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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_842_Библиотеки_им_академика_М_И_Перельмана.pdf
280
U. A. Dietz and J. Bingener-Casey
25
Muysoms et al. (2009)
Subxiphoidal:M1
Epigastric: M2
M1
M2 L1
L1
L2 M3
L3
L2L3L4L4
M4
M5
Midline hernia
3cm
E H S
Incisional Hernia Classification
subxiphoidal
Midline
Recurrent incisional hernia? Yes O No O
epigastric
umbilical
Infraumbilical
suprapubic
subcostal
flank
Lateral
iliac
lumbar
Length: Widthcm cm
Width
cm
W1 W2 W3
<4cm
OOO
M1
M2
M3
M4
M5
L1
L2
L3
L4
≥4-10cm ≥10cm
Lateral hernia
L1: Subcostal
Umbilical: M3
Infraumbilical: M4
Suprapubic: M5
Width
Length
Lumbar: L4
3cm
3cm
E H S
Primary Abdominal Wall Hernia
Classification
Midline
Lateral
Epigastric
Umbilical
Spigelian
Lumbar
Diameter
cm
Small
<2cm
Medium
≥2-4cm
L2: Fianc
L3: Iliac
Large
≥4cm
3cm
Multiple hernia defects
. Fig.25.4 EHS Classication. Figure according to Muysoms etal. (2009). This is the classication recommended in
EuraHS [3] and by the current EHS guidelines (European Hernia Society) [16]
Classication ofVentral andIncisional Hernias
Recurrence rating Morphology Size Reducibility Risk factors
281
25
(New)
Recurrence
Postoperative
complications
[10]
[11]
[11]
[10]
[11]
[26]
[27]
[28, 30]
[19, 22, 23]
Influence on
surgical
procedure
[13]
2B
3
[11, 18]
2C
4
[19, 20]
[11, 18]
[19, 20]
[19]
For each available level of evidence, only one
circle is pictured, even if more than one
publication supports the respective evidence in
the same level.
Level of evidence
. Fig.25.5 Classication criteria for patient counseling (prognosis and postoperative complications) and planning of
OP strategy (From Ref. [16])
e International Endohernia Society (IEHS)
guidelines of 2013 devote a chapter to the topic of
classication [16]. e consensus among experts
is that ventral and incisional hernias must be classied in order to standardize the collection of data
and to facilitate individualized patient therapy
and comparison of data (statement level 5). e
IEHS recommends classication prior to surgical
therapy, intraoperatively immediately prior to the
surgical treatment (recommendation grade D)
according to the recommendation of the EHS classication (recommendation grade D) [10]. Data
from all ventral and incisional hernia patients
should be prospectively collected into a registry to
facilitate standardized evaluations. Examples [of
such registries] are the EuraHS (7 www.eurahs.
eu
), the registry of the EHS, and the Herniamed
Registry (7 www.herniamed.de) in Germany.
References
1. Loves C. Trends and pitfalls with nomenclatures
and classications in medicine. Into J Med Inform.
1998;52:141–8.
2. Popper K.Logik der Forschung. Wien: Julius Springer;
1935.
3. Museums FE, Deisenberg EB, Peters E, Agrestic F, Brevet F, Campanili G, etal. Recommendations for reporting outcome results in abdominal wall repair: results
of a consensus meeting in Palermo, Italy, 28-30 June
2012. Hernia. 2013;17:423–33.
4. Chute CG. Clinical classication and terminology:
some history and current observations. J Am Med
Inform Assoc. 2000;7:298–303.
5. Kennedy J, Kossmann CE.Nomenclatures in medicine.
Bull Med Libr Assoc. 1973;61:238–52.
6. Kumar A, Yip YL, Smith B, Marwede D, Novotny D.An
ontology for carcinoma classication for clinical bioinformatics. Stud Health Technol Inform. 2005;116:
635–40.
7. Chevrel JP, Rath AM.Classication of incisional hernias
of the abdominal wall. Hernia. 2000;4:7–11.
8. Korenkov M, Paul A, Sauerland S, Neugebauer E, Arndt
M, Chevrel JP, et al. Classication and surgical treatment of incisional hernia. Results of an experts´ meeting. Langebeck’s. Arch Surg. 2001;386:65–73.
9. Dietz UA, Hamelmann W, Winkler MS, Debus ES, Malafaia O, Czeczko NG, etal. An alternative classication
of incisional hernias enlisting morphology, body type
and risk factors in the assessment of prognosis and tailoring of surgical technique. J Plast Reconstr Aesthet
Surg. 2007;60:383–8.
10. Muysoms FE, Miserez M, Berrevoet F, Campanelli G,
Champault GG, Chelala E, et al. Classication of primary and incisional abdominal wall hernias. Hernia.
2009;13:407–14.
11. Breuing K, Butler CE, Ferzoco S, Franz M, Hultman CS,
Kilbridge JF, Rosen M, Silverman RP, Vargo D, Ventral
282
U. A. Dietz and J. Bingener-Casey
25
Hernia Working Group. Incisional ventral hernias:
review of the literature and recommendations regarding the grading and technique of repair. Surgery.
2010;148:544–58.
12. Dietz UA, Winkler MS, Härtel RW, Fleischhacker A,
Wiegering A, Isbert C, etal. Importance of recurrence
rating, morphology, hernial gap size, and risk factors
in ventral and incisional hernia classication. Hernia.
2012;18:19–30.
13. Dietz UA, Wiegering A, Germer CT.Indikationen zur
laparoskopischen Versorgung großer Narbenhernien.
Chirurg. 2014;86:338–45.
14. Sellers AH. The clinical classication of malignant
tumours: the TNM system. Can Med Assoc J. 1971;105:
836.
15. Payne PR, Mendonça EA, Johnson SB, Starren JB.Conceptual knowledge acquisition in biomedicine: a
methodological review. Biomed Inform. 2007;40:
582–602.
16. Bittner R, Bingener-Casey J, Dietz UA, Fabian M, Ferzli
G, Fortelny R, etal. Guidelines for laparoscopic treatment of ventral and incisional abdominal wall hernias
(international Endohernia society IEHS) part I. Surg
Endosc. 2013;28:2–29.
17. Conze J, Prescher A, Kisielinski K, Klinge U, Schumpelick
V.Technical consideration for subxiphoidal incisional
hernia repair. Hernia. 2005;9:84–7.
18. Losano JE, Basson MD, Laker S, Weiner M, Webber JD,
Gruber SA.Subxiphoid incisional hernias after median
sternotomy. Hernia. 2007;11:473–9.
19. Varnell B, Bachman S, Quick J, Vitamvas M, Ramshaw
B, Oleynikov D.Morbidity associated with laparoscopic
repair of suprapubic hernias. Am J Surg. 2008;196:983–7.
20. Höer J, Lawong G, Klinge U, Schumpelick V. Factors
inuencing the development of incisional hernia. A
retrospective study of 2,983 laparotomy patients over
a period of 10 years. Chirurg. 2002;73:474–80.
21. Klinge U, Si ZY, Zheng H, Schumpelick V, Bhardwaj RS,
Klosterhalfen B.Collagen I/III and matrix metalloproteinases (MMP) 1 and 13in the fascia of patients with
incisional hernias. J Investig Surg. 2001;14:47–54.
22. Sørensen LT, Hemmingsen UB, Kirkeby LT, Kallehave
F, Jørgensen LN.Smoking is a risk factor for incisional
hernia. Arch Surg. 2005;140:119–23.
23. Jenkins ED, Yom VH, Melman L, Pierce RA, Schuessler
RB, Frisella MM, etal. Clinical predictors of operative
complexity in laparoscopic ventral hernia repair: a prospective study. Surg Endosc. 2010;24:1872–7.
24. K linge U.Mesh for hernia repair. Br J Surg. 2008;95:539–40.
25. Dietz Dietz UA, Wiegering A, Germer CT.Eingrisspezische Komplikationen der Hernienchirurgie. Chirurg.
2014;85:97–104.
26. Dietz Dietz UA, Spor L, Germer CT.Therapie der Netz(Implantat) Infektion. Chirurg. 2011;82:208–17.
Perioperative
Management ofVentral
andIncisional Hernias
RudolfSchrittwieser
26.1 Part I–284
26.1.1 How IDo It–284
26.2 Part II: Scientic Evidence–284
References–285
283
26
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_26
284
R. Schrittwieser
26
26.1 Part I
26.1.1 How IDo It
For patients with small primary ventral hernias,
such as a small umbilical hernia or an epigastric
hernia, no specic preoperative preparation is
carried out. Any accompanying conditions, which
could have a possible inuence on the patient’s
suitability for surgery, are crucial. Aer relevant
examinations are performed, the patient is introduced to the anaesthetist, who assesses the
patient’s degree of tness to potentially undergo a
pneumoperitoneum.
In the case of small, primary ventral hernias,
without the presence of any accompanying illnesses, it is possible to perform surgery on a day
patient basis.
Larger ventral hernias and all incisional hernias are treated without exception on an inpatient
basis. With large hernias, it is advisable to undertake a lung function test, due to the fact that following the displacement of very oen quite
extensive hernia contents, postoperative pulmonary problems can result in patients who have no
previous pulmonary impairments. orough
breathing exercises, as part of the preoperative
preparations, can in many cases signicantly
improve the patient’s condition prior to surgery.
With very obese patients and the absence of
an incarceration trend as well as with complaints
only slightly linked to hernias, a preoperative
weight reduction is recommended. e patient
must however be informed about the higher perioperative risks concerning systemic as well as
local complications. Likewise smokers also need
to be informed about the higher risks of relapse,
and a preoperative period of abstinence from
smoking should be demanded.
Within the context of the initial examination,
particularly with very obese patients, a close skin
condition inspection should be performed in
order to be able to strive for an improvement
where necessary.
Patients who have hernias with loss of domain
represent special cases.
With the help of a preoperative progressive
pneumoperitoneum, it is sometimes possible to
achieve an enlargement of the abdominal cavity
in order to make displacement of the hernia contents feasible.
is method, however, involves a considerable
degree of complexity and is therefore only
employed in very special cases.
For all patients with ventral hernias and with
the implanting of meshes, we undertake a singleshot antibiotic prophylaxis, regardless of whether
an open or laparoscopic approach is used. Ideally
this should be given on the ward about 1h before
surgery.
romboembolic occurrences present particularly dicult perioperative complications. A
thrombosis prophylaxis with low-molecular heparin is given to all patients with risk factors at least
until their discharge from hospital or their full
rehabilitation. As rapid a postoperative rehabilitation as possible should be aimed for. Compression
stockings can be prescribed; however, many
patients are unable to tolerate wearing them, particularly during the summer months.
We provide an abdominal compression belt at
the operating table, above all with the aim of preventing the build-up of serum, which can occur
quite frequently. In the case of laparoscopic repair
and large hernias with open repair, we recommend to wear an elastic mieder for 6weeks.
e length of physical recuperation required
depends upon the size of the hernia. With large
hernias, it is advisable that patients avoid liing
heavy loads and general heavy physical activity
for approximately 6weeks. Regular, light physical
activity is of course permitted and required.
26.2 Part II: Scientic Evidence
In relation to the question of antibiotic prophylaxis in connection with ventral hernias, there is
very little literature available. Concerning inguinal hernia repair, there are several studies available. A recently published meta-analysis does not
support the routine use of antibiotic prophylaxis
in open mesh repair for inguinal hernia [1]. e
infection rate for laparoscopic ventral hernia
repair can be as much as 16% according to some
studies; however, it normally lies in the range
0.5–4%.
Rios etal. [2] showed, in a study published in
2001 about open ventral hernia operations, that
there are signicant advantages in using antibiotic
prophylaxis; however, the rate of infections was
recorded as 18.1%, which is rather high.
Perioperative Management ofVentral andIncisional Hernias
285
26
Likewise Abramov etal. [3] undertook a study
of 35 patients chosen at random, who had undergone open umbilical hernia and incisional hernia
surgery. is study considered the eectiveness of
preoperative an antibiotic prophylaxis using 1g of
cefonicid 30min before surgery.
e wound infection rate amongst the antibiotic group was 1in 17 patients, whilst the rate in
the nonantibiotic rate was 8 from 18. Also here
the infection rate amongst the nonantibiotic
group appears to be high.
In connection with wound infection, White
etal. [4] carried out a follow-up study of 250 hernia operations performed on a total of 206 patients
over a period of 14years. ey could not identify
any signicant impact caused by either administering an antibiotic prophylaxis or inserting a
wound drain.
Furthermore, there are a number of publications that acknowledge the routine use of an antibiotic prophylaxis. ey range from administering
amoxicillin (1 g) and clavulanic acid (200 mg)
before surgery and 8h following an operation [5]
up to administering a rst-generation cephalosporin at the time of the skin incision and a repeat
dose during operations that take longer than 2h
[6]. From these investigations, clear recommendations for or against the use of an antibiotic prophylaxis cannot be derived.
e increased intraperitoneal pressure and the
reverse Trendelenburg bed position could,
according to some studies, lead to a higher rate of
thromboembolic incidences in connection with
laparoscopic surgical interventions [7].
In an extensive study of laparoscopic surgery
and the incidences of thromboembolic complications, a total of 2384 patients were examined [8].
From this study, the authors drew the conclusion
that thrombosis prophylaxis should continue to
be given up until the time of hospital discharge.
In relation to the use of abdominal compression to prevent the build-up of seroma formation
and reduce postoperative pain, there is only nonsignicant data. Aer open and laparoscopic ventral hernia repair, no eects on postoperative
well-being, quality of life and movement limitation could be found [9]. But physical function was
improved, and the binder had also a benecial
eect on psychological distress aer open abdominal surgery [10].
References
1. Erdas E, Medas F, Pisano G, Nicolosi A, Calò PG.Antibiotic prophylaxis for open mesh repair of groin hernia:
systematic review and meta-analysis. Hernia.
2016;20(6):765–76. [Epub ahead of print].
2. Ríos A, Rodríguez JM, Munitiz V, Alcaraz P, Pérez Flores
D, Parrilla P.Antibiotic prophylaxis in incisional hernia
repair using a prosthesis. Hernia. 2001;5(3):148–52.
3. Abramov D, Jeroukhimov I, Yinnon AM, Abramov Y,
Avissar E, Jerasy Z, Lernau O.Antibiotic prophylaxis in
incisional hernia repair using a prosthesis. Eur J Surg.
1996;162(12):945–8. discussion 949.
4. White TJ, Santos MC, Thompson JS.Factors aecting
wound complications in repair of ventral hernias. Am
Surg. 1998;64(3):276–80.
5. Bansal VK, Misra MC, Kumar S, Rao K, Singhal P, Goswami A, Guleria S, Arora MK, Chabra A.A prospective
randomized study comparing suture mesh xation
versus tacker mesh xation for laparoscopic repair of
incisional and ventral hernias. Surg Endosc.
2011;25:1431–8.
6. Heniford T, Park A, Ramshaw B, Voeller G. Laparoscopic repair of ventral hernias nine years’ experience
with 850 consecutive hernias. Ann Surg. 2003;238:
391–400.
7. Holzheimer RG.Laparoscopic procedures as a risk factor of deep venous thrombosis, supercial ascending
thrombophlebitis and pulmonary embolism–case
report and review of the literature. Eur J Med Res.
2004;9(9):417–22.
8. Catheline JM, Capelluto E, Gaillard JL, Turner R, Champault G.Thromboembolism prophylaxis and incidence
of thromboembolic complications after laparoscopic
surgery. Int J Surg Investig. 2000;2(1):41–7.
9. Christoersen MW, Olsen BH, Rosenberg J, Bisgaard
T.Randomized clinical trial on the postoperative use
of an abdominal binder after laparoscopic umbilical
and epigastric hernia repair. Hernia. 2015;19(1):147–
53. https://doi.org/10.1007/s10029-014-1289-6. Epub
2014 Sep 9.
10. Rothman JP, Gunnarsson U, Bisgaard T. Abdominal
binders may reduce pain and improve physical function after major abdominal surgery – a systematic
review. Dan Med J. 2014;61(11):A4941.
Standard Technique Laparoscopic Repair of Ventral and Incisional Hernia
Karl A.LeBlanc, AnilSharma andJanF.Kukleta
27.1 Introduction – 289
27.2 Positioning ofthePatient – 289
27.3 Pneumoperitoneum – 289
27.4 Positioning ofTrocars – 289
287
27
27.5 Dening Defect Size – 291
27.6 Dissection Techniques – 292
27.6.1 Adhesiolysis – 292
27.6.2 Reduction ofHernial Sac Contents – 292
27.7 Extent ofMobilization oftheAbdominal
Fatty Tissues – 293
27.7.1 Introduction – 293
27.7.2 Problem – 293
27.7.3 Method – 293
27.7.4 Results – 293
27.7.5 Discussion – 294
27.7.6 Conclusion – 294
27.8 Closure oftheDefect, Reconstruction
oftheMidline – 294
27.8.1 Introduction – 294
27.8.2 Indication – 295
27.8.3 Technique – 295
27.8.4 Discussion – 296
27.8.5 Conclusion – 296
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
R. Bittner et al. (eds.), Laparo-endoscopic Hernia Surgery,
https://doi.org/10.1007/978-3-662-55493-7_27
27.9 Mesh Sizing, Manipulation, andFixation – 296
27.9.1 Mesh Sizing – 296
27.9.2 Mesh Manipulation – 297
27.9.3 Mesh Fixation – 299
27.10 Endoscopic Component Separation – 299
References – 300
Standard Technique Laparoscopic Repair ofVentral andIncisional Hernia
289
27
27.1 Introduction
is repair of these hernias laparoscopically has
been well established. ere are many variations
in technique to obtain the best outcomes. We have
attempted to outline the methods that are known
to provide for the best results within the literature
reviewed. e reader is encouraged to explore the
most recent data in an eort of continuous quality
improvement.
27.2 Positioning ofthePatient
e position of the patient for the standard midline hernia is generally supine. It is preferable to
put the arms at the side of the patient to allow the
surgeon and sta access to the entire abdominal
wall without the hindrance of the arms that are
not tucked. However, in the modern era of obesity, this may not be feasible in many patients. It is
important to drape the patient as far as possible
laterally to permit trocar placement to be as far
away from the midline as this can be. is will
facilitate all aspects of the operation, dissection,
mesh manipulation, and the xation of it.
For midline hernias that are either high in the
abdomen or suprapubic, the patient will require
steep reverse or traditional Trendelenburg position, respectively. In these instances, the patient
must be padded and secured to the table appropr iately.
For hernias that are o midline, one must
allow for some degree of rotation of the patient on
the operating table. Special padding or “beanbags” will aid in the maintenance of the position
of the patient. is is especially true for lumbar or
parastomal hernias.
27.3 Pneumoperitoneum
e entry into the abdominal cavity can be
accomplished in many dierent methods. e
older methods of Hasson technique or Veress
needle insertion reliably allow for the establishment of the required pneumoperitoneum [1, 2].
e newer method of the use of an optical trocar
also permits this to be achieved easily [3]. e latter method does necessitate more experience to
appreciate the dierent tissue planes that are penetrated as one gains entry into the abdominal cav-
ity. An alternative method is direct trocar entry,
which appears to be safe and eective also [4].
Once this has been achieved, the surgeon must
decide upon the level of pressures that are needed
during the operation. Generally speaking, the
operating level is between 12 and 15mm Hg. is
will allow for greatest visualization of the contents
of the abdomen while aiding in the separation of
the adhesions and/or intestine from the anterior
abdominal wall. However, this also serves to distract the fascial defect(s) apart thereby increasing
the hernia size. is becomes an important consideration when the hernia is fully dissected, and
the measurement of the fascial separation must be
done to choose the appropriate size of mesh. is
is the surgeon’s preference as to making this measurement at this pressure (which increases overlap) or lowering the pressure (which decreases the
defect size and mesh size somewhat).
If the choice is made to lower the pressure, this
is usually decreased to 8 or 9mm Hg. is lessens
the distractive forces on the abdominal wall. If so
chosen, the defect will be more easily closed at the
lower level. e mesh will provide more coverage
and be more easily xed at the lower level of Hg.
Additionally, this will be slightly more physiologic
than the higher levels of pressure. However, the
level of evidence for these statements is only level 5.
27.4 Positioning ofTrocars
e trocar positions in laparoscopic incisional
and ventral hernia repair (LIVHR) vary depending on the site of the hernia (
27.3, and 27.4).
In a patient with incisional hernia, the position of the initial trocar for peritoneal access
should be at least 10 cms away from the previous
abdominal incision. e initial access with the
rst trocar may be Palmer point in the le hypochondrium (a ngerbreadth below le subcostal
margin in midclavicular line) [5]. e trocars on
the abdominal wall should be located at least 5cm
away from each other.
One 10/12 mm trocar is required for introduction of the mesh. All other trocars are 5mm.
e trocars are sited on the abdominal wall in the
form of an arc of a circle whose center is the hernial defect. One or two 5mm ports on the contralateral ank may be required to x the margin of
mesh on the ipsilateral ank.
. Figs. 27.1, 27.2,
290
K. A. LeBlanc et al.
Camera
Assistant
Camera
Assistant
Surgeon
27
Monitor
Instruments
. Fig.27.1 Typical trocar positions for a midline hernia
Camera
Assistant
Surgeon
Surgeon
Scrub
nurse
Monitor
Scrub
Monitor
. Fig.27.3 Typical trocar positions for a suprapubic hernia
Monitor
nurse
Instruments
Scrub
nurse
Instruments
. Fig.27.2 Typical trocar positions for a left upper
quadrant hernia
e le subcostal trocar may be used for the
telescope (angled, 30°/45° to optimally view the
hernia and the anterior abdominal wall) and the
other trocars for the operating instruments [1].
However, the telescope may need to be used from
other trocars also for optimal xation of dierent
segments of the mesh.
Scrub
Camera
Assistant
Surgeon
. Fig.27.4 Typical trocar positions for a subxiphoid hernia
nurse
Instruments
Additional 5mm trocars may be used whenever required to facilitate the operative procedure, particularly when the trocar site is likely
to be covered with mesh used for the hernia
repair.
Ergonomically, the most comfortable working
position is when the surgeon, his primary operative