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E. Iqbal et al.
linked to advanced age, denervation (shingles, polio), or chronic illness. Posterior
surgical approaches to kidney and adrenal, spine, and aortic surgery may lead to true
incisional ank hernias or cause eventration from denervation. Patients with denervation injuries should be appropriately counseled preoperatively about the change
that even after repair, there will be some residual bulging in their ank.
3.4.4 Presentation andRadiology
The most commonly presenting symptoms of lumbar hernias are bulge and pain.
Valsalva and spine exion may help reveal a lumbar hernia on a clinical exam.
Being a rare clinical entity, lower back pain in these patients will often be attributed
to musculoskeletal or spine pathology, and bulging on a physical exam can be confused with a soft tissue mass. Direct contact with the 12th rib and ballooning of
overlying latissimus dorsi are pathognomonic for a superior lumbar hernia, while an
inferior lumbar hernia directly contacts the iliac crest and has no overlying latissimus muscle.
Point of care dynamic sonography with a 12-MHz linear probe can be useful in
experienced hands, but the gold standard of lumbar and ank hernia imaging
remains computed tomography. Disruption of myofascial layers will be evident in
true hernias (as opposed to eventration) (Figs.2 and 3), particularly compared with
the contralateral intact side. Cross-sectional imaging should be used liberally for
preoperative planning. A non-contrast CT scan will comprehensively describe the
hernia morphology and dimensions, adjacent critical structures, estimate the volume of herniated content and presence of loss of domain (LOD), identify concomitant remote fascial defects, thickness of preperitoneal plane, adhesions, old mesh,
the necessary extent of mesh overlap and xation. Physical exam adds invaluable
information supplementing cross-sectional anatomy, such as the incarceration of
Fig. 2 Example of a left
sided ank eventration
with a defect between the
lateral edge of the rectus
and the medial edge of the
internal oblique and
transversus abdominis. The
external oblique is intact
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Fig. 3 Example of a true
large right side ank hernia
with chronically
incarcerated viscera
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hernia content, compliance of the abdominal wall, presence of an atrophic scar that
might need excision, and other potential soft tissue work. It is important to remember that lateral hernias, particularly originating from oblique or transverse incisions
(such as Chevron), often appear on axial CT sections more challenging in terms of
approximation of fascial edges, but intraoperatively can be closed without excessive
tension in the transverse direction.
The combination of the factors listed above help to determine the nal surgical
plan, whether it is purely minimally-invasive repair, hybrid approach, or open.
3.5 Operative Approaches
3.5.1 Minimally Invasive Approach
Patient Positioning
Patients are placed in a semi-lateral decubitus position with various degrees of axial
bed tilt (Fig.4). Knees are exed and separated by pillows. Thighs, legs and chest
straps are used. A vacuum bean bag may be helpful for securing the intended position. Both arms are exed and separated by pillows, with elbows slightly exed as
well and strapped to the exed upward armrest with gauze roll and tape. An axillary
roll is used. We don’t recommend exing (breaking) the OR table at the level of
patient hip as it increases the distance between iliac crest and costal margin, making
fascial approximation more difcult. However, a kidney rest may be helpful. All
bony prominences should be padded. The entire abdomen (table to table) should be
prepped, paying particular attention to prep the back well beyond the hernia extent
if hybrid repair will be necessary. Adhesive antimicrobial drapes such as Ioban™
may be considered.
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Fig. 4 Lateral decubitus
positioning for ank hernia
repair. (Source: Beffa etal.
[11])
E. Iqbal et al.
Approach
The most commonly used minimally invasive approaches to repair ank hernias are
the transabdominal preperitoneal (TAPP) repair or the enhanced totally extraperitoneal (eTEP) repair. The choice of access depends on anticipation of extensive intraabdominal adhesions and quality of peritoneum. The most thin and vulnerable
peritoneum with minimum preperitoneal fat typically covers the posterior rectus
sheath, and the layer of preperitoneal fat becomes thicker lateral to the semilunar
line. If intended mesh overlap does not need to cross linea semilunaris, the TAPP
may be a reasonable and easily reproducible approach.
In our practice, as with many others, these operations are done on the robotic
platform, which provides superior visualization, precise dissection and enhanced
wrist articulation compared to laparoscopy.
Robotic Transabdominal Preperitoneal Repair (TAPP)
Once the patient has been positioned and prepped as above, our preference is to
enter with a cut down at the umbilicus and place an 8mm port. Two 8mm ports are
then placed above and below the umbilicus, either through or just lateral to the midline. The robotic platform is docked. The defect is visualized and fully reduced. To
start the dissection, the peritoneum is incised at least 5cm medial to the defect. As
the dissection is carried out laterally, the colon is mobilized from a lateral to medial
direction. This dissection is carried out to the posterior pararenal space leaving the
quadratus lumborum covered by an anterior leaet of thoracolumbar fascia, until
the medial border of the psoas is reached. Care should be taken to identify and protect the ureter and gonadal vessels, which run along the medial border of the psoas.
The ilioinguinal, iliohypogastric, genitofemoral and lateral femoral cutaneous
nerves will be running along the QL and psoas and should be left in their investing
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fascia. Superiorly, the preperitoneal dissection is carried to below the costal margin.
Inferiorly, the dissection enters the space of Retzius and Cooper’s ligament and the
iliopubic tract are identied. Once a sufcient pocket is created, a mesh is placed in
the preperitoneal space; it should drape across the psoas. Our preference is to secure
it sparingly with interrupted vicryl sutures to the lateral abdominal wall as well as
brin sealant. In general, the viscera will act to hold the mesh in place in this location, and one must be careful to avoid nerve entrapment with xation. A drain is not
usually used. The peritoneum is then closed over the mesh, and any defects in the
peritoneum closed to prevent internal herniation.
Robotic eTEP/Tranvsersus Abdominis Release (TAR)
A robotic eTEP/TAR procedure is a good choice for a ank hernia that extends into
either the rectus abdominis compartment or has an associated midline hernia component. A 5mm optical trocar is used to enter the contralateral retro rectus space.
Blunt dissection is used to complete the retro-rectus dissection and two other 8mm
robotic ports are placed in the contralateral retro rectus space, just medial to the
semilunar line. The 5mm optical trocar port is upsized to a robotic 8mm port and
the robot docked. The posterior sheath is incised just medial to the linea alba until
the preperitoneal fat is identied. The preperitoneal space is bluntly dissected until
the ipsilateral (side with the hernia) posterior sheath is identied. This is incised,
exposing the underlying rectus abdominis muscle (“cross-over maneuver”). This
incision is expanded in the cranial and caudal directions. The retro-rectus space is
then dissected superiorly to the sub-xyphoid space, inferiorly into the space of
Retzius, and laterally to the semilunar line. It is important to identify and preserve
the neurovascular bundles that pierce the posterior rectus sheath just medially to the
semilunar line. Once the retro-rectus dissection is complete, the transversus abdominis release is begun. The posterior sheath is incised just medial to the semilunar
line, exposing the underlying transversus abdominis (TA) muscle. This is easiest at
the costal margin, where the transversus abdominis muscle is most medial and easily identiable. The TA muscle is exposed and transected from the costal margin to
the arcuate line. Using a combination of blunt dissection and electrocautery, the
space between the TA muscle and its underlying transversalis fascia is created. This
plane is extended posteriorly laterally into the retroperitoneum up to the medial
border of the psoas. Just as with the TAPP dissection, the critical structures of the
retroperitoneum, including the ureter and various neurovascular structures, must be
identied and preserved. Once the dissection is complete, the defect is closed with
a running barbed suture. A mesh is placed in the retroperitoneum and secured sparingly with vicryl sutures to the lateral abdominal wall as well as brin sealant. For
larger ank hernias, we prefer to use a heavyweight polypropylene mesh. The peritoneum is then closed over the mesh and all associated defects closed as well. When
the patient is rolled into the supine position the viscera will hold the mesh in place
as well. Depending on the size of the defects, patients can either go home the same
day or be admitted for pain control.
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Open
Patients are placed supine within a decubitus or semi-lateral position. If a patient
has a previous ank incision, the previous incision is opened. Otherwise, a transverse incision is made 2–3 cm cephalad to the ASIS.Dissection is taken down
through the skin and soft tissue to the external oblique, which is frequently intact in
these types of hernias. It is incised in the direction of its bers to reveal the underlying hernia. If there is a hernia sac it is sharply entered and all contents reduced. A
localized lysis of adhesions is performed. With the surgeon facing the lateral
abdominal wall, the preperitoneal plane is entered and the dissection taken posterolaterally into the retroperitoneum until the medial border of the psoas is identied.
This blunt dissection is carried superiorly below the costal margin and inferiorly to
enter the Space of Retzius. In a male the spermatic cord is identied and preserved,
while in a female the round ligament is ligated to create a more contiguous space for
the mesh. The surgeon then stands on the opposite side of the table. The medial dissection is the most difcult portion of this case, because the peritoneum is very thin
overlying the rectus muscle. If possible, the preperitoneal dissection is continued
medially towards the linea alba. If the peritoneum becomes too thin, ideally transition into the pretransversalis plane is preferred to completing a “reverse TAR”,
which is technically very difcult and carries a high risk of injury to the neurovascular bundles. Once a large enough ap is created, the posterior sheath and all associated defects are closed. Our preference is to use a heavyweight polypropylene
mesh in this space; it should lay well below the costal margin superiorly and into the
space of Retzius inferiorly. We prefer xation with brin sealant rather than sutures
for this repair. A drain can be placed atop the mesh. The layers of the abdominal
wall are then closed in layers using a #1 slowly absorbable suture. A binder is
encouraged after the surgery. Patients are admitted for pain control.
Hybrid Approach
There are situations when it may be challenging to reach the posterior pararenal
space via an MIS approach, for instance, when the trocars have to be placed through
the rectus contralateral to the hernia. This may be needed with the eTEP approach
to address a midline hernia component as well as a lateral ank hernia. In these
instances, to avoid placing an additional set of more lateral trocars and redocking,
most posterior dissection can be accomplished by making a limited incision over the
posterior extent of ank hernia. Fascial closure starts via the MIS approach in the
medial to lateral direction and is continued in the open fashion after mesh is unrolled
to the psoas muscle.
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Outcomes
Due to the rarity of true lumbar hernias, reported data on outcomes of surgical repair
is scarce. In open series, recurrence rate is quoted as high as 16%, while in an MIS
series the recurrence rate is 3% [11]. Similar to other types of herniorrhaphies, MIS
lumbar hernia repairs also achieve shorter lengths of hospitalization and lower overall rate of complications [11, 12]. In a recent database study comparing open to
robotic ank hernia repairs, Pereira etal. found a reduced length of stay and postoperative complications associated with a robotic repair, although the robotic repairs
did take longer [12].
4 Conclusions
Flank hernias are rare entities which require thoughtful pre-operative planning with
cross-sectional imaging and excellent understanding of anatomy. Proper patient
positioning is important and the hybrid approach is often necessary. Lumbar hernias
share the same principles of repair as other off-midline hernias and extensive sublay
mesh overlap for visceral sac reinforcement is the key for durable repair.
References
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affecting abdominal core health. Hernia. 2023;27:415–21.
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4. Webber V, Low C, Skipworth RJE, Kumar S, de Beaux AC, Tulloh B.Contemporary thoughts
on the management of Spigelian hernia. Hernia. 2017;21:355–61.
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embryology, and technique of repair. Am Surg. 2006;72:42–8.
6. Larson DW, Farley DR.Spigelian hernias: repair and outcome for 81 patients. World J Surg.
2002;26:1277–81.
7. Moreno-Egea A, Carrasco L, Girela E, Martin JG, Aguayo JL, Canteras M.Open vs laparoscopic repair of spigelian hernia: a prospective randomized trial. Arch Surg. 2002;137:1266–8.
8. Ruiz de la Hermosa A, Amunategui Prats I, Machado Liendo P, Nevarez Noboa F, Munoz
Calero A.Spigelian hernia. Personal experience and review of the literature. Rev Esp Enferm
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10. Huntington CR, Augenstein VA.Laparoscopic repair of ank hernias. In: Novitsky Y, editor.
Hernia surgery. Cham: Springer; 2016.
11. Beffa LR, Margiotta AL, Carbonell AM.Flank and lumbar hernia repair. Surg Clin North Am.
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12. Pereira X, Lima DL, Huang LC, Salas-Parra R, Shah P, Malcher F, Sreeramoju P. Robotic
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E. Iqbal et al.
Part VIII
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Hepatobiliary Pancreas Surgery
Hepatic Procedures
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AntonyHaddad andTimothyE.Newhook
1 Introduction
Hepatectomy is often the only potential for cure for patients with hepatobiliary
malignancies, may prevent malignant transformation for those with premalignancies, or provide symptomatic relief for patients with benign lesions. With an increase
in rates of hepatectomy over the years [1], the performance of safe and efcient
liver-related procedures is of utmost importance. A critical aspect of operative
safety is preoperative preparation, mastery of hepatobiliary anatomy, patient medical optimization, and an absolute understanding of the pathology being addressed
with hepatectomy [2–4]. In this chapter, we describe and illustrate the overall performance of foundational liver surgery techniques that should be helpful for training
and practicing liver surgeons.
2 Incision andExposure
Incision and exposure are critical for liver operations. The modied Makuuchi incision provides wide exposure and view of important structures in the right and left
liver (Fig.1a) [5]. Other benets of this incision are it does not violate the intercostal nerves by remaining within dermatomal distributions, decreasing post-operative
pain and muscle atrophy. Optimal exposure can be achieved by strategically placing
A. Haddad · T. E. Newhook (*)
Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center,
Houston, TX, USA
e-mail: TNewhook@mdanderson.org
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_39
461© The Author(s), under exclusive license to Springer Nature
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A. Haddad and T. E. Newhook
ab
Fig. 1 (a) Modied Makuuchi incision (b) Exposure technique using the retractors
the retractors (Fig. 1b) [5]. It is critical to recognize that adequate exposure is
required for safe hepatectomy, and inadequate exposure is often a component of
intraoperative complications and difculty with steps of hepatic procedures.
3 Intraoperative Ultrasound
Methodological understanding and consistent use of intraoperative ultrasound
(IOUS) is critical for hepatobiliary surgeons to examine intrahepatic anatomy, plan
surgical margins, and create an intraoperative map of the liver that matches preoperative imaging. Initial IOUS steps are aimed at orientation with the intrahepatic
anatomy through placing the ultrasound probe at 4 cardinal positions. Then, we use
the ultrasound not only to locate existing lesions known from preoperative imaging,
but also to look for radiologically occult lesions that may change operative plans. It
is essential to differentiate between portal triads and hepatic veins while using
IOUS; portal triads are encased with a hyperechoic sheath that is not present for
hepatic veins (Figs.2 and 3).
(a) Position 1: the IOUS probe is placed on the anterior surface of segment VIII of
the liver. With careful rotation and translocation, the hepatic veins are identied
as they converge into the inferior vena cava (Fig.2).
(b) Position 2: Once the hepatic veins are identied in position 1, the probe is
rotated or translocated caudad to identify the right anterior and posterior portal
vein branches, and their anatomical location relative to the right and middle
hepatic veins (Fig.3).
(c) Position 3: after identifying the right anterior and posterior portal veins, the
ultrasound probe is translocated along the course of the right portal vein to
identify the portal vein bifurcation (Fig.4).
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