Parastomal Hernia

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280

C. Ballecer and E. Parra-Davila

The hernia defect is primarily closed with 0 or #1 V-loc barbed suture as described above. Partial desufﬂ ation of the abdominal cavity may be required to adequately close the defect. The dome of the defect may also be incorporated into the closure in order to obliterate the dead space, thereby reducing the risk of seroma formation. An adequately sized light or medium weight polypropylene mesh is introduced into the abdominal cavity (Fig. 26.11 ). Absorbable tacks or sutures are placed to secure the mesh to the abdominal wall. Then, 00 or 0 prolene suture is used to secure the mesh to Cooper’s ligament bilaterally as well as to the symphysis pubis. Upon completion of mesh ﬁ xation, the mesh is reperitonealized with 00 running absorbable suture or tacks.

Parastomal Hernia

The trocar strategy relies on the same principles as described above. The trocars are placed as far lateral as possible opposite the ostomy to ensure sufﬁ cient distance for medial mesh overlap during Sugarbaker repair (Figs. 26.12 and 26.13 ). After adhesiolysis, exposing the defect, and identifying the bowel limb of the ostomy, the defect is closed with 0 or 1 barbed permanent or long-term absorbable V-loc suture. We then lateralize the segment of bowel to the wall with 00 absorbable monoﬁ lament suture. The mesh is introduced through the 12–15 mm trocar depending on the size the mesh. Using mesh with a positioning device (ECHO, CR Bard) signiﬁ cantly facilitates

Fig. 26.10 Dissection of suprapubic space (Emailed ﬁ gure 26.10)

Fig. 26.11 Suture ﬁ xation to the pelvic rim

Fig. 26.12 Trocar placements in parastomal hernia repair

Fig. 26.13 Trocar placements in parastomal hernia repair

26 Robotic Ventral Hernia Repair

281

this step. The details of laparoscopic Sugarbaker technique are described in Chapter 23 .

Robotic Rives-Stoppa Repair with Bilateral Transversus Abdominis Muscle Release

The retromuscular hernia repair as described by Rives is considered by many to be the standard by which all hernia repairs are judged [ 1 , 2 , 18 ]. The posterior component separation (PCS) technique allows for the closure of large hernia defects with wide prosthetic mesh overlap. These two techniques performed in tandem have traditionally been exclusive to open hernia repair.

The retromuscular repair, as described by Rives, uses the natural myofascial planes of the abdominal wall while preserving the integrity of the subcutaneous tissue [ 18 ]. In this technique, mesh is secured in the retrorectus position, sandwiched by closure of the anterior fascia above and by the posterior fascia below. With recurrence rates reported to be in the range of 0–4%, many consider this technique of open ventral hernia repair as the gold standard for all hernia repairs [ 1 , 2 ]. The limitation of the Rives-Stoppa repair is that the maximal transverse diameter of the mesh is conﬁ ned to the lateral edge (linea semilunaris) of the rectus muscles.

The transversus abdominis muscle release (TAR), as described by Novitsky, involves posterior sheath mobilization off the rectus, incision of the lateral posterior sheath, identiﬁ cation and division of the transversus abdominis, and dissection of the preperitoneal space [ 2 ]. This technique is described in detail in Chapter 13 . TAR allows for wide release and advancement of the posterior rectus sheath and peritoneum below the arcuate line, preservation of the neurovascular bundle serving the rectus abdominis, and wide lateral dissection to the level of the lateral border of the psoas muscle. In the setting of large incisional hernias, this technique allows for reconstruction of the linea alba, re-approximation of the rectus to the midline, and placement of a large overlapping mesh beyond the conﬁ nes of the linea semilunaris.

While considered an effective and durable technique associated with low recurrence rates, trauma to the abdominal wall via open hernia repair is associated with a high incidence of wound complications including mesh infection which may lead to unacceptable patient morbidity [ 13 , 14 ]. Utilization of the daVinci robot has enabled minimally invasive replication of this technique traditionally reserved for open repair.

General Considerations

Abdominal wall reconstruction by way of PCS mandates dissection of individual layers of the abdominal wall intended to primarily close large hernia defects, create a large space for the placement of a reinforcing prosthetic mesh, and ultimately restore the anatomy and physiology of the abdominal wall. Therefore, a thorough knowledge of the anatomy of the abdominal wall is critical to optimizing patient outcome. Hernia repair by way of abdominal wall reconstruction and component separation should be highly regarded as the ultimate deﬁ nitive repair for large hernias. Therefore, it is mandatory that surgeons performing robotic TAR are not only experienced in the open counterpart, but also deemed experts with the robotic platform.

It is also important to consider that robotic TAR is a technique that continues to evolve. Although larger defects have been closed in our early experience, general recommendations for hernia width remain between 10 and 16 cm. Candidates most amenable to robotic abdominal wall reconstruction are patients with large mid-abdominal wall defects. Factors which preclude robotic abdominal wall reconstruction include hernias with loss of domain, defects which extend from ﬂ ank to ﬂ ank or subxiphoid to pubis, and signiﬁ cant overlying skin issues— those patients would generally beneﬁ t from traditional open repair. Inability to gain adequate laparoscopic access is another contraindication to the robotic repair.

282

C. Ballecer and E. Parra-Davila

Patient Positioning , Trocar Placement, and Dockin g

For the majority of patients with large defects in the midline, supine positioning with the arms tucked is preferred, unless trocar access to the lateral abdomen is obscured. In this setting, the arms are situated at a 90° angle relative to the trunk. Trocars are placed in the lateral abdomen similar to conventional laparoscopic repair. Optical trocar technique, preferably in a location remote to previous surgical intervention is used to gain initial access. An 8–12 mm trocar is placed in the lateral abdomen and then two 8 mm trocars follow on each side of this trocar (Fig. 26.14 ). It is also important to consider, if you are utilizing the da Vinci SI, that this procedure requires a double docking technique. All effort should be made to communicate with the anesthesiologist and surgical staff that the patient will require 180° rotation to access the contralateral abdomen.

Essential Steps

Posterior Sheath Incision

The anterior abdominal wall is cleared of all adhesions to adequately deﬁ ne and size the hernia defect. The retromuscular space is accessed by incision and subsequent mobilization of the posterior sheath. Below the arcuate line, the peritoneum and transversalis fascia are mobilized in a similar fashion. The degree of cranial-caudal

dissection is based on the size of the defect, assuring a bare minimum of 5 cm overlap (Fig. 26.15 ).

Transversus Abdominis Release

The uniform retraction afforded by pneumoperitoneum allows dissection within an avascular plane to the level of the linea semilunaris. The neurovascular bundle serving the rectus is exposed and preserved. An incision is made in the lateral posterior sheath in the upper third of the abdomen where the medial ﬁ bers of the transversus abdominis muscle are most prominent. The muscle is exposed and divided along the extent of posterior sheath and peritoneal dissection (Figs. 26.16 , 26.17 , 26.18 and 26.19 ). This step allows entry and dissection into the preperitoneal space resulting in wide release of both the posterior and anterior fascial layers.

Once sufﬁ cient posterior sheath release has been achieved, the robot is undocked, mirror image trocars are placed on the contralateral abdomen, and the patient is rotated 180° and the robot is re-docked. This step is eliminated by the rotational capability of the daVinci Xi. The contralateral posterior sheath is then dissected and the steps above are repeated.

Closure of the Anterior Sheath, Mesh Placement, and Posterior Sheath Closure

Closure of the anterior sheath is accomplished utilizing a 0 V-loc suture in a running fashion. The subcutaneous tissue and hernia sac are incor-

Fig. 26.14 Double docking technique and port position Fig. 26.15 Posterior sheath mobilization

26 Robotic Ventral Hernia Repair

283

Fig. 26.16 Posterior sheath mobilization

Fig. 26.18 Division of transversus abdominis and pre-

peritoneal plane

Fig. 26.17 Division of the transversus abdominis muscle and preperitoneal plane

porated into the closure to obliterate the anterior dead space. This step restores the linea alba and mobilizes the rectus abdominis muscle in its correct anatomical and physiologic position.

The extent of dissection is then measured in cranial caudal and axial dimensions to choose an appropriately sized mesh. It is important that the associated length and width of the mesh completely covers the area of dissection. A single central transfascial suture is utilized to position the light or mid-weight polypropylene mesh in the retromuscular position (Fig.

26.20 ).

Circumferential ﬁ xation is accomplished with an

Fig. 26.19 Preperitoneal dissection

Fig. 26.20 Retromuscular mesh placement

284

C. Ballecer and E. Parra-Davila

Fig. 26.21 Posterior sheath closure

absorbable tacker or suture. The posterior sheath is then re-approximated using 0 V-loc suture (Fig. 26.21 ). It is often helpful to incorporate a bite of mesh to elevate the two leaves of the posterior sheath away from the intra-abdominal viscera. The peritoneum is re-approximated below the arcuate line.

Drain Placement

Secondary to pneumoperitoneum, the retromuscular space represents a large potential space for seroma formation. Trocars are withdrawn from the intraperitoneal cavity and positioned into the retrorectus space under laparoscopic guidance. In this position, adequate hemostasis can be conﬁ rmed and two 19F drains are placed. Alternatively, a sequence of fascial closure which more closely resembles the open technique may be employed. This involves re-approximation of the posterior sheath after bilateral TAR is accomplished. Mesh is then placed overlying the posterior sheath along the extent of dissection. The anterior fascia is then re-approximated thereby restoring the linea alba.

Summary

The technique of robot-assisted laparoscopic incisional hernia repair with intracorporeal closure of the fascial defect and continuous circumferential suturing for mesh ﬁ xation is feasible and may reduce postoperative pain by eliminating transfascial sutures. The component separation techniques performed robotically may decrease the incidence of surgical site infection

in this difﬁ cult group of patients. Long- term data is lacking to truly assess the beneﬁ t to the patient and, therefore, further evaluations and studies are required.

References

1. Jin J, Rosen MJ. Laparoscopic versus open ventral hernia repair. Surg Clin North Am. 2008;88:1083–100.

2. Novitsky YW, Elliott HL, Orenstein SB, et al. Transversus abdominis muscle release: a novel approach to posterior component separation during complex abdominal wall reconstruction. Am J Surg. 2012;204:709–16.

3. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias: nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238:391–9.

4. Perrone JM, Soper NJ, Eagon JC, et al. Perioperative outcomes and complications of laparoscopic ventral hernia repair. Surgery. 2005;138:708–15.

5. Carbajo MA, Martin de Olmo JC, Blanco JI, et al. Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13:250–2.

6. Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and incisional hernia repair. Surg Laparosc Endosc. 1998;8:294–9.

7. Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair: a report of 100 consecutive cases. Surg Endosc. 2000;14:419–23.

8. Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg. 2000;190:645–50.

9. Sanders LM, Flint LM, Ferrara JJ. Initial experience with laparoscopic repair of incisional hernias. Am J Surg. 1999;177:227–31.

10. Ballantyne GH, Hourmont K, Wasielewski A. Telerobotic laparoscopic repair of incisional ventral hernias using intraperitoneal prosthetic mesh. JSLS. 2003;7:7–14.

11. Earle D, Seymour N, Fellinger E, et al. Laparoscopic versus open incisional hernia repair: a singleinstitution analysis of hospital resource utilization for 884 consecutive cases. Surg Endosc. 2006;20:71–5.

12. Harrell AG, Novitsky YW, Peindl RD, et al. Prospective evaluation of adhesion formation and shrinkage of intraabdominal prosthetics in a rabbit model. Am Surg. 2006;72:808–13.

13. McKinlay RD, Park A. Laparoscopic ventral incisional hernia repair: a more effective alternative to conventional repair of recurrent incisional hernia. J Gastrointest Surg. 2004;8:670–4.

14. Heniford BT, Carbonell AM, Harold K, et al. Local Injection for the Treatment of Suture Site Pain after Laparoscopic Ventral Hernia Repair. Am Surg. 2003;69:688–91.

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285

15. Lange JF, Halm JA, de Wall LL, et al. Intraperitoneal polypropylene mesh hernia repair complicates subsequent abdominal surgery. World J Surg. 2003;31(2):423–9.

16. Ballantyne GH. Robotic surgery, telerobotic surgery, telepresence, and telementoring: review of early clinical results. Surg Endosc. 2002;16:1389–402.

17. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86:519–26.

18. Rives J, Pire JC, Flament JB, et al. Treatment of large eventrations. New therapeutic Indications apropos of 322 cases. Chirurgie. 1985;111:215–25.

Evidence-Based Optimal Fixation During Laparoscopic Hernia Repair: Sutures, Tacks, and Glues

H. Reza Zahiri and Igor Belyansky

2 7

Introduction

Mesh ﬁ xation during ventral and inguinal hernia repair is a critical step which should aim to secure the mesh in place, and prevent hernia recurrence while promoting rapid ingrowth and reducing associated pain, formation of adhesions, and mesh shrinkage [ 1 ]. Additional consideration should be given to the prevention of seroma, infection, and ﬁ stula during this important step. Correctly selecting the appropriate mesh and ﬁ xation device contributes signiﬁ cantly towards these goals. For example, a macroporous mesh paired with a smaller ﬁ xation device will inevitably lead to an inadequate mesh/device interface and weak securing of the mesh.

At present, seventeen various devices may be used for mesh ﬁ xation, which may be divided into four categories : Nonabsorbable tacks , absorbable tacks , sutures, and glues [ There are also a variety of mesh products available on the market, including two with selfadhering properties. Nevertheless, the focus of this chapter is on ﬁ xation options, and a detailed discussion of mesh types is beyond the scope of this chapter.

1 ].

Fixation Products

Nonabsorbable Tacks

Three products exist u nder this category and it is the most common technique for securing mesh in place during hernia repair due to strength and facility of use [ 1 ]. The ProTack™ (Covidien Corp., Mansﬁ eld, MA) is the most popular of the three and utilizes helical titanium tacks with a diameter of 5 mm and length of 3.8 mm. The EndoAnchor™ (Ethicon Endosurgery, Inc., Cincinnati, OH) uses a double-armed nickel titanium tack with a length of 5.9 mm. Finally, the PermaFix™ (Bard Davol, Warwick, RI) uses hollow core tacks made of polymer blend with a

6.8 mm penetration depth. Current evidence, regarding both nonabsorbable

and absorbable tacks, if used as an exclusive means of ﬁ xation, supports application in a double row or “double crown” fashion (an outer row 0.5 cm from the mesh edge, and an inner row around the fascial defect) [ 1–2 cm apart. Figure crown” technique with two rows of ﬁ xation.

2 ]. Tacks should not be spaced more than

27.1 illustrates the “double

Absorbable Tack s

H. R. Zahiri , D.O. • I. Belyansky , M.D. (*) Department of Surgery , Anne Arundel Medical Center , Annapolis , MD , USA

igor.belyansky@gmail.com

e-mail:

Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_27

Six products exist under this category [ 1 ]. Securestrap™ (Ethicon EndoSurgery, Inc., Cincinnati, OH) is designed to resemble a strap

287© Springer International Publishing Switzerland 2016

288

H.R. Zahiri and I. Belyansky

Inner Row of

Outer Row of Fixation

Fig. 27.1 The “double crown” technique of mesh ﬁ xation with two rows of tacks, an outer and an inner layer

with two points of ﬁ xation that are 6.7 mm long. Its absorption time is 12 months. AbsorbaTack™ (Covidien Corp., Mansﬁ eld, MA) is designed like a screw with 4 mm of penetration and an absorption time of 6–12 months. Sorbaﬁ x™ (Bard Davol, Warwick, RI) is designed with a hollow core and blunt edge, promising enhanced tissue integration. Its reach after deployment is

6.8 mm and is absorbed after 1 year. I-Clip™ (Covidien Corp, Mansﬁ eld, MA) is 7.5 mm in length and also completes absorption in 1 year. PermaSorb™ (Bard Davol, Warwick, RI) utilizes a needle as an introducer to facilitate mesh and tissue entry, reaching 5 mm of depth with an absorption time of 16 months. Finally, the iMesh Tacker™ (Easy-Lap, Wrentham, MA) uses an articulating tip to deliver helical tacks that reach

6.3 mm with an unknown absorption time.

Fixation

Melsungen AG, Melsungen, Germany) and Glubran II™ (GEM, Viareggio, Italy), reacts with water to polymerize and join adjacent surfaces within 60 s. In time, the hardened glue will undergo hydrolysis and degradation allowing for tissue ingrowth. Thus, limited targeted use is recommended to prevent delays in tissue integration while adequately ﬁ xing mesh. Under the biologic glue sub-category, ﬁ brin sealant is marketed as EVICEL® (Ethicon EndoSurgery, Inc., Cincinnati, OH), Tisseel™, Tissucol™, and Artiss™ (Baxter, Deerﬁ eld, IL) comprise a sealer protein solution and a thrombin solution. These are mixed at the time of ﬁ xation to duplicate the terminal coagulation reaction and generate polymerized ﬁ brin. Applied to mesh, it can serve as a ﬁ xator, with 3 min required for reaction completion. Another product, Bioglue™

Mesh

(CryoLife Inc., Kennesaw, GA), combines bovine serum albumin and glutaraldehyde to

Adhesive s

provide stable adhesion lasting 12 months prior

to breakdown. Finally, genetically engineered Tissue sealants may be utilized as atraumatic ﬁ xators of mesh products [ 1 ]. This category can be further divided into synthetic, biologic, and genetically engineered polymer protein glues. Under the synthetic products sub-category, cyanoacrylate, marketed as Histoacryl™ (B. Braun

polymer protein glues mainly have applications

in the laboratory due to cost, but efforts persist

to incorporate their use in the clinical settings in

the near future.

Table 27.1 is a summary of various ﬁ xation

devices and their properties.

27 Evidence-Based Optimal Fixation During Laparoscopic Hernia Repair: Sutures, Tacks, and Glues

Depth of

penetration (mm)

6.7

289

continued

6.3

Nonabsorbable Titanium 3.8

Covidien (Mansﬁ eld,

MA)

Nonabsorbable Nickel 5.9

Ethicon (Cincinnati,

OH)

Nonabsorbable Molded polymer blend 6.8

Bard Davol (Warwick,

RI)

Glycolide

Absorbable Polydioxanone/L(−)-Lactide/

Ethicon (Cincinnati,

OH)

Absorbable Polyester from lactic and

Covidien (Mansﬁ eld,

glycolic acid copolymers

Absorbable Poly (D,L) lactide material 6.8

Bard Davol (Warwick,

MA )

RI)

glycolic acid copolymers

Absorbable Poly (D,L) lactide material 7.5

Absorbable Polyester from lactic and

MA)

Table 27.1 Comparison of ﬁ xation products

Fixation device Image Company Type Material

ProTack™

EndoAnchor™

PermaFix™

Securestrap™

AbsorbaTack™

SorbaFix™

I-Clip™ Not Available Covidien (Mansﬁ eld,

iMesh™ Not Available Easy-Lap (Wrentham,

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Parastomal Hernia

Robotic Rives-Stoppa Repair with Bilateral Transversus Abdominis Muscle Release

General Considerations

Patient Positioning , Trocar Placement, and Dockin g

Essential Steps

Posterior Sheath Incision

Transversus Abdominis Release

Closure of the Anterior Sheath, Mesh Placement, and Posterior Sheath Closure

Drain Placement

Summary

References

Further Reading

Evidence-Based Optimal Fixation During Laparoscopic Hernia Repair: Sutures, Tacks, and Glues

Introduction

Fixation Products

Nonabsorbable Tacks

Absorbable Tack s

Adhesive s