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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 3 • Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxiphoid, and Lumbar 45
12th rib
Lumbar triangle
External
oblique muscle
Latissimus
dorsi muscle
Figure 3-3.
Phantom of colon
Iliac
crest
Lumbar hernia
Transversus
abdominus muscle
Iliac
crest
Lateral cutaneous branch
of iliohypogastric nerve
Lateral cutaneous branches
of L1-L3 spinal nerves
12th rib
Figure 3-4.
Quadratus
lumborum
muscle
Psoas
muscle
Gonadal vessels
Liver
Right kidney
Ureter
Inferior vena cava
46 Section II • Laparoscopic Repairs
2. Patient Positioning and Trocar Placement
s
3. Special Considerations
s
For laparoscopic suprapubic and subxiphoid hernia repairs, the patient is placed in the
supine position, with arms tucked and carefully padded. Laparoscopic lumbar hernia
repair often requires elevation of the ipsilateral side for posterior transabdominal fixation
(Fig. 3-5). Usual trocar placement for laparoscopic ventral hernia repair should suffice for
initial approach and lysis of adhesions (see Chapter 2, Fig. 2-3). These parts are placed
more medially than usual on the contralateral side of the hernia defect. Access to the
suprapubic region and myopectineal orifice is facilitated through three trocars at the level
of the umbilicus; two are placed just lateral to the linea semilunaris, and one is placed at
the umbilicus.
A three-way Foley catheter is placed before laparoscopic repair of suprapubic hernias to
facilitate identification of the distended bladder during dissection.
Chapter 3 • Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxiphoid, and Lumbar 47
Iliac crest
Figure 3-5.
Lumbar triangle
Costal margin
48 Section II • Laparoscopic Repairs
3. Operative Steps
1. Suprapubic
s
After complete adhesiolysis and delineation of the hernia defect (Fig. 3-6), the relationship
of the inferior extent of the hernia and the bladder is defined. The three-way Foley catheter
is clamped and 300 mL of sterile normal saline is instilled into the bladder, distending it
for ease in identification (Fig. 3-7).
Chapter 3 • Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxiphoid, and Lumbar 49
Pubic symphysis
Area of
symphysis
pubis
Rectus muscles
Hernia defect
A
Figure 3-6.
Cooper’s ligament (lt)
Cut edges of
peritoneum
B
Remnant of median
umbilical ligament
Rectus muscles
Fundus
of uterus
Decompressed
bladder
Cooper’s ligament (rt)
Suspensory
ligament
of uterus
Bladder instilled
with 300 ml sterile
saline
A
Figure 3-7.
Bladder
B
Medial
Colon
umbilical
fold
50 Section II • Laparoscopic Repairs
s
The inferior epigastric vessels are located on the opposite side of the operating surgeon
and the preperitoneal space entered, mobilizing the flap medially. A preperitoneal tunnel
is developed to identify Cooper’s ligament. The preperitoneal space lateral to the inferior
epigastric vessels is developed toward the iliopubic tract if needed. The peritoneum is then
swept away from the inferior epigastric vessels, fully mobilizing the preperitoneal space on
this side. A similar dissection is performed to expose the contralateral preperitoneal space.
The bladder is then mobilized off the midline using electrosurgical current. The dissection
is carried down to the pubis. Cooper’s ligament is identified bilaterally, and the bladder
is mobilized inferiorly into the space of Retzius. If the hernia abuts the pubis, it is important to mobilize the bladder sufficiently to allow several centimeters of mesh to be tucked
under the pubis (Fig. 3-8).
Chapter 3 • Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxiphoid, and Lumbar 51
Space of Retzius
Suprapubic hernia defect
A
Figure 3-8.
inferior epigastric vessels (lt)
Location of
Location of
Cooper’s ligaments
Bladder
B
Bladder flap
inferior epigastric vessels (rt)
Medial umbilical
fold
Location of
Location of
Iliopubic tract
52 Section II • Laparoscopic Repairs
s
The mesh is fixated to Cooper’s ligament bilaterally using tacks in addition to suprapubic
transabdominal suture fixation (Figs. 3-9 and 3-10). If the defect is close to the pubis,
the inferior transfascial suture is placed several centimeters off the edge of the mesh. In
doing so, the surgeon is able to bring the suture adjacent to the pubic bone, and the mesh
drapes several centimeters inferiorly for adequate overlap. When applying tacks to the
lower abdominal wall, it is important to confirm bimanual palpation of the tip of the tacker
externally. This ensures the tack is placed above the iliopubic tract and avoids major neurovascular injuries. If there is excess mesh below the iliopubic tract that cannot be secured
with tacks, we occasionally apply fibrin sealant to secure the inferior edge of the mesh over
the iliac vessels.
Chapter 3 • Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxiphoid, and Lumbar 53
Inferior epigastric
Shadow of suprapubic hernia
Transabdominal suture fixation
Cut edges of
peritoneum
vessels
Pubic
symphysis
Cooper’s ligaments
Figure 3-9.
Adequate
mesh overlap
Bladder
Shadow of suprapubic hernia
Transabdominal suture fixation
Tacks placed in
Cooper’s ligaments
Figure 3-10.
Pubic
symphysis
Bladder
54 Section II • Laparoscopic Repairs
2. Subxiphoid
s
s
3. Lumbar
s
Space is created for cephalad overlap of the defect by dividing the falciform ligament
toward the diaphragm. This often can be done with electrosurgical current; however,
meticulous hemostasis should be confirmed at the conclusion of this step (Figs. 3-11 and
3-12).
The mesh is fixated just below the costal margins bilaterally and allowed to drape gener-
ously over the diaphragm (Fig. 3-13). If the defect abuts the xiphoid process, adequate
overlap can be challenging. We do not suture around ribs because of the risk of severe
chronic pain, nor do we advocate placing tacks above the costal margin because of the
risk of pericardial injury. In order to achieve adequate overlap, the cephalad suture can be
placed several centimeters off the edge of the mesh (Fig. 3-14). The extra mesh is allowed
to drape over the diaphragm. Typically this mesh doesn’t require fixation because the liver
will hold it in place; however, if the surgeon is concerned, applying fibrin sealant to the
diaphragm can help secure the mesh.
The surgeon must be comfortable with retroperitoneal exposure. In order to gain adequate
posterior coverage of the defect with the mesh, the colon must be mobilized medially.
Careful identification of the ureter is paramount to safe fixation of the mesh. We prefer
to clearly identify the psoas muscle. Once the psoas muscle is identified and the ureters
delineated, the dissection stops and any major vascular structures are avoided (Figs. 3-15
and 3-16).