Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_761_Библиотеки_им_академика_М_И_Перельмана.pdf
45 The Extended-View Totally Extraperitoneal (eTEP) Technique for Inguinal Hernia Repair
Fig. 45.2 Because of a
previous surgery at the right
lower abdominal quadrant, the
camera port was placed in the
left fl ank. Working ports are
placed in triangulation
469
Fig. 45.3 The location of the camera port in the classic
TEP approach is shown ( red ). The semilunar lines ( solid
blue vertical lines ) and the possible locations for the camera port ( blue stripes ) in the eTEP technique are
indicated
classical TEP approach (highlighted in red); the
semilunar lines marked under ultrasound guidance are indicated with solid vertical blue lines,
and possible sites for the camera port in the eTEP
technique are highlighted by blue stripes. The
camera port can also be positioned lateral to the
semilunar lines, as shown in Fig. 45.4 .
The initial incision is then extended to the
anterior fascia, and the fascia is exposed and
incised with an inverted 11 blade. This allows a
fi nger to be introduced through the fascia and
muscle to reach the posterior fascia, which is
thick at this location, and the retro-rectus space is
manually dissected. The balloon trocar is then
introduced along the same path to reach the pubic
spine, and the balloon is infl ated to create a working space. The surgeon and camera operator
stand on the side opposite to the hernia.
Flexible Port Distribution
Two additional working ports can be placed
according to each individual case. In a unilateral
hernia, we often use the umbilicus as one working port and place the second port high in the
lower abdominal quadrant opposite to the hernia
(Fig.
45.5 ). The working ports can also be placed
with one port lateral to the umbilicus and the
470
J. Daes
Fig. 45.4 The eTEP enables access to the preperitoneal
space outside of the semilunar lines, as shown. This
maneuver is rarely necessary
other port slightly lower and lateral to the fi rst.
When the camera is opposite the hernia site, we
use the distribution shown in Fig. 45.6 , which
allows for perfect triangulation. For bilateral hernia cases, we use the distribution shown in
Figs. 45.7 and 45.8 . Placement of a second port
in these cases allows for a more ergonomic repair.
Division of the Posterior Fascia (Douglas’s Line)
Occasionally, the posterior fascia descends
enough to reduce visibility within the preperitoneal space. In such cases of a low-lying arcuate
line, we usually divide it. This can be done while
maintaining visibility if a 5 mm camera is used
through the lowest working trocar. The posterior
fascia and peritoneum are fi rmly adhered at midline, but the peritoneum can be dissected free
from the fascia laterally. Usually, we divide the
Douglas’s line blindly using laparoscopic scissors introduced through one of the working trocars, though this can risk dividing the peritoneum
and generating a pneumoperitoneum.
The key technical aspects of the eTEP technique
can be observed in the supplemental video.
Fig. 45.5 Port setup for a
right inguinal hernia. Note
how the working port for the
right hand is placed at the
umbilicus. The left hand
working port is placed high in
the left fl ank
Fig. 45.6 Port distribution for a left inguinoscrotal hernia. The camera port is located at the right fl ank, and the working
ports are placed to obtain a perfect triangulation
Fig. 45.7 Port distribution for
a bilateral inguinal hernia case
showing setup of the camera
and working ports for the right
hernia
Fig. 45.8 Port distribution for
a bilateral inguinal hernia case
showing setup of the camera
and working ports for the left
hernia. An additional trocar
can be placed to allow a more
ergonomic repair, although
this is not strictly necessary
472
J. Daes
Hernia Repair
Once the extraperitoneal space is created, pubic
tubercle and Cooper’s ligament are exposed,
epigastric vessels are identifi ed and the space of
Bogros is fully developed. When a direct hernia
is present, lax transversalis fascia is freed from
the hernia content. In case of an indirect hernia,
the indirect sac is retracted medially while elements of the cord are dissected free laterally,
being careful not to grasp them. Dissection is
completed when the indirect sac is separated
from cord structures by a bluish transparency.
The sac can be reduced completely in most
cases. When indirect sac extends deep into the
scrotum in a large inguinoscrotal hernia, we
ligate the sac and divide it distal to the ligation.
The ligated sac and peritoneum are dissected as
proximally as possible to achieve parietalization of cord elements and ensure correct positioning of the mesh at the end of the procedure.
Failure to deal with the distal sac carries the
risk of formation of large and sometimes cumbersome seromas, hematomas, and pseudohydroceles. We grasp the lateral edge of the
divided distal sac, which is exposed with the
help of external pressure applied to the ipsilateral scrotum. We pull the edge of the divided
sac upwards and laterally and fi x it with tacks
(and sometimes sutures) to the abdominal wall
well above the ileopubic tract. This maneuver
has been helpful to avoid cumbersome seromas
(8). In cases of large direct hernias, the lax
transversalis fascia is reduced and fi xed with
tacks to Cooper’s ligament to reduce the dead
space. Lipomas of the cord are sought for and
dissected out. When a complete dissection of
the space is achieved, a mesh is introduced,
unrolled and placed over the posterior inguinal
wall. We use a 15–17 cm by 10–12 cm, midweight, macroporous polyester mesh. Fixation
is optional for small hernias. We usually fi x the
mesh with a few tacks placed on Cooper’s ligament and on the upper border of the mesh well
above the ileopubic tract/inguinal ligament.
Finally, we instill diluted bupivacaine into the
space, make sure sac and peritoneum lie behind
the mesh and keep the inferior lateral border of
the mesh under pressure with a dissector while
slowly releasing CO 2 from the space.
Clinical Experience with eTEP
Between October 2010 and September 2014, we
performed 307 eTEP repairs in 276 patients. This
unselected series included all patients with inguinal hernias. Six cases were converted to TAPP,
and none were converted to open surgery. The
hernia recurred in two cases. There was one
bladder lesion that was corrected during the
procedure and fi ve self-limiting seromas. None
of the patients have experienced chronic pain.
Conclusions
The eTEP technique has a place in the armamentarium of hernia surgeons. Residents and surgeons
early in their experience will fi nd this technique
easier to master than the classic TEP method. It can
expand the traditional indications of the extraperitoneal approach to patients with a diffi cult body
habitus, a short umbilicus-pubis distance, and previous pelvic surgery. As the surgeon’s experience
increases, the indications for the traditional TEP
technique can be expanded to more complex cases.
References
1. Daes J. Reparo laparoscopico de la hernia inguinal.
Experiencia de la Unidad de Laparoscopia. Clinica
Bautista, Barranquilla, Colombia. Rev Colomb Circ.
1999;14:97–103.
2. Wake BL, McCormack K, Fraser C, Vale L, Perez J,
Grant AM. Transabdominal preperitoneal (TAPP) vs
totally extraperitoneal (TEP) laparoscopic techniques
for inguinal hernia repair. Cochrane Database Syst
Rev. 2005. doi:
3. Leibl BJ, Jager C, Kraft B, Swartz J, Ulrich M, Bittner
R. Laparoscopic hernia repair—TAPP or/and TEP?
Langenbecks Arch Surg. 2005;390:77–8.
4. Ferzly G, Sayad P, Vasisht B. The feasibility of lapa-
roscopic extraperitoneal hernia repair under local
anesthesia. Surg Endosc. 1999;13:588–90.
5. Ismail M, Garg P. Laparoscopic inguinal total extraperi-
toneal hernia repair under spinal anesthesia without mesh
fi xation in 1,220 hernia repairs. Hernia. 2009;13:115–9.
6. Daes J. The enhanced view- totally extraperitoneal
technique for repair of inguinal hernia, answer to letter to the editor. Surg Endosc. 2012;26:3693–4.
7. Daes J. The enhanced view- totally extraperitoneal
technique for repair of inguinal hernia. Surg Endosc.
2012;26:1187–88.
8. Daes J. Endoscopic repair of large inguinoscrotal her-
nias: management of the distal sac to avoid seroma
formation. Hernia. 2014;18:119–22.
10.1089/lap.2008.0212
Inguinal Hernias: an Algorithmic Approach to Procedure Selection
Brian P. Jacob
4 6
The Problem
Employing a minimally invasive versus open inguinal hernia repair for a primary inguinal hernia
remains debatable. It has been clearly established
that in experienced hands, both the open and laparoscopic techniques can produce excellent short- and
long-term results. All inguinal hernia operations
carry a small risk of chronic pain and recurrences .
Weighing the benefi ts of open versus laparoscopic
repair for any new patient presenting with a primary
inguinal hernia will remain an academic pursuit, but
practical focus needs to shift to establishing the best
technique to utilize at different times, depending on
the patient, with the goal being outcome optimization. Treatment algorithms for the many different
types of patients presenting with inguinal hernias
can help guide surgeons toward this objective.
These algorithms do require that surgeons feel comfortable performing both open and laparoscopic
techniques, but assuming this is the case, following
them can help build a complete surgical arsenal.
History and Surgical Work Up
The work-up for a primary inguinal hernia includes
a detailed history, a focused physical exam, and
in certain situations some further imaging. All
B. P. Jacob , M.D., F.A.C.S. (*)
Icahn School of Medicine at Mount Sinai ,
New York , NY , USA
bpjacob@gmail.com
e-mail:
treatment decision trees for patients with primary
inguinal hernias should start with the patient and
not be limited to one approach. Knowing there is
no single “best” approach to every patient; surgeons must pay careful attention to the patient’s
history and try to match their procedure choice to
each patient’s specifi c goals and expectations, as
well as any intraoperative fi ndings.
The fi rst question all patients should be asked
is, “why do you want your hernia fi xed?” “What
bothers you about your hernia?” An attempt to
document the precise symptoms (whether it is
simply a bulge, some bulge and some intermittent
pain, or concern for an emergent scenario) related
to the patient’s hernia will be an important factor
to help decide if this patient even needs surgery at
all. Patients with completely asymptomatic hernias who have been referred by a physician when
the patient themselves did not even know they
had a primary inguinal hernia can be safely
watched non-operatively, if the patient chooses,
to do so and once they have been educated [ 1 ].
Even after education, patients with only rare
symptoms from a palpable and easily reducible
hernia can also be offered non-operative strategies , assuming they are compliant and will return
for follow-up if symptoms arise or become more
frequent. My words of wisdom are, “if you
cannot document a clear reason why you are
repairing the hernia, don’t repair the hernia.”
Sometimes, patients have a chief complaint of
groin pain (with or without a bulge). It cannot be
stressed enough how important it is to document
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_46
473© Springer International Publishing Switzerland 2016
474
B.P. Jacob
any preoperative groin pain complaints, and then
do a full pain history and physical on these
patients. Groin pain can be the result of an extensive differential diagnosis, and if there is any
doubt that the patient’s complaint of pain is not
related directly to the hernia bulge, then they
should not be operated on initially.
Groin pain complaints should be fully evaluated by those experienced in narrowing down that
vast differential and should not be initially assumed
to be related to an inguinal hernia, even if a hernia
is obvious on exam. Additionally, it is well
accepted that there is a higher incidence of postoperative hernia pain complaints in patients who
complained of pain preoperatively. Documenting
the patient’s goals for seeking surgery will help a
surgeon choose the best procedure. Patients who
want the hernia fi xed with the fastest recovery and
return to work option should be advised that, in
experienced hands, laparoscopy has been shown to
offer this advantage.
Once the decision to operate is made, navigating the inguinal hernia repair algorithm can be
facilitated by taking and processing a detailed
patient history that includes the patient’s body
mass index (BMI), prior medical history (PMH) ,
prior surgical history (PSH) , current medications,
and social history to evaluate for tobacco smoking. It is well accepted that a history of smoking
and/or obesity can increase recurrence and infection rates, and thus surgical options known to
minimize these risks should be employed.
Documenting the details of a previous inguinal
hernia repair can aid in deciding whether an open
or laparoscopic repair is preferable. Some recurrences after an open Lichtenstein or tissue repair
may be better diagnosed and treated with a laparoscopic technique; and a previous laparoscopic
repair recurrence may be best repaired by an
anterior approach in some hands, but by a laparoscopic method in others. It will truly depend on
the history and the surgeon’s experience. A surgical
history that involves a previous lower midline
incision may violate otherwise avascular tissue
planes, and thus could be a reason to proceed
with an open (anterior) repair. Medications such
as blood thinners and Aspirin may play a role in
choosing between open and laparoscopic methods.
A history of immunosuppression medications
may also help direct a surgeon down a particular
pathway. Advanced patient age is not an absolute
contraindication to performing a laparoscopic
procedure, but the ability for each patient to tolerate general anesthesia must be evaluated carefully. That being said, some patients simply do
not want to undergo general anesthesia. Since an
open repair can be performed safely under local
anesthesia, and epidural, or with IV sedation only,
this may be the best option for those patients.
Management Options
The current list of available, well-described, and
commonly utilized inguinal hernia repair techniques is extensive (Table 46.1 ).
Surgeons who wish to embrace inguinal hernia repair as a practice sub-specialty should be
familiar with all of these techniques, and be able
to perform both open as well as laparoscopic
TEP, TAPP, eTEP, and IPOM inguinal repairs.
However, at some point in their training, many
surgeons become more comfortable with one
specifi c technique over others. Consequently,
once training is complete, surgeons trained on
open techniques tend to have limited exposure to
advanced laparoscopic training, and are therefore
likely to avoid adopting such methods. However,
in order to accommodate all hernia patients, a
surgeon should have a variety of weapons in his
or her armamentarium.
Table 46.1 Common hernia repair surgical options
Open techniques Laparoscopic techniques
Tissue repair—no mesh TEP (total
extraperitoneal)
Lichtenstein (tension-free)
(Mesh onlay, no plug)
Transinguinal preperitoneal
(TIP)
Mesh plug (alone) Robotics
Mesh plug and patch
Prolene™ Hernia System
(single mesh device with an
intraperitoneal and
extraperitoneal layer)
TAPP (Transabdominal
preperitoneal)
IPOM (intraperitoneal
onlay mesh)
46 Inguinal Hernias: an Algorithmic Approach to Procedure Selection
475
Robotic surgery is an emerging minimally
invasive tool that surgeons are choosing to use to
repair inguinal hernias. Robotics, like laparoscopy, is a minimally invasive option, and in this
chapter when I mention the use of laparoscopy to
perform TEP or TAPP, it can be easily exchanged
with the use of a robot to perform a TAPP or
TEP, if the surgeon is experienced with and
performs a majority of their cases with the robot.
In other words, whether a robot or laparoscopy is
used, the procedure itself is still a TAPP or a TEP.
Until comparative data is available, a robotic
inguinal hernia repair is certainly feasible, but
has not been shown to be superior or inferior to an
open inguinal approach by an open hernia expert
or to a laparoscopic approach by a laparoscopic
expert, when considering measurable patient
outcome metrics.
Author’s Preference
While most surgeons with extensive experience
in hernia repair techniques have optimized their
outcomes, randomized prospective trials are still
benefi cial in helping to direct surgeons to choose
to master operations with proven and optimized
success rates. The outcomes after TEP, TAPP,
and Open repairs have been scientifi cally studied in large databases [ 2 ]. For instance, in the
open technique debate, a Cochrane review of 20
randomized trials comparing open Lichtenstein
to open-tissue repair revealed shorter hospital
stays, quicker return to activities of daily living,
less chronic pain, and lower recurrence rates for
the Lichtenstein [ 3 ]. That being said, in the open
versus laparoscopic debate, the LEVEL-trial
concluded that the laparoscopic total extraperitoneal (TEP) procedure, when compared to the
Lichtenstein repair , was associated with lessreported acute pain and a slightly faster recovery
time [ 4 ]. Several other randomized prospective
studies have also demonstrated better quality of
life and chronic pain outcomes for laparoscopic
hernia repair compared to open Lichtenstein
repair [ 5 , 6 ]. For an experienced laparoscopic
trained surgeon, recurrence rates following
laparoscopic repair are no different than those
following an open repair and might be even better, while, if inexperienced, recurrence rates will
be higher [ 7 ]. Finally, within the laparoscopic
repair options debate, when comparing TAPP
and TEP, a large 12,000 patient review showed
no signifi cant differences in operating times,
vascular injuries, recurrence rates, or chronic
pain complaints [ 8 ]. The TEP repair was associ-
ated with more intraoperative conversions to
other techniques, and it may be harder for trainees to learn. At the same time, TAPP procedures
led to slightly more trocar site hernias, transperitoneal hernias, and visceral injuries, as well as
increased intra- abdominal adhesive disease
leading to bowel obstruction (0.5%, vs. 0.07%
for TEP). Most importantly, after a TEP is complete, there is no peritoneum to close at the end
of the procedure. Thus, any morbidity related to
this peritoneal closure is eliminated. A large
19,582 patient review found that both laparoscopic and open preperitoneal mesh placement
were associated with signifi cantly lower rerecurrence rates than the same repairs of a recurrent hernia using an open technique [ 9 ].
However, TAPP has been shown to increase
incidence of postoperative obstruction [ 10 ].
Combined with TAPP in certain scenarios,
TEP’s diagnostic ability is superior to an open
alternative in patients with, for example, a
missed femoral hernia during a plug repair of a
direct hernia. Given all of these facts, I routinely
rely on the TEP repair for the majority of my
patients including all primary unilateral and
bilateral inguinal hernias. For the TAPP surgeon
advocates, there are not many contraindications
to using a TAPP other than the routine contraindications to performing intra-abdominal laparoscopy, like in patients with a history of
peritonitis or previous laparotomy with known
extensive adhesive disease. The question they
may need to answer is why choose an operation
where the peritoneum is cut and then sewn
together when there is a technique available that
can avoid that step.
476
Fig. 46.1 Reduction of excess indirect right hernia sac. Used with permission from personal fi les of Dr. Jorge Daes
performed. The use of mesh after fi nding a true
Caveats and Pearls
While TEP appears to be an ideal operation for
all unilateral and bilateral primary inguinal hernias, as well as recurrence after an open inguinal
hernia, a TAPP remains advantageous for several
specifi c patient scenarios. A standard approach to
all patients with an inguinal hernia is presented
here in an easy-to-follow algorithm (Fig. 46.1 ).
strangulation or bowel ischemia remains at the
discretion of the surgeon, though employing a
permanent synthetic material in a cleancontaminated or contaminated fi eld carries a risk
of chronic mesh infection and is therefore best
avoided. An absorbable material is probably the
safest choice if the fi eld is clean-contaminated.
However, if the fi eld is contaminated, then it is
best to stage the repair (if mesh is needed), or
perform a primary tissue repair without mesh.
B.P. Jacob
Incarcerations and Strangulations
Incarcerations and possible strangulations are a
contraindication for the TEP repair. A true TEP
repair does not allow easy visualization of the
incarcerated tissue, and thus risks leaving behind
strangulated or ischemic remnants. If performing
a TEP where possible bowel ischemia is suspected,
the peritoneal layer should be opened and the
bowel inspected. By performing a TAPP repair in
these scenarios, the surgeon can evaluate the
bowel properly. Should he or she fi nd an ischemic segment of bowel, it can be reduced; but
then the patient’s primary problem is no longer
the hernia, and a bowel resection should be
Scrotal Hernias and Large Hernia Sacs
Inguino-scrotal hernias are probably more common than typical reporting might indicate. Small
scrotal hernias that are reducible can be
approached initially via the TEP procedure; but
the larger, more incarcerated or chronic scrotal
hernias, especially those with large diameter
necks, are sometimes better approached using a
TAPP or open technique. Again, it certainly is
acceptable to approach these with a TEP, but the
number one reason to consider starting with a
TAPP repair is that it provides a great view of the
46 Inguinal Hernias: an Algorithmic Approach to Procedure Selection
477
incarcerated contents, and usually allows for a
straightforward reduction. Often, a TEP repair
can be modifi ed (or converted partially) to a
TAPP (by opening the peritoneum) to help
reduce the incarcerated contents.
In these large hernias, a partial hernia sac can
be left in situ in the scrotum (it is not always
necessary to excise the entire sac). If sac is left
within the canal, an attempt should be made to
close the peritoneum on the proximal end (with
an endoloop or endoclips or suture) if possible,
but you can leave the end within the canal open
and patent. Some surgeons leave the rents in the
peritoneum open, and report no issues, though I
tend (and highly recommend) to close them.
One trick we like to employ for direct defects
to reduce seroma rates is to take the retained peritoneum hernia sacs within the canal and pull
them intrapreperitoneally and tack its lateral edge
to the anterior abdominal wall to reduce the volume of sac in the canal. This will decrease the
incidence and size of seroma formation.
Nonetheless, patients with these types of hernias
should also be forewarned about seromas, as they
are fairly common (Fig. 46.2 ).
Inguinodynia
Chronic groin pain is a complex topic covered in
another chapter. The choice of operation will
depend on the previous surgery, as well as the
patient’s response to local and regional nerve
blocks, which can be performed for diagnostic
purposes, as indicated above. The TAPP is very
useful as a diagnostic, and possibly therapeutic,
tool for patients presenting with groin pain.
Patients should be educated that there is a chance
the surgery will not resolve their pain, but can
still contribute greatly to the workup, with the
goal being an eventual diagnosis and resolution.
Before the TAPP, the patient should mark the
spot with the maximal pain. He or she should
understand that if a TAPP exploration fails to
identify the etiology of the pain, an additional
surgery requiring neurectomy might be needed.
But he or she should also be made aware that
proceeding in a staged fashion is the logical and
appropriate course of action. During the TAPP
procedure, potential pain-inducing tacks and
mesh can be removed, adhesions can be identifi ed
and lysed, and the femoral, direct, and indirect
Fig. 46.2 Algorithmic approach to a patient with an inguinal hernia
478
B.P. Jacob
spaces can be carefully examined for missed,
new, or recurrent hernias. Simply stated, a TEP
may miss many etiologies and is therefore not as
useful as a TAPP for approaching inguinodynia.
Recurrence After a TEP or TAPP
For experienced laparoscopists, a recurrence
after a previous TEP or TAPP approach demands
a TAPP, or even an IPOM repair. Some surgeons
will always resort to an open anterior approach
for a patient with a recurrence, but compared to
the diagnostic ability of the laparoscope, I fi nd
an open approach (used alone) limited. During
the laparoscopic dissection, an additional open
incision may help with mesh removal or cord
preservation, and it may be added at this point.
Choosing which procedure is best to perform
after a recurrence has been extensively evaluated
in the literature and is beyond the scope of this
chapter; but it is clearly dependent on surgeon
experience.
Using laparoscopy for a recurrence after an
open tissue or Lichtenstein repair allows for a
precise diagnosis under magnifi ed vision, minimizing untoward outcomes. Preoperatively, if
palpable, the recurrence should be marked or
prepped into the fi eld. A urinary catheter should
be inserted, which can be used to distend the
bladder, if necessary, during the dissection. The
fi rst step during a recurrent hernia repair is to
perform an adequate diagnostic laparoscopy, to
survey the entire region and assess the possible
etiology of the recurrence. In general, I start with
a detailed diagnostic laparoscopy, where I survey
the nearby viscera, and then examine the direct,
femoral, and indirect spaces. It is important to be
particularly careful taking the previous mesh off
the myopectineal orifi ce to avoid injury. It is
important to be particularly careful to avoid
injury to the cord structures, epigastric vessels,
bladder, lateral femoral cutaneous nerve, and
iliac vessels (and Genitofemoral nerve, if posterior
dissection is needed). The dissection should
continue until the recurrence is identifi ed. Usually
there is a small defect medially near the Cooper’s
ligament and pubic tubercle, where the previous
mesh pulled away from the periosteum of the
tubercle. Less commonly, the indirect hernia may
have recurred or a femoral hernia may have been
missed. If no defect is found, the patient’s symptoms may be the result of a cord lipoma, which
then needs to be ruled out.
Old mesh can be left in situ if it is densely
adherent to vital structures and not causing pain.
New mesh may be implanted in standard fashion,
or, in specifi c case scenarios, laparoscopically
sutured to the old mesh as needed. If the peritoneum is destroyed during the dissection, a twosided mesh with a barrier coating (also known as
tissue separating mesh) can be inserted as an
intraperitoneal onlay (IPOM). Laparoscopic
sutures may then be used to fi x the new mesh to
the peritoneum overlying vital structures, to
avoid injury by tacks. Adhesive glues are also
useful for this purpose.
Women with Previous Pfenensteil
Some women with previous Pfenensteil incisions
will not have a peritoneal layer and thus are not
candidates for a TEP repair. In such situations, a
TAPP or IPOM repair is required. In addition, some
Pfenensteil incisional hernias will be felt on palpation like inguinal hernias, when indeed the defect is
in the midline. A preoperative CT scan can help
differentiate between the two. Also, using a laparoscopic approach allows for an accurate diagnosis
and remedy to be achieved concomitantly.
Previous Surgical History Involving Lower Midline Skin Incisions (Prostatectomy)
As with women who have previous Pfenensteil
incisions , patients with previous lower midline
skin incisions may have an obliterated retrorectus
plane. This is most signifi cant in patients who
have had open or laparoscopic radical prostatectomies. The history of a prostatectomy deserves
specifi c mention, because, although rare (0.04%),
bladder injuries can still occur. An open repair,
on the other hand, avoids this risk completely. An