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378
Fig. 23.7 Fully dissected
subxiphoid hernia
Fig. 23.8 Closure of the
defect (view is from the
right side of the patient)
K. A. LeBlanc
incorrect (off center) position of the mesh. The defect will then be closed with permanent barbed suture (polypropylene) when possible.
Fixation of the prosthetic material is critically important here. The signicant
advantage of the robotic technology is the ability to sew very effectively compared
to the traditional laparoscopic technique. The prosthetic chosen should be sewn
with the sutures of surgeon preference, but I prefer the use of barbed permanent
sutures. The superior portion of the mesh should be sewn to the diaphragm taking
care to avoid penetration into the mediastinum or chest cavity. One should assure
that the mesh is taut and without any laxity (Fig.23.9) (see footnote 1).
Similar considerations apply to the suprapubic hernias. If the denition of this
hernia is the location at 4cm or less from the pubic bone, then it is impossible to
obtain a 5cm overlap of the prosthetic to just tissue. The most common cause of
recurrence in the repair of suprapubic hernias is inadequate dissection in the pelvis
which results in inadequate overlap and inadequate xation. To avoid this fact,
thedissection should be performed similar to that of TAPP inguinal hernia repair.
23 Subxiphoid andSuprapubic Hernia Repair
Fig. 23.9 Mesh in place
to cover the defect (view is
from right side of the
patient)
Fig. 23.10 Closed fascial
defect of suprapubic hernia
379
Fig. 23.11 Mesh xation
with sutures and tacks to
Cooper’s ligament
380
The exposure down to Cooper’s ligament will allow excellent xation the mesh
onto that structure. The fascial defect of the hernia will be closed rst
(Fig. 23.10). One may sew the material to this ligament and/or use permanent
tacks(Fig.23.11). If there is any remnant of tissue above the pubic bone, I will also
sew this to the mesh with permanent barbed sutures. The remaining portion of the
prosthetic will be sutured in place as well as described above (Fig.23.5). It is recommended that any positioning aid such as the suture or positioning device be
pulled through the abdominal wall prior to the closure of the fascia as discussed for
the subxiphoid hernia.
K. A. LeBlanc
23.4 Postoperative Care
An immediate postoperative chest radiograph after subxiphoid hernia repair is frequently performed if there is concern of passage of the suture through the diaphragm. Occasionally one will see a small pneumothorax, but this is merely
observed as the carbon dioxide in the chest will resorb quickly. If the patient develops symptoms from this, then appropriate measures should be undertaken, although
I have never had to act on any of them.
Most of these have been performed on an outpatient basis. If there are multiple
co-morbidities or extensive dissection resulting in potential medical or postsurgical
adverse events, then the patients will remain in the hospital. Activities are limited
for 2–4weeks to allow sufcient time for the fascial closure to become secure and
ingrowth of tissue into the mesh. These are very tenuous tissues in some cases, so
caution is preferred. Higher risk patients, such as those that are diabetic, overweight
or with compromised immune systems, etc., will take a much longer period of time
to heal these tissues. In these cases, I will limit activities for even longer periods of
time.
In these locations of the body it is virtually impossible to insure a good t of an
abdominal binder. Therefore, these are rarely used. Most individuals will not
develop a seroma. Even those that do, these will resolve in nearly all cases.
23.5 Conclusion
The use of the robot to repair these infrequent yet difcult hernias has allowed the
opportunity to perform these repairs with more secure xation. While more data is
needed, the perception that these techniques will improve outcomes. Due to the
infrequent development of these defects, more time is needed to establish the best
methods of repair. In my practice, I am unaware of any recurrence of these hernias
to date.
23 Subxiphoid andSuprapubic Hernia Repair
381
References
1. Charles A, Shaikh AA, Domingo S, Kreske E.Falciform ligament hernia after laparoscopic
cholecystectomy: a rare case and review of the literature. Am Surg. 2005;71(4):359–61.
2. Dusu K, Dindyal S, Gadhvi V.Small bowel obstruction via herniation through an iatrogenic
defect of the falciform ligament following laparoscopic cholecystectomy. Ann R Coll Surg
Engl. 2015;97(6):e93–5.
3. Landau O, Raziel A, Matz A, Kyzer S, Haruzi I.Laparoscopic repair of poststernotomy subxi-
phoid epigastric hernia. Surg Endosc. 2001;15(11):1313–4.
4. Davidson BR, Bailey JS.Incisional herniae following median sternotomy incisions: their inci-
dence and aetiology. Br J Surg. 1986;73:995–6.
5. Losanoff JE, Basson MD, Laker S, Weiner M, Webber JD, Gruber SA.Subxiphoid incisional
hernias after median sternotomy. Hernia. 2007;11:473–9.
6. Sharma A, Dey A, Khullar R, etal. Laparoscopic repair of suprapubic hernias: transabdominal
partial extraperitoneal (TAPE) technique. Surg Endosc. 2011;25:2147–52.
7. Palanivelu C, Rangarajan M, Parthasarathi R, etal. Laparoscopic repair of suprapubic inci-
sional hernias: suturing and intraperitoneal composite mesh onlay. A retrospective study.
Hernia. 2008;12:251–6.
8. Renard Y, Simonneau AC, de Mestier L, Teuma L, Meffert JL, Palot JP, Kianmanesh R.Standard
of open surgical repair of suprapubic incisional hernias. World J Surg. 2017;41(6):1466–74.
9. Blair LJ, Cox TC, Huntington CR, Ross SW, Kneisl JS, Augenstein VA, Heniford BT.Bone
anchor xation in abdominal wall reconstruction: a useful adjunct in suprapubic and para-iliac
hernia repair. Am Surg. 2015;81(7):693–7.
10. Carbonell AM, Kercher KW, Matthews BD, etal. The laparoscopic repair of suprapubic ven-
tral hernias. Surg Endosc. 2005;19:174–7.
11. Varnell B, Bachman S, Quick J, etal. Morbidity associated with laparoscopic repair of supra-
pubic hernias. Am J Surg. 2008;196:983–7.
12. Hope WW, Hooks WB 3rd. Atypical hernias: suprapubic, subxiphoid and ank. Surg Clin
North Am. 2013;93:1135–62.
13. Sikar HE, Çetin K, Eyvaz K, Kaptanoglu L, KüÇük HF.Laparoscopic repair of large suprapu-
bic hernias. Wideochir Inne Tech Maloinwazyjne. 2017;12(3):244–50.
14. Jenkins ED, Yom VH, Melman L, Pierce RA, Schuessler RB, Frisella MM, Christopher Eagon
J, Michael Brunt L, Matthews BD.Clinical predictors of operative complexity in laparoscopic
ventral hernia repair: a prospective study. Surg Endosc. 2010;24(8):1872–7.
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scopic ventral hernia repair. Surg Innov. 2008;15(4):292–6.
Lumbar Hernia
24
MaamounHarmouch andKarlA.LeBlanc
24.1 Introduction
24.1.1 Historical Background
Lumbar hernia was rst noted in the sixteenth century by P. Barbette. It was not
until 1731 when Garangeot published the rst case of an incarcerated lumbar hernia
found at autopsy [1]. In 1750, Ravaton performed the rst surgical repair on a strangulated lumbar hernia in a pregnant woman. In 1783, the French surgeon Jean Petit
described the anatomical boundaries of what is known as the inferior lumbar triangle [2]. In 1866, Grynfeltt described the superior lumbar space [3]. This was also
conrmed by Lesshaft in 1870 when he described another case of lumbar hernia
through the superior lumbar space. Hence, the superior lumbar space is often called
the Grynfeltt-Lesshaft triangle. In 1906, Selby described the rst case of traumatically acquired lumbar hernia after a fall [4]. In 1939, Kelton described iatrogenic
post-incisional lumbar hernias [5] and in 1951 Kretchmer published a case series of
acquired lumbar hernias after renal surgery [6].
24.1.2 Classifications
Lumbar hernias are uncommon and represent a reported incidence of 1.5% of all
hernias. Consequently these are rarely encountered by the average surgeon.
Certainly, there are controversies and overlap when classifying these defects. Often,
they are described as congenital or acquired. Congenital lumbar defects consist of
M. Harmouch
Fellow, Minimally Invasive Surgery Institute, Our Lady of the Lake Physician Group,
Baton Rouge, LA, USA
K. A. LeBlanc (
Our Lady of the Lake Physician Group, Baton Rouge, LA, USA
© Springer Nature Switzerland AG 2019
K. A. LeBlanc (ed.), Robotic Assisted Hernia Repair,
https://doi.org/10.1007/978-3-030-23025-8_24
*)
383
384
M. Harmouch and K. A. LeBlanc
approximately 20% of cases and are classically described as Grynfeltt and Petit
which arise in the superior and inferior lumbar triangle; respectively. Acquired lumbar defects consist of approximately 80% of cases [7]. These are further classied
as primary or spontaneous and secondary which occur as a result of trauma, surgical
procedures, and infections. Some of the risk factors that have been shown to contribute to the development of spontaneous herniation include older age, obesity,
COPD, extreme leanness, and/or chronic debilitating illness [5]. Secondary defects
are further divided into “true hernia” with a fascial defect and “pseudo-hernia” with
intact fascia but denervated and paralyzed lateral abdominal wall musculature.
Pseudo-hernia results from injury to the intercostal nerves which result in muscle
paralysis and subsequent atrophy. The end result of which is a ank bulge that is
accentuated with the Valsalva maneuver. This entity presents a challenge to the
treating surgeon, as they are often difcult to affect a permanent and cosmetically
acceptable repair.
24.1.3 Surgical Anatomy
Lumbar hernia is a broad term that encompasses defects that arise in the posterolateral abdominal wall. The abdominal wall in this region is made up of the skin,
Camper’s and Scarpa’s fascia, three muscular layers (supercial, middle, and deep),
lumbodorsal fascia, transversalis fascia, and the extraperitoneal tissue [8]. The
supercial muscle layer consists of latissimus dorsi and external oblique muscles.
The middle muscular layer consists of the sacrospinalis, internal oblique, and the
serratus inferior muscles. The deep muscular layer consists of quadratus lamborum
and psoas muscles [7].
Anatomically, the lumbar region spans the area bounded by the 12th rib cephalad, the iliac crest caudad, the erector spinae muscles posterolaterally, and the linea
semilunaris anterolaterally [5, 7]. There are two anatomical spaces in the lumbar
region known as the superior and inferior lumbar triangles. The superior lumbar
triangle tends to be larger, deeper, and of variable morphology [9]. This inverted
triangle is bordered by the 12th rib and the inferior edge of the serratus muscle as its
base, the posterior edge of the internal oblique muscle anteriorly, and the anterior
edge of the sacrospinalis muscle posteriorly. The roof and oor are bounded by the
external oblique/latissimus dorsi and the aponeurosis of the transverses abdominis,
respectively. It is believed that this is the most common site of lumbar hernias [9,
10]. On the other hand, the inferior triangle is often consistently triangular and is
bordered by external oblique laterally, latissimus dorsi medially, iliac crest inferiorly, with the internal oblique muscle as its oor [9, 10]. Lumbar hernias that do not
respect the anatomical boundaries are often termed “diffuse”. These often surpass
the boundaries of the lumbar space and can encompass both triangles [5, 11]
(Fig.24.1).
tr
(inf
)
24 Lumbar Hernia
385
Trapezius M.
Latissiumus
dorsi m.
External
oblique m.
Hernia in
iangle of petit
erior lumbar
triangle)
Iliac crest
Gluteus
maximus m.
Serratus posterior
inferior m.
12th Rib
Hernia in the space
of grynfelt (superior
lumbar triangle)
External oblique m.
Internal oblique m.
Erector spinae m.
(covered by aponeurosis
Fig. 24.1 Anatomy of superior and inferior lumbar hernias
24.1.4 Pathogenesis
It has been theorized that the combination of increased intraabdominal pressure, anatomical alteration of muscles, and the presence of a natural orice in the lumbodorsal
fascia predispose certain individuals to acquire this defect [5]. In contrast, secondary
herniation can result from direct injury to one or more of the musculature, lumbodorsal fascia, and intercostal nerves. This is often the result of a surgical incision or
trauma [4, 6, 12]. The abdominal wall muscles are segmentally innervated by spinal
roots T7–T12 [13]. Violation of these nerves, which can occur with certain surgical
procedures, will cause atrophy of the abdominal wall musculature [9, 14]. This can
ultimately result in either a “denervation” bulge and/or a true fascial defect. Common
surgical procedures that yield this pathology include nephrectomies, aortic surgery,
and lateral approaches to lumbar disc fusion, resection of abdominal wall tumors,
iliac bone harvest, and the latissimus dorsi ap used for reconstruction of a tissue
defect [5]. It has been noted that up to 50% of patients that undergo radical nephrectomy through a lumber incision will develop a permanent bulge [15].
386
M. Harmouch and K. A. LeBlanc
24.1.5 Clinical Presentation
Clinically, a lumbar hernia can present as an incidental nding on an imaging study
or as an asymptomatic bulge that increases in size with the Valsalva maneuver.
There can be signicant asymmetry of the abdominal wall in the instance of the
“denervation hernia” (Fig. 24.2). When symptomatic, it typically presents with
vague lower back pain. In extreme cases, it can cause bowel or urinary obstruction.
Diagnosis is often made by history and physical examination. The CT scan can be a
helpful tool in not only conrming the diagnosis, but more importantly it can provide valuable information that will guide the surgical approach [5, 8, 9, 11, 14].
24.2 Preoperative Planning
Similar to other types of abdominal wall hernias, surgical planning for ank hernias
can be quite challenging especially when faced with a complex defect and a patient
with multiple co-morbidities. Therefore, patient selection, pre-operative medical
optimization, and meticulous surgical techniques are keys to desirable outcomes.
Due to its elective nature, surgery should be reserved for symptomatic patients with
a favorable risk prole. It is prudent for the surgeon and the patient to work together
to identify modiable risk factors. This should be followed by a plan to implement
Fig. 24.2 Right sided
denervation defect in a
patient after a right
nephrectomy
24 Lumbar Hernia
387
an effective pre- operative multidisciplinary counseling and therapy. The patient
must show motivation and comply with any dietary, exercise, and smoking session
programs when applicable [16, 17].
Factors that play an important role in surgical decision making can be divided
into patient specic and hernia specic factors. These include obesity, smoking status, poorly controlled diabetes, size of the hernia, status of abdominal wall domain,
presence of overlaying redundant and atrophic skin, and lastly whether the hernia
represents a true defect versus a denervation injury [16, 17]. Owing to the rarity of
the condition and the poor quality of the available evidence, recommendations
regarding the optimal surgical approach are still ambiguous. Based on the current
evidence, the laparoscopic approach appears to have fewer complications, less post
operative pain, and a decreased length of hospital stay when compared to open surgery [17–19]. In general, the inherent advantages seen with minimally invasive surgery are often translated to the management of lumbar hernias. Although, one must
take all factors into consideration to help guide the surgical decision making. For
example, patients that have multiple risk factors for poor wound healing and a small
to moderate sized hernia will be better served with a minimally invasive approach.
On the other hand, patients with large defects, redundant overlaying skin and soft
tissue or a “denervation” hernia might have better outcomes with an open or hybrid
approach. More recently, there has been an increase utilization of robotic technology in the management of abdominal wall hernias. This stems from the multiple
features that it offers which enable the surgeon to perform more complex repair in a
minimal invasive fashion that was once considered to be too difcult or impossible
laparoscopically. It is therefore not surprising that there seems to be a trend in the
treatment of these large ank hernias utilizing a minimally invasive fashion with the
robotic platform [20].
24.3 Operative Technique
The surgical approach to lumbar hernia repair is inherently similar to other types of
abdominal wall hernia repair. These include open, laparoscopic, robotic, and hybrid
techniques. In addition, the surgical techniques and intraoperative pearls that deal
with abdominal wall hernia repair are quite similar to the management of these
uncommon fascial defects. These include dissection of hernia sac to the fascial
edges and development of a preperitoneal pocket if mesh placement will be in that
location. Additional important considerations are the primary closure of fascial
defect, allowance for 5cm or greater overlap of mesh, appropriate mesh xation,
and layered closure of soft tissue and skin. Unlike other forms of abdominal wall
hernias, the presence of two bony landmarks (ribs and iliac wing) can make repair
and mesh xation a challenging task for the surgeon dealing with ank hernias. This
is especially challenging in those situations where traumatic events have disrupted
the anatomic muscular attachments to these bony structures.
Irrespective of the approach employed, the patient is positioned similarly whether
a minimally invasive or an open approach is utilized. After induction of general
anesthesia, a urinary drainage catheter and an orogastric tube should be placed. The
388
M. Harmouch and K. A. LeBlanc
patient is then placed in the lateral decubitus position with the involved side up. All
areas must be padded appropriately. One must ensure that the surgical eld spans
the 4 to 5th intercostal space cephalad, below the iliac crest caudad, the spinous
process medially and the contralateral midclavicular line laterally. For excellent
exposure the operating room table is exed in order to stretch the lumbar space.
While this exion will aid in exposure of the operative eld, it can compromise the
laxity of the nal repair and mesh tautness so this must be restricted as much as possible. In general, we prefer to avoid exion of the bed completely.
24.3.1 Open Approach
The open technique is often used with very large ank hernias. The incision is typically made over the old incision or directly over the primary hernia. Dissection is
carried down to the hernia sac which is then freed circumferentially.
Musculocutaneous aps are then developed. The preperitoneal space entered and a
space is then developed to allow a minimum 5cm of mesh overlap in all directions.
The mesh that is selected will be based upon surgeon preference but a lightweight
material is not recommended.
24.3.2 Mimimally Invasive Approach
24.3.2.1 Conventional Laparoscopy
These hernias can be repaired with either the preperitoneal placement or intraperitoneal placement of mesh (IPOM). It has been shown that the main consideration in
the repair of lumbar hernias is the placement of a prosthetic material, whether open
or laparoscopically repaired [21]. The choice of mesh will be inuenced by the location of its nal placement. The preperitoneal dissection will expose the fascia as part
of the procedure and covers it once the repair is complete. In that method, a “noncoated” product may be used. A “coated” (i.e. tissue separating) product is required
if the IPOM is performed. If the latter technique is utilized, it is important to dissect
the preperitoneal fat away from the fascia so that the uncoated surface of the mesh
contacts as little of the adipose tissue as possible to ensure an effective repair. This
is the fundamental difference between these methods. In many patients, this extraperitoneal fat will be so extensive that the use of the preperitoneal space for placement of an uncoated mesh will be most appropriate. The following procedure
description will apply to both.
This repair will be similar to the traditional incisional hernia repair. If possible,
the fascial defect can be closed with either transfascial or intracorporeal sutures.
The latter option seems easiest if barbed sutures are utilized in the closure. If transfascial sutures are to be placed, one must be careful not to inadvertently place them
through the chest cavity if the hernia is adjacent to the thoracic cavity. Closure of the
defect becomes more difcult with larger defects.
The mesh will be placed to cover the defect with at least a ve-centimeter overlap of the fascial defect. It is preferred that the size be selected on the measurement