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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_832_Библиотеки_им_академика_М_И_Перельмана
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P. McCarty and A. M. Coker
is more robust in the epigastrium, and the developing ap is less likely to tear.
Similarly, a suprapubic docking strategy can be employed for epigastric hernias.
After adhesiolysis, the peritoneum is scored at least 5cm from the hernia defect.
By previously measuring the width of an open robotic instrument, the surgeon can
closely estimate this distance. Alternatively, a ruler is placed inside the abdomen for
precise measurement. The peritoneal ap is extended to be 5cm wider than the
defect on each side. Unlike inguinal hernia repair—where the peritoneal fat is dissected free anteriorly from the preperitoneal ap—keeping the fat posteriorly with
the ap assists in maintaining the ap integrity. Indeed, this dissection occurs most
easily at midline where there is more preperitoneal fat. The hernia sac is reduced,
and the preperitoneal space developed approximately 5cm around the edges of the
hernia defect. The hernia defect and dissected spaces are then measured with a ruler.
Debate exists regarding the optimal suture to close the defect. Some surgeons favor
permanent suture to, theoretically, reduce the risk of recurrence. Chronic pain and
infectious concerns lead other surgeons to prefer slowly absorbable suture.
Generally, a running, barbed suture is utilized to close the fascial defect. Mesh is
placed into the preperitoneal space to cover the defect by 5cm in all directions.
Many surgeons choose to secure the mesh to the posterior rectus sheath to prevent
migration. This can be accomplished by placing transfacial sutures or by suturing
with the robot. In theory, avoiding transfascial sutures decreases post-operative
pain, without sacricing efcacy in terms of hernia recurrence. Some surgeons
forego any mesh xation when placed in the preperitoneal space or opt for minimum xation with surgical glue. Finally, a running, often barbed, absorbable suture
is used to close the peritoneal ap. It is critical to close any defects that may be
present in the ap to prevent short-term complications of interparietal hernia and
long-term complications of bowel adhesions to mesh (Fig.8).
In the event that the surgeon is not able to develop the preperitoneal ap an
IPUM may be performed with a coated mesh.
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a b
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c
d
e
Fig. 8 Robotic TAPP technique: (a) Creation of peritoneal ap, (b) Closure of hernia defect, (c)
Mesh placement within ap, (d) Closure of peritoneal ap, (e) Closure of ap defect
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3 Mesh Considerations
Available studies and meta-analyses of mesh VHR are difcult to interpret due to
variable techniques, mesh types and positions as well as the xation methods used
by surgeons [17]. A full review of all types of mesh is outside the scope of this
chapter. We will review the pertinent and common mesh types and optimal traits for
those used in VHR in the preperitoneal space and underlay position.
The type of mesh used for VHR can impact outcomes, but often the surgeon’s
experience and training—or the options available in the operating room—dictate
the type of mesh used for VHR.Mesh characteristics include composition, synthetic
vs biologic, permanent vs absorbable, monolament vs multilament, pore size,
weight, and tensile strength. Non-absorbable synthetic mesh is most commonly
made of polypropylene, expanded polytetrauoroethylene (ePTFE), or polyester.
Absorbable synthetic mesh is commonly made from poly lactic-co-glycolic acid
(PLGA) or polyglycolide [18]. Tensile strength of the mesh, based on mesh weight,
a function of polymer weight and pore size, is important to consider in VHR.Heavy
weight mesh, although high in tensile strength, are more prone to chronic pain, foreign body reaction, brosis, and shrinkage [19]. Light-weight mesh, with large
pores, has less tensile strength but are more elastic and allow for ingrowth of tissue
through the pores, resulting in satisfactory mechanical strength while having lower
risk of chronic pain, as seen with inguinal hernia repairs [20]. Recurrence, however,
may be higher for light weight mesh. This may not be generalizable to ventral hernia repair, but it’s something for the surgeon to consider. Biologic mesh can be
produced from porcine small intestine submucosa, human acellular dermis, xenogenic acellular dermis or bovine pericardium [18]. Biologic mesh is an extracellular
matrix that acts as a scaffold for scar tissue during VHR.Most VHR with mesh use
permanent prosthetic material but absorbable synthetic and biologic mesh material
may be favorable in contaminated operative elds, or when permanent mesh is suboptimal. There are cost considerations, however, as biologic mesh and some of the
newer bioresorbable meshes can be much more expensive than a synthetic permanent mesh.
Intraperitoneal underlay mesh should have an anti-adhesions barrier due to the
risk of bowel adhesions to synthetic uncoated mesh, leading to infection, perforation, obstruction or stula formation. For smaller ventral hernias repaired via an
open technique, there are several commercially available composite mesh systems
available, including Parietex™ (Medtronic, plc), Proceed® Ventral patch (Ethicon,
Inc.), C-QUR V-patch (Atrium, Inc) and Ventralex ST patch (Bard, Inc). These generally have different sizes available depending on the size of the hernia defect and
planned overlap. These can be placed in the preperitoneal space or intraperitoneal in
the underlay position. Using coated mesh in the preperitoneal space is generally
acceptable but some data show increased risk of infection requiring IV antibiotics
[21]. An uncoated mesh is most commonly utilized in the preperitoneal space as
these are typically very cost effective and ingrowth is desired, which may be
impeded by an adhesive barrier in the short term. An example would be Ventralex
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Hernia Patch (Bard, Inc). In laparoscopic IPUM, a coated mesh is used and unrolled
over the defect; some systems are equipped with a positioning system that deploys
the mesh against the abdominal wall such as Ventralight Echo (Bard, Inc.).
4 Summary
Pre-peritoneal and underlay ventral hernia techniques are very common and any
surgeon performing hernia repairs should be familiar with them. There are many
techniques that can be deployed to achieve this including open, laparoscopic, and
robotic. The choice of which depends on many variables including patient factors,
hernia characteristics, equipment availability, surgeon skill, and cost. Utilization of
the pre-peritoneal space may have some advantages, including avoiding intraabdominal mesh placement. Ultimately, the best hernia repair is one that is skillfully
performed, adheres to best practices in hernia repair, and provides the patient the
best outcome.
References
1. LeBlanc KA, Booth WV.Laparoscopic repair of incisional abdominal hernias using expanded
polytetrauoroethylene: preliminary ndings. Surg Laparosc Endosc. 1993;3(1):39–41.
2. Henriksen N, Montgomery A, et al. European and Americas Hernia Societies (EHS and
AHS). Guidelines for treatment of umbilical and epigastric hernias from the European Hernia
Society and Americas Hernia Society. Br J Surg. 2020;107(3):171–90. https://doi.org/10.1002/
bjs.11489. Epub 2020 Jan 9.
3. Hawn M, Snyder C, Graham L, Gray S, Finan K, Vick C.Long-term follow-up of technical
outcomes for incisional hernia repair. J Am Coll Surg. 2010;210(5):648–55.
4. Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J.Long-term follow up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg.
2004;240(4):578–83.
5. Luijendijk RW, Hop WC, van den Tol MP, etal. A comparison of suture repair with mesh
repair for incisional hernia. N Engl J Med. 2000;343(6):392–8.
6. Novitsky YW.Chapter 19: Umbilical hernia repair: the spectrum of management options. In:
Hernia surgery current principles. Cham: Springer; 2016. p.199–202.
7. Novitsky YW.Chapter 19: Umbilical hernia repair: the spectrum of management options. In:
Hernia surgery current principles. Cham: Springer; 2016. p.202–3.
8. Khan RMA, Bughio M, Ali B, Hajibandeh S, Hajibandeh S.Absorbable versus non- absorbable
tacks for mesh xation in laparoscopic ventral hernia repair: a systematic review and metaanalysis. Int J Surg. 2018;53:184–92. https://doi.org/10.1016/j.ijsu.2018.03.042. Epub
2018 Mar 22.
9. Muysoms F, Vander Mijnsbrugge G, Pletinckx P, etal. Randomized clinical trial of mesh xation with “double crown” versus “sutures and tackers” in laparoscopic ventral hernia repair.
Hernia. 2013;17:603–12.
10. Schoenmaeckers EJP, Wassenaar EB, Raymakers JT, Rakic S.Bulging of the mesh after laparoscopic repair of ventral and incisional hernias. J Soc Laparoendosc Surg. 2010;14:541–6.
https://doi.org/10.1007/s10029- 013- 1084- 9.
436
https://t.me/med1917
11. Tse GH, Stutcheld BM, Duckworth AD, de Beaux AC, Tulloh B.Pseudo-recurrence following laparoscopic ventral and incisional hernia repair. Hernia. 2010;14:583–7. https://doi.
org/10.1007/s10029- 010- 0709- 5.
12. Clapp ML, Hicks SC, Awad SS, etal. Trans-cutaneous Closure of Central Defects (TCCD)
in Laparoscopic Ventral Hernia Repairs (LVHR). World J Surg. 2013;37:42–51. https://doi.
org/10.1007/s00268- 012- 1810- y.
13. Martin-del-Campo LA, Miller HJ, Elliott HL, etal. Laparoscopic ventral hernia repair with
and without defect closure: comparative analysis of a single-institution experience with 783
patients. Hernia. 2018;22:1061–5.
14. Nguyen D, Szomstein S, Ordonez A, Dip F, Rajan M, Menzo EL, Rosenthal RJ.Unidirectional
barbed sutures as a novel technique for laparoscopic ventral hernia repair. Surg Endosc.
2016;30(2):764–9.
15. Orenstein SB, Dumeer JL, Monteagudo J, Poi MJ, Novitsky YW.Outcomes of laparoscopic
ventral hernia repair with routine defect closure using “shoelacing” technique. Surg Endosc.
2011;25:1452–7.
16. Novitsky YW.Chapter 19: Umbilical hernia repair: the spectrum of management options. In:
Hernia surgery current principles. Springer.: Cham; 2016. p.233–8.
17. Earle D, Roth JS, Saber A, etal. SAGES guidelines for laparoscopic ventral hernia repair. Surg
Endosc. 2016;30:3163–83.
18. See CW, Kim T, Zhu D.Hernia mesh and hernia repair: a review. Eng Regen. 2020;1:19–33.
https://doi.org/10.1016/j.engreg.2020.05.002.
19. Kalaba S, Gerhard E, Winder JS, Pauli EM, Haluck RS, Yang J.Design strategies and applications of biomaterials and devices for hernia repair. Bioact Mater. 2016;1(1):2–17.
20. Agarwal BB, Agarwal KA, Mahajan KC. Prospective double-blind randomized controlled
study comparing heavy- and lightweight polypropylene mesh in totally extraperitoneal repair
of inguinal hernia: early results. Surg Endosc. 2009;23:242–7.
21. Ayuso SA, Aladegbami BG, Kercher KW, Colavita PD, Augenstein VA, Heniford BT.Coated
polypropylene mesh is associated with increased infection in abdominal wall reconstruction. J
Surg Res. 2022;275:56–62. https://doi.org/10.1016/j.jss.2022.01.027. Epub 2022 Feb 24.
https://doi.org/10.1007/s00464- 015- 4275- x. Epub 2015 Jun 24
https://doi.org/10.1007/s10029- 018- 1812- 2.
https://doi.org/10.1007/s00464- 016- 5072- x.
P. McCarty and A. M. Coker
Advanced Techniques inVentral Hernia
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Repair: Retromuscular Mesh Placement
andMyofascial Releases
CarolineG.Porter andVahagnC.Nikolian
1 Preoperative Evaluation andPreoperative Pathways
Postoperative success in hernia repair often hinges on thoughtful preoperative planning. Patients commonly present with a variety of symptoms which can range from
functional limitations related to the hernia to gastrointestinal complications. It is
vital to perform a thorough review of their medical and surgical history in order to
appropriately risk-stratify patients and to determine if further optimization of modiable risk factors is necessary. Optimization may provide an opportunity to enhance
outcomes and overcome the vicious cycle of hernia recurrence that many patients
nd themselves within, particularly those undergoing complex reconstruction of the
abdominal wall or presenting with multi-recurrent hernias [1]. Preoperative optimization is often a multi-disciplinary endeavor and requires patience by both the surgeon and the patient. Factors such as poorly controlled diabetes, active smoking,
and morbid obesity have all been associated with higher rates of perioperative complications, which may contribute to the burden of recurrence, and are key endpoints
in preoperative optimization programs for many hernia centers.
While optimizing risk factors for surgery, it is imperative to review the patient’s
surgical history to understand the impact prior operations may have had on the
operative approaches available for hernia repair. Review of surgical records, in particular if prior hernia repairs have been performed, will clue a surgeon into specic
C. G. Porter
Oregon Health & Science University, Portland, OR, USA
e-mail: portecal@ohsu.edu
V. C. Nikolian (*)
Hernia & Abdominal Wall Center, Department of Surgery, Oregon Health & Science
University, Portland, OR, USA
e-mail: nikolian@ohsu.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_37
437© The Author(s), under exclusive license to Springer Nature
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challenges that may be encountered during the next hernia repair attempt. Finally,
review of cross-sectional imaging is often necessary to evaluate intraabdominal and
hernia anatomy, to understand neurovascular injuries to the abdominal wall, and to
determine safe approaches for repair.
Many hernia centers are now utilizing enhanced recovery protocols to standardize
patient care and reduce variation in outcomes. Preoperative management of patients
includes giving oral acetaminophen, celecoxib, and gabapentin, and administering
DVT prophylaxis. Epidurals and regional blocks (e.g., erecter spinae catheters, transversus plane blocks) are utilized selectively. The next sections will review advanced
techniques in the repair of complex ventral hernias. Though the focus will primarily
be for the open approach, it should be noted that these reconstruction techniques are
now performed via endoscopic, laparoscopic, and robotic-assisted approaches.
C. G. Porter and V. C. Nikolian
2 Retrorectus Repair
Retrorectus ventral hernia repair, which is derived from techniques popularized by
Rives and Stoppa for giant prosthetic reinforcement of the visceral sac, has long
been considered the standard by which all ventral hernia repairs are measured [2].
This repair utilizes mesh placed in a sublay position between the rectus abdominis
muscle and the posterior rectus sheath [3].
The patient is placed supine with arms abducted. The abdominal wall is widely
prepped and draped with the use of an iodine-impregnated antimicrobial drape. The
boney prominences and prior scars are all marked and the operation is initiated via
a midline laparotomy. It is imperative to review the cross-sectional imaging preoperatively to identify safe entry points into the abdominal cavity. Upon identication
of the anterior fascia, Kocher clamps are placed on the fascia and the linea alba is
incised. We favor entering the abdomen cephalad to the defect to allow for entry into
the natural preperitoneal fat pad associated with the falciform ligament, however
other entry points may be utilized for patients with prior laparotomy scars that
extend to the xiphoid process. The incision is extended and the abdominal cavity is
entered. A thorough lysis of adhesions is performed of the viscera to the anterior
abdominal wall. For patients who are presenting with chronic bowel obstructions
independent of the hernia sac, it is important to thoroughly lyse all adhesions to
assure no points of obstructions are missed. Bowel resections may be required and
do not preclude the possibility of performing a concurrent abdominal wall reconstruction [4]. It is vital to ensure all adhesive attachments to intraabdominal viscera,
including the liver, are released, to minimize complications from myofascial release.
Upon completion of adhesiolysis, abdominal wall reconstruction will be initiated. The viscera are protected by using a moistened extra-large countable towel
that is placed to span both pericolic gutters transversely and extended from the
subxiphoid to the suprapubic space. Upon excluding the viscera, a retromuscular
dissection is initiated. Kocher clamps are applied to the linea alba and hernia sac
medially and the surgeon works on the contralateral retrorectus dissection. The posterior sheath is grasped with toothed forceps and retracted away from the muscle
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belly. Electrocautery is used to incise the posterior sheath roughly 1cm from the
linea alba (Fig.1). Upon identifying the underside of the rectus abdominis, the surgeon will transition to a dissecting instrument to expose the posterior sheath, retracting it away from the muscle, allowing the assistant to open the plane using
electrocautery. The posterior sheath is dissociated from the linea alba along the
length of the laparotomy. Care is taken to ensure that the entire length of the hernia
defect is fully addressed. Next, Kocher clamps are applied to the cut edge of the
posterior sheath to allow for counter-traction of the tissue from the anterior sheath
and rectus muscle complex. The areolar tissue plane is exposed and dissected, taking care to avoid injury to the neurovascular bundles and epigastric vasculature. The
retrorectus dissection is extended to the semilunar line, which is identied by the
neurovascular bundles and which marks the lateral extent of a standard retrorectus
repair. A comparable dissection is completed on the contralateral retrorectus space.
Unication of the retrorectus dissection across the linea alba is then accomplished both cephalad and caudad to the defect. For centrally located hernias, this
frequently means incising the posterior sheath and entering the preperitoneal space
associated with the falciform ligament. However, for hernias that extend to the
xiphoid process, this will often require a preperitoneal dissection that extends to the
subdiaphragmatic space and exposes the central tendon of the diaphragm (Fig.2).
Fig. 1 Entry into the
retrorectus space. The
dotted line denes the cut
edge of the posterior rectus
sheath, lateral to the
linea alba
Fig. 2 Subdiaphragmatic
dissection extending to the
central tendon of the
diaphragm (arrow head) in
a patient with a subxiphoid
hernia related to prior
sternotomy
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C. G. Porter and V. C. Nikolian
Caudad, the dissection will usually enter the retropubic and retroinguinal preperitoneal compartment and expose the myopectineal orices bilaterally (Fig.3). Upon
completion of the retrorectus dissection, tension related to closure of both the posterior and anterior fascial layers is assessed. Myofascial advancement is considered
when the anterior fascia is unable to be closed without undue tension. For posterior
sheath defects with tension that would preclude safe closure, autologous tissue (e.g.,
omentum, hernia sac), absorbable coated meshes, and other techniques have been
described. In general, myofascial releases should be avoided for the sake of reapproximating posterior fascial defects.
Upon completion of the dissection, the abdominal wall closure is initiated. The
posterior sheath is rst addressed. Some surgeons will advocate for reapproxmiation of the medial edges of the posterior sheaths to one another, while others will
close the peritoneum centrally. Regardless, the visceral sac should be closed and
inspected for any fenestrations. We will typically use a braided polyglactin suture or
an absorbable barbed suture on a small-bore needle to close the posterior sheath and
visceral sac (Fig. 4). Small fenestrations are typically closed with interrupted
stitches in a gure-of-eight fashion. Prior to completion, the previously placed
Fig. 3 Unication of the
inferior retrorectus
dissections and access to
the retropubic space in a
patient with a suprapubic
incisional hernia. The
midline pubis is identied
with the arrowhead
Fig. 4 Closure of the
posterior sheath and
visceral sac following
robotic transversus
abdominis release. The
edge of the left posterior
rectus sheath is identied
with the dotted line and is
being reapproximated to
the right posterior sheath
using a barbed suture
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countable towel is removed. Upon closure of the visceral sac, the retromuscular
space is irrigated with saline and hemostasis is achieved. Antibiotic solutions are
sometimes used by surgeons, though data related to the efcacy of antibiotic irrigation is limited [5]. The space is measured and a macroporous polypropylene mesh
is cut to accommodate the entire retromuscular dissection. Mesh xation strategies
are well described and included the use of quilting sutures, transfascial sutures, and/
or chemical xation with brin sealants [6]. We prefer the efciency of brin sealants, which we apply as an epoxy to the mesh-visceral sac complex, thereby fortifying the closure and theoretically ofoading tension that may result in posterior
sheath dehiscence (Fig.5). Closed suction drains can be utilized selectively for the
retrorectus space, with the author’s preference being 19-French channel drains that
are passed through the abdominal wall with a trocar. The drain serves to reduce the
potential of a retained hematoma and increases the mesh-tissue interface in the early
postoperative period.
Next, the anterior sheath and linea alba are reconstructed. Prior to fascial closure,
Kocher clamps are applied to the diastatic tissue and hernia sac. The assistant will
retract these Kochers anteriorly and the linea alba is identied. Electrocautery is
used to excise the poor-quality tissue (Fig.6). A similar process is completed on the
Fig. 5 Retromuscular
mesh placement and
application of brin sealant
following robotic
transversus abdominis
release
Fig. 6 Excision of
diastatic fascia and hernia
sac prior to closure of the
midline anterior fascia.
The dotted line identies
the linea alba
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