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_842_Библиотеки_им_академика_М_И_Перельмана.pdf
Standard Technique Laparoscopic Repair ofVentral andIncisional Hernia
trocar, operative site and primary monitor are
all located in one straight line (Chowbey et al.
2012) [5].
Recommendations
5 Grade B: Visually guided entry of trocars
is recommended because these decrease
the size of the wound.
5 Grade D: When additional trocars are
needed, the principles of triangulation
and maintenance of optimal distance
should be taken into consideration.
5 The left or right upper quadrant subcos-
tally is recommended for the first access
port to the peritoneal cavity. The use of a
30° laparoscope is recommended.
5 The trocar entry points should be as far
as possible from the site of expected
adhesions and the size, site, and number
of wall defects, and they should be
placed to achieve triangulation of the
hernia site.
. Fig.27.5 External marking of the palpated fascial
edges
291
27
27.5 Dening Defect Size
e exact sizing of the defect is critical to the
repair of any hernia. It is especially critical for
mesh size selection. ere are a number of methods that have been used to measure the defect(s).
Approximately 25% of incisional hernias will be
composed of more than one defect. In these circumstances, one simply measures the furthest
extent of the combined defects as if they were one.
e lateral extent should be the defect that is the
largest of all of the defects. Despite the many years
that this repair has been done, there is no standard method of measurement. It is well known
that improper measurement will result in an inadequately sized mesh, which will result in increased
rates of recurrence [6, 7].
Measurement of the defect by physical examination alone is inaccurate [8]. Another method
that I personally prefer is to mark the anterior
abdominal wall externally (. Figs.27.5, 27.6, and
27.7) with the abdomen fully insuated then mea-
suring the marks following deation [9]. One
eective method is to insert a ruler into the
abdominal cavity and measure the defect directly
with a reduction of the pressure. Some surgeons
do not lower the pressure to measure so as to pro-
. Fig.27.6 Measurement of the vertical dimension
. Fig.27.7 Measurement of the transverse dimension
vide for a larger mesh size. Other surgeons puncture the abdominal wall with spinal needles to
mark the edges of the defect(s) and measure these
needles intraperitoneally [3, 4]. Whatever method
is chosen, it must be reproducible and accurate.
is size will determine the dimension of the mesh
and will greatly impact the rate of recurrence.
292
K. A. LeBlanc et al.
27
From the literature cited, there is level 2B,
3, and 4 evidence that the measurement if critical and the laparoscopic method is a very eective manner to accurately dene the defect(s).
Consequently, the Grade B recommendation is
to use the laparoscopic intracorporeal method to
successfully size the fascial defect.
27.6 Dissection Techniques
27.6.1 Adhesiolysis
Once the appropriate number of ports is introduced into the abdomen, adhesiolysis is commenced. Adhesiolysis is performed to include the
areas of the entire scar of previous abdominal surgery and at least 5cm around the hernia defect. e
laparoscopic approach provides a view of the entire
ventral abdominal wall so that occult hernias may
be diagnosed and treated appropriately [10].
Iatrogenic enterotomy is one of the most serious complications of LIVHR, particularly if it is
not recognized intraoperatively [11]. It follows
that there should be increased awareness of the
possibility of an iatrogenic enterotomy during
bowel adhesiolysis. Cold scissors are the best
means of performing adhesiolysis (. Fig. 27.8)
[12]. Electrocautery or any other energy source
is best avoided during adhesiolysis to preclude
the possibility of bowel injury. e omentum and
the bowel are commonly adherent at the site of
previous scar or around the hernial defect. In
most patients, there exists an avascular plane
between abdominal wall and viscera which may
be accessed and developed for adhesiolysis. e
advantage of remaining in this avascular plane
is that the eld of vision remains clear which in
turn reduces the chances of enterotomy during
adhesiolysis. In patients with dense bowel adhesions to the anterior abdominal wall, the parietal
peritoneum may be incised well away from the
bowel and adherent bowel reduced along with
peritoneum wherever required.
27.6.2 Reduction ofHernial Sac
Contents
Omentum and bowel comprise the most common
content of hernial sacs in incisional and ventral
abdominal wall hernias. e hernial sac contents
need to be reduced back to the abdominal cavity.
It is important to ensure that the contents of the
sac are completely reduced, especially omentum
and extraperitoneal fat in epigastric hernia.
Complete reduction of the contents can be conrmed by palpating the hernia on the abdominal
wall for any residual omentum or fat (. Fig.27.9).
Once the sac contents have been completely
reduced, the light from the telescope transilluminates the skin on the abdominal wall at the site of
the hernia. e omentum is reduced in continuity
from the hernial sac. is ensures that the reduced
omentum can be subsequently used as a sheet to
cover the bowel surface at the end of surgery. is
provides a natural protective adhesive barrier
between mesh and underlying bowel at the end of
surgery [5]. Any bowel that is present in the hernial sac is reduced back to the abdominal cavity.
Atraumatic bowel forceps are used to handle and
manipulate bowel. It is not unusual to nd several
loops of small bowel incarcerated within a hernia
with a relatively narrow neck. e direction of
. Fig.27.8 Adhesiolysis with cold scissors . Fig.27.9 Fully dissected incisional hernia
Standard Technique Laparoscopic Repair ofVentral andIncisional Hernia
293
27
pull on the bowel needs to vary to achieve reduction of bowel when incarcerated. Great patience
and delicate handling are required when bowel is
being manipulated. Sometimes, traction on the
abdominal wall at the site of the hernia aids in
reduction of bowel.
Recommendations
5 Grade B: Adhesiolysis should be limited
to freeing the abdominal wall to enable
adequate overlapping of the defect by
the mesh.
5 Grade C: Cold and sharp adhesiolysis is
preferred to ultrasonic dissection. Bipolar
coagulation is allowed, but monopolar
coagulation should be avoided.
5 Grade D: Adhesiolysis should be
performed near the abdominal wall away
from the adherent bowel.
27.7 Extent ofMobilization
oftheAbdominal Fatty Tissues
27.7.1 Introduction
e objective of the classical intraperitoneal onlay
(underlay) mesh (IPOM) technique or the augmentation form of such repair with closure of the
defect and additional intraperitoneal mesh
(IPOM Plus) is to achieve full surface contact of
the prosthetic material with the overlying abdominal wall. An adequate overlap of mesh over the
area of the repair (in all directions not only the
defect, but the whole scar) and adequate xation
(hernia size and hernia type dependent) should
guarantee the future stability of the bridged repair
(IPOM) or the augmentation repair (IPOM Plus).
e majority of midline ventral/incisional hernias
(M1–5) are surrounded by a fatty strip extending
from the ligamentum falciforme hepatis and ligamentum teres hepatis over median and medial
umbilical ligaments to the space of Retzius with
the prevesical fat pad.
27.7.2 Problem
e durability of the interface between mesh and
preperitoneal fat, e.g., posterior rectus sheath, is
questioned. e tissue property, which promotes
the ingrowth in macroporous mesh structure, and
the tissue quality that serves as abutment for xation could be of paramount importance for the
outcome. ese data are not available yet.
erefore the title question cannot be answered
with evidence-based support but only with
consensus- based suggestion.
27.7.3 Method
Extensive search of published data between 1993
(LeBlanc’s rst publication of laparoscopic IPOM)
and August 2015 was conducted [13]. ere are
not only no RCTs or another high level of evidence data existing, but the very few comments
regarding the disinsertion or resection of ligamentum teres and/or umbilical medial ligaments
with the corresponding fatty street are of low or
no evidence at all. e published comments on
this topic (see . Sects. 27.7.1 to 27.7.4) are very
rare and only gut feeling based.
e International Hernia Collaboration (IHC)
is a closed Facebook-based community of hernia
interested/hernia expert surgeons, which counts
in August 2015 1662 members. is group appreciates all advantages of social media to exchange
opinions, share knowledge, share experience, or
just ask for a professional advice and all that
within hours. What a challenge to ask for “vox
populi”, to listen to a collective gut feeling of a
community dedicated to hernia aairs. e IHC
was asked whether they never remove (1), occasionally remove (2), or always remove the fatty
street (3) in order to achieve better contact of
mesh with a solid abdominal wall and accurate
xation.
27.7.4 Results
e “search” revealed only ve statements on
transsection, disinsertion, and resection of the
abovementioned fatty complex in the last 14years.
e IHC reaction was overwhelming.
Within minutes and hours, many comments
and personal opinions came from four continents. e prudent consensus reveals that the
removal of fatty strip of the anterior abdominal
wall is for vast majority obvious, the resection of
it (extraction out of abdominal cavity) not always
imperative.
294
K. A. LeBlanc et al.
27
27.7.5 Discussion
In 2010 Berger mentions in his description of
IPOM technique that “structures like the space of
Retzius, falciform ligament and the ligamentum
teres hepatis must be dissected and the prevesical
space must be opened to allow adequate xation
and incorporation of the mesh” [14]. Stirler comments in 2013 separately the adhesiolysis and the
de-insertion of the ligamentum teres hepatis and
removal of fat from the hernia sac in cases of epigastric and umbilical hernias [15]. Stirler states:
“e ligamentum teres hepatis and fatty tissue
were removed from the abdominal wall in preparation for placement of a mesh.”
Misiakos states in 2015 “for hernias located in
the upper midline, the falciform ligament should
be dissected from the abdominal wall by using
energy source” [16].
Chelala in 2015 summarizes briey the main
technical steps of laparoscopic augmentation
ventral/incisional hernia repair, and one of the
steps is “the preparation of a good “landing
zone”: in all cases, the proper excision of all fatty
tissue or lax hanging peritoneum is performed
to enable a secure xation of the mesh to the
healthy fascial layers, for better tissue ingrowth”
[17].
In the Guidelines for Laparoscopic Ventral
Hernia Repair of the Society of American
Gastrointestinal and Endoscopic Surgeons
(SAGES) (7 http://www.sages.org), there is a
casual statement: “Dependent on the hernia location, the falciform and umbilical ligaments may
need to be taken down and the space of Retzius
dissected to identify occult hernia defects and
allow adequate exposure of the abdominal wall
for placement of an appropriately sized prosthetic” [18].
All responding IHC members (50 within 24h)
would transect the ligaments and remove the preperitoneal fat from the posterior rectus sheath
in majority of cases in order to facilitate the best
possible contact of mesh with abdominal wall.
Several would rex the pedicle to the mesh, some
would leave the pedicle in situ, and some would
resect it and remove from the cavity.
It is remarkable that the importance of the
“cleanup” of the “landing zone” was so rarely highlighted in the corresponding literature [13, 19–28].
27.7.6 Conclusion
e act of removing the fatty tissue from the
area where the mesh is to be placed seems to be
obvious and as such accepted in the hernia community despite missing evidence or strong recommendations from any guidelines or consensus
conferences.
27.8 Closure oftheDefect,
Reconstruction oftheMidline
27.8.1 Introduction
Abdominal wall hernias are common. eir surgical therapy, especially the traditional sutured
repair, leads to high recurrence rate and frequent
wound complications. e general introduction
of prosthetic reinforcement in open repairs demonstrated to diminish the recurrence rate, but the
infectious complications remained problematic.
e laparoscopic intraperitoneal onlay mesh
(IPOM) technique, as rst presented by LeBlanc in
1993, reduced markedly the wound problems and
shortened up the hospital stay, but the recurrence
rate still had to be improved [13, 29–31]. e new
technique brought up new morbidities especially
related to diculty of laparoscopic adhesiolysis
and the risk of bowel injury. Appropriate selection of patients, awareness of the risk of thermic
injury, improved technique of mesh xation, and
new materials (meshes, xation devices) further
decreased overall morbidity and recurrence rate
[32]. In bigger hernias bulging, clinical eventration and frequent seroma formation are still
unsatisfactory.
Unlike in laparoscopic groin hernia repair,
acute postoperative and chronic pain aer
abdominal wall repair deserves substantial
improvements. e standard IPOM is a bridging repair [33]. It may prevent a herniation, but
the bridge is adynamic and doesn’t solve the
functional decit. In midline hernias, straight
muscle is displaced and lateral muscle complex
sac predisposes to seroma formation. In contrary to a bridging repair is the primary closure
of the defect and intraperitoneal onlay mesh an
augmentation repair (IPOM Plus) [28]. e linea
Standard Technique Laparoscopic Repair ofVentral andIncisional Hernia
295
27
alba is an important structure as primary attachment of rectus muscle and secondary attachment
of oblique muscle group. Linea alba is the central
tendon of abdominal wall. Closing the midline
defects reconstructs linea alba and restitutes the
anatomy of the abdominal wall. e re-stretched
lateral muscles regain its physiologic tension,
which contributes to improved stability of the
trunk. IPOM- Plus is a more solid repair. Fascial
closure and the xed mesh distribute the tension
force more evenly; the eliminated gap allows bigger mesh overlap in order to neutralize the shear
forces more eciently [17, 24, 28, 34–41, 50, 62].
IPOM-Plus reduces the dead space by incorporating parts of the hernia sac in the aponeurotic
suture if anatomically feasible. Decreased seroma
rate is the consequence [28, 34–36, 50]. IPOMPlus is not a tension-free repair. Nevertheless the
expected elevated pain perception could not be
conrmed in clinical practice [28, 34].
27.8.2 Indication
Not all ventral/incisional hernias can be repaired
with IPOM-Plus technique. Size and type of the
defect and elasticity of the abdominal wall are the
most important predictors of feasibility. ere is
a belief that low BMI, female gender, and older
age are more amenable for primary fascial closure [35]. Small defects don’t require closure to
improve physiology but may appreciate lower
risk of recurrence. It is the relation between the
abdominal wall surface and the width of the
defect rather than the absolute size in cm. e
next limiting factor may be the proximity of
bony structures (suprapubic or subxiphoidal).
e type of index operation and number of previous repairs with or without prosthetic material
do certainly inuence the tailoring and choice of
repair technique. Although successful closures of
defect up to 12cm wide were reported, the width
over 10cm should raise the attention to proper
choice of the repair strategy [34, 36]. e high
hernia recurrence rate observed in larger defects
W3>10cm reects the signicant risk factor of
the “hernia width defect” irrespective of the technique, open or laparoscopy [62]. Additional endoscope-assisted component separation technique
or hybrid procedure with defect closure through
anterior approach with laparoscopic mesh placement can facilitate a dicult IPOM- Plus. In larger
hernias and/or increased risk for recurrence open
approach with anterior or posterior components,
separation with/without appropriate preoperative preparation (progressive pneumoperitoneum
and/or botulinum toxin A-induced relaxation of
the lateral muscle complex) might be necessary.
27.8.3 Technique
e landing zone has to be prepared rst. orough
adhesiolysis with cold scissors or with prudent use
of energy source helps to prevent inadvertent injury
to adjacent structures. e extent of adhesiolysis
must allow secure manipulation and placement of
the adequate size of mesh overlapping the whole
scar vertically by 5cm and by 7cm in transverse
direction if the defect can be completely closed.
ere are various techniques how to suture
the defect.
e technically most demanding is the running intracorporeal suturing as described by
Palanivelu. Robotic instruments facilitate this
task. e intracorporeal interrupted sutures can
be tied sequentially either with the help of Endo
Stitch or extracorporeal knot-pusher. e disadvantage is the remaining necessary distension of
the wall despite of the purposely lowered intraabdominal pressure in order to maintain sucient vision.
e transcutaneous transfascial suturing can
be accomplished with curved needle or suture
passer [24, 28]. e interrupted suture can be tied
with completely desuated abdomen with more
realistic tension control. e tiny skin incisions
allow sometimes placement of more than just one
suture, but the multiple skin perforation increases
theoretically the risk of infection. erefore we
repeat over and over the skin disinfection before
any percutaneous manipulation. e suture material should be nonabsorbable. In patients with
a thin subcutaneous layer, the knots have to be
buried thoroughly, because the palpable “granulomas” can be bothersome. Liing the skin aer
tying lets the knot dive deeper and helps to prevent unpleasant dimples.
To place, correctly orient, and nally secure
the mesh, the intra-abdominal pressure has to
296
K. A. LeBlanc et al.
27
be increased, but not necessarily over 8mm of
mercury. When closing larger defects, the extendibility of the abdominal wall will be limited. Less
working space may make the mesh positioning
more dicult.
27.8.4 Discussion
Franklin and Chelala reported early of closing the
defect prior to intraperitoneal mesh placement [24,
36, 50]. Kukleta made a literature search in 2012 and
identied 27 relevant articles about defect closure or
augmentation repair. e overall evidence level was
low or very low [28]. Nguyen published a systematic
review on primary fascial closure with laparoscopic
ventral hernia in 2014 [35]. Eleven articles met the
inclusion criteria. He found no randomized controlled trial but three comparative studies, ve of
them retrospective and six prospective [34, 38, 39].
e comparative studies showed that IPOM-Plus
resulted in lower recurrence rate (0–5.7% vs. 4.8–
16.7%) when compared with non-closure
IPOM.Seroma formation rates were lower in closure group (5.6–11.4% vs. 4.3–27.8%).
Clapp et al. examined additionally bulging,
chronic pain, functional status, and patient satisfaction [34]. e bulging rate in closure– vs. nonclosure groups– was 8.3 vs. 69.4%. e scores for
patient satisfaction and functional status were
higher in the closure group. Despite placing more
sutures and increased tension on the abdominal
wall, there was no dierence in chronic or postoperative pain between the two patient cohorts. e
dierence in hernia recurrence aer mean follow up of 24months (0.0% vs.16.7%; p= 0.02) was
signicant.
Chelala demonstrated in his large series of
1326 augmentation repairs that the ventral and
incisional hernias should be evaluated separately.
e recurrence rate of incisional ventral hernias is
3.45%, the one of primary ventral hernias 1.27%
only [17]. With 0.82% conversions and 2.42% of
no closures, he showed an unexpected high rate of
feasibility of the suturing concept or augmentation technique reducing the overall morbidity
with a low rate of recurrences.e recently published review of IPOM-Plus literature of Suwa
et al. in 2015 identied 16 reports in which the
recurrence rate, incidence of seroma formation,
and incidence of mesh bulging were clearly lower
in the defect closure group [42].
27.8.5 Conclusion
ere is level 3 evidence that the reconstruction
with permanent sutures of the linea alba improves
the functionality of the abdominal wall and
decreases the rate of wound complications. e
augmentation of the anterior abdominal wall causes
less pain in the early postoperative period than a
bridging repair. e augmentation repair (due to
the combination of defect closure and mesh overlap) results in a stronger repair than bridging alone.
Level 4 evidence suggests that the closure of
the defect decreases the rate of seroma formation
and mitigates against the postoperative bulging
that can occur. Augmentation decreases recurrence rates. Finally, reconstruction of the linea
alba without mesh reinforcement can lead to
increased rates of hernia recurrence.
erefore, the Grade B recommendations are
that nonabsorbable sutures should be used to
close the defect. Grade C recommends that defect
closure with a mesh onlay should be used. Grade
D recommendations are that the use of transfascial sutures to close the defect should incorporate
the hernia sac to obliterate the dead space to prevent seroma formation.
27.9 Mesh Sizing, Manipulation,
andFixation
27.9.1 Mesh Sizing
Mesh size is a very critical component to successful laparoscopic incisional hernia repair. is is
oen discussed, but there are still gaps in the
overall understanding of this factor. Accurate sizing of the fascial defect will determine the size of
the mesh itself. It has long been known that the
larger the mesh, the lower the incidence of recurrence. Past studies have demonstrated that the
lack of transfascial sutures inuences recurrence
rates, but a larger overlap (5cm vs. 3cm) of the
prosthesis was required if no sutures were used
[43, 44]. Other studies have conrmed that the
overlap beyond the fascial defect should be at least
4 cm [6]. A recent meta-analysis has conrmed
this fact but found that even more overlap was
preferred [7]. is paper evaluated nearly 9000
patients. ere was a statistical dierence in
recurrence rates based upon the amount of overlap of the mesh. If the mesh overlap was <3cm,
Standard Technique Laparoscopic Repair ofVentral andIncisional Hernia
the recurrence rate was 8.6%, but if the overlap
was between 3 and 5cm, the recurrence rate was
4.6%. However, when this overlap was 5 cm or
greater, the rate of recurrence was only 1.4%.
Consequently, this fact must be used in these
repairs. It is also been noted that during the repair,
the mesh should cover the entire scar where the
hernia has developed to avoid the development of
a subsequent hernia in the incision [45].
Recent publications have investigated the
overall size of defect and the mesh to repair the
defect as ratios (mesh/defect) to consider in the
repair of these hernias [46]. In this particular
study, if this M/D ratio was ≤12 and the defect
overlap was less than 5cm, the recurrence rate
was 100%, but if the M/D ratio was ≤12 and the
defect overlap was greater than 5 cm, there was
still a recurrence rate of 22%. Increasing the M/D
ratio to greater than 12 resulted in a recurrence
rate of 4% with a<5cm mesh overlap and a 1%
recurrence rate if the overlap was 5cm or greater.
is study indicates that mere overlap is an insufcient indicator of recurrence rates with the
bridging laparoscopic technique for ventral and
incisional hernia repair. It also suggests that with
larger defects perhaps the laparoscopic repair
should not be done if consideration is given to the
M/D ratio. is article is recommended to the
reader for further clarication.
Given these articles, there are levels of evidence from 2B to 4 that the overlap should be at
least 4cm but 5cm is preferred, especially if no
transfascial sutures are used. Level 4 evidence
suggests that the M/D ratio should be considered
in the typical bridge repair with a larger than 12
ratio being preferred. ere is level 4 evidence to
overlap the entire incision to prevent recurrence
of the hernia. e Grade B recommendation is
that the overlap should be 5cm beyond the fascial
defect. ere is Grade C recommendation that the
overlap should be 5cm if no transfascial sutures
are utilized to xate the prosthetic material.
Additional Grade C recommendation is that the
M/D ratio should be used in the sizing of the
mesh for the laparoscopic repair of these hernias.
27.9.2 Mesh Manipulation
e type of mesh and its stiness will inuence
methods of mesh introduction and manipulation once the product is introduced (. Fig.27.10).
. Fig.27.10 Mesh with preplaced sutures and marks
First step Second step
. Fig.27.11 Folding of the mesh
is latter fact will be aected by the pore size
and thickness of the material. In general, the
product will be rolled and introduced into the
abdominal cavity via a 10 or 12 mm trocar
(
. Figs. 27.11, 27.12, 27.13, 27.14, and 27.15)
[47]. Hussain et al. use an additional 10 or
15mm port placed in the center of the hernia to
insert the mesh [48]. Other authors prefer to
place a 2–3cm incision at the hernia site through
which the mesh is placed [49–52]. Some prefer
to merely pull the mesh into the abdominal cavity through a 5mm trocar site as long as the site
is covered with an iodine impregnated drape
[53]. It has been shown that it is best to avoid
contact of the prosthetic material with the skin
[10, 54, 55].
297
27
298
K. A. LeBlanc et al.
27
. Fig.27.12 Final rolled mesh prior to insertion
. Fig.27.13 Grasper through a trocar site to grasp the mesh
. Fig.27.14 Mesh being pulled into the abdomen
(outside view)
. Fig.27.15 Mesh being pulled into the abdomen
(inside view)
ere are various ways that this roll can be
made such as a standard roll or some type of
scroll. is roll can be held secure with the use of
sutures placed prior to mesh insertion. Some will
place one to four sutures to allow for the positioning of the prosthetic against the abdominal wall
prior to xation with a device of some type. ese
sutures will be placed transfascially and generally
tied to xate the mesh.
erefore, there is level 3–5 evidence that the
mesh can be brought into the abdominal cavity
through a separate incision, through a trocar site,
or through a trocar. e larger meshes, of course,
will require larger orices to introduce them.
Level 5 evidence dictates that the mesh should not
contact the skin. Given these data, there is a Grade
B recommendation that the larger meshes should
be tightly rolled for insertion. Grade C recommendation that the larger meshes should have
larger trocar and/or incisions for introduction
and that mesh to skin contact should be avoided.
ere are currently at least two dierent
devices to which mesh if xed to allow for positioning of the material. One incorporates a balloon assist device (Echo PS, Davol, Inc.), which is
Standard Technique Laparoscopic Repair ofVentral andIncisional Hernia
attached to the mesh, while the other has a frame
to which the mesh material is attached (AccuMesh,
Medtronic, Inc.). ese products are quite dierent and are only available with the meshes of the
manufacturer that produces the product. ere
are currently no publications that reveal levels of
evidence to make any recommendation in their
use. However, there many “expert” opinions that
agree with the concept.
. Fig.27.16 Completed repair; transfascial sutures are
27.9.3 Mesh Fixation
Fixation is a critical component of successful hernia repair. ere are a multitude of devices that
allow the surgeon to achieve mesh xation to the
abdominal wall during the operation. e choice
of these products should be based upon the thickness of the mesh utilized, the depth of penetration
of the fastener, and whether or not the product is
permanent or absorbable. Newer fasteners mimic
this method of xation and perhaps represent the
future of xation. e discussion of the various
methods available to xate these mesh products is
beyond this chapter, and the reader should be
aware of the options available.
ere have been a number of studies that have
evaluated the eectiveness of the xation method
used. A recent meta-analysis did not nd any statistically signicant dierence in xation relating
to recurrence rates [4]. However there are at least
10 studies that have evaluated the use of sutures
and tacks [8, 21, 56–63]. e recurrence rate in
the 2211 patients that were in these studies was
3.65%. ere have been two papers that evaluated
the use of suture xation alone [64, 65]. e
recurrence rate was 1.05% in these 1121 patients.
ere have been at least 11 studies that evaluated
the use of tack xation alone [14, 15, 66–73].
ere were 2473 patients in this group, and the
incidence of recurrence was 4.5%. ere is no statistical dierence between the groups in either the
length of follow-up or recurrence rate. is veries the more recent evaluation of the data. ere
are a variety of variables that could aect the outcomes, the surgeon and his or her technique
should simply be the best that be achieved. e
amount of overlap of the fascial defect is more
important than the method of xation.
e statements that can be made are that at
level 4, the method of xation is no dierent in
dening the rate of hernia recurrence. Also at this
marked with white small arrow; central row of tacks
marked with yellow up arrow; yellow down arrow marks the
outer row of tacks
level of evidence is that the use of nonpermanent
xation devices achieves low recurrence rates. It is
recommended that the sutures and/or tacks
should be placed no more than 1.5 cm apart.
Finally, the Grade B recommendation is that
suture xation with or without additional tacks is
considered preferable (. Fig.27.16).
27.10 Endoscopic Component
e use of this technique has been advanced over
the last several years as part of the armamentarium
of the surgeon to repair complex hernias. Its use
has become somewhat limited due to the fact that
more patients seem to require the more extensive
releases of the anterior abdominal wall fascia and
musculature that ever before. is type of release
accomplishes the incision of the external oblique
fascia lateral to the rectus sheath. It can provide for
a release of approximately 8cm in some patients.
ere are a variety of methods to approach this
technique. e original method was to dissect
below the costal margin near the midaxillary line
to the external oblique fascia. is tissue is penetrated and dissected with either laparoscopic
instruments or with the insertion with a dissection
balloon of some type. e balloon is inated to
create a space between the planes of the internal
and external oblique musculature. is is done
under direct visualization with the laparoscope.
Once this is accomplished, the external oblique
fascia was divided with scissors. is may or may
not require the placement of an additional trocar
laterally. Some surgeons will use a single port technique near the costal margin to incise the fascia.
Separation
299
27
300
K. A. LeBlanc et al.
27
e use of this technique does eliminate the
need for the dissection of large tissue aps to
expose these tissue layers, and because of this fact,
the incidence of tissue necrosis due to the division
of perforating vasculature is signicantly
decreased. Although this method does not provide the extent of mobilization of the tissue planes,
as does the open method, it still allows for this to
be done in certain patients. e use of the transversus abdominus release (TAR) either laparoscopically or robotically may reduce the adoption
of this technique.
is technique can be combined with the laparoscopic or open intraperitoneal mesh placement
or with the open sublay or onlay repair of complex
hernias. Harth reported a retrospective study of
open vs. endoscopic release and found that there
was a statistically signicant dierence in wound
morbidity with the open technique with no dierence in rates of recurrence. However the recurrence rate was 32% (open) and 27% (endoscopic),
which are very high [74, 75]. ese results have
been veried in other studies [76–79]. More recent
publications have shown that the use of endoscopic release had no dierences in the rate of
wound complications between laparoscopic and
open ventral hernia repair. Disturbingly, however,
three patients in the total of 42 patients developed
lateral hernias in the follow-up period of less than
4years [80]. A systematic review and meta-analysis found that the recurrence rate was lower with
the open component separation but was associated with higher wound complication rates [81].
e following statements can be made. e
endoscopic component separation is associated
with lower morbidity compared to the open
method with level 3 evidence. ere is also level 3
evidence that there is frequent lateral herniation
with this method. Grade C recommendation is
that the surgeon could utilize this intervention if
they are able to do so and that the lateral compartment should be augmented.
References
1. Roberts KE, Panait L, Duy AJ, Bell RL. Single port
laparoscopic umbilical hernia repair. Surg Innov.
2010;17(3):256–60. Level 3.
2. Podolsky ER, Mouhlas A, Wu AS, Poor AE, Curcillo
PG. Single port access (SPA) laparoscopic ventral
hernia repair: initial report of 30 cases. Surg Endosc.
2010;24(7):1557–161. Level 3.
3. Tinelli A, Malvasi A, Mynbaev OA, Tsin DA, Davila F,
Dominguez G, Perrone E, Nezhat FR.Bladeless direct
optical trocar insertion in laparoscopic procedures on
the obese patient. JSLS. 2013;17(4):521–8. Level 1B.
4. Godara R, Bansal AR, Verma S, Yadav S, Verma N, Gupta
S, Tamaknand V, Garg P.Direct trocar insertion without
the pneumoperitoneum in laparoscopic surgery – is
this a safe technique? Hell J Surg. 2015;87(5):415–8.
Level 3.
5. Chowbey PK, Khullar R, Sharma A, Soni V, Baijal M.Laparoscopic repair of ventral and incisional abdominal
wall hernias. In: Chowbey P, editor. Endoscopic repair
of abdominal wall hernias. 2nd ed. New Delhi: Byword
Books Pvt. Ltd; 2012. (level 5).
6. Tsimoyiannis EC, Tsimogiannis KE, Pappas-Gogos G,
Nikas K, Kars E, Sioziou H.Seroma and recurrence in
laparoscopic ventral hernioplasty. JSLS. 2008;12(1):51–
7. (level 3).
7. LeBlanc KA. Mesh overlap is a key determinant of
hernia recurrence following laparoscopic ventral and
incisional hernia repair. Hernia. 2016;20(1):85–9. (level
2B and 3).
8. Sharma A, Mehrotra M, Khullar R, Soni V, Baijal M,
Chowbey PK. Laparoscopic ventral/incisional hernia
repair: a single center experience of 1242 patients
over a period of 13 years. Hernia. 2011;15:131–9.
(level 4).
9. LeBlanc KA, Allain BW. Prevention and management
of laparoendoscopic surgical complications. In: Kavic
MS, Nezhat C, Wineld H, editors. Laparoscopic repair
of ventral wall abdominal hernia. 3rd ed. World wide
web: Society of Laparoendoscopic Surgeons (SLS).
Miami, FL: CRC Press; 2010. (level 5).
10. Sharma A, Khullar R, Soni V, Baijal M, Kapahi A, Najma
K, Chowbey PK.Iatrogenic Enterotomy in laparoscopic
ventral / incisional hernia repair -a single center
experience of 2346 patients over 17 years. Hernia.
2013;17(5):581–7. (level 4).
11. LeBlanc KA, Elieson MJ, Corder JM. Enterotomy and
mortality rates of laparoscopic incisional and ventral
hernia repair: a review of the literature. J Soc Laparoendosc Surg. 2007;11:408–14. (level 1a).
12. Miller SK, Carey SD, Rodriguez FJ, Smoot Jr RT.Complications and their management. In: LeBlanc KA, editor.
Laparoscopic hernia surgery-an operative guide. Boca
Raton, FL: CRC Press; 2003. (level 5).
13. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrauoroethylene: preliminary ndings. Surg Laparosc
Endosc. 1993;3:39–41. (level 4).
14. Berger D. Laparoscopic IPOM technique. Chirurg.
2010;81(3):211–5. https://doi.org/10.1007/s00104-009-
1819-4. (level 5).
15. Stirler VMA, Schoenmaeckers EJP, de Haas RJ, Raymakers JTFJ, Rakic S. Laparoscopic repair of primary and
incisional ventral hernias: the dierences must be
acknowledged. A prospective cohort analysis of 1,088
consecutive patients. Surg Endosc. 2014;28(3):891–5.
(level 3).
16. Misiakos EP, Patapis P, Zavras N, Tzanetis P, Machairas
A.Current trends in laparoscopic ventral hernia repair.
JSLS. 2015;19(3):e2015.00048. (level 5).