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250
E.M. Garvey and K.L. Harold
2012, Sajid et al. and Shabbir et al. performed
systematic reviews of the RCT literature. Sajid
et al. analyzed the three RCTs by Janes,
Hammond, and Serra-Aracil encompassing 128
patients who underwent colorectal resections
with stoma creation (64 patients in the mesh
group versus 64 patients in the non-mesh group),
and found signifi cantly decreased odds for developing a PH with the use of mesh without added
morbidity [ 48 ]. Shabbir et al. reviewed 27 RCTs
and excluded all but the same three RCTs as the
Sajid paper. This review demonstrated an incidence of PH in 13% in the mesh group compared
to 53% in the control group ( p < 0.0001). There
were no differences in mesh-related complications between the two groups [ 49 ]. A similar sys-
tematic review that included the same three RCTs,
but also three prospective observational studies
and one retrospective study, found a lower rate of
PH in the mesh group [ 50 ]. All three systematic
reviews concluded the use of prophylactic mesh
at the time of stoma creation can reduce the incidence of PH. In contrast, a recently published
prospective multicenter randomized controlled
trial examined the utility of porcine-derived acellular dermal matrix reinforcement at the time of
end-stoma creation in 55 patients compared to 58
control patients without mesh reinforcement.
They found a similar incidence of PH for both
groups at 12.2% for the mesh group and 13.2%
for the control group [ 51 ]. The ideal technique
including mesh selection and operative approach
for PH prevention remains to be determined.
Parastomal hernias commonly develop after
stoma creation, and the sequelae can range from
mild to severe necessitating repeat operative
intervention. Open and laparoscopic repairs with
mesh are preferable to non-mesh repairs. For the
open approach, a sublay or intraperitoneal placement of mesh is favored, and for the laparoscopic
approach, the Sugarbaker technique has been
shown to have a lower recurrence rate. It is our
preference to perform a laparoscopic modifi ed
Sugarbaker technique. The use of prophylactic
prosthetic mesh decreases the rate of PH development and is not associated with increased
infectious complications.
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parastomal hernia using three-dimensional intrastomal ultrasonography. Br J Surg. 2011;98(7):1026–9.
27. Smietanski M, Bury K, Matyja A, Dziki A, Wallner
G, Studniarek M, et al. Polish guidelines for treatment
of patients with parastomal hernia. Pol Przegl Chir.
2013;85(3):152–80.
28. Burgess P, Matthew V, Devlin H. A review of terminal
colostomy complications following abdominoperineal resection for carcinoma. Br J Surg. 1984;71:1004.
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30. Rolstad BS, Boarini J. Principles and techniques in
the use of convexity. Ostomy Wound Manage.
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31. Armstrong E. Practical aspects of stoma care. Nurs
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32. Kane M, McErlean D, McGrogan M, Thompson MJ,
Haughey S. Clinical protocols for stoma care: 6.
Management of parastomal hernia. Nurs Stand.
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33. Berger D, Bientzle M. Laparoscopic repair of parastomal hernias: a single surgeon’s experience in 66
patients. Dis Colon Rectum. 2007;50(10):1668–73.
34. Hansson BM, Slater NJ, van der Velden AS,
Groenewoud HM, Buyne OR, de Hingh IH, et al.
Surgical techniques for parastomal hernia repair: a
systematic review of the literature. Ann Surg.
2012;255(4):685–95.
35. Sugarbaker PH. Peritoneal approach to prosthetic
mesh repair of paraostomy hernias. Ann Surg.
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36. Bayer I, Kyzer S, Chaimoff C. A new approach to primary strengthening of colostomy with Marlex mesh
to prevent paracolostomy hernia. Surg Gynecol
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37. Figel NA, Rostas JW, Ellis CN. Outcomes using a
bioprosthetic mesh at the time of permanent stoma
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39. Martinek L, Dostalik J, Gunkova P, Gunka I, Mazur
M. Prevention of parastomal hernia using laparoscopic introduction of a prosthetic mesh--initial experience. Rozhl Chir. 2012;91(4):216–8.
40. Nagy A, Kovacs T, Bognar J, Mohos E, Loderer
Z. Parastomal hernia repair and prevention with PHSL
type mesh after abdomino-perineal rectum extirpation. Zentralbl Chir. 2004;129(2):149–52.
41. Marimuthu K, Vijayasekar C, Ghosh D, Mathew
G. Prevention of parastomal hernia using preperitoneal mesh: a prospective observational study.
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42. Vijayasekar C, Marimuthu K, Jadhav V, Mathew
G. Parastomal hernia: Is prevention better than cure?
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of stoma formation. Tech Coloproctol.
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43. Lee L, Saleem A, Landry T, Latimer E, Chaudhury P,
Feldman LS. Cost effectiveness of mesh prophylaxis
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44. Lopez-Cano M, Lozoya-Trujillo R, Quiroga S,
Sanchez JL, Vallribera F, Marti M, et al. Use of a prosthetic mesh to prevent parastomal hernia during laparoscopic abdominoperineal resection: a randomized
controlled trial. Hernia. 2012;16(6):661–7.
45. Hammond TM, Huang A, Prosser K, Frye JN,
Williams NS. Parastomal hernia prevention using a
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46. Janes A, Cengiz Y, Israelsson LA. Preventing parastomal hernia with a prosthetic mesh. Arch Surg.
2004;139(12):1356–8.
47. Serra-Aracil X, Bombardo-Junca J, Moreno-Matias J,
Darnell A, Mora-Lopez L, Alcantara-Moral M, et al.
252
E.M. Garvey and K.L. Harold
Randomized, controlled, prospective trial of the use
of a mesh to prevent parastomal hernia. Ann Surg.
2009;249(4):583–7.
48. Sajid MS, Kalra L, Hutson K, Sains P. Parastomal hernia as a consequence of colorectal cancer resections
can prophylactically be controlled by mesh insertion
at the time of primary surgery: a literature based systematic review of published trials. Minerva Chir.
2012;67(4):289–96.
49. Shabbir J, Chaudhary BN, Dawson R. A systematic
review on the use of prophylactic mesh during primary stoma formation to prevent parastomal hernia
formation. Colorectal Dis. 2012;14(8):931–6.
50. Tam KW, Wei PL, Kuo LJ, Wu CH. Systematic review
of the use of a mesh to prevent parastomal hernia.
World J Surg. 2010;34(11):2723–9.
51. Fleshman JW, Beck DE, Hyman N, Wexner SD,
Bauer J, George V, PRISM Study Group. A prospective, multicenter, randomized, controlled study of
non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in patients
undergoing surgery for permanent abdominal wall
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52. Mancini GJ, McClusky 3rd DA, Khaitan L,
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mesh technique. Surg Endosc. 2007;21(9):1487–91.
53. McLemore EC, Harold KL, Efron JE, Laxa BU,
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54. Craft RO, Huguet KL, McLemore EC, Harold
KL. Laparoscopic parastomal hernia repair. Hernia.
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55. Berger D, Bientzle M. Polyvinylidene fl uoride: a suitable mesh material for laparoscopic incisional and
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56. Hansson BM, de Hingh IH, Bleichrodt
RP. Laparoscopic parastomal hernia repair is feasible
and safe: early results of a prospective clinical study
including 55 consecutive patients. Surg Endosc.
2007;21(6):989–93.
57. Hansson BM, Bleichrodt RP, de Hingh
IH. Laparoscopic parastomal hernia repair using a
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Surg Endosc. 2009;23(7):1456–9.
58. Liu F, Li J, Wang S, Yao S, Zhu Y. Effectiveness analysis of laparoscopic repair of parastomal hernia using
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59. Wara P, Andersen LM. Long-term follow-up of laparoscopic repair of parastomal hernia using a bilayer
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2012;26(1):267–70.
Laparoscopic Subxiphoid
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and Suprapubic Hernia Repair
William S. Cobb
24
Background
Subxiphoid defects can be congenital or incisional , usually following coronary bypass procedures or subcostal incisions for liver or foregut
procedures (Fig. 24.1 ). Congenital epigastric
defects can approach the xiphoid as well.
Frequently, epigastric defects can be multiple
and well suited for laparoscopy to avoid missed
defects. Solitary defects can be addressed in an
open fashion either with suture alone or mesh
reinforcement. The incidence of subxiphoid hernias is unknown, as most authors do not routinely
separate these types of defects in their reports.
Suprapubic hernias are almost always incisional in nature. Fascial defects that are within
5 cm of the symphysis pubis are considered
suprapubic (Fig. 24.2 ). These types of hernias are
more common in females due to gynecologic
procedures via a lower midline or Pfannenstiel
approach. Additionally, colorectal procedures
and urologic procedures through a lower midline
incision can result in suprapubic-type defects.
The true incidence of suprapubic hernias is not
Electronic supplementary material: The online version
of this chapter (doi:
contains supplementary material, which is available to
authorized users.
W. S. Cobb , M.D. (*)
Department of Surgery , Greenville Health System ,
Greenville , SC , USA
wcobb@ghs.org
e-mail:
10.1007/978-3-319-27470-6_24 )
well reported, as the defi nition varies by author.
In our database of 860 laparoscopic ventral
repairs, 15% required bladder mobilization and
were classifi ed as suprapubic [ 2 ].
Many times the subxiphoid or suprapubic areas
are approached during a routine incisional defect
that involves the midline. For incisions that course
from “stem to stern,” incisional hernias may result
that are both subxiphoid and suprapubic. These are
especially challenging when it comes to placing
sutures for mesh fi xation. In this chapter, I will discuss the nuances of the laparoscopic approach to
subxiphoid and suprapubic hernias.
Preoperative Consideration s
By defi nition, a subxiphoid or suprapubic hernia is
one in which the extent of the fascial defect is
within 5 cm of the bony prominence. Preoperative
imaging of the abdomen and pelvis using computed
tomography (CT) is critical to plan one’s approach.
On CT imaging, it is important to measure the number of “cuts” from the xiphoid down to the superior
aspect, or from the symphysis up to the inferiormost point of the fascial defect. This determination
is more important for suprapubic defects because
preoperative knowledge will prompt the surgeon to
plan for potential saline infusion of the bladder prior
to draping. This technique will be described in further detail in the “Technical Considerations” section.
Apart from imaging, all other preoperative
concerns mimic those of any incisional hernia
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_24
253© Springer International Publishing Switzerland 2016
254
W.S. Cobb
Fig. 24.1 Upper midline hernia involving a subxiphoid
region
Following laparoscopic repair of subxiphoid
and suprapubic hernias, pain management is defi nitely an issue. The subxiphoid repair is especially uncomfortable due to placement of sutures
and fi xation constructs along the sensitive costal
margin. Proper preoperative consent should
address this concern with patients. Non-narcotic
measures for pre-emptive pain control should be
considered and addressed preoperatively, not
after the fact. The use of preoperative “pain cocktails” to include intravenous non-steroidal analgesics, epidural catheters to assist with
postoperative analgesia, and low-dose ketamine
infusions can be utilized to improve patient satisfaction and pain control postoperatively. A collaborative approach with anesthesiology can help
to establish enhanced recovery pathways for a
better patient experience.
Technical Considerations
Subxiphoid
Fig. 24.2 Intra-operative view of the suprapubic hernia
patient that is being considered for a laparoscopic approach. The patient must be able to
tolerate general anesthesia. Preoperative optimization should include tobacco cessation, management of blood glucose, and reasonable
weight control.
For epigastric and subxiphoid hernias, it is not
critical to tuck the patient’s arms. The surgeon
will be positioned typically at the patient’s lower
quadrant and working cephalad. We recommend
always tucking the arms, however, to avoid any
potential unexpected surprises like adhesions
extending down to the inferior aspect of the midline, or an unanticipated umbilical defect.
For adhesiolysis during a subxiphoid hernia,
the transverse colon should always be identifi ed.
Once its location is established and shown to be
well away from the defect, takedown of adhesions can proceed rather quickly. The liver and
stomach can be involved in subxiphoid defects;
however, they typically reduce easily and are
much easier to deal with if injuries occur to them.
Once the upper abdomen is cleared of adhesions,
the falciform should be taken down. This maneuver requires energy for hemostasis, which is why
confi rmation of the location of the transverse
colon is critical. Monopolar or ultrasonic energy
can be used to mobilize the falciform ligament at
its juncture with the abdominal wall. This dissec-
24 Laparoscopic Subxiphoid and Suprapubic Hernia Repair
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255
tion should extend to at least 5 cm superior to the
edge of the defect to allow for fl ush mesh placement. Not infrequently, the falciform ligament
may be involved in the hernia defect. It should be
grasped and brought into the abdominal cavity to
visualize its insertion point into the underside of
the fascia.
Mesh Orientation and Fixatio n
For atypical location hernias, placement of the mesh
can be the most diffi cult step of the operation. Due
to the bony structures and the vicinity of important
structures like diaphragm, pericardium, iliac vessels, etc., placement of sutures and orientation of the
mesh can be tricky. Some additional time should be
given to these steps to avoid improper overlap and
potential recurrences long term.
Following safe adhesiolysis , the defect is prepared for mesh placement. Spinal needles can be
used to mark the edges of the defect in a lateral
and cephalad-to-caudad orientation. Many techniques to measure the size of the defect can be
employed. We use an internal metric ruler to
determine the distance between the edges of the
defect. Umbilical tape or suture can be stretched
between the two marks as well. Some measure
while the abdomen is desuffl ated. The midpoints
of the defect should be determined and marked
externally on the patient. These marks will be
important to position the mesh precisely.
Particular note should be made of the distance
from the superior aspect of the defect and the tip
of the xiphoid process . The determination of
mesh size and location of the superior suture (if
used) will be based on this measurement. If the
superior aspect of the hernia defect is at the
xiphoid, in order to achieve a 5-cm mesh overlap,
the superior suture should be placed 5 cm off the
mesh edge. For example, if the defect is 10 cm
long, a mesh that is 20 cm in length will be
selected. However, if the superior aspect of the
defect is 3 cm from the xiphoid process, the overlap will be calculated to allow for 5 cm of overlap
onto the ribs in addition to the distance from the
xiphoid. So, for the same 10 cm long defect, a
mesh that is 23 cm in length would be chosen. It
is also important to note the distance from the lateral edges of the defect and the costal margin. For
patients with steeply sloped ribs, sutures at the
lateral edge may have to be placed away from the
mesh edge to avoid passing them through the
chest wall.
Once the mesh is introduced into the abdominal cavity through a trocar, the mesh is unfurled.
The fi rst suture to be retrieved is the superior
suture at the level of the xiphoid. One of the lateral sutures is then placed along the grid that was
created earlier. The assistant pulls up on these
two sutures and the mesh is stretched inferiorly to
gauge the location of the inferior suture. The
same technique is used to place the fi nal lateral
suture. Once the sutures are secured, tacks are
placed. The decision to use permanent versus
absorbable tacks is surgeon dependent . However,
the use of absorbable tacks does not change the
fact that no fi xation constructs should be placed
above the costal margin! A double-crown
approach may be utilized as long as all tacks are
caudal to the costal margin. The superior aspect
of the mesh is left to be held in place by the liver,
by holding the mesh in place during desuffl ation
of the abdominal cavity. Frequently, suturing the
edge of the mesh or utilization of the glue is
needed to ensure that no bowel is trapped between
the mesh and the diaphragm. No tacks should be
used cephalad to the costal margin and xiphoid
process in order to avoid devastating cardiopulmonary injuries (Fig. 24.3 ).
Suprapubic
Positioning of the patient is more critical in
suprapubic hernia repai rs. The arms must be
carefully padded and tucked at the side of the
patient. Given that the fascial defect is inferior
and the surgeon will be standing at the patient’s
head, both arms should be tucked to prevent harm
to the patient’s arm while leaning against the arm
board. Tucking the arms will also prevent undue
stress on the surgeon’s back that results from
twisting and other gyrations used to avoid the
outstretched arm. The patient should be secured
to the bed with the waist strap and additional tape
256
Fig. 24.3 Mesh placement for
subxiphoid hernias. Note, no
tacks are placed cephalad to
the costal margin and xiphoid
process
W.S. Cobb
around the thighs if necessary. During dissection,
steep Trendelenburg positioning helps to assist
with retraction of the intestinal contents. Pads
that minimize sliding of the patient can be considered as well.
Intra-operative bladder infusion is critical to
facilitate its safe dissection. A three-way urinary
catheter should be placed and the bladder infusion should be set up prior to draping. Standard
intravenous infusion tubing is attached to the
infusion port using the luer-lock tip. When it is
time for bladder infusion, the nurse should place
a clamp on the tubing that drains the urinary
catheter close to the catheter. This clamp should
not be placed on the urinary catheter itself or the
tubing. Experience has taught us to instruct the
nurse prior to prepping and draping where to
place the clamp to avoid any confusion during
the case. We infuse 250–500 cm 3 of Normal
saline into the bladder to identify its superior
extent so that the peritoneal fl ap can be safely
developed superior to this margin. Signs of
injury to the bladder include visualization of the
urinary catheter balloon, excessive bleeding, or a
rush of fl uid. Once the peritoneal fl ap is raised,
the remaining portion of the dissection to develop
the space of Retzius is largely blunt. There may
be small venous tributaries to the bladder, but
these are easily controlled with light touches of
the cautery. Even in multiply operated patients,
keeping the dissection close to the abdominal
wall when lowering the bladder fl ap will help to
avoid injury. The bladder is much thicker than
the peritoneum. If the dissection does not progress bluntly, or if the tissue that is being dissected is very thick or bleeds a lot, the surgeon
should reassess the plane. Once the pubic symphysis is visualized, dissection should continue
for 1–2 cm inferior to symphysis to allow for
subsequent mesh overlap. Cooper’s ligaments
should be identifi ed bilaterally (Fig. 24.4 ). At
the lateral edge of Cooper’s ligament, the
entrance to the femoral canal and iliac vessels
has to be identifi ed. Careful dissection of the
medial aspect of the myopectineal orifi ce is
essential for suffi cient mesh overlap, but extreme
caution in that area is necessary to avoid devastating injuries to major vascular structures.
Bladder injuries can occur. Usually, cystotomy results from impatience and not instilling
the bladder with saline. Injuries should be
repaired based on the comfort level of the surgeon. A two-layer repair with absorbable suture
is ideal. Since the injury occurs at the dome of the
bladder, large bites can be taken without concern
for compromising the bladder lumen or injuring
the ureters. The decision to proceed with the hernia repair is again the choice of the surgeon.
Urine is technically sterile, and multiple reports
describe repair of the bladder laparoscopically
and completion of the hernia repair without any
infectious complications. This approach is our
24 Laparoscopic Subxiphoid and Suprapubic Hernia Repair
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Fig. 24.4 Laparoscopic suprapubic hernia repair. The urinary bladder needs to be mobilized to expose both Cooper’s
ligaments and pubic symphysis to allow for subsequent adequate mesh overlap
preference, but it is also acceptable to abandon
the repair and bring the patient back to the
Mesh Orientation and Fixatio n
operating room in 3–5 days to complete the repair
and place the mesh. This time frame is chosen
because adhesions will not have formed and there
will be enough time to clear any bacterial
contamination.
Once bladder mobilization is complete, the
defect size is assessed as described earlier. The
distance from the symphysis to the inferior aspect
of the fascial defect should be determined. In
contrast to the subxiphoid hernia, the inferior
suture in the suprapubic defect will need to be
positioned at a distance from the mesh edge to
allow for appropriate overlap onto the pubis. By
leaving 5 cm of overlap beyond the symphysis,
the mesh can be secured to Cooper’s ligaments
bilaterally. The potential weak point of the repair
of suprapubic defects is inferior. Recurrences are
more likely inferior due to improper mesh overlap and/or fi xation. In our experience, those
recurrences are due to failure to take down the
bladder fl ap. The surgeon is then unable to provide adequate mesh overlap or fi xation due to
fear of injury to the bladder. By identifying the
bladder upfront, injuries from sutures and fi xation constructs can be avoided.
After introducing the mesh, the preplaced inferior suture is retrieved fi rst just off the pubic symphysis (Fig. 24.5 ). The superior suture should be
the next one to be pulled up. The site for suture
placement is determined by stretching the mesh
taut. An alternative method of mesh fi xation is to
utilize a mesh-positioning system. For suprapubic defects, placement of additional inferior
sutures is critical. Once the sutures are secured,
circumferential tacks are placed. Permanent,
metallic tacks are preferred here as they more
reliably penetrate the ligaments along the superior ramus. Absorbable tacks may be also used if
placed just superior to the ramus and not into the
bone directly. Tacks may be placed in a double
crown confi guration with the inner row around
the hernia orifi ce. One additional suture is then
placed on either side of the inferior, cardinal
suture for more secure fi xation inferiorly. It is
important not to put any tacks below Cooper’s
ligaments (Fig. 24.6 ). Also, the inferior-lateral
aspect of the mesh could be in the “Triangles of
Doom and Pain”. No tack fi xation should be done
in that area. This is accomplished by identifying
257
258
Fig. 24.5 Mesh coverage and fi xation of
the suprapubic hernia. The inferior-most
stitch should be placed fi rst, just off the
pubic symphysis. Please note that the
stitch should be preplaced 2–5 cm off the
lower edge of the mesh
Fig. 24.6 Tacking the mesh. No tacks
should be placed below the Cooper’s
ligaments in the area of the neurovascular
structures within myopectineal orifi ces
W.S. Cobb
the iliopubic tract and providing external palpation for EVERY tack in that area. Fibrin glue is a
very helpful adjunct for fi xation of the inferior
aspect of the mesh. Following mesh fi xation, the
bladder is desuffl ated and the fl ap left in situ.
There is no need to attempt to re- approximate the
fl ap, since a barrier-coated mesh was used.
Incomplete closure of the fl ap may actually cre-
ate potential openings that may result in internal
hernias involving the small bowel.
For large defects or recurrent defects in the
suprapubic position, more secure fi xation can be
provided by bone anchors [
3 ]. A small, stab inci-
sion is made over the pubic symphysis. The bone
guide is placed through the skin incision and
rested against the symphysis. A pilot hole is
24 Laparoscopic Subxiphoid and Suprapubic Hernia Repair
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Fig. 24.7 Bone anchors
259
created with the drill, and the bone anchor is
inserted into the symphysis. The bone anchors
contain a double-armed braided suture (Fig.
24.7 ). The needles are cut off and the tails of the
suture are passed through the stab incision and
into the mesh. Additional anchors may be placed
along the superior ramus as well.
Postoperative Concerns
For the most part, the postoperative management
of the patient undergoing laparoscopic subxiphoid or suprapubic hernia repair is similar to
standard laparoscopic ventral hernia repair. All
patients are admitted predominantly for pain control. The concerns for ileus versus small bowel
obstruction, seroma, and infection are the same
as with all ventral herni a repairs. Early ambulation and generous use of analgesics is encouraged. Urinary catheters are removed on the
morning of postoperative day one unless there
was a bladder injury that required repair.
Seromas frequently complicate suprapubic
repairs. Attempts to close the defect laparoscopically at the time of repair may help mitigate some
of this concern. The defect may be closed with a
series of stab incisions and fi gure-of-eight sutures
in a “shoelace” fashion (Chapter 22 ). Intracorporeal
suturing of the defect has also been described,
including recent modifi cation with the use of the
robot. Fascial closure of the subxiphoid defects
can be attempted as well, however, the benefi t is
not as great and the trade-off is increased pain.
Conclusion
Laparoscopic approach to repair of subxiphoid
and suprapubic defects represents an additional
challenge. Familiarity and profi ciency with laparoscopic repairs of routine to midline ventral
defects is mandatory prior to embarking on the
repair of the atypical defects. Understanding of
anatomic nuances of both the upper and lower
abdomen is paramount to avoid visceral and vascular injuries as well as providing durable and
lasting repairs. Understanding and implementation of strategies for safe urinary bladder identifi cation and mobilization is critical for suprapubic
repairs. Mesh placement in both locations should
be aimed to extend beyond the bony margins with
fi xation performed off the edge of the mesh.
Importantly, maintaining the xiphoid process and
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