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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
19 Stapled Closure forMid-Line Hernia Repair
305
considered a viable option to close the defect of the anterior abdominal wall in a
manner similar to the method used in other organs such as the bowel or vascular
structures.
With that in mind we brought the stapler to the animal lab in order to see its
characteristics and possibilities regarding the closure of abdominal wall defects.
Figure 19.1a shows the abdominal wall open after laparoscopic stapling.
Figure 19.1b is another view of the same open abdominal wall after stapling.
Figure19.1c shows the device being used in pigs for laparoscopic methods. After
these studies we identied that the best method was to place the stapler in a sublay
position, inserting each jaw of the stapler behind the left and right rectus abdominis
muscles (Fig.19.2) [9].
Once the best location was identified we evaluated the various types of cartridge in the dry lab followed by use in living tissue in the porcine model. This
allowed an evaluation of the correct type of staple load for use at the aponeurosis. A pilot study was undertaken in pigs to evaluate the safety and feasibility
of the procedure. Once we were assured of the safety and efficacy the first case
in a patient was undertaken [21]. The first case series was attempted were in
post bariatric surgery patients because of their propensity to develop supraumbilical midline hernias. The proved to be the first indication for the new
technique [22].
The technique was shown to the scientic community and other colleagues tried
various methods for use which resulted in an evolution of the surgical procedure,
a
Fig. 19.1 Animal lab. (a) open (b) laparoscopic (c) pig lab
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T. N. Costa and R. Z. Abdalla
b
Fig. 19.1 (continued)
19 Stapled Closure forMid-Line Hernia Repair
c
Fig. 19.1 (continued)
307
Fig. 19.2 Insertion of the stapler
Posterior rectus sheaths
Arcuade lines L&R
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T. N. Costa and R. Z. Abdalla
Table 19.1 Selection/indications
Recti diastasis
Small and medium midline hernias
M2–M3–M4
Limitations:
Large (> 8cm), location, skin issue
like every new method in technology [23, 24]. However, patient selection, evaluation and preparation of the patient, indications and the use of the various instruments and prosthetics are still undergoing scrutiny to determine the feasibility and
results of this new technique.
19.4 Pre-Operative Workup
Before starting the procedure, an evaluation must be made to identify the correct indication and to plan the appropriate surgical repair to be done. While a good physical
exam is critical, a CT scan evaluation must be done in order to see assess the defect,
identify potential complications and the overall status of the abdominal wall [25, 26].
The indications can be seen in Table19.1. In general, this technique is most suitable for midline hernias and recti diastasis. Patients with large hernias and skin
issues should be carefully evaluated. Any contraindications to the laparoscopic
approach and hernias outside of the midline must be considered.
19.5 Patient Preparation andPositioning (Fig.19.3)
The patient is positioned in a horizontal supine position with the arms close to the
body. A slight ex is made on the table so that the staple can be positioned suprapubically (Fig.19.4a). A urinary catheter is used to empty the bladder and prevent
injury to the bladder. All the abdomen must be exposed, especially the midline and
the hernia defect(s) (Fig.19.4b). Patient must be secured to the table and the areas
of the body at risk for injury should be protected.
It is important to have in the operative room (OR) all the materials required to
complete the procedure (Endostapler, energy devices, cartridges, meshes). It is best
if at least two monitors, one at the head of the patient and other one at the right side
to allow excellent visualization of the procedure at all times.
19.6 Surgical Technique
The surgical technique can be divided into the respective steps for better comprehension of the procedure. Hence, it will be separated into the following: access, port
placement, dissection/adhesiolysis, access to the arcuate line, reconstruction of the
midline, mesh placement and xation.
19 Stapled Closure forMid-Line Hernia Repair
309
Fig. 19.3 Patient preparation and positioning
19.6.1 Access
The peritoneal cavity is accessed by placement of an optical view cannula at the
superior left quadrant, 2cm below the costal margin, at anterior axillary line. This
approach can be done using a Veress needle or with an open access method (Hasson
technique).
19.6.2 Port Placement
After the access to the abdominal cavity has been achieved a suprapubic 12mm
trocar is placed either in the intraperitoneal or extraperitoneal space. Two additional
3 or 5mm trocars are inserted under direct vision in the left and right lower quadrants (Fig.19.5).
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T. N. Costa and R. Z. Abdalla
a
b
Left costal margin
Lower abdomen
Fig. 19.4 Port placement. (a) Trocar positions, (b) exposure of the abdomen
19.6.3 Dissection/Adhesiolysis
This is a very important step in minimally invasive hernia repair. The adhesiolysis
of all organs from the hernia sac is done to assure that they are freely inside the
abdominal cavity. In this manner the complete exposure of the fascial defect borders
and recognition of the position of the rectus abdominal muscles is achieved. All the
19 Stapled Closure forMid-Line Hernia Repair
Fig. 19.5 Access to the arcuate line
311
abdominal wall must be exposed in order to have a clean view of the defect to be
repaired.
19.6.4 Access totheArcuate Line (Fig.19.6)
After the complete exposure of the abdominal wall the arcuate line is accessed
either from a Trans-peritoneal (TAPP) or Extra-peritoneal (TEP) approach.
Similar to the laparoscopic TAPP inguinal hernia repair, the access to the arcuate
line can be done by opening the peritoneum to the level of the arcuate line and then
accessed.
The other method of approach is by an extra-peritoneal approach (TEP) in which
the trocars are inserted directly into the pre-peritoneal space. With this method the
arcuate line is accessed above the peritoneum. The main advantage of this approach
is to the ability to achieve this working space without the need to open into the peritoneal cavity.
19.6.5 Midline Reconstruction
Once the arcuate line is exposed, the approximation of the dissected posterior
sheaths of each side is done using a grasper to observe the retromuscular space formation. This is done by moving the to the lower quadrant trocar. The linear endostapler will be inserted via the supra pubic trocar. This is placed into the dissected
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T. N. Costa and R. Z. Abdalla
Left arcuate line
Right arcuate line
Lower abdomen
Fig. 19.6 Reconstruction of the midline
Upper abdomen
space with one of the arms on the left and the other on the right retromuscular
spaces. Closure of the jaws of the device with result in the approximation of either
side of the posterior sheaths. One must avoid any inclusion of muscular bers
between them these sheaths which can be a source of staple-line dehiscence. With
this procedure there is the construction of one retro muscular space which will in
turn result in an anterior reconstruction of the midline concomitantly with the closure of the peritoneal cavity by the act of stapling of the posterior sheaths together
(Fig.19.7).
19.6.6 Mesh Placement andFixation (Fig.19.8) [27]
Next, the surgeon will insert a lightweight monolament macroporous mesh into
the newly created common retromuscular space. This mesh can then be xed with
either a brin sealant or stapled from the inside.
If the TAPP approach was used, the opening in the arcuate line should be completely closed by any preferred method such as closure with sutures, staples or brin
glue.
19 Stapled Closure forMid-Line Hernia Repair
Fig. 19.7 Mesh placement
and xation
Rectus muscle
Posterior sheath
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19.7 Complications
All types of surgery have possible complications. In the hernia eld, those complications can impact in the quality of life (QOL), return to normal activities and
recurrence.
The main complications of this procedure are similar to other techniques that
place the mesh in a sublay position. Hematoma, seroma and infection are the majority of the problems. Other issues related to any laparoscopic treatment of hernias
such as bowel injury or clinical complications can also been seen (Table19.2).
19.8 Results andPerspectives
Since it is a new technique, there are only a few only case series [22–25], that have
shown safety and feasibility. Larger studies are needed to identify the most appropriate indications and outcomes. Nevertheless, the current studies have veried the
technical feasibility of the procedure and the low rate of recurrence.
314
Fig. 19.8 Perspectives—
L-TAR
T. N. Costa and R. Z. Abdalla
Retro muscular space
Mesh
Posterior sheath
Staples
Staples
Table 19.2 Complications
Mesh
Seroma
Hematoma
Skin infection
Mesh infection
Bowel injury
Clinical complications
CT scan and QOL follow up evaluations done before and after the procedure
demonstrated adequate abdominal wall reconstruction and improvement in both
pain scores and functional activity (Fig.19.9) [21].
Moreover, the technique can be added to the surgical options in addition to other
procedures such as e-tep and L-TAR (Fig.19.10) [24]. There is potential to perhaps
show improvement in the safety prole and speed of the robotic hernia repair.
To further enhance this surgical option, there is the need for the development of
new products such as a specic stapler for the abdominal wall or technological
devices that can add energy or other substance to the hernia repair.