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
Lumbar andOther
Unusual Hernias
Karl A.LeBlanc
35.1 Introduction – 374
35.2 Laparoscopic Technique – 374
35.3 Evidence – 378
35.4 Conclusion – 378
References – 379
373
35
© 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_35
35
374
K. A. LeBlanc
35.1 Introduction
e practicing general surgeon has an opportunity to these types of hernias very infrequently.
While most surgeons will have an opportunity to
repair a Spigelian hernia occasionally, many will
never see or treat the unusual ones such as the
lumbar or sciatic hernias. e lumbar hernia has
recently become more frequent due to the increasing use of the lumbar approach to anterior fusion
of the lumbar spine. However, in many instances
these “hernias” actually represent pseudohernias
because these lateral bulges are the result of intercostal nerve injury (T11 and T12) and subsequent
paralysis of the at muscles of the abdominal wall.
ese are especially dicult to treat.
Barbette rst suggested the existence of a lumbar
hernia in 1672, but the rst publication regarding
this entity was in 1731 by Garangeot. It is believed
that the rst surgical repair of a strangulated lumbar
hernia occurred in 1750 by Ravaton. e rst anatomic description of the inferior lumbar space was
by Petit in 1783. Grynfeltt described the superior
lumbar space in 1866. Because of their descriptions,
Petit and Grynfeltt’s names are associated with these
hernias rather than that of the other individuals. e
anatomic boundaries of the superior lumbar hernia
are the 12th rib superiorly, the internal oblique muscle anteriorly, and the erector spinae muscle posteriorly (. Fig.35.1). e anatomic boundaries of the
inferior lumbar hernia are the latissimus dorsi
muscle posteriorly, the external oblique muscle
anteriorly, and the iliac crest inferiorly.
Selby described traumatic acquired lumbar
hernia in 1906, and Kelton noted incisional
acquired lumbar hernia in 1939. Kretchmer published the rst study of 11 of these latter hernias
. Fig.35.2 Left Spigelian hernia with incarcerated small
intestine
following renal surgery in 1951 [1]. Eighty percent
of these hernias are acquired, while the remainder
is congenital. is ratio has remained stable over
time. e etiology of the acquired defects has
changed, however. Infectious etiology has declined
from 17% to 2%, whereas incisional hernias have
increased from 10% to 31% [2]. e laparoscopic
approach to the repair of the lumbar hernia was
rst described by Burick and Parascandola in
1996 [3]. Both of these techniques are eective.
Similar to the lumbar hernias, the name of the
Spigelian hernia is credited to someone who claried the anatomic description of the entity, van der
Spieghel (1578–1625). Similar to the lumbar hernias, his name was associated with this hernia by
someone else, Klinkosch in 1764. is hernia
occurs at the level of the semicircular line where
the fascias of the oblique and transversus muscles
begin to split to for the two separate layers of the
abdominal musculature. Generally the overlying
external oblique fascia remains intact making this
herniation interstitial and more dicult to diagnose (. Fig.35.2). ese entities are more common than that of the lumbar hernias. ey
represent 0.12–1% of all abdominal hernias.
. Fig.35.1 CT view of a left lumbar hernia
Laparoscopic Technique
35.2
e laparoscopic approach is based upon the
intraperitoneal method of other ventral and incisional hernia repairs rst described in 1993 [4].
e laparoscopic trocars are introduced by whatever method is familiar and preferred by the surgeon. For the traditional “fascial defect” hernia,
Lumbar andOther Unusual Hernias
the intra-abdominal adhesions must be dissected
rst. is will expose the hernia and its contents
(. Fig.35.3). e fascial edge must be cleared of
all of the adjacent adipose tissue with enough
margins to allow for a 5cm overlap of the selected
prosthetic material to repair the defect
(. Fig.35.4). Once this is completed, an accurate
measurement of the defect is necessary. is can
be accomplished in a variety of methods. One can
insert a ruler of some type and physically measure
the defect. Others will either palpate externally or
use needles to outline the edges of the hernia.
Many surgeons elect to deate the abdomen
somewhat to accomplish this but others do not.
Once this has been done, a minimum of 10cm
should be added in all directions to provide for an
overlap of the fascial defect of 5cm in all directions. is will be the chosen size of the mesh.
If the defect is not too large, the fascial defect
will be closed with transfascial sutures. is will be
performed by making one or more small skin incisions over the defect to allow for passage of a permanent suture(s) to close the defect (. Fig.35.5a).
Once these are placed, the insuation pressure
will be brought to near zero, whereupon the sutures
are tied (. Fig.35.5b). It is important to keep constant tension on these sutures during desuation
so that no intra-abdominal contents will be trapped
within the sutures. e abdomen will then be reinated, sometimes to a pressure at some level less
than prior to the closure of the fascia.
375
. Fig.35.3 Primary left lumbar hernia containing the
colon
. Fig.35.4 Fully dissected hernia with a large margin of
tissue
35
ab
. Fig.35.5 a Transfascial suture placement. b Tied transfascial sutures to close the defect
376
ab
K. A. LeBlanc
35
A variety of mesh products are available to
repair the place as an onlay over the fascial defect,
whether closed or not. It is critical to note that the
size of the mesh is selected prior to closure of the
fascial defect. In only this manner, will one assure
that if the closure becomes dehisced, the coverage
will still be adequate. Once the mesh introduced it
will be xed with an absorbable “tack” device. In
general, a double-crown technique will be utilized. is will be followed with the application of
transfascial sutures. Generally two to four are
placed depending upon the size of the original
defect. ese are usually placed close to the closed
defect to act as an additional buttress to the closure (. Fig.35.6).
Recently, the surgical robot has been utilized
in the repair of these hernias. Its advantages are
the ease of closure of the defect and the avoidance
of transfascial sutures and the tacks (. Fig.35.7a,
b
). Although there is anecdotal evidence that this
is advantageous in terms of diminution of postoperative as well as the incidence of chronic pain,
there are no long-term studies on these apparent
benets.
. Fig.35.6 Completed repair with an ePTFE mesh,
double-crown “tacks”, and transfascial sutures
e other type of lumbar hernia is much more
challenging to repair. As noted above, the pseudohernia is the result of muscle paralysis and lacks a
true fascial defect (. Fig.35.8a, b). In the past, the
use of an onlay mesh with or without the use of plication of these muscles resulted in a very high rate
of failure. To mitigate against such an outcome, a
sandwich repair has been devised. In this method, a
“sandwich” repair involving two meshes and the
hybrid technique of both the open and laparoscopic
repairs are utilized. In this manner, the benets of
both of these options are realized. Initially the
abdomen is approached through the lumbar incision, and any adhesions are lysed.
Initially, the intraperitoneal mesh is sized by
requiring a size that extends at least 8cm above the
costal margin superiorly, below the iliac crest inferiorly, medially beyond the semilunar line, and posteriorly to near the paraspinous muscles. Prior to
placement in the abdomen, two to four sutures are
axed to become transfascial sutures inferiorly. is
is required to assure coverage of the entire paralyzed
at muscles of the abdomen. It is then placed into
the abdominal cavity and sewn to the diaphragm.
e transfascial sutures are not pulled through at
this time. If they were done so at that time, the mesh
will be too lax following the closure and plication of
the muscles. e lateral and superior portions of the
mesh are sutures to the abdominal wall and diaphragm. ree trocars are place laterally to the
opposite side of the midline (. Fig.35.9).
e muscles are then closed in a vest over
pants closure so as to plicate them (. Fig.35.10).
An overlay of macroporous lightweight polypropylene is placed over this closure. It is important
that the skin and subcutaneous tissue layers have
been dissected far enough away from the closure
. Fig.35.7 a Robotically closed fascial defect; b Mesh sutured over the closed defect
Lumbar andOther Unusual Hernias
a
b
377
35
. Fig.35.8 a Preoperative view of the patient. b
Laparoscopic view of the “bulge”
so that this mesh will cover above the costal margin superiorly, below the iliac crest inferiorly, over
the rectus sheath, and posteriorly to the paraspinous muscles. is will assure that this mesh will
buttress the paralyzed muscles anteriorly
(. Fig.35.11). A drain is placed followed by closure of the subcutaneous layer and skin.
e abdomen is then insuated and the laparoscopic portion of the procedure commences.
e mesh is then xated with the transfascial
sutures such that the mesh is taut. Final xation
with absorbable tacks in a double-crown method
is the nal portion of the procedure (. Fig.35.12).
e benet of laparoscopy is that the mesh will
not have any laxity against the abdominal wall so
that the support of the musculature is complete.
. Fig.35.9 The transfascial sutures are seen inferiorly;
the costal margin is to the right of the gure
. Fig.35.10 Plicated musculature
A very rare unusual hernia is located in the
sciatic notch. is can occur above or below the
piriformis muscle or below the sacrospinous
ligament (
. Fig.35.13). While an open repair can
be done, a laparoscopic approach is preferred. An
onlay of mesh may or may not be placed following
closure of the defect.
35
378
K. A. LeBlanc
. Fig.35.11 Onlay of polypropylene mesh covering the
plicated musculature
. Fig.35.12 Laparoscopic view of the completed mesh
xation
. Fig.35.13 Suprapiriformis left sciatic notch hernia
35.3 Evidence
sole prospective (nonrandomized) study of 16
patients [2]. Moreno-Egea etal. showed that the
open repair was associated with a longer operative
time, longer length of stay, higher morbidity, and
three of seven patients recurred. ere were no
recurrences in the laparoscopic group. is paper
represents a level of 2B evidence in support of the
laparoscopic repair.
Twelve additional articles were found that
provided level 4 evidence of repair with either
technique and with or without the use of mesh
[5]. However, the length of follow-up of these
patients varied from only 1month to as long as
40 months. Given these varied periods of time
and the evidence of the former paper, it would
seem that the laparoscopic repair with mesh is
preferred.
ere has only been a single publication of a
prospective randomized trial of open vs laparoscopic repair of Spigelian hernias [6]. ere were
11 patients in each arm of the study. Mesh was
used in all cases with placement in the extraperitoneal plane except for three patients in the laparoscopic group. ere were no recurrences in
either group, but there was less morbidity
(p<0.05) and shorter length of stay (p<0.001) in
the laparoscopic group. e authors felt that the
laparoscopic extraperitoneal mesh repair should
be preferred. is level of evidence is at 2B.
e prior paper of Bittner etal. also researched
Spigelian hernias [5]. Fieen articles were found
with level 4 evidence. A total of 318 patients were
identied. e recurrence rate for the open tissue
repair was 4.6%, but the recurrence rate when
mesh was placed was zero in both the open and
laparoscopic groups. erefore the use of mesh
should be included in these repairs.
ere is Grade B recommendation for the
laparoscopic repair of both Spigelian hernia and
lumbar hernia due to the improvement in morbidity. e use of mesh is also recommended with
any repair method.
ere is very little published literature on the sciatic notch hernia due to the rarity of the problem.
ere are many papers, however, discussing the
lumbar and Spigelian hernias. A recent publication has provided evidence and recommendations
regarding these and many other hernias [5]. In
that report, one paper was identied that was the
35.4 Conclusion
e dierent operative choices for lumbar and
unusual hernias favor the use of mesh to prevent
recurrences. e laparoscopic repair is favored
due to reduction in morbidity and length of stay.
e very rare hernia types are infrequently or not
Lumbar andOther Unusual Hernias
379
35
at all discussed in the literature. is fact does not
allow evidence-based approaches to these hernias, but given the results of the lumbar and
Spigelian hernia, one might infer that the laparoscopic mesh repair is a better option.
References
1. Kretchmer HL.Hernia of the kidney. J Urol. 1951;65:944–9.
2. Moreno-Egea A, Baena EG, Calle MC, Martınez JAT,
Albasini JLA. Controversies in the current Management of Lumbar Hernia. Arch Surg. 2007;142:
82–8.
3. Burick AJ, Parascandola SA.Laparoscopic repair of a
traumatic lumbar hernia: a case report. J Laparoendosc Surg. 1996;6:259–62.
4. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded Polytetrauroethylene: preliminary ndings. Surg Laparosc
Endosc. 1993;3(1):39–41.
5. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli G,
Fortelny R, etal. Guidelines for laparoscopic treatment
of ventral and incisional abdominal wall hernias (International Endohernia Society (IEHS)) - part III. Surg
Endosc. 2014;28:2.
6. Moreno-Egea A, Carrasco L, Girela E, Martín JG, Aguayo
JL, Canteras M.Open vs laparoscopic repair of Spigelian hernia. A prospective randomized trial. Arch Surg.
2002;137:1266–8.
Single-Port Technique
andRobotics in Ventral
Hernia Repair
DavideLomanto andSujithWijerathne
36.1 Principles andConcept–382
References–383
381
36
© 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_36
382
D. Lomanto and S. Wijerathne
36
36.1 Principles andConcept
Ventral hernia can be broadly divided into primary and secondary. Secondary hernias are
mainly incisional hernias, and the complexity of
these hernias still poses a challenge to the surgeons. Open approach for these complex hernias
can be associated with a prolonged hospital stay
and poor pain control. e laparoscopic approach
has given hope for this particular group of patients
by minimizing the surgical trauma and minimizing the postoperative pain and complications.
roughout the past decade the laparoscopic
approach has accomplished many milestones in
the area of minimally invasive surgery. ese
accomplishments have been incorporated into
many specialty elds including ventral hernia
repair. But together with the development of minimally invasive laparoscopic techniques, the ventral hernias have also become more complex and
challenging. With the discovery of new biomaterials and techniques, hernia repair has become a
continuously changing and upgrading eld in
surgical practice.
Only the presence of a ventral/incisional
hernia does not represent an indication to
surgery. e goals of “elective” repair are relief of
symptoms (pain and discomfort) and prevention
of complications (strangulation/incarceration)
[1]. Laparoscopic approach has shown superior
capabilities in achieving these targets compared
to open technique. A recent meta-analysis of ten
randomized controlled trials comparing laparoscopic versus open ventral/incisional hernia
repair, involving 880 patients, demonstrated the
superiority of the laparoscopic approach in terms
of shorter hospital stay and reduced wound
infection rate [2]. anks to the enhanced visualization, laparoscopic technique provides a complete high resolution view of the entire defect,
including smaller defects that have not always
been appreciated clinically, and allows tacking of
the mesh to healthy tissue [3].
Laparoscopic repair of ventral/incisional hernias is currently accepted when the defect size is
at least of 2cm or larger, because smaller defects
can be safely treated with suture repair under
local anesthesia [1, 4–6].
In view of the weak integrity of the abdominal
wall, the use of a prosthetic mesh to reinforce the
abdominal wall is essential in laparoscopic ventral
hernia repair. e same principle applies to
reduced port ventral hernia repair as well. e
preferred method of mesh placement is intraperitoneal onlay mesh (IPOM) technique with securing the mesh in a double-crown manner with an
overlap of 3–4cm from the defect when using
trans-fascial sutures [6].
Standard laparoscopic approach for these
patients has its own downside as well. e risk of
incisional hernia at access port sites aer laparoscopic surgeries remains a concern and seems
non- negligible according to the literature (1–22%).
Factors negatively aecting the rate of port-site
incisional hernias are port size, fascial closure
method, and port mobilization [7]. It has been
demonstrated that patients presenting with primary or incisional hernia are prone to develop
further hernia due to extracellular matrix and
wound healing deciencies [8]. More surgical
trauma may further damage the abdominal wall
architecture and may lead to further weakness and
hernia defects. Minimally invasive surgery may
play a key role in instances like this, but it may be
challenging to the surgeons due to complexity of
these cases. One of the disadvantages of singleport surgery, compared to multiport, surgery is the
relative loss of triangulation, but this may be overcome with increased experience, modication of
dissection techniques, smaller and longer laparoscopes, and angulated or roticulated instruments.
Single-port access ventral hernia repair may
be advantageous, as it may reduce the number of
incisions in these patients who are at high risk for
incisional hernia, as long as the single-access
incision is not too large [7]. e other principal
advantage of single-port ventral hernia repair
over multiport laparoscopic approach is the
decreased number of ports, thus reducing parietal trauma and scarring [9]. But one of the challenges in using this technique could be the
learning curve to perform surgery for complex
ventral hernia with minimal access at the fascial
level and skin. is could be the reason that only
a handful of literature is available on this technique [3, 7, 9–13]. With this approach, surgery
can be performed in patients with primary hernia
with only a small scar, and also in patients who
are prone to develop incisional hernia because,
the number of fascial incisions can be reduced
[3]. According to the guidelines for laparoscopic
treatment for ventral and incisional abdominal
wall hernias by the International Endo Hernia
Society, the literature reviewed demonstrates that
Single-Port Technique andRobotics in Ventral Hernia Repair
383
36
the single-port ventral hernia repair procedure is
feasible, safe and reproducible. No intraoperative
complications were observed in the published
studies. Standard instruments were used, and
patients were discharged on the rst day aer
surgery [14].
e use of the da Vinci robot has expanded in
the recent past to a number of general surgery procedures including ventral hernia repair, likely due
to its magnied, three-dimensional high- denition
view, computer-aided elimination of tremor, and
seven degrees of freedom at the distal ends of the
instruments with superior maneuverability [15].
During ventral hernia repair the robot permits
relatively easy access to the anterior abdominal
wall, allowing the surgeon to perform the ideal
repair for the individual patient by allowing
primary defect closure, retro-rectus mesh placement, intracorporeal suturing, and concomitant
posterior component release.
In 2007, Tayar etal. [16] published their initial
experience of using the da Vinci robot for robotassisted laparoscopic incisional hernia repair with
exclusive intracorporeal suturing for mesh xation in 11 patients. eir median operative time
was 180 minutes and the overall morbidity rate
was 27%. e ndings show that the technique is
feasible and may not be associated with chronic
postoperative pain. No recurrence was reported
with a median follow-up of 25months. In 2012, in
another retrospective review of 13 patients, the da
Vinci robot was used for closure of the fascial
defects and circumferential suturing of the mesh
[17]. eir mean operative time was 131minutes
and the overall morbidity rate was 13%. None of
the patients experienced chronic suture site pain
or discomfort, and only one recurrence was
reported with a median follow-up of 23months.
e ease of robotics may decrease the learning
curve for surgeons, making a good laparoscopic
surgeon even better by allowing them to replicate
the tenets of open repair [15]. However more
structured and randomized studies are needed
with long-term results to delineate the future of
robotics in ventral hernia repair.
References
1. Silecchia G, Campanile FC, Sanchez L, Ceccarelli G,
Antinori A, Ansaloni L, etal. Laparoscopic ventral/inci-
sional hernia repair: updated guidelines from the EAES
and EHS endorsed consensus development conference. Surg Endosc. 2015;29(9):2463–84.
2. Sauerland S, Walgenbach M, Habermalz B, Seiler CM,
Miserez M. Laparoscopic versus open surgical techniques for ventral or incisional hernia repair. Cochrane
Database Syst Rev. 2011;16(3):CD007781. https://doi.
org/10.1002/14651858.CD007781.pub2.
3. Dapri G, Bruyns J, Paesmans M, Himpens J, Cadière
G. Single-access laparoscopic primary and incisional
prosthetic hernia repair: rst 50 patients. Hernia.
2013;17(5):619–26.
4. Alder AC, Alder SC, Livingston EH, Bellows CF.Current
opinions about laparoscopic incisional hernia repair: a
survey of practicing surgeons. Am J Surg.
2007;194:659–62.
5. De Beaux AC, Tulloh B. Laparoscopic ventral hernia
repair. Br J Surg. 2012;99:1319–21.
6. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli
GS, Fortelny RH, et al. Guidelines for laparoscopic
treatment of ventral and incisional abdominal wall
hernias (International Endohernia Society (IEHS))—
part 1. Surg Endosc. 2014;28(1):2–29.
7. Bucher P, Pugin F, Morel P. Single-port access prosthetic repair for primary and incisional ventral hernia:
toward less parietal trauma. Surg Endosc.
2011;25(6):1921–5.
8. Franz M.The biology of hernia formation. Surg Clin
North Am. 2008;88(1):1–15.
9. Bucher P, Pugin F, Morel P. Single port laparoscopic
repair of primary and incisional ventral hernia. Hernia.
2009;13(5):569–70.
10. MacDonald E, Pringle K, Ahmed I.Single port laparoscopic repair of incarcerated ventral hernia: re: laparoscopic repair of incarcerated ventral abdominal wall
hernias, Shah RH et al. (2008) hernia 12(5):457–463.
Hernia. 2009;13(3):339.
11. Podolsky ER, Mouhlas A, Wu AS, Poor AE, Curcillo PG
II.Single port access (SPA™) laparoscopic ventral hernia repair: initial report of 30 cases. Surg Endosc.
2010;24(7):1557–61.
12. Bower CE, Love KM. Single incision laparoscopic ventral hernia repair. JSLS J Soc Laparoendosc Surg/Soc
Laparoendosc Surg. 2011;15(2):165–8.
13. Tsivian A, Tsivian M, Sidi AA.Laparoendoscopic single
site repair of incisional hernias after urological surgery. Urology. 2011;78(3):715–8. 30.
14. Bittner R, Bingener-Casey J, Dietz U, Fabian M, Ferzli G,
Fortelny R, etal. Guidelines for laparoscopic treatment
of ventral and incisional abdominal wall hernias (international Endohernia society [IEHS])—part III. Surg
Endosc. 2014;28(2):380–404.
15. Vorst AL, Kaoutzanis C, Carbonell AM, Franz MG.Evolution and advances in laparoscopic ventral and incisional hernia repair. World J Gastrointest Surg.
2015;7(11):293–305.
16. Tayar C, Karoui M, Cherqui D, Fagniez PL. Robot- assisted
laparoscopic mesh repair of incisional hernias with
exclusive intracorporeal suturing: a pilot study. Surg
Endosc. 2007;21:1786–9.
17. Allison N, Tieu K, Snyder B, Pigazzi A, Wilson E.Technical feasibility of robot-assisted ventral hernia repair.
World J Surg. 2012;36:447–52.