion is complex given the proximity to neurovascular and bony structures. Always obtain a
preoperative CT scan to help delineate the anatomy, define overlap planes, and document
previous mesh repairs.
The most important technique to learn from this type of repair is that overlap may be
superior to fixation. Reliance on transfascial or bony fixation as the backbone for a flank
hernia repair implies that there is inadequate overlap. Dissection of the preperitoneal plane
allows a 5- to 10-cm overlap that can overcome hernia defects and eliminate the need for
excessive fixation.
The described method for flank hernia repair may not be appropriate in a setting of con-
tamination. Specifically, the patient and surgeon must consider the infectious risk of the
procedure. If the risk is elevated beyond a clean case, the bony fixation described below
may be contraindicated due to the risk for subsequent osteomyelitis.
Appropriate mesh fixation to follow the contour of the abdominal wall can be technically
challenging. Fixating laterally, medially, inferiorly, and finally superiorly can help minimize
these issues.
Selected References
Carbonell AM, Kercher KW, Sigmon L, Matthews BD, Sing RF, Kneisl JS, Heniford BT: A novel technique of lumbar hernia repair using
bone anchor fixation, Hernia 9(1):22, 2005.
Heniford BT, Iannitti DA, Gagner M: Laparoscopic inferior and superior lumbar hernia repair, Arch Surg 132:1141, 1997.
Stumpf M, Conze J, Prescher A, Junge K, Krones CJ, Klinge U, Schumpelick V: The lateral incisional hernia: anatomic considerations for
a standardized retromuscular sublay repair, Hernia 13(3):293, 2009.
Yee JA, Harold KL, Cobb WS, Carbonell AM: “Bone anchor mesh fixation for complex laparoscopic ventral hernia repair.” Surgical
Innovation 15(4):292, 2008.
Chapter 6 • Open Flank Hernia Repair 109
Figure 6-9.
Figure 6-10.
1. Introduction
C HAPT E R
7
Open Repair of Parastomal
Hernias
Harry L. Reynolds, Jr., MD, FACS, FASCRS
s
2. Clinical Anatomy
1. Dissection Planes
s
s
s
Multiple techniques of parastomal hernia repair have been described. This chapter outlines
an open retrorectus biologic mesh placement technique that is suitable for simultaneous
repair of large parastomal and midline hernias.
Abdominal wall anatomy is discussed in detail in Chapter 1. It is essential to understand
the anatomic layering of the abdominal wall for proper retrorectus/retroperitoneal mesh
placement and anterior component separation.
The linea semilunaris lies at the lateral aspect of the posterior rectus sheath. Rectus inner-
vation is preserved and plane development is facilitated by entrance into the retroperitoneal space medial to the linea semilunaris. Dissection in the retroperitoneal space is below
the transversus abdominis muscle and can be completed to the psoas. Mesh placement is
in this retroperitoneal space.
Anterior component separation involves division of the external oblique aponeurosis lat-
eral to the rectus sheath. Access for this division can be achieved via subcutaneous flap or
via laparoscopic techniques as described previously (see Chapters 8 and 11) (Fig. 7-1).
2. Ostomy Site Selection
s
110
Ostomy sites are chosen with the assistance of an enterostomal therapist and are marked
preoperatively. Patients should be examined while sitting and supine, and an appropriate location visible to the patient is found. Transrectus placement is typically preferred.
Rectus
abdominus
muscle
Transversalis
fascia
Chapter 7 • Open Repair of Parastomal Hernias 111
Linea semilunaris
Subcutaneous fat
ANTERIOR
COMPONENT
SEPARATION
Subcutaneous flap
External oblique
aponeurosis division
Peritoneum
A
NORMAL ANATOMY
Posterior
rectus
sheath
External oblique muscle
Internal oblique muscle
Transversus abdominus muscle
Psoas muscle
Entrance into retroperitoneal space
1 cm medial to linea semilunaris
POSTERIOR
COMPONENT
SEPARATION
Transversalis fascia
and peritoneum
B
Figure 7-1.
C
112 Section III • Open Repairs
Folds should be avoided to facilitate appliance adhesion. Thus, it is essential to examine
the patient while he or she is sitting in order to visualize folds. Obese patients with a significant pannus should be sited in the upper abdomen. During complex abdominal wall
reconstruction, excess skin and subcutaneous tissues are often resected, and therefore consideration must be given to the eventual placement of the stoma (Figs. 7-2 and 7-3).
3. Preoperative Considerations
1. Comorbidities
s
s
s
s
s
Appropriate patient selection and optimization is essential. The procedure results in a
significant physiologic insult. An extended operation with a long midline incision and
prolonged adhesiolysis is typical. Significant fluid shifts should be expected. Those with
extensive cardiac, pulmonary, or renal disease should be vetted carefully and optimized
maximally. Risk of surgery may be prohibitive in some.
Combined ventral and parastomal hernias are typical. With large hernias there may be sig-
nificant loss of abdominal domain. Intraabdominal reduction results in increased abdominal compartment pressures with potential for pulmonary and renal compromise. The use
of a large biologic mesh prosthesis partially mitigates this problem; however, perioperative
intensive care including brief ventilator support is not unusual.
Timing of the operation is important as well. An appropriate interval from previous surger-
ies should be allowed. This typically should be a minimum of 3 months. However, with a
history of a significant inflammatory process or hostile abdomen on previous exploration,
a longer interval (6 months to a year) may be appropriate. On exam before exploration,
ideally, the abdominal skin overlying any midline hernia should be mobile and soft without significant adherence to underlying bowel loops.
Those that present with infected prosthetic mesh with or without fistulas are particu-
larly good candidates for this approach. The duration and complexity of operation can be
expected to increase significantly in this situation.
Preoperative imaging with abdominal pelvic computed tomography (CT) scans is routinely
performed. These images provide important information as to the exact location of the
stoma in the abdominal wall, the integrity of the rectus muscle and lateral abdominal wall
musculature, and the size of the parastomal and midline hernias. In addition, the surgeon
can be alerted to possible loss of abdominal domain and plan appropriately.
2. Two-Team Approach
s
We have found a two-team approach particularly efficacious. One team focuses on adhe-
siolysis, intestinal mobilization, resection, and repair as appropriate. A second team proceeds with abdominal wall reconstruction. In our institution, we typically use a colorectal
surgical team and a general surgical team. Although, one surgeon can certainly accomplish
these procedures, fatigue of the operating team does become a factor with operative times
averaging about 5 hours. A planned two-team approach helps facilitate procedure progression in these prolonged cases.
Chapter 7 • Open Repair of Parastomal Hernias 113
Upper abdominal sites
preferred in obese patients
Costal
margin
Rectus
XX
muscles
Figure 7-2.
X
OSTOMY SITES
Large pannus, upper abdomen
placement preferred
X
Avoid
folds
Figure 7-3.
SUPINE SITE EVALUATION SITTING SITE EVALUATION
114 Section III • Open Repairs
3. Operative Options
s
s
s
4. Operation Steps
1. Midline Laparotomy
s
Multiple methods of parastomal hernia repair, both laparoscopic and open, have been
described. The multiplicity of procedures belies the complex nature of the problem and
the lack of a clear and simple, yet efficacious repair.
Direct suture repair has been frequently described but has an unacceptably high recur-
rence rate. Mesh, either biologic or synthetic, placed in a subcutaneous overlay, or in a
retrorectus underlay has been described with variable results. Stomal transposition with or
without mesh use has been used also, and results have also been variable.
Our preferred option, particularly for those with combined ventral and parastomal her-
nias, is component separation, stomal transposition, and retrorectus reinforcement with
biologic mesh. This method is the focus of this chapter.
After preoperative bowel preparation, deep venous thrombosis prophylaxis, and intra-
venous antibiotics, the patient is approached through a midline laparotomy. Patients are
placed in low lithotomy with Allen stirrups or Yellow Fin stirrups to allow easy access to
the pelvis for adhesiolysis. The stoma is isolated and excluded with an impervious iodine
impregnated sticky drape. Midline entry can be challenging in those with a previously
placed mesh prostheses, which is commonly seen after previous attempts at repair. The
previous scar is excised, fistulas are mobilized, and mesh is explanted. Particularly careful
and tedious dissection is necessary to prevent enterotomy (Fig. 7-4).
2. Complete Adhesiolysis and Stomal Mobilization
s
A complete adhesiolysis is undertaken to the root of the mesentery. It is essential to fully
free the abdominal wall to allow complete mobility of the wall for reconstruction. The
bowel proximal to the stoma is typically divided with a linear cutter intraabdominally,
isolating the stoma to limit contamination. The mucocutaneous junction is then taken
down, and the old stoma is excised. The intestinal segment used for the stoma is mobilized
adequately to transpose it, preferably to the contralateral side. The ventral and parastomal
hernia defect size is assessed, and a decision is made as to whether component separation
will be necessary.
Chapter 7 • Open Repair of Parastomal Hernias 115
A
C
Figure 7-4.
B
116 Section III • Open Repairs
3. Anterior Component Separation
s
4. Retrorectus Mobilization
s
An open component separation technique is preferred for the old stoma site. This allows
mobilization of a subcutaneous skin flap including the old stoma site. The skin flap is
mobilized at least 2 cm lateral to the rectus sheath, and the external oblique aponeurosis
is identified. The external oblique aponeurosis is opened from above the costal margin
to the pelvis. In some cases, there may be enough redundant skin with this flap to allow
complete resection of the skin and subcutaneous tissue containing the old stoma site after
abdominal wall reconstruction. The fascial edges are assessed to see if closure will be feasible anteriorly. If deemed necessary to gain additional anterior abdominal wall mobilization, a contralateral anterior component separation is performed, either by lifting a flap or
proceeding with an endoscopic technique, which we prefer for the side opposite the stoma.
The endoscopic technique preserves the perforators to the abdominal wall skin and avoids
a large skin flap around the new stoma, as described in Chapter 11 (Figs 7-5 and 7-6).
The rectus sheath is now entered in the midline, and the muscle is mobilized anteriorly,
allowing visualization of the posterior rectus sheath and the linea semilunaris laterally.
This space can be difficult to access with a prior stoma. However, if one dissects above and
below the old stoma site, the space can almost always be recreated. The parastomal hernia
sac can be left in situ on the posterior rectus sheath if possible, although this is often difficult. Alternatively, the hole created in the posterior rectus sheath at the old stoma site
can be reapproximated with sutures. One of the limits of the posterior rectus sheath is the
lateral extent of mesh placement. For standard midline defects, this is often not a significant problem. For parastomal defects or when reinforcing new stomas, creating space for
lateral overlap and fixation of the mesh can be difficult. Utilizing the preperitoneal dissection plane in the lateral abdominal wall, large sheets of mesh can be utilized to reinforce
the old stoma site and the newly created stoma. To access this plane, the posterior rectus
sheath is superficially opened approximately 1 cm medial to the linea semilunaris, and the
retroperitoneal space is entered, posterior to the transversus abdominis muscle. By opening medial to the linea semilunaris, injury to the segmental intercostal nerves innervating
the rectus is less likely. The dissection is continued laterally in the retroperitoneal space to
the psoas muscles from the costal margin to the pelvis. This dissection is completed on the
opposite side as well. It is more difficult on the side of the previous stoma, but with care,
full mobilization can be accomplished, preserving the posterior sheath and the peritoneum
laterally for closure over the bowel before mesh placement (Figs. 7-7 to 7-9).