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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
OVERLAP MEASUREMENT
Order of primary
suture placement
(1-4)
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 35
FOR FIRST CARDINAL
SUTURE PLACEMENT
4 cm
1
Abdominal grid for
mesh orientation
Figure 2-12.
Pulling tagged sutures to bring mesh
2
Mesh
outline
against abdominal wall
4
3
1
Figure 2-13.
2
Spinal needle advanced for
guiding appropriate suture
retrieval
4
3
Grasper adjacent to suture knot
while pulling mesh in vertical axis
taut along y axis
36 Section II • Laparoscopic Repairs
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The mesh at the final suture site is grasped adjacent to the knot and stretched along the
x-axis. A spinal needle passed along the x-axis marks the spot for final cardinal suture
retrieval, just as was done when placing the third suture. The suture passer retrieves the
suture tails, and they are secured. Placing a hemostat into the small skin incision and lifting
it allows the knot to fall below Scarpa fascia and not dimple the skin (Fig. 2-14).
Once the mesh is secured and overlap ensured, a tacking device is used to fixate the
edges of the mesh circumferentially (Fig. 2-15). The purpose of the tacks is not to provide
strength to the repair, but rather, to prevent bowel or mesenteric fat from creeping over the
top of the mesh, exposing it to the ingrowth side. Fixation devices are both permanent and
absorbable.
Skin dimple
after tying down
Scarpa’s fascia
Mesh
Figure 2-14.
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 37
Place hemostat into small incision and lift
to release Scarpa’s fascia which allows knot
to go underneath
Figure 2-15.
CIRCUMFERENTIAL FIXATION OF MESH EDGES
38 Section II • Laparoscopic Repairs
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The strength of the repair is the transabdominal fixation that the permanent sutures pro-
Before completion of the case, one last inspection of the abdominal cavity is performed to
An abdominal binder may be placed for patient comfort. The role of binders in seroma
4. Postoperative Care
1. Perioperative Concerns
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Appropriate pain management is vital in the immediate postoperative period. Apart from
The postoperative diet depends on the degree of adhesiolysis. Following procedures where
Hospitalization in the immediate postoperative period also allows the surgeon to monitor
vide. After tack fixation at the periphery of the mesh, additional permanent, monofilament
sutures are placed every 5 to 7 cm around the circumference of the mesh (Fig. 2-16).
Large defects require more frequent sutures; smaller, “Swiss cheese”–type defects may need
fewer.
rule out continued bleeding. The fascia at trocars larger than 5 mm should be closed with
suture in this hernia-prone population. The skin at the trocar sites is closed with subcuticular stitches, followed by skin tapes or tissue cyanoacrylate.
reduction is unclear.
the 2- to 3-cm umbilical defect or trocar-site hernia, all patients undergoing laparoscopic
ventral herniorrhaphy are admitted. Patient-controlled analgesia is very effective, especially in the first 24 to 48 hours after surgery. Scheduled intravenous ketorolac is a useful
adjunct.
there is a lengthy lysis of adhesions or when bowel is densely involved, the patient is kept
NPO. The diet may be advanced when abdominal distention has resolved, and the patient
is without nausea.
for any signs of missed enterotomy. There should always be an index of suspicion, particularly in difficult cases. Any unexplained tachycardia, leukocytosis, or persistent fever
should be evaluated to rule out the presence of a bowel injury. Plane abdominal films or
computed tomography can be used; however, if there is any concern, the patient should
be returned to the operating room for diagnostic laparoscopy or laparotomy.
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 39
Figure 2-16.
40 Section II • Laparoscopic Repairs
2. Long-term Issues
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Nearly all patients undergoing laparoscopic ventral hernia repair develop some degree of
seroma at the previous hernia site. Patients should be educated about this possibility in the
preoperative evaluation. Seromas rarely, if ever, require drainage or aspiration. The risk of
contaminating the mesh with drainage should be weighed against the benefits of relieving
the fluid. Indications for aspiration include failure to resolve after 6 months, significant
patient discomfort, or pressure on the skin causing excoriation or necrosis.
Persistent pain can be seen beyond 6 weeks following laparoscopic ventral herniorrha-
phy. The pain almost always occurs at suture sites. Patients describe a burning or pulling
sensation with movement. These suture sites can be injected with 30 mL of a mixture of
lidocaine and bupivacaine; however, this treatment is rarely required.
Mesh infection is the bane of all hernia surgeons’ existence. Fortunately, the incidence of
mesh infection is low; however, the consequences are grave. The management of mesh
contamination is extensive and many times requires mesh removal. In patients that present
with erythema of the abdominal wall or delayed abdominal pain over the mesh, CT imaging of the abdomen should be obtained. Fluid collection above or deep to the prosthetic
that contains air is a mesh infection and is treated as such. The fluid may be aspirated
and sent for gram stain and culture. The mesh should be removed if it has a component
of ePTFE. Attempts to salvage the prosthetic should involve open drainage of the fluid
collection with negative pressure vacuum therapy. This maneuver may be successful with
lightweight polypropylene materials but is less so with polyester-based materials.
Follow-up in patients after laparoscopic ventral hernia repair has historically been very
poor in the literature. The postoperative schedule should include appointments at
2 weeks, 6 weeks, 6 months, 1 year, and yearly thereafter. Ideally, hernia patients should be
examined at least up to 1 year for complications of seroma, persistent pain, and recurrence.
5. Pearls/Pitfalls
Chapter 2 • Laparoscopic Ventral Hernia Repair—Standard 41
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Patients with poor skin quality should not be offered a laparoscopic ventral hernia repair.
Many times the adhesions to the underlying fat or viscera provide blood supply to the
compromised skin. Skin loss may result postoperatively, leaving the mesh exposed.
Leakage of gas at a trocar site or trocars that repeatedly fall out during a prolonged case can
be quite frustrating. Replacing the leaking or loose trocar with a balloon-tipped trocar to
reestablish a seal against the abdominal wall can save significant time and insufflation gas.
For measuring large defects, an umbilical tape may be used internally. The tape is held at
one of the needles and is stretched taut between the two points, marking the edge of the
defect. The tape is brought out through the trocar and measured.
One drawback to the laparoscopic repair of ventral hernias has been the inability to reap-
proximate the midline and reestablish a functional abdominal wall. Patient expectations
should clearly be discussed preoperatively. In this instance, an open retrorectus mesh repair
may be more beneficial. The ventral defect may be closed during a laparoscopic repair with
transabdominal sutures. This technique is usually reserved for defects measuring less than
10 cm in width.
Be cautious of the patient with a history of previous mesh infection! If the prosthetic was
contaminated with methicillin-resistant Staphylococcus aureus, an open repair reinforced
with a biologic or bioresorbable graft may be preferred. This approach may require a component separation to gain midline closure of the fascia.
Selected References
Carbonell AM, Harold KL, Mahmutovic AJ, et al: Local injection for the treatment of suture site pain after laparoscopic ventral hernia
repair, Am Surg 69:688–691, 2003.
Cobb WS, Kercher KW, Heniford BT: Laparoscopic repair of incisional hernia, Surg Clin N Am 85(1):91–103, 2005.
Heniford BT, Park A, Ramshaw BJ, Voeller G: Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias,
Ann Surg 238:391–399, 2003.
Novitsky YW, Paton BL, Heniford BT: Laparoscopic ventral hernia repair. In Koltun W, editor: Operative techniques in general surgery:
techniques of laparoscopic hernia repair, New York, 2006, Elsevier, Inc, Chapter 3, pp 4–9.
Rosen MJ: Polyester-based mesh for ventral hernia repair: is it safe? Am J Surg 197:353–359, 2009.
Stoppa RE: The treatment of complicated groin and incisional hernias, World J Surg 13:545–554, 1989.
C HAPT E R
3
Laparoscopic Repair
of Atypical Hernias:
Suprapubic, Subxiphoid,
and Lumbar
Benjamin K. Poulose, MD, MPH
1. Clinical Anatomy
s
1. Suprapubic Hernia
s
The laparoscopic repair of incisional hernias that occurs at the extremes of the abdomen
either superiorly, inferiorly, or laterally can present many unique challenges to the surgeon. These hernias are often near major neurovascular or bony structures, making adequate overlap of mesh and fixation difficult. Typical locations for these types of hernias
include the subxiphoid, suprapubic, or lumbar areas. These atypical hernias can often be
approached and repaired laparoscopically with careful preoperative planning.
Correct and timely identification of the key structures in the lower anterior abdominal
wall is critical for the safe laparoscopic repair of suprapubic hernias (Fig. 3-1). A careful
preperitoneal dissection provides the needed landmarks for appropriate fixation to lessen
the chance of postoperative recurrence.
2. Subxiphoid Hernia
s
42
Identification of the costal margins and xiphoid process provide the laparoscopic bounds
of transabdominal fixation for repair of subxiphoid hernias (Fig. 3-2). Generous overlap of
the mesh over the diaphragm helps provide adequate coverage of the fascial defect in lieu
of superior fixation.
Chapter 3 • Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxiphoid, and Lumbar 43
Xiphoid process
Rectus muscles
Inferior epigastric vessels
Medial
umbilical folds
Median
umbilical
ligament
Symphysis
pubis
Cooper’s
ligaments
Round ligament
Peritoneum
Figure 3-1.
Inguinal ligament
Bladder
External iliac vessels
Falciform ligament
Right costal margin
Area of pericardium
(blue shadow)
Left costal margin
Diaphragm
Liver
Figure 3-2.
44 Section II • Laparoscopic Repairs
3. Lumbar Hernia
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The lumbar triangle is defined superiorly and laterally by the latissimus dorsi muscle,
medially by the external oblique muscle, and inferiorly by the iliac crest (Fig. 3-3). Weakness of the internal oblique and transversus abdominis musculature within the lumbar
triangle leads to hernia formation (Fig. 3-4). An anterior abdominal approach can be used
for laparoscopic repair, with proper patient positioning used to strategically expose the
lumbar triangle.
2. Preoperative Considerations
1. Laparoscopic or Open Approach?
s
The decision to proceed between a laparoscopic or open approach to atypical hernias
rests on the surgeon’s ability to estimate adequate coverage of the defect via laparoscopic
approach and the candidacy of the patient for creation of a more physiologic repair via
an open abdominal wall reconstruction. Relatively large fascial defects within 4 cm of the
iliac crest are difficult to approach laparoscopically. Younger, active patients with sizable
subxiphoid hernias may benefit from an open retrorectus or preperitoneal repair when
dissection above the costal margins can be performed along with rectus medialization.
Conversely, patients with smaller defects and those who may not tolerate an extensive
abdominal wall reconstruction may benefit from a laparoscopic approach.