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Knots towards rough side
ePTFE mesh
(dual mesh plus)
Chapter 4 • Laparoscopic Repair of Parastomal Hernias 65
Long CV-0
nonabsorbable sutures
1/32/3
3 x 3 cm cruciate cut
Figure 4-5.
2.0 vicryl stay sutures
Rough side
facing outward
Figure 4-6.
A B C
66 Section II • Laparoscopic Repairs
s
Mesh Fixation
s
s
s
s
s
Once the mesh is inside the abdominal cavity, the two transfascial sutures at the sides of
the mesh are pulled through the abdominal wall with the suture passer. This will bring
the rolled mesh adherent to the abdominal wall, centering it over the defect with the mesh
split toward the colostomy side (Fig. 4-7).
Care must be taken that the rough surface faces the anterior abdominal wall and the smooth
surface faces the viscera.
The transabdominal sutures are tied. The Vicryl stay suture is cut, and the upper half of the
mesh is unfolded (Fig. 4-8).
By using a suture passer, the superior suture is pulled through the abdominal wall.
Next, 5-mm hernia tacks are placed circumferentially, 1 cm from the edge of the mesh and
1 to 2 cm apart.
Chapter 4 • Laparoscopic Repair of Parastomal Hernias 67
Additional
Two side transfascial sutures
pulled through abdominal wall
securing mesh over defect
Parastomal
hernia defect
Parastomal
hernia defect
Rolled mesh centered
under defect:
• Rough side up towards wall
• Smooth side facing viscera
Rolled mesh
passed through trocar
Figure 4-7.
Stay sutures
transfascial sutures
Placement of 5-mm hernia tacks
Superior suture pulled
through abdominal wall
Stay suture cut and
upper half of mesh
unfolded
Figure 4-8.
68 Section II • Laparoscopic Repairs
s
s
s
s
s
The same procedure is repeated on the other half of the mesh (Fig. 4-9), cutting the Vicryl
stay suture and spreading each part of the lower portion of the mesh individually. The
mesh portions are fixed using transabdominal sutures and 5-mm hernia tacks.
After the mesh is secured properly to the abdominal wall, the gaps between the colostomy
and the cruciate defect in the mesh are closed with interrupted 2-0 nonabsorbable sutures
securing the mesh to the seromuscular layer of the colostomy loop.
This will form a collar around the colostomy, eliminating potential spaces for future
recurrence.
Additional transfascial sutures are placed circumferentially at 5-cm intervals to augment
long-term stability.
At the completion of the procedure, the mesh covers the entire hernia defect with 5 cm of
overlap while the mesh defect hosts the colostomy loop without restriction (Fig. 4-10).
Chapter 4 • Laparoscopic Repair of Parastomal Hernias 69
Cruciate gaps of mesh closed
via 2-0 interrupted sutures to
seromuscular colostomy loop
Figure 4-9.
Lower portion of mesh released
and secured with
transabdominal sutures and tacks
Figure 4-10.
70 Section II • Laparoscopic Repairs
2. Laparoscopic Sugarbaker Technique (Fig. 4-11)
s
s
s
s
s
s
s
s
s
The laparoscopic Sugarbaker technique involves placing a flat sheet of mesh on the abdom-
inal wall and lateralizing the stoma’s loop of bowel. In order to perform this procedure,
the bowel must have sufficient mobilization to allow it to be displaced laterally without
excessive kinking. Occasionally, ileal conduit hernias cannot be lateralized because of the
posterior fixation of the ureters.
Once the defect is measured, an appropriately sized piece of mesh is designed to provide
at least 5 cm of overlap.
We typically suture the bowel to the lateral abdominal wall before bringing in the mesh.
This allows the surgeon to see the angle of the bowel before being obscured by the prosthesis. Additionally it confirms that there is not too much tension on the bowel as it makes
this angle and avoids the mesh acting as a sling on the bowel wall that is not secured to the
abdominal wall.
Placing the four cardinal transfascial sutures at each corner of the mesh aids in mesh posi-
tioning (see Fig. 4-11).
The mesh is brought into the abdominal cavity through a trocar and unrolled.
The inferior lateral suture is retrieved first, after 5 cm of overlap is measured. Given the
typical lower lateral location of most stomas on the abdominal wall, it is important to
retrieve this suture first, since you will often be limited by the major neurovascular structures of the pelvis.
The superior lateral suture is subsequently retrieved. These sutures are then tightened on
the abdominal wall. The surgeon can then see over the mesh and confirm that the bowel is
not being too acutely angled as it exits the mesh.
The remaining two sutures are then stretched out across the abdominal wall and secured.
A tacking device is then used to secure the mesh to the anterior abdominal wall every
1 cm. When placing tacks next to the stoma site, great care must be used to avoid injuring
or obstructing the lumen. There is no exact measurement to allow the surgeon to confirm
appropriate mesh and bowel placement, and great care should be used. Because the mesh
is placed during full insufflation, it is likely that as the abdomen is desufflated the mesh
will loosen a bit.
4. Postoperative Care
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s
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Use appropriate stoma care.
Patients are allowed a liquid diet that is advanced as tolerated, although some degree of
There are no restrictions of activity.
Abdominal binders aid in the management of postoperative pain and in the preventing of
postoperative ileus may follow, depending on the operative trauma.
seromas.
Chapter 4 • Laparoscopic Repair of Parastomal Hernias 71
Initial closure of defect
Order of cardinal transfascial
suture placement (1-4)
4
2
3
Lateral mobilization
1
of stoma
Bowel sutured
to lateral
abdominal wall
Figure 4-11.
Final mesh fixture with tacks
72 Section II • Laparoscopic Repairs
5. Pearls/Pitfalls
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When dealing with parastomal hernias, we need to repair the hernia while maintaining the
defect in the abdominal wall for the colostomy loop to pass without obstruction.
Scroll technique facilitates intracorporeal mesh manipulation, maintains precise orienta-
tion of the mesh in relation to the hernia defect, and allows secure fixation of the mesh to
the anterior abdominal wall.
The rolled mesh is placed through the 12-mm Hasson trocar into the abdominal cavity;
this will avoid mesh contamination from the skin.
The fundamental components of a sound hernia repair of wide mesh overlap of the defect
and transabdominal sutures are used.
Full-thickness nonabsorbable sutures are crucial for long-term stability of the mesh to
the abdominal wall while the 5-mm tacks close the gaps between the abdominal wall and
the mesh, thereby preventing incarceration of a loop of bowel between the mesh and the
abdominal wall.
The laparoscopic approach visualizes the entire abdominal wall, thus detecting any impal-
pable hernia defect that also may be repaired at the same time.
Large midline defects in addition to parastomal hernias can be very challenging to simulta-
neously repair, and occasionally, an open approach or the use of two meshes laparoscopically is warranted.
Suture closure of the hernia defect and reinforcement with the mesh is an optional maneu-
ver that adds security to the mesh repair. However, this may create a tension repair that
may necessitate a concomitant component separation.
These are challenging hernias to repair in a challenging patient population, and all tech-
niques have a potential risk for complication and recurrence, mandating appropriate preoperative counseling.
Selected References
Berger D, Bientzle M: Laparoscopic repair of parastomal hernias: a single surgeon’s experience in 66 patients, Dis Colon Rectum
50(10):1668–1673, 2007 Oct.
Craft RO, Huguet KL, McLemore EC, Harold KL: Laparoscopic parastomal hernia repair, Hernia 12(2):137–140, 2008 Apr.
Hansson BM, Bleichrodt RP, de Hingh IH: Laparoscopic parastomal hernia repair using a keyhole technique results in a high recurrence
rate, Surg Endosc 23(7):1456–1459, 2009 Jul.
Muysoms EE, Hauters PJ, Van Nieuwenhove Y, Huten N, Claeys DA: Laparoscopic repair of parastomal hernias: a multi-centre retrospec-
tive review and shift in technique, Acta Chir Belg 108(4):400–404, 2008 Jul-Aug.
Muysoms F: Laparoscopic repair of parastomal hernias with a modified Sugarbaker technique, Acta Chir Belg 107(4):476–480, 2007
Jul-Aug.
Saber AA, Rao AJ, Rao CA, Elgamal MH: Simplified laparoscopic parastomal hernia repair: the scroll technique, Am J Surg 196(3):
16–18, 2008 Sep.
1. Clinical Anatomy
C HAPT E R
5
Open Retromuscular
Ventral Hernia Repair
Yuri W. Novitsky, MD, FACS
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Retrorectus repair requires a thorough knowledge of the relative anatomy of the myofascial
components of the abdominal wall.
The rectus abdominis, a long, broad, strap-like muscle, is the principal vertical muscle of
the anterior abdominal wall. Its origin is at the pubic symphysis and pubic crest. The muscle is inserted into the cartilages of the fifth, sixth, and seventh ribs. The rectus abdominis
is three times as wide superiorly as it is inferiorly.
The rectus abdominis is innervated by the thoracoabdominal nerves T7-T12. The main
trunks of the intercostal nerves pass anteriorly from the intercostal spaces and run between
the internal oblique and transversus abdominis muscles in a so-called neurovascular plane.
The inferior intercostal, subcostal, and lumbar arteries accompany the nerves of this plane.
In addition, the lateral cutaneous nerve branch of T12, as well as the ilioinguinal and ilio-
hypogastric both enter the space between the internal oblique and transversus abdominis
via the lateral border of the transversus muscle. These nerves, along with the ventral primary rami of the inferior six thoracoabdominal nerves (T7-11) innervate the anterolateral
abdominal wall skin and musculature.
The rectus sheath is the strong, incomplete fibrous compartment for the rectus abdominis
muscle. It forms by the fusion and separation of the aponeurosis of the lateral abdominal
muscles.
At its lateral margin, the internal oblique aponeurosis splits into two layers, one passing
anterior to the rectus muscle and the other passing posterior to it. The posterior layer joins
with the aponeurosis of the transverse abdominis muscle to form the posterior wall of the
rectus sheath. Muscle fibers of the transversus abdominis end in an aponeurosis, which
contributes to the formation of the rectus sheath.
The lateral abdominal wall consists of three flat muscles: external oblique, internal oblique,
and transversus abdominis. The flat muscles cross each other similar to a three-ply corset
that strengthens the abdominal wall and diminishes the risk of herniation between the
muscle bundles. One important consideration for the retrorectus repair is the fact that in
the upper third of the abdomen, the transversus abdominis extends medially beyond the
overlying linea semilunaris as a primary muscular component not as fascia (Fig. 5-1).
74
Chapter 5 • Open Retromuscular Ventral Hernia Repair 75
5
6
Cut edge of
anterior
External
oblique
muscle
and fascia
Rectus muscle
Pyramidalis muscle
7
8
9
10
Arcuate line
Diaphragm
Costal margin
Posterior rectus sheath
Overlying linea semilunaris
External oblique muscle
(removed)
Internal oblique muscle
(removed)
Transversus abdominis
muscle
ASIS
Linea alba
Inguinal ligament
Figure 5-1.
Pubic crest
and symphysis