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Fig. 7 Closure of anterior
rectus sheath at midline
and reconstruction of linea
alba. This is performed
following excision of the
hernia sac, allowing for
approximation of healthy
fascial edges
C. G. Porter and V. C. Nikolian
other side. In scenarios with large midline scars, the skin is excised concurrently
with the hernia sac. The anterior sheath is then reapproximated with a running
suture technique using either 0- or #1 monolament slow absorbing suture (e.g.,
Polyglycolide-trimethylene carbonate) (Fig.7). In scenarios with more tension, we
have a low threshold to close the anterior fascia with interrupted gure-of-eight
stitches which will allow for sequential closure of the abdominal wall. The subcutaneous tissues and dermis are closed with interrupted stitches using fast absorbing
multilament materials. A subcutaneous 15- or 19-French channel drain is often
placed in the subcutaneous tissue to prevent seroma formation. The skin is closed
with a running slow absorbing 4-0 barbed suture and skin glue. An abdominal
binder is applied and the patient is extubated.
3 Myofascial Advancement Techniques
In patients presenting with larger hernias, a retrorectus dissection alone is inadequate to achieve a tension-free abdominal wall closure that will restore anatomy and
improve functional outcome. In these scenarios, surgeons will utilize a variety of
techniques to reconstruct the linea alba. Though many techniques exist, lateral myofascial release, either with external oblique release or transversus abdominis release,
is the most well described.
4 External Oblique Release
An external oblique release may be performed with or without a concurrent retrorectus dissection. If a surgeon anticipates that a retrorectus dissection may be inadequate, a proactive approach, exclusively utilizing an external oblique release
Advanced Techniques in Ventral Hernia Repair: Retromuscular Mesh Placement…
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procedure, may be advantageous. This will preserve the retromuscular plane for
future reconstruction procedures should the patient have a hernia recurrence.
Following laparotomy and lysis of adhesions, lipocutaneous aps are developed
along the anterior rectus sheath circumferentially around the hernia defect. These
aps are dissected laterally until just beyond the semilunar line.
Anterior component separation technique is performed by rst incising the external oblique aponeurosis roughly 1–2cm lateral to the semilunar line. The aponeurosis can be released from the costal margin to the inguinal ligament. Next, the
external oblique muscle is transected and the plane between the underside of the
muscle and the posterior lamella of the external abdominal oblique aponeurosis is
developed laterally. A comparable dissection may be performed on the other side.
Once completed, the fascia can be reapproximated and an onlay macroporous polypropylene mesh is placed on the anterior fascia. Fixation is again achieved with the
techniques described above. Given the large size of the skin aps developed, multiple subcutaneous drains will be placed to minimize the consequences of seromas.
If an anterior component separation is used in conjunction with a retrorectus dissection, the surgeon may opt to have the mesh placed in the retrorectus space.
However, if such a technique is used, it would be worthwhile to consider perforator
preserving strategies in performing an anterior component separation [7]. This technique is well described but beyond the scope of this review.
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5 Transversus Abdominis Release
The techniques of retrorectus repair and anterior component separation via external
oblique release served as the basis of abdominal wall reconstruction for decades.
Each was associated with various shortcomings that made them less than ideal and
led to limited adoption among general surgeons. Retrorectus repairs, though effective for smaller and moderate sized defects, lacked sufcient myofascial advancement to be used in larger defects. Meanwhile, anterior component separation was
associated with high rates of wound complications as a result of the lipocutaneous
aps developed in order to release the external oblique. Ventral hernia repair with
posterior component separation, via transversus abdominis release, has emerged as
the modern-day work-horse for abdominal wall reconstruction. This technique
developed by Novitsky etal. [8] has been disseminated broadly as a result of encouraging outcomes that appear to minimize short term complications while achieving
reproducible long term results related to hernia recurrence and patient reported
quality of life.
Performing a transversus abdominis release can be considered a natural continuation of a standard retrorectus repair. Upon completion of the lateral retrorectus
dissection and identication of the semilunar line, the surgeon should assess the
tension on the anticipated closure. If the tension is felt to be excessive, a transversus
abdominis release may be considered. Unlike the other muscles of the lateral side
wall, the transversus abdominis will extend medial to the semilunar line in the
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C. G. Porter and V. C. Nikolian
cephalad aspect of the abdominal wall, interdigitating with the diaphragm, and
inserting to the edge of the costal margin and the xiphoid process (Fig.8). By taking
advantage of this consistent abdominal wall anatomy, one is able to successfully
release the muscle and achieve myofascial advancement without disrupting neurovascular bundles or the semilunar line.
To accomplish this, the posterior lamella of the internal abdominal oblique aponeurosis is identied and incised medial to the neurovascular bundles, revealing the
underlying transversus abdominis muscle. The muscle is released by dividing it
along its medial edge, revealing the underlying transversalis fascia and peritoneum
(Fig.9). A combination of sharp and blunt dissection is used to develop the retromuscular dissection towards the lateral abdominal wall and the retroperitoneum.
The dissection is carried caudad until the preperitoneal fat is encountered in the
retropubic and retroinguinal spaces. The superior and inferior dissections are unied, similar to a traditional Rives-Stoppa retrorectus repair. Upon completion of the
dissection, a large retromuscular pocket has been developed that can span the spaces
Fig. 8 Right retrorectus
dissection in the cephalad
portions of the abdominal
wall. The posterior sheath
is identied and the
transversus abdominis
muscle is identied deep to
the sheath (arrow head)
Fig. 9 Left retromuscular dissection with performance of a transversus abdominis release. The
dotted line denes the lateral transected edge of the transversus abdominis muscle and the overlying posterior lamella of the internal abdominal oblique aponeurosis. The muscle is transected
medial to the lateral neurovascular bundles (arrow heads)
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dened by the psoas muscles posteriorly, the central tendon of the diaphragm cephalad, and the myopectineal orices inferiorly. This plane may be utilized to address
midline hernias, but can sufciently be developed to address ank, lumbar, inguinal,
and diaphragmatic defects as well.
Upon completion of the dissection, a similar approach to closure of the visceral
sac is used, as described above. Upon closure of the visceral sac, a large piece of
macroporous polypropylene mesh is introduced into the space to sufciently cover
the entire retromuscular space. In larger patients, or in scenarios where the manufactured mesh available is smaller in size, overlapping macroporous light-weight
and mid-weight meshes may be necessary. Anterior fascial closure and management
of the skin and soft tissue will often be similar to the techniques described above.
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6 Postoperative Care
Patients with larger hernias and loss of domain will need special intraoperative
monitoring of pulmonary dynamics to assess the risk for postoperative compartment syndrome, which may result in respiratory collapse [9]. This entity is rare but
can have catastrophic outcomes if not managed appropriately. For the vast majority
of patients, extubation at the completion of complex abdominal wall reconstruction
with myofascial advancement is safe. Enhanced recovery protocols with resumptions of diet, ambulation, and multi-modal pain management is common and allows
for most patients to be discharged within a week of the procedure [10, 11]. Drains
are removed when volume and quality criteria are met. Upon discharge, patients
will slowly resume activities of daily living, but will avoid strenuous activity for
months as the wounds heal.
7 Conclusions
Abdominal wall reconstruction has evolved signicantly as a function of an
increased appreciation for the complexity of the disease process and the need to
develop techniques centered around more durable outcomes. A new era in hernia
surgery is likely on the horizon as these techniques permeate through general surgical practices. Future work centered around hernia prevention strategies, mesh and
biomaterial analysis, minimally invasive techniques, and management of multirecurrent hernias will be imperative for the continued evolution of hernia surgery.
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C. G. Porter and V. C. Nikolian
References
1. Orenstein SB, Martindale RG. Enhanced recovery pathway for complex abdominal wall
reconstruction. Plast Reconstr Surg. 2018;142(3 Suppl):133S–41S.
2. Pauli EM, Rosen MJ.Open ventral hernia repair with component separation. Surg Clin North
Am. 2013;93(5):1111–33.
3. Parker SG, Halligan S, Liang MK, etal. International classication of abdominal wall planes
(ICAP) to describe mesh insertion for ventral hernia repair. Br J Surg. 2020;107(3):209–17.
4. Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ.Outcomes of synthetic mesh in
contaminated ventral hernia repairs. J Am Coll Surg. 2013;217(6):991–8.
5. Fatula LK, Nelson A, Abbad H, etal. Antibiotic irrigation of the surgical site decreases incidence of surgical site infection after open ventral hernia repair. Am Surg. 2018;84(7):1146–51.
6. Ellis RC, Petro CC, Krpata DM, etal. Transfascial xation vs no xation for open retromuscular ventral hernia repairs: a randomized clinical trial. JAMA Surg. 2023;158(8):789–95.
7. Elhage SA, Marturano MN, Prasad T, etal. Impact of perforator sparing on anterior component
separation outcomes in open abdominal wall reconstruction. Surg Endosc. 2021;35(8):4624–31.
8. Novitsky YW, Fayezizadeh M, Majumder A, Neupane R, Elliott HL, Orenstein SB.Outcomes
of posterior component separation with transversus abdominis muscle release and synthetic
mesh sublay reinforcement. Ann Surg. 2016;264(2):226–32.
9. Blatnik JA, Krpata DM, Pesa NL, etal. Predicting severe postoperative respiratory complications following abdominal wall reconstruction. Plast Reconstr Surg. 2012;130(4):836–41.
10. Sartori A, Botteri E, Agresta F, et al. Should enhanced recovery after surgery (ERAS) pathways be preferred over standard practice for patients undergoing abdominal wall reconstruction? A systematic review and meta-analysis. Hernia. 2021;25(2):501–21.
11. Wiener JG, Bellido D, Smolinsky T, etal. Retrospective evaluation of short-term outcomes of
an enhanced recovery protocol for patients undergoing complex abdominal wall reconstruction. J Am Coll Surg. 2022;235(5):764–71.
Off-Midline Hernia Repair
https://t.me/med1917
EmaadIqbal, ArtemShmelev, andDinaPodolsky
1 Introduction
Hernia repair is one of the most performed general surgery procedures in the world,
with approximately 611,000 ventral hernia repairs being completed annually in the
United States [1]. A well-done hernia repair can offer patients a vast improvement
in their quality of life and a return to normal function. The past decade has seen a
massive change within the eld of abdominal wall surgery, with new surgical techniques and technology allowing for complex repairs done via a minimally invasive route.
Off-midline hernias, as the name suggests, refers to any hernia that does not
include a defect through the linea alba. These include Spigelian and ank hernias,
of which lumbar hernias are included. Techniques to x off-midline hernias, like
any hernia, requires a comprehensive approach that considers the patient’s medical
and surgical history, the size and location of the defect, and the skill set available to
the surgeon. Many of these hernias can be xed via the robotic approach, which
allows for enhanced visualization and wrist articulation as compared to traditional
laparoscopy. Over the past decade there has also been a move towards extraperitoneal repair and mesh placement via the preperitoneal, retro-rectus, and retromuscular planes. This chapter will focus on the evaluation and treatment of off
midline hernias as well as their associated outcomes.
E. Iqbal · D. Podolsky (*)
Department of Surgery, Columbia University Medical Center, New York, NY, USA
e-mail: eji2109@cumc.columbia.edu; dp2957@cumc.columbia.edu
A. Shmelev
Department of Surgery, Stonybrook University Hospital, Stoney Brook, NY, USA
e-mail: artem.shmelev@stonybrookmedicine.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_38
447© The Author(s), under exclusive license to Springer Nature
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2 Principles ofRepair
Similarly to midline hernias, the goal of an off-midline hernia repair is the reduction
of herniated content, reapproximation of fascial edges, generous overlap of a sublay
mesh with or without xation, and sparing of adjacent critical anatomic structures.
We believe that high-risk patients (diabetics, smokers, obese patients and those who
are immunocompromised) benet from an MIS approach. An open approach is
often required for hernias with loss of domain, those who cannot tolerate prolonged
pneumoperitoneum, patients with extensive adhesions or a history of multiple failed
mesh repairs. A hybrid approach consists of combining both the MIS and open
approach; these are good options for patients with defects that require signicant
soft tissue work. Recovery of patients operated with a hybrid approach is typically
faster than that of those who undergo a purely open repair.
3 Spigelian Hernia
Spigelian hernia was rst described in 1764 by anatomist Joseph Klinkosch, named
after Adriaan van der Spieghel, a Flemish anatomist who rst described the anatomy of the semilunar line (or linea spigeli) over 100years ago [2, 3]. Spigelian
hernias are relatively rare, occurring in 0.12–0.2% of all hernias, and there is a 2:1
ratio between females to males [4]. Like other hernias, pathologies that either
increase intra-abdominal pressure or weaken the connective tissue increase the risk
of developing a hernia.
3.1 Clinical Presentation andEvaluation
Spigelian hernias can be difcult to appreciate on a physical exam due to the intact
anterior rectus sheath and external oblique, especially in patients with thick abdominal walls (Fig.1). Patients may present with pain or discomfort in their groin or
lower abdomen. A dynamic sonogram can be used as a rst line diagnostic tool. If
inconclusive, cross-sectional imaging, specically a non-contrast CT abdomen/pelvis, can help delineate the anatomy.
3.2 Anatomy
Spigelian hernias are a protrusion of preperitoneal fat or intra-abdominal contents
through a defect in the Spigelian aponeurosis. The Spigelian aponeurosis is formed
from the membranous portions of the internal oblique and transversus abdominis
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Fig. 1 Example of a right
sided spigelian with an
intact external oblique
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located laterally to the rectus abdominis and medially to the semilunar line [5]. They
are most often located in the so-called “Spigelian hernia belt”. This area starts at the
level of the umbilicus and extends inferiorly at the interspinous line, a horizontal
line between the right and left ASIS.The spigelian hernia belt encompasses the widest part of the spigelian aponeurosis and contains over 90% of all spigelian hernias [4, 5].
Defects in this spigelian fascia leads to an interparietal hernia, where hernia contents protrude through this posterior layer but are covered by an intact external
oblique (Fig.1). The interparietal nature of a spigelian hernia creates signicant
angulation of the herniated contents and increases the risk of strangulation or
obstruction [6]. As such, the diagnosis alone of a spigelian hernia is an indication
for repair [6].
3.3 Operative Approaches
3.3.1 Laparoscopic/Robotic Transabdominal Preperitoneal
Repair (TAPP)
Our preference for repair is a minimally invasive preperitoneal approach. The technique is the same either laparoscopically or robotically, and there has been no data
to suggest a clinical difference between approaches. The patient is placed supine
with their arms tucked. The abdomen is entered either with a 5mm optical trocar in
the left upper quadrant or with a cut down at the umbilicus. A total of three ports are
placed across the abdomen at or slightly above the level of the umbilicus and triangulated towards the defect. Any contents of the hernia are reduced. A preperitoneal
ap is then created to ensure at least 5cm overlap around the defect. It is easiest to
start medially at the medial umbilical ligament and work towards the anterior
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superior iliac spine. The medial dissection is completed rst, bluntly dissecting the
Space of Retzius until the pubic symphysis and Cooper’s ligaments are identied.
Laterally, the preperitoneal dissection is taken to the psoas muscle, and transitioning
into a pretransversalis plane is a common occurrence. The arcuate line can be
incised just medial to the semilunar line to create a large, more contiguous retromuscular space for the mesh. Once the preperitoneal ap has been created, the
defect is closed with a running barbed suture and appropriately sized mesh is placed
in the preperitoneal pocket. Our preference is to use a macroporous synthetic mesh.
The mesh is secured to the abdominal wall with interrupted vicryl sutures or with
brin sealant. The peritoneal ap is then closed over the mesh with a running v-loc
suture in robotic cases and absorbable tacks for laparoscopic cases. Any fenestrations in the peritoneal ap should be closed to avoid an internal hernia. These are
considered ambulatory procedures.
3.3.2 Open Repair
The patient is placed supine on the table with their arms out. A transverse or oblique
incision is made over the defect, which should be marked beforehand. The external
oblique is frequently intact over the hernia and will need to be incised in the direction of its bers. Once the external oblique is opened, the hernia contents are identied and reduced into the abdomen. The fascia edges are freshened up. The defect is
closed in layers, with the internal and transversalis fascia being closed together as
the rst layer, and the external oblique being the second. Our preference is to use a
slowly absorbable suture for closure. For defects that are two centimeters or less,
mesh does not have to be used, although a pre-operative discussion with patients
regarding recurrence should be had. For larger defects, a mesh can be placed either
between the internal and external oblique layers, or as an onlay. If an onlay mesh is
used, a subcutaneous ap is made 3–5 cm circumferentially around the defect.
Hemostasis must be meticulous. Our preference is to use a macroporous synthetic
mesh in these situations. The mesh is placed in an onlay position and must be well
secured with a combination of vicryl sutures or brin sealant. A drain should be
used for an onlay mesh and a binder to reduce the risk of seroma. As with the minimally invasive approach these are considered ambulatory procedures.
3.3.3 Outcomes
The most common adverse outcomes after spigelian hernia repair are hernia recurrence, seroma, hematoma, and infection, however the risk prole is low. Spigelian
hernias overall have a low rate of recurrence, with a rate of 0–5% being quoted in
the literature [7, 8]. There is a decreased length of stay and return to function with
an MIS repair [9].
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3.4 Flank Hernias
3.4.1 Nomenclature
From a surface anatomy standpoint, the ank is outlined by costal margin, iliac
crest, midclavicular line and paraspinal musculature. This region is often interchangeably referred to as “ank” or “lumbar”. However, the European Hernia
Society (EHS) distinguishes lumbar from ank hernias by the anterior axillary line.
These hernias represent a unique challenge to any surgeon, due to their anatomical
location and less frequent clinic presentation.
3.4.2 Relevant Anatomy ofPosterolateral Abdominal Wall
Almost all primary lumbar hernias originate in the superior (Grynfeltt-Lesshaft) or
inferior (Petit) triangles. The superior inverted triangle is present in 82% of people
and is outlined by the erector spinae and quadratus lumborum muscles medially, the
internal oblique laterally, and the 12th rib superiorly [10]. The transversus abdomi-
nis muscle forms its oor, and latissimus dorsi its ceiling. The inferior triangle is
outlined by latissimus dorsi medially, the external oblique laterally and the iliac
crest inferiorly. The oor of the inferior triangle is formed by the internal oblique.
As opposed to superior and inferior lumbar hernias, iatrogenic ank hernias are not
outlined by distinct anatomic structures and are mostly traumatic or incisional by
etiology.
The thoracolumbar fascia is a three-layered fusion of aponeurosis of latissimus
dorsi, internal oblique and transversus abdominis. Anterior to this deep fascia lies
the quadratus lumborum muscle, overwhich the subcostal, iliohypogastric, and ilioinguinal nerves pass en route to the anterior abdominal wall [10]. Supercial to the
quadratus lumborum is the kidney and adrenal glands covered in Gerota’s fascia
[10]. The ureter starts proximally within the renal hilum before muscle anteriorly
along the psoas, crossing under the gonadal vein and over the iliac vessels at their
bifurcation [10]. The medial extent of any sublay mesh placement is within posterior
pararenal space, between the posterior Gerota’s and innermost layer of thoracolumbar fascia. It is important to be cognizant of gonadal vasculature and ureter when
dissecting the mesh pocket medially to psoas. The lateral femoral cutaneous nerve
crosses lower on the surface of iliacus muscle. These nerves should be recognized if
attempting any penetrating mesh xation in that area and when closing the defect.
3.4.3 Epidemiology
Almost two-thirds of lumbar hernias are congenital and acquired primary, and the
majority of these will involve the inferior triangle [10]. These are associated with
chronically increased intra-abdominal pressure and local musculofascial weakness,
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