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260
W.S. Cobb
costal margin as cranial safety margins for safe
tacker/suture placement is absolutely necessary
to avoid pulmonary/cardiac injuries. Defect closure may be of particular use for suprapubic
defects to minimize postoperative seromas and
bulging. Overall, suprapubic and subxiphoid
defects can be effectively repaired laparoscopically, provided the important principles of safe
dissection and mesh positioning described in this
chapter are always maintained.
References
1. Cobb WS, Kercher KW, Heniford BT. Laparoscopic
repair of incisional hernias. Surg Clin North Am.
2005;85(1):91–103.
2. Carbonell AM, Kercher KW, Matthews BD, Sing RF,
Cobb WS, Heniford BT. The laparoscopic repair of
suprapubic ventral hernias. Surg Endosc.
2005;19(2):174–7.
3. Yee JA, Harold KL, Cobb WS, Carbonell AM. Bone
anchor fi xation for complex laparoscopic ventral hernia repair. Surg Innov. 2008;15(4):292–6.
Laparoscopic Repair of Flank
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Hernias
Ciara R. Huntington and Vedra A. Augenstein
Introduction and Background
Flank Hernia Defi nition and Anatomy
Flank hernias, including lumbar and parailiac
hernias, are hernias of the lateral abdominal wall
which occur between the 12th rib and iliac crest.
The lateral abdominal wall is constructed of several large muscle groups from the back and abdomen including the latissimus dorsi, serratus
posterior, external and internal oblique muscles,
and transversus abdominis. Flank hernias occur
within anatomic areas termed the “superior” and
“inferior lumbar triangles.” The majority of
spontaneous and incisional hernias occur in the
superior triangle, while congenital hernias are
usually found in the inferior triangle [
The superior lumbar triangle (Fig.
formed with a base as the 12th rib, posterior bor-
1 ].
25.1 ) is
25
der formed by the erector spinae muscles and
anterior border of the external oblique muscle.
The triangle’s fl oor is formed by the transversus
abdominis, and its apex touches the iliac crest.
This triangle is found in 82% of humans; in a
recent cadaver study, 18% did not exhibit this triangle, and instead, the natural space of the triangle, which usually contains only the aponeurosis
of the transversus abdominis, was covered by the
external abdominal oblique and erector spinae
muscles [ 2 ].
The inferior lumbar triangle (Fig. 25.2 ) is
formed with the iliac crest as its base, the medial
border of the external oblique, posterior/lateral
border of the latissimus dorsi, and a fl oor formed
by the internal oblique.
Hernias occurring within the superior and
inferior triangles account for 95% of fl ank hernias; “diffuse” hernias, which occur on the fl ank
without a specifi c relation to these anatomic triangles, account for the remaining 5% [
3 , 4 ].
C. R. Huntington , M.D.
Department of Surgery , Carolinas Medical Center ,
1025 Morehead Medical Drive, Suite 300 , Charlotte ,
NC 28204 , USA
Ciara.huntington@carolinas.org
e-mail:
V. A. Augenstein , M.D., F.A.C.S. (
Division of Gastrointestinal and Minimally Invasive
Surgery , Carolinas Medical Center ,
1025 Morehead Medical Drive, Suite 300 , Charlotte ,
NC 28204 , USA
Vedra.augenstein@carolinas.org
e-mail:
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_25
*)
Related Anatomy
of the Posterolateral Abdominal Wal l
Despite advances in laparoscopy and endovascular surgery, open access to the lateral abdominal
wall for nephrectomies, adrenalectomies, back
surgery, iliac graft harvests, retroperitoneal aortic
surgery, advanced abdominal wall reconstruction
and component separation techniques, and repair
261© Springer International Publishing Switzerland 2016
262
Fig. 25.1 Superior
lumbar triangle: The
superior lumbar triangle
(Grynfeltt’s triangle) is
formed by the erector
spinae muscles, internal
oblique muscles, and
12th rib. Its fl oor is the
transversus abdominis
C.R. Huntington and V.A. Augenstein
Latissimus dorsi
(cut away)
External oblique
Serratus posterior
12th rib
Fig. 25.2 Inferior
lumbar triangle: The
inferior lumbar triangle
(Petit’s triangle) is
formed by the latissimus
dorsi muscle, external
oblique muscle, and iliac
crest. Its fl oor is the
internal oblique muscle
Erector
spine
Vertebrae
Transversus abdominis
Superior lumbar triangle
(Grynfeltt’s space)
Internal oblique
Iliac rest
Latissimus dorsi
External oblique
Internal oblique
Inferior lumbar triangle
(Petit’s triangle)
Iliac crest
25 Laparoscopic Repair of Flank Hernias
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263
of retroperitoneal traumatic injuries is still common. Prevention and repair of fl ank hernias rely
on good understanding of the anatomy. Avoiding
injury to surrounding structures and careful fi xation of the mesh are key to good quality of life
outcomes.
The fl ank is the intersection of the back and
abdominal musculature, several of which fuse to
form aponeuroses. The deep fascia of the back,
also known as lumbodorsal or thoracolumbar fascia, is formed by the fused aponeuroses of the
latissimus dorsi, internal oblique, and transversus
abdominis muscles [ 5 ]. The internal oblique
muscles and transversus abdominis muscle join
together at the lateral edge of the erector spinae
muscles, and this aponeurosis extends to cover
portions of the bony spine [ 5 ]. A surgeon can
judge the depth of an incision here by the fact that
the internal oblique muscle fi bers begin at the
edge of the erector spinae muscles while the
transversus abdominis muscle fi bers continue to
be aponeurotic laterally [ 5 ].
The quadratus lumborum muscle lies anterior
to the deep fascia, and the subcostal, iliohypogastric, and ilioinguinal nerves pass laterally and
anterior to this muscle before entering the plane
between the transversus abdominis and internal
oblique muscles to course towards the anterior
midline [ 5 ]. Superfi cial to the quadratus lumbo-
rum, contained within Gerota’s fascia, lays the
kidney and adrenal glands with their attendant
vascular structures. The ureter also starts proximally with the renal vessels before moving in a
curvilinear path in the retroperitoneum to the
ureteropelvic junction at approximately the level
of L2, then moves anteriorly along the psoas
muscle [ 6 ]. It crosses under the gonadal vein and
crosses over the iliac vessels at the bifurcation of
the common iliac into the external and internal
iliac vessels [ 7 ]. The ureter is found medial to
the sacroiliac joint before moving laterally into
the pelvis [ 6 ].
When performing a hernia repair, constant
awareness of one’s dissection and proximity to
pelvic nerves, vasculature, and the ureter is necessary; moreover, lateral positioning can further
distort anatomy leading to injury.
Brief History of Flank Hernias
The fl ank hernia was fi rst described in the literature in 1672 by the Dutch anatomist and surgeon
Paul Barbette [ 8 ]. Physicians Dolée in 1703 and
Budgeon in 1728 are also credited with early
descriptions , and Garangeot (1731) described the
fi rst report of a strangulated fl ank hernia, which
was reduced after the patient’s death [ 9 ]. In 1750,
the fi rst surgical reduction and repair was reported
by Ravanton [ 9 ]. The anatomical boundaries of
the inferior lumbar triangle were again described
by the French physician Petit in 1783, and the
hernia of that space now bears his eponym [ 10 ].
Hernias of the superior lumbar triangle are named
by the surgeon Grynfeltt, who described the
space in 1866 [ 11 ]. He was a contemporary with
the German physician Lesshaft who defi ned the
triangle independently in 1870, and the superior
lumbar triangle hernia is sometimes referred to as
a Grynfeltt–Lesshaft hernia [ 9 ].
Flank hernias are rare with only an estimated
300 cases reported in the literature [ 12 ].
Laparoscopic case series are similarly scarce.
The fi rst laparoscopic repair of a traumatic fl ank
hernia was reported by Burick et al. in 1996 [ 13 ]
and the fi rst laparoscopic primary fl ank hernia
repair by Heniford et al. in 1997 [ 14 ].
Epidemiology
Flank hernias account for 1.5–2% of abdominal
wall defects [ 4 ]. The majority (2/3) of fl ank her-
nias occur in men [ 14 ]. Incarceration risk is esti-
mated to be approximately 25%, with 8% chance
of strangulation [ 3 , 4 ]. Overall, 20–25% of fl ank
hernias are congenital, and 55% are primary.
Primary or spontaneous fl ank hernias are most
common in the fi fth to seventh decades of life
and are associated with states that promote herniation of the abdominal contents through the
weakened superior lumbar triangle, such as
obesity, chronic illness, advanced age, polio, and
local muscle weakness [ 3 , 12 ]. There are reports
of herpes zoster contributing to eventration leading to herniation [ 15 ].
264
C.R. Huntington and V.A. Augenstein
Incisional or traumatic hernias have become
more prevalent than in decades past and now
account for 25–30% of fl ank hernias [ 3 , 12 ]. Faro
et al. reported that 7 out of 850 patients who
received CT scan imaging for acute abdominal
trauma were diagnosed with traumatic lumbar
hernia [ 16 ]. CT scan has a 98% sensitivity for
traumatic fl ank hernias which can be easily
missed by physical exam on trauma survey but
are commonly associated with intra-abdominal
injuries (61%) [ 17 ]. Traumatic fl ank hernias are
more often diffuse or located within the inferior
lumbar triangle [ 17 ]. Seat belt injury via rapid
deceleration and shearing of the iliac crest and
associated muscles can be associated with traumatic fl ank herniation [ 17 ].
Similar to ventral hernias, incidence of incisional hernias in the fl ank is about 20–30% [ 12 ].
Eventration can occur as a result of iatrogenic
injury of the 12th subcostal nerve, which runs
anterior to the quadratus lumborum muscle,
enters through the transversalis fascia, and runs
under the internal oblique muscles before joining
the iliohypogastric nerve [ 18 ]. When injured, the
lateral abdominal wall muscles will weaken and
eventrate. In one study of patients undergoing
radical nephrectomy, 34 of 70 (49%) reported
persistent fl ank bulging 1 year postoperatively;
the authors did not differentiate between eventration and herniation in this study [ 18 ].
Surgical Approach
Preoperative Worku p
Patients with fl ank hernias often present with
posterolateral bulges (Fig. 25.3 ) that are exacer-
bated by Valsalva maneuver and resolved with
lying fl at. A history is taken with careful attention to precipitating factors such as illness,
trauma, or surgery. Symptoms of small bowel
obstruction, colon obstruction, and urinary
obstruction are pertinent. Physical exam is performed in standing and lateral laying positions,
noting the presence of previous surgical scars in
the region, the approximate size of the fl ank hernia defect, reducibility of hernia contents, and
Fig. 25.3 Flank hernia on exam: This patient with neurofi bromatosis has a posterior bulge on Valsalva consistent
with a primary fl ank hernia
proximity to the iliac crest. Auscultation and
palpation may reveal incarcerated colon, bowel,
or even the kidney. Though ultrasound may be
helpful because of the ability to recognize the
presence of the hernia and any contents within
the sac, CT scanning is routinely recommended
[ 3 , 12 , 14 ]. A CT scan differentiates between
muscle laxity and true fl ank herniation and provides preoperative identifi cation of the contents
of the hernia sac, defect location, and which layers of muscle may be atrophied or contracted
(Figs. 25.4 and 25.5 ). The size of the defect and
the presence of a previous hernia repair can
infl uence the decision to proceed with an open
or laparoscopic approach (Table 25.1 ). Moreno-
Egea et al. published the fi rst prospective trial of
laparoscopic versus open repair of 16 incisional
lumbar hernias . They reported reduced mean
operating time, postoperative complications,
mean length of stay, quicker return to activities,
and lower associated costs with the laparoscopic
repair compared to open, though the laparo-
25 Laparoscopic Repair of Flank Hernias
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265
Fig. 25.4 CT scan fl ank hernia—Axial view: This preoperative CT scan demonstrates a right sided fl ank hernia
Fig. 25.5 CT scan fl ank hernia—Coronal view: Another
patient with a large, right -sided fl ank hernia containing
colon
scopic group had a smaller average defect size
[ 19 ]. In a follow-up of this study in 2013,
Moreno-Egea et al. confi rmed these fi ndings
and recommended a laparoscopic approach for
those with a hernia defect size of less than 15
cm, especially if the hernia was located within
one of the lumbar triangles [ 20 ]. However, pre-
operative evaluation and discussion with the
patient regarding repair techniques are key in
choosing the best approach for repair. Long- and
Table 25.1 Factors infl uencing operative approach to
fl ank hernia repair
Operative approach to repair of fl ank hernias
Consider open approach
Very large defects where muscle approximation is
desired
Numerous previous repairs ± mesh
Inability to tolerate pneumoperitoneum
Extensive intra-abdominal adhesions
Large unappealing scar with atrophic skin
Consider laparoscopic approach
Smaller defects where muscle approximation is less
important
Morbidly obese patients
Diabetic patients
Tobacco users who necessitate repair
Immunocompromised patients
Patients with high risk of wound complications
short-term patient goals are important; data
from large ventral hernia series indicates that
laparoscopic repairs may have more initial pain
but fewer wound complications compared to
open repairs [ 21 ].
Regardless of surgical approach, the
patient’s risk of wound complications and hernia recurrence can be optimized by smoking
cessation 4–6 weeks prior to surgery, weight
loss depending on patient BMI, and improving
glucose control in patients with diabetes [ 22 –
24 ]. Cardiac and medical clearance may be
appropriate for elderly or patients with signifi cant comorbidities [ 25 ]. Involving the trans-
plant team in the hernia operation for patients
who have a kidney transplant can be very valuable in identifi cation and prevention of transplanted ureter or kidney injury. Consultation
with an orthopedic surgeon for placement of
bone anchors in cases where there is no fascia
on the bone is recommended.
For patients with contracted muscles and large
defects, preoperative injection of Botulinum
toxin A (Botox) under CT or U/S guidance into
the transversus abdominis, internal oblique,
and/or external oblique muscles should be considered. The injection is done approximately
1 month prior to surgery. In small non-random-
266
C.R. Huntington and V.A. Augenstein
ized studies on ventral hernias, preoperative
injections of Botox have been shown to paralyze
lateral muscles, reduce transverse hernia defects,
decrease intra-abdominal pressure and muscle
tension, and allow easier surgical closure [ 26 ].
This method has been utilized by our group with
good results for an open repair in a patient with
recurrent fl ank hernia after partial nephrectomy
(unpublished data, Heniford 2014). Muscles will
retain laxity for approximately 3 months postoperatively, which may give the appearance of
persistent herniation.
Monitor,
insufflator
Positioning and Trocar Placement
Patient positioning is crucial to a successful operation. Before moving the patient from the supine
position, the patient’s midline, hernia defect and
intended trocar sites should be marked with a
marking pen, as the abdomen will be distorted
with positioning. The patient is then placed in a
semilateral position with 45° elevation of the side
ipsilateral to the hernia with fl exion at the hip
(Fig. 25.6 ) [ 27 ]. This position allows the patient
to be rolled fl at or in full lateral position to opti-
Anesthesiologist
Monitor, video
camera
Assistant
Nurse
Surgeon
Fig. 25.6 Diagram of patient positioning. The patient is positioned in the semilateral position which allows the patient
to be rolled fl at or in full lateral position to optimize exposure
25 Laparoscopic Repair of Flank Hernias
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267
5mm
10mm
5mm
Fig. 25.7 Trocar placement. Three trocars are placed in
the midline, depending on the patient’s body habitus,
location of the hernia defect, and presence of previous
surgical incisions
mize exposure. In the semilateral position, the
viscera fall away from hernia. Adding a kidney
rest will further open the space between the iliac
crest and costal margin. The patient should be
adequately padded and secured to the operating
table so that positioning can be changed during
the operation safely and as needed.
Trocar positioning depends on the location and
size of the defect, presence of other surgical scars,
and patient body habitus [ 26 ]. One option is to
place a 10 mm trocar at the umbilicus. Two additional 5 mm trocars can be placed anteriorly along
the midline infraumbilically and supraumbilically, 5–6 cm from the umbilical port (Fig. 25.7 ).
Hernia Repair
D e fi ning the Hernia Defect
After insuffl ation and brief survey of the abdomen, adhesiolysis with sharp and blunt dissection
commences. Energy devices are used infrequently
due to the risk of iatrogenic injury. Mobilization
of the colon is generally required [ 14 ]. This is
performed by incision of the peritoneum along
the white line of Toldt with cautery or endoscopic
scissors [ 14 ]. Occasionally, mobilization of the
kidney is also needed [ 14 ]. Any incarcerated con-
tents are reduced laparoscopically.
With the takedown of adhesions and mobilization of the colon, the retroperitoneum including
the psoas and erector spinae muscles becomes
accessible [ 28 ]. Superiorly, the dissection is car-
ried to allow mesh fi xation to the costal margin,
but care must be taken to avoid violation of the
thoracic cavity, diaphragm, or pericardium [ 28 ].
Similarly, inferior dissection to expose Cooper’s
ligament and the iliopubic tract is necessary for
larger defects [ 28 ]. As noted previously, meticu-
lous identifi cation of the ureter, iliac vessels,
spermatic cord, and pelvic nerves is required
[ 27 , 28 ].
After the hernia defect is visualized, it is measured intracorporeally to plan for appropriate
mesh coverage. A disposable ruler can be introduced via the 10 mm port or a laparoscopic
instrument of known size (such as the open jaws
of an endoscopic grasper) can be used for reference. Alternatively, spinal needles can be introduced through the skin at cardinal directions
surrounding the defect. A piece of suture is used
to measure the distance between needles (as the
defect size is reduced within the abdominal cavity) and provides the dimensions of the hernia
defect (Fig. 25.8 ). An adequate overlap generally
requires 4–6 cm overlap at the hernia edge.
Securing the Mesh
Mesh used for laparoscopic intra-abdominal
placement should have an adhesion barrier and
should be selected according to criteria similar
for laparoscopic ventral hernia repairs.
Transfascial sutures and tacks attach the mesh to
the abdominal wall, and both absorbable and
nonabsorbable materials may be used.
Adequate mesh coverage is paramount for
successful repair of the fl ank hernia. The posterior suture attaches the mesh far posteriorly to the
268
Fig. 25.8 Measuring the
defect laparoscopically.
The fi gure demonstrates
one method for
measuring the hernia
defect. Spinal needles are
placed through the skin
to mark the edges of the
defect. Two laparoscopic
graspers span the
distance from one spinal
needle to the other using
a piece of suture, then the
suture length is measured
extracorporeally
C.R. Huntington and V.A. Augenstein
Fig. 25.9 Mesh positioning. The mesh is placed retroperitoneally, posterior to the kidney. Depending on the
size of the defect, the mesh may cover from the abdominal
erector spinae fascia and muscles and the anterior
suture will depend on the size and area of the
defect. Superiorly, the mesh can be secured to the
costal margin as needed but can extend beyond
this and drape over liver or spleen for increased
overlap. Inferiorly, the mesh is secured above the
iliac crest or to the Cooper’s ligament.
The mesh is secured using tacks and sutures
where the number depends on the size of mesh
and defect as with ventral hernias. Making sure
that the mesh is taut and in good contact with the
abdominal wall is important to help with incorporation. Sutures are usually secured to the mesh
midline to the psoas muscle, and from the iliac crest to the
coastal region, behind the liver
extracorporeally and with the knots on the side
that opposes the abdominal wall. The mesh is
then rolled and inserted into the abdomen. It is
laid out to overlap the defect adequately and then
sutures are exteriorized using a suture passer
(Figs. 25.9a, b and 25.10 ). The mesh is secured
superiorly by suture through the rib, avoiding
fi xation to the diaphragm, and to the iliac crest
inferiorly by passing the suture through the periosteum of the bone. Use of bone anchors in the
iliac crest to fi x the mesh inferiorly [ 27 , 29 ] or
fi xation of the mesh to Cooper’s ligament and the
iliopubic tract with tacks [
28 ] can be performed.
25 Laparoscopic Repair of Flank Hernias
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Adhesive barrier
faces outward
Sutures placed
and rolled inside
269
Fig. 25.10 Transfascial sutures. Using a suture passer, the surgeon secures the mesh with transfascial sutures
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