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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 55
Subxiphoid hernia defect
Left costal margin
Falciform
ligament
A
Figure 3-11.
A
Figure 3-12.
B
Subxiphoid hernia sac
B
Right costal margin
Xiphoid process
Inferior aspect
of pericardium
abutting diaphragm
A B
Figure 3-13.
Hernia sac area above mesh
Area of pericardium
Costal margin
Inferior
aspect
of liver
Omental fat
above mesh
Mesh fixation
Adequate mesh overlap
draped over diaphragm
56 Section II • Laparoscopic Repairs
Cephalad suture placed several cm off edge of mesh
Cut edge of peritoneum
Figure 3-14.
Costal margin
A
Figure 3-15.
B
Retroperitoneal fat
Lumbar
hernia
Right kidney Inferior aspect,
right lobe of liver
Psoas muscle
Chapter 3 • Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxiphoid, and Lumbar 57
Perinephric fat
Lumbar hernia
Tendinous insertion of psoas muscle
Right kidney
A
Figure 3-16.
Psoas
Psoas
B
Inferior aspect,
Ureter
Inferior vena cava
right lobe of liver
58 Section II • Laparoscopic Repairs
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Space must be left for transabdominal fixation sutures to secure the mesh. Fixation to the
4. Postoperative Care
1. Immediate Postoperative Management
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In general, patients are allowed a clear liquid diet that is advanced as bowel function
5. Pearls/Pitfalls
iliac crest is usually not necessary if adequate inferior overlap is obtained (Fig. 3-17).
returns. Ambulation is begun on the night of operation with aggressive efforts at pulmonary toilet. An appropriately sized abdominal binder is employed to help minimize the
formation of large seromas.
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Patients must understand the potential risks associated with these repairs. A complete dis-
cussion of the potential outcomes and management strategies for any neurovascular injury
is paramount.
The decision to mobilize the preperitoneal space in the laparoscopic repair of suprapubic
hernias should be made preoperatively to ensure that adequate equipment and expertise
are available for success. Unlike mobilization of the preperitoneal space during laparoscopic transabdominal preperitoneal inguinal hernia repair, this maneuver can be very difficult in the repair of suprapubic hernias. Often, this space has been entered multiple times
because of lower abdominal or pelvic operations. This dissection can often be facilitated by
developing the preperitoneal space on the medial aspect of the separated rectus muscles
within the hernia sac.
Atypical hernias often involve nearby bony structures in close proximity to the hernia
defect (pubic bone, xiphoid process, iliac crest). When selecting the appropriately sized
mesh, it is paramount to incorporate extra overlap beyond that included for transabdominal suture fixation. This allows additional overlap over difficult areas where fixation is
impossible or ill-advised.
One of the most common reasons for failure after repair of an atypical hernia is lack of
mesh overlap. Regardless of the approach (laparoscopic or open), the surgeon should rely
heavily on mesh overlap and not mesh fixation. Any mesh fixated to the edge of the defect
will likely contract over time and eventually dissociate from any bony structure. Therefore,
the true key to repairing an atypical hernia is the comfort in gaining appropriate lateral and
inferior dissection planes to afford mesh overlap.
Selected References
Losanoff JE, Basson MD, Laker S, Weiner M, Webber JD, Gruber SA: Subxiphoid incisional hernias after median sternotomy, Hernia
11:473–479, 2007.
Varnell B, Bachman S, Quick J, Vitamvas M, Ramshaw B, Oleynikov D: Morbidity associated with laparoscopic repair of suprapubic
hernias, American Journal of Surgery 196:983–987, 2008:discussion 987-988.
Yavuz N, Ersoy YE, Demirkesen O, Tortum OB, Erguney S: Laparoscopic incisional lumbar hernia repair, Hernia 13:281–286, 2009.
Chapter 3 • Laparoscopic Repair of Atypical Hernias: Suprapubic, Subxiphoid, and Lumbar 59
Area of lumbar hernia
A
Figure 3-17.
covered by mesh
B
Psoas
Tacks
Inferior aspect,
of kidney
Psoas
Cut edge of fatty peritoneum
1. Clinical Anatomy
1. Types of Parastomal Hernias
C HAPT E R
4
Laparoscopic Repair of
Parastomal Hernias
Alan A. Saber, MD, FACS
Parastomal hernia has been anatomically classified into four subtypes: (Fig. 4-1)
1. Subcutaneous: The hernia sac goes alongside the stoma into the subcutaneous tissue. This
is the most common type of paracolostomy hernia.
2. Interstitial: The hernia sac is within the layers of the abdominal wall. This hernia is at a
high risk for strangulation.
3. Peristomal: The bowel prolapses through a circumferential hernia sac enclosing the stoma.
4. Intrastomal: The hernia sac is between the intestinal wall and the everted intestinal layer.
2. Characteristics of the Facial Defect
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2. Preoperative Considerations
Most hernia defects are lateral to the rectus abdominis muscle, alongside the mesentery of
the emerging bowel, and medially and cranially to the stoma loop.
Commonly the parastomal hernia sac is very large with a relatively small fascial defect.
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60
The life expectancy of the patient and any predisposing factors, such as malignancy and
obesity, should influence the decision to proceed with surgery.
Accurate diagnosis and assessment of the anatomy of the hernia are essential. This is done
with clinical examination, or more accurately, with a computed tomography (CT) scan.
CT scan is useful to delineate parastomal defects, any associated incisional hernia, and the
content of the hernia (Fig. 4-2).
Chapter 4 • Laparoscopic Repair of Parastomal Hernias 61
Subcutaneous Interstitial
Figure 4-1.
Peristomal Intrastomal
Figure 4-2.
62 Section II • Laparoscopic Repairs
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3. Operative Steps
There are two techniques for laparoscopic repairs of parastomal hernias: the keyhole and the
Sugarbaker techniques. Keyhole technique may be associated with bowel herniation between
the mesh hole and the stoma loop. We have developed a technique that closes the gap between
the mesh and the stoma loop and facilitates intracorporeal mesh manipulations (Scroll technique) during keyhole repairs. The Sugarbaker technique avoids the risk of herniation through
the keyhole, but it does create an acute angle as the bowel exits the mesh and can cause obstruction (see Fig. 4-11). Meticulous attention to the details of mesh fixation and placement can limit
these complications.
A preoperative bowel preparation may diminish the risk of infection if there is a colonic
injury during laparoscopy.
Intravenous prophylactic antibiotic therapy covering both skin and intestinal flora is
initiated.
A large Foley catheter may be inserted into the stoma to facilitate location of the bowel
intraoperatively.
Seal the skin and stoma from the operative field with adhesive plastic drapes after prepar-
ing the skin.
1. Laparoscopic Parastomal Hernia Repair Technique: The Scroll Technique
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Operating Room Setup (Fig. 4-3)
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Trocar Placement (Fig. 4-4)
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The patient is placed in the supine position with the arms extended laterally.
The surgeon and the assistant stand contralateral to the stoma site.
General anesthesia is administered.
The abdomen is prepared and draped, including the colostomy, in standard fashion; the
stoma is covered with transparent adhesive drapes. Placement of a Foley catheter in the
stoma is optional.
For a left lower quadrant stoma, an initial 12-mm Hasson trocar is placed in the right
upper quadrant away from the hernia defect.
Initial diagnostic laparoscopy usually reveals abdominal adhesions and the parastomal
hernia.
Under direct vision, two 5-mm trocars are inserted into the right lower quadrant.
All the trocars are placed away from the hernia defect to facilitate surgical manipulation.
Chapter 4 • Laparoscopic Repair of Parastomal Hernias 63
Figure 4-3.
Figure 4-4.
64 Section II • Laparoscopic Repairs
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Lysis of Adhesions
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Mesh Choice and Preparation (Figs. 4-5 and 4-6)
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Lysis of adhesions is the most challenging part of this procedure; this is performed using
sharp or blunt dissection as close as possible to the anterior abdominal wall.
An energy source can be used only after ensuring no bowel is nearby to avoid lateral ther-
mal injury.
The hernia contents are reduced by a combination of external pressure and internal
traction.
One of the most challenging aspects of this type of laparoscopic repair is that one loop
of bowel must remain on the abdominal wall. This can be difficult to differentiate with
laparoscopic visualization. As mentioned, a Foley catheter, or occasionally, intraoperative
endoscopy can guide the surgeon.
The hernia margins are demarcated and measured, either extracorporeally or preferably
intracorporeally, to determine the size of the mesh that would allow 5 cm of overlap
circumferentially.
We typically use ePTFE mesh (Dualmesh Plus, W.L. Gore). The lack of ingrowth on the peri-
toneal side is particularly advantageous when placing prosthetic mesh around the bowel.
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Keyhole Technique
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The mesh is fashioned by creating a 3 × 3 cm cruciate cut at the junction of two thirds and
one third of the mesh (see Fig. 4-5).
A split is made from the defect to the edge of the mesh.
Long CV-0 nonabsorbable sutures are placed at each corner of the mesh and tied.
The sutures are tied with the knot toward the rough surface of the mesh.
The mesh is rolled tightly from each side to the middle like a scroll so that the rough sur-
face of the mesh faces outward with sutures inside the rolled mesh. 2-0 Vicryl stay sutures
are placed around the rolled mesh to keep it rolled tightly (Fig. 4-6).
The rolled mesh is placed into the abdominal cavity through the 12-mm Hasson trocar;
this will avoid mesh contamination from the skin.