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19 Stapled Closure forMid-Line Hernia Repair
Fig. 19.9 Midline closure after 2 years under Valsalva
Pre peritoneal e-tep
Open
peritonium
L-TAR
315
L-TAR
Fig. 19.10 Laparoscopic view of e-tep and L-TAR procedures
19.9 Discussion
Laparoscopic and robotic surgical approaches to hernia repair have an important
appeal for causing less tissue damage while improving recovery. There is no need
for a large incision and the area to be reconstructed can be well visualized by the
intraperitoneal camera. The prosthesis is clearly placed in the right position and its
xation is done with suitable options of stapling, gluing or suturing, as preferred by
the surgeon. Another important fact is the lower incidence of wound complications,
such as infection or dehiscence when compared to an open procedure.
This procedure is able to achieve better rectus muscular function with approximation of the muscle tissue compared to the laparoscopic bridging maneuver. The
use of liner stapling is more appealing than endoscopic suture, due to a safer
approach for the patient and better management of time for the surgeon.
This procedure was developed previously by this group through the robotic
reconstruction of the midline using single sutures [7]. Afterwards, the linear
316
T. N. Costa and R. Z. Abdalla
endo- stapling closure was tested in the laboratory. During these studies the potential
benets of this procedure were identied. Following this conrmation we felt comfortable offering this as a new option of treatment for the patient. The anterior suturing of the midline through the robotic arms from inside the abdominal cavity was
able return to the patient the sensation of a normal abdominal wall function and
movement.
After linear stapling of the midline, the patient often complained about a bulge
that was considered to be the resolution of hernia sac. It is different issue that that
noted from the classical laparoscopic approach in which, the bulge is loose and
covered by the mesh.
We now believe that this procedure should be another option for patients with
multiple or smaller defects of the midline, cranial to the arcuate lines. It is also an
option in some patients with some diastasis of the rectus muscles who could be
treated without the midline xyphoid to umbilical incision.
19.10 Concluding Remarks
• Indications are mainly midline hernias and recti diastasis.
• The correct indication and preparation must be done for the success of the
procedure.
• Although there are few studies, the results show low recurrence and good impact
on the QOL.
• Current perspectives are beginning to be considers such as application as an
adjunct to other techniques and development of new materials and devices may
make more options feasible.
Glossary
Transabdominal Midline Reconstruction (TMR) Surgical procedure to treat
midline hernias and rectus diastasis with the use of a linear stapler and sublay
mesh repair.
Laparoscopic Transversus Abdominis Release (L-TAR) Minimally invasive sur-
gical procedure proposed as a posterior component separation with transversus
abdominis muscle release.
References
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19 Stapled Closure forMid-Line Hernia Repair
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Endoscopic Component Separation Techniques
JorgeDaes
20.1 Endoscopic Component Separation Techniques
The objective of abdominal wall reconstruction (AWR) is to provide a durable
structural, functional, and cosmetic repair. The repair of complex ventral hernias
remains a vexing problem with successful outcomes requiring a combination of
techniques, technologies and tools. A lack of comparative effectiveness data ensures
that we are a long way from standardization of hernia repair to any particular technique. Nevertheless, principles exist that should be applied to all repairs irrespective
of technique selected. Incorporating these principles into every day practice allows
a surgeon to base a complex ventral hernia repair not on a particular technique but
on principles that have consistently resulted in improved outcomes.
Primary closure of defects and reestablishment of the integrity of the linea alba
with physiologic tension have been the mainstays of open repairs and recently have
been considered essential components of minimally invasive (MI) abdominal wall
reconstruction (AWR).
Primary repair of ventral hernias is in general possible with defects up to 3–4cm
depending on tissue pliability. For defects greater than that, a form of physiologictension reconstruction is advised. This can be accomplished using various muscle
relaxation techniques, including surgical, pharmacological, and mechanical methods, with component separation (CS) techniques being the most common. Almost
invariably, repair is reinforced with a mesh.
The anterior component separation (ACS) technique described by Ramirez and
colleagues [1] in 1991 creates a compound ap composed of the rectus abdominis,
internal oblique, and transversus abdominis muscles that can be moved across the
abdominal wall to assist in closing defects. The main drawback of the classic open
ACS technique is the need for extensive dissection and its unwanted consequences.
20
J. Daes (*)
Minimally Invasive Surgery Department, Clínica Porto Azul, Barranquilla, Colombia
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_20
319
320
Studies have reported major wound morbidity in 30–40% of patients treated with
this method [2]. Modications of the classic ACS to spare the periumbilical perforating vessels and to limit the extent of the dissection have reduced the wound complication rates.
The endoscopic (E) approach to CS addresses these issues. Lowe and associates
in 2000 reported an open assisted subcutaneous endoscopic ACS [3]. Maas described
a laparoscopic balloon-assisted subfascial approach in 2002 consisted of endoscopically performed dissection, with release through a small cutaneous counter incisions [4]. Rosen is credited with popularization of transfascial endoscopic ACS in
2007 as an adjunct to AWR in combination with mesh reinforcement [5]. Chen
described a modication that simplied the transfascial approach by making the
initial incision medial to the anterior superior spine and working cephalad with the
help of an additional port, making it more ergonomic and easier to perform [6].
Finally, Daes described a totally endoscopic subcutaneous approach in 2010. With
this technique preoperative skin marking of the semilunar line under ultrasonic
guidance precedes the creation of the subcutaneous space. This space is then developed with a balloon dissector with subsequent division and dissection of the external oblique aponeurosis [7]. This modication imitates the Ramirez approach and is
ergonomic and familiar to surgeons.
J. Daes
20.2 Indications forECS asAdjunct toMinimally Invasive
Surgery
1. As an adjunct to the robotic-assisted or laparoscopic intraperitoneal onlay mesh
(IPOM) repair or transabdominal preperitoneal (TAPP) ventral repair with pri-
mary closure of the fascial defect. This has been the main indication of ECS in
our group.
2. As part of robotic-assisted or laparoscopic extended-view totally extraperitoneal
(eTEP) access Rives-Stoppa or transabdominal Rives-Stoppa repair as long as
the need for mesh coverage does not extend beyond the width of the retrorectus
space. When greater mesh coverage is necessary a posterior components separa-
tion is indicated.
Other indications of the ECS in open surgery or for the management of the
abdominal compartment syndrome are not discussed in this chapter.
20.3 Contraindications forECS
1. Severe skin dystrophy or ulceration requiring extensive resection or the creation
of extensive aps.
2. Fascial defects that can be closed primarily without undue tension.
3. Fascial defects that are disproportionally wider than longer.
4. Patients with noncompliant abdominal walls from multiple previous repairs/
meshes. In these cases, a PCS-TAR may be more appropriate.
20 Endoscopic Component Separation Techniques
321
5. Patients who have undergone previous bilateral PCS-TAR.However, concomi-
tant anterior and posterior separations to avoid a bridged mesh repair may be a
relative contraindication and it is possible to use a PCS-TAR approach on one
side (for stoma reversal) and an anterior CS on the other side.
20.4 Operative Steps
20.4.1 Preoperative Preparation
Endoscopic component separation should not be considered a stand-alone procedure but is part of an overall operative plan. Other preoperative considerations
depend upon the particulars of that operative plan.
Skin preparation extends from the nipples to the upper thighs and should be laterally extended to beyond the posterior axillary lines. For clean operations, a single
dose of a rst-generation cephalosporin is administered during anesthetic induction.
Urinary catheters are used in complex cases or when pelvic dissection is anticipated. Pneumatic compression devices are used in all patients. During clean contaminated or contaminated cases, ECS should be performed rst.
20.4.2 Techniques ofECS
The three approaches to anterior ECS create exactly the same myofascial advancement ap. The two most recent modications are considered more ergonomic and
easier to perform because they imitate the traditional open technique. Moreover,
they avoid the difcult dissection in the costal area, avoid a parallax operation
method, and require only one additional trocar.
20.5 Operative Technique
20.5.1 Transfascial Approach
In this technique, the patient is placed in the supine position with both arms
abducted. A 12-mm incision is made just below the tip of the eleventh rib using an
S retractor. The subcutaneous tissues are bluntly divided, exposing the external
oblique aponeurosis. The external oblique is sharply incised, exposing the internal
oblique muscle. The potential space between the external and internal oblique aponeuroses is developed lateral to the semilunar line using a bilateral balloon dissector. A structural 12-mm balloon port is then placed and the space maintained with a
CO
insufation pressure of 12 mmHg. The areolar attachments are bluntly dis-
2
sected under direct vision using a 10-mm 30° laparoscope. Two additional 5-mm
ports are created, one at the level of the umbilicus on the posterior axillary line and
another just above the inguinal ligament lateral to the rectus. This entire plane
between the external and internal oblique muscles is dissected, extending from just
322
Fig. 20.1 Division of the external oblique muscle takes place at the top of the screen about 2cm
lateral to the semilunar line
J. Daes
above the costal margin to the inguinal ligament and from the semilunar line medially to the posterior axillary line laterally, where the oblique muscles meet the latissimus dorsi. Coagulating scissors are used for component separation, with the
division of the external oblique aponeurosis released from the costal margin to the
inguinal ligament. The external oblique muscle will be at the top of the screen, the
internal oblique muscle at the bottom, and the semilunar line present medially
(Fig.20.1). This process is repeated on the opposite side. Each of the lateral compartments is drained with a closed suction drain. A video of the technique can be
found at https://www.youtube.com/watch?v=lKtKXDKIiRM.
20.5.2 Modified Subfascial Approach
The external oblique aponeurosis is accessed 2cm medially to the anterior superior
iliac spine (Fig.20.2). In this location, the anatomy is easily recognized as the external oblique is less muscular and almost entirely aponeurotic. After making a 1-cm
incision in the aponeurosis, a bilateral balloon dissector is used to develop the plane
in a similar fashion. A structural 10-mm balloon port is placed, and CO
is initiated, to a pressure of 12mmHg (Fig.20.3). A single 5-mm port is inserted at
the level of the umbilicus on the posterior axillary line. The areolar attachments
between these muscle layers are dissected in similar fashion. Component separation
is performed by incising the external oblique aponeurosis 2cm lateral to the semilunar line. This release is continued well above the costal margin to the insertion of
the external oblique on the ninth and tenth ribs (Fig.20.4). The inferior release from
the port site to the inguinal ligament can be easily performed in an open fashion,
using shears to divide the aponeurosis 2–3cm to the inguinal ligament under direct
visualization. A closed suction drain is passed through the lateral 5-mm port and
insufation
2
20 Endoscopic Component Separation Techniques
Fig. 20.2 Initial incision 2cm medial to the anterior superior iliac spine
Fig. 20.3 A balloon
dissector is introduced
between the external and
the internal oblique
muscles and is directed
toward the costal margin
323
inserted into the intermuscular space. A video of the technique can be found at:
https://youtu.be/OXzH_1UQRKE
20.5.3 Endoscopic Subcutaneous CS Approach
The patient is placed in a supine position with both arms tucked and padded at their
sides. Under ultrasound guidance, the semilunar lines lateral to the rectus abdominis
324
Fig. 20.4 Complete release of the external oblique muscle lateral to the semilunar line
J. Daes
muscle are identied and marked on the skin bilaterally. Marking can be performed
by the surgeon using portable ultrasound equipment immediately before skin preparation or can be performed by a radiologist in advance using indelible ink. A 12-mm
incision is made in the lower lateral quadrant of the abdomen, lateral to the previously marked semilunar line. A balloon dissector is introduced and advanced over
the anterior aponeurosis until the tip reaches the costal margin. The balloon is
inated at two levels using eight to ten pumps (Fig.20.5). Occasionally, in obese or
post-bariatric patients or in patients who have undergone previous abdominoplasty,
a blunt rod (trocar interchanger) is used to create a subcutaneous tunnel over the
fascia before introducing the balloon dissector. The balloon is then replaced by a
simple 10- to 12-mm trocar. The space is maintained with CO
insufation at a pres-
2
sure of 10mmHg (Fig.20.6). An additional 5-mm port is introduced at a position
lateral and slightly superior to the camera port (Fig. 20.7). The external oblique
aponeurosis is incised laterally to the semilunar line, using the marking on the skin
as a guide (Fig.20.8). Exposure of the fatty tissues without visualization of muscle
ensures entry into the correct plane (Fig.20.9). If muscle can be visualized at this
level, either the rectus sheath medially or the muscular part of the external oblique
laterally has been divided.
20 Endoscopic Component Separation Techniques
Fig. 20.5 Balloon
dissection of the
subcutaneous space
325
Semilunar lines
Rectus abdominis
External oblique
Internal oblique
Transversus abdominis
The external oblique aponeurosis is incised from this level to 4–6cm above the
costal margin. Above the costal margin, the aponeurosis changes to muscle and division should be performed carefully to avoid bleeding. An ultrasonic device may be
useful for this purpose. Scissors and judiciously used cautery can be used to dissect
under the external oblique muscle laterally in an avascular plane to provide maximum
advancement. With the camera turned downward, the incision in the external oblique
muscle is continued below the camera port to include the inguinal ligament. Drains
are not used routinely during this technique. The subcutaneous space is re- insufated
at the end of AWR to verify hemostasis. A video of the technique can be found at
https://www.youtube.com/edit?video_id=4SpWz7U5uZ0&video_referrer=watch.
A cross-sectional view of the abdomen that shows a comparison of the subcutaneous and subfascial techniques of component separation is provided in Fig.20.10
for both the balloon dissection and the division of the external oblique fascia (blue
arrow).