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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_874_Библиотеки_им_академика_М_И_Перельмана.pdf
24 Lumbar Hernia
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of the unclosed defect as one cannot be assured that the closed defect will remain
permanently closed [22] If a bridged repair is chosen, then an even greater attention
to the amount of mesh overlap is required. The mesh:defect ratio will be a factor
[23]. If xation to the diaphragm is necessary, this can be sutured with either interrupted or running permanent sutures. If additional xation with a device other than
sutures is needed, one should only place them below the diaphragm
24.3.2.2 Robotic Assisted
Minimal invasive lumbar hernia repair can be performed via different approaches.
We describe a technique for robotic-assisted transabdominal laparoscopic repair
1. Trocar placement
Access to the abdominal cavity can be done via the Hassan method, a Veress
needle, and optical trocar techniques. We prefer using a 5mm optical trocar at
the ipsilateral subcostal space. Pneumoperitoneum is established and pressure
set to 15mm Hg. A 30-degree scope is used to explore the abdominal cavity to
ensure no adhesions that will prohibit the placement of the remaining reusable
trocars. The 8.5mm robotic trocars will then be placed at appropriate locations.
Two additional trocars are placed to allow sufcient distance from the working
site, including both the fascial defect and the desired 5cm overlap of the mesh.
Most often, these will be placed in the midclavicular line. Consideration must be
given to the laxity of the abdominal wall especially in morbidly obese individuals. Insufation can result in a signicant increase in the distance away from the
hernia defect making the performance of the operation more challenging. The
trocars are placed in a linear or “C” shaped fashion if the Xi or Si platforms are
used, respectively. After the robotic trocars are positioned the 5mm trocar will
be replaced with a 12mm trocar to allow the introduction of needles, suture and
mesh (Fig.24.3). The robotic scissors, bipolar grasper and needle holder are the
instruments of choice for the authors. The use of three arms of the robot is all that
is usually required.
Fig. 24.3 Robotic trocar placement for a “true” right lumbar hernia repair (red arrow denotes the
12mm trocar)
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M. Harmouch and K. A. LeBlanc
2. Docking the robot
The robot is brought in from the ank. Fine adjustment should be made to
bring the robotic arms in line with the dissection. Sufciently distant trocar
placement is essential prior to docking to limit the collision of the robotic arms
(Fig.24.4). It is important to ensure that all arms are “bumped up” to ensure both
that there is no tension on abdominal wall and that the range of movement for
each arm is sufcient. Proper port placement and docking of the robot entails a
learning curve; ensuring proper port placement and arm docking will limit an
increase in the operative time for needed trouble shooting during the case.
3. Identication of the lumbar hernia
The peritoneum is incised from the 10th rib to the iliac crest. The peritoneum
and retroperitoneal tissues are dissected at least 6–8cm away from the hernia
defect to ensure proper mesh coverage. In general, however, more dissection is
required to allow for ample manipulation of the mesh and the proper placement
of sutures. Reduction of all hernia contents is performed to identify the exact
dimensions of the hernia defect (Fig.24.5a,b).
4. Defect closure
The hernia defect is closed primarily using a double armed 0 barbed non-
absorbable suture. Barbed sutures facilitate closure as they more evenly distribute the tension of the closure itself. However, other suture types can be used
according to surgeon preference. Decreasing the pneumoperitoneum to 6–8mm
Hg and utilizing the shoelace concept by taking all fascial bites and then tightening each one separately to decrease defect size will facilitate fascial closure in
larger defects. The authors nd it best to insert the mesh and pull out a centrally
placed suture to accurately locate the material. Once the defect itself is closed,
the exact location of the central portion of the fascial defect may be difcult.
This could cause an inadvertent shift of mesh placement resulting in an improper
overlap and increase the likelihood of recurrence. Closure of the defect is nearly
always possible but occasionally the defect must be bridged with very large
Fig. 24.4 Typical spatial relationship between the robotic arms
24 Lumbar Hernia
a
b
391
Fig. 24.5 (a) Left lumbar hernia prior to dissection (arrows delineate the border). (b). Left lumbar
hernia after full dissection (from Fig.24.5a)
hernias. An attempt is always made a defect closure because the sutures can also
act as a “backstop” for the mesh in such situations.
5. Mesh placement and xation
It is important to size the mesh based on the defect prior to closure of the
fascial defect. Mesh should be sized with minimum of 5cm overlap in mind. As
noted above, if the mesh is entirely within the preperitoneal space, a non-coated
material can be used. If there is exposure to the internal organs, then a tissue
separating product should be used. There are many products available and are
discussed extensively in Chap. 4. The authors prefer either a polypropylene or
polytetrauoroethylene hybrid material. Although the mesh could be tacked with
a few sutures or a xation device of some type, we prefer to use the same permanent suture described above using in two rows on either side of the closed defect
(Fig.24.6). This allows the suture line to bolster the fascial closure while approximating the mesh to the abdominal wall, which will increase the rapidity of
ingrowth into the material. All techniques utilizing xation with either suture or
tacks should respect the path of the nerves that arise from the anterior rami of the
T12/L1 nerve roots (ilioinguinal, iliohypogastric, and genitofemoral nerves).
392
emoral n.
Fig. 24.6 Intracorporeal sutured mesh using barbed polypropylene suture
M. Harmouch and K. A. LeBlanc
12th Rib
Ilio-inguinal n.
Lateral femoral
cutaneous n.
Genitof
Fig. 24.7 Anatomic course of the nerves near the 12th rib
This path will not be consistent and will splay out over the psoas muscle.
Consequently, the course of these nerves can be difcult to identify (Fig.24.7).
Biosynthetic glue has been described as a method for mesh xation as well but
we have no experience in this application.
24 Lumbar Hernia
393
6. Peritoneal closure
The peritoneal ap is then closed using an 18-inch double armed long lasting
absorbable suture. During the suturing to close the peritoneal pocket it is crucial
to assess the peritoneal ap at the end to identify and close any signicant tears
with interrupted absorbable sutures.
24.3.3 Hybrid Approach
Due to the inherent anatomic issues due to the paralysis of these muscles, the authors
prefer this approach for the “denervation” hernia. It typically consists of both an
initial open followed by a robotic assisted approach. The skin incision of the prior
procedure is utilized and in most cases, this must be extended. The initial dissection
will require the development of signicant skin aps in all directions to accommodate an onlay mesh overlap that extend above the ribs superiorly, below the iliac
crest inferiorly, onto the rectus sheath medially, and near the spine posteriorly. This
will provide coverage of the entire area of denervation injury.
At that point, the muscles are incised to enter the abdominal cavity. Adhesiolysis
is performed as necessary. Again, this dissection must extend above the diaphragm
superiorly, into the pelvis inferiorly, to the midline medially, and to the paraspinus
muscles posteriorly. The mesh should be large enough to cover all of these areas.
This is required whether the mesh is to be placed in the extraperitoneal space or
intra-abdominally. Generally the intraperitoneal onlay approach is selected as this
combined method is best completed in this fashion.
Preplaced sutures will allow for transfascial suture xation as described above
(Fig.24.8). The mesh material will be inserted and sutured to the paraspinus muscles initially. One to three posteriorly placed transfascial sutures are also utilized.
The superior portion of the mesh will then be sutured to the diaphragm with
Fig. 24.8 Preplaced transfascial suture to help with mesh xation
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M. Harmouch and K. A. LeBlanc
interrupted sutures. Occasionally, transfascial sutures are added below the costal
margin. However, a medially placed transfacial suture will allow this portion of the
mesh to be identied and xed. Usually, two sutures that are preplaced on the mesh
will allow the transfascial sutures to assure that the mesh is apposed against the
closed muscles and fascia, which greatly aids in the robotic xation. The inferior
location of the mesh will be determined during the robotic portion of the procedure
so no xation will occur at this time. This fact is the reason that the hybrid approach
is so benecial as this allows us to x the mesh with minimal laxity.
Prior to the medial xation of the mesh, three robotic trocars are placed where
best located. Usually these are to the contralateral side of the midline. At this point
the divided muscles will be plicated in a “vest over pants” conguration and these
should be pulled as tight as feasible. One must account for this portion of the procedure during placement of the subcostal transfascial sutures, if used. We usually elect
to place the onlay mesh at this time (Fig.24.9). This mesh will cover all of the previously dissected areas below the skin aps. We generally do this at this time but one
might occasionally need to reopen the closed muscles for additional xation should
these become dislodged during the robotic portion. This is so seldom necessary that
we will place the selected mesh and quilt the subcutaneous tissue using barbed
absorbable sutures to the underlying mesh and fascia to close the dead space and
thereby eliminate the need for any drains (Fig.24.10). Frequently, brin tissue glue
is used to xate the product in its entirety.
The robot will then be docked and the laparoscopic portion will commence. The
goal here is to pull the inferior portion of the mesh taut and xate it rmly. This will
be done with running barbed sutures robotically. The robotically placed sutures will
also be run over the interior of the mesh to rmly xate all of it to the abdominal
wall (Fig.24.11). This will aid in the prevention of a seroma while assuring rm
attachment and early ingrowth of tissue into the prosthesis.
Fig. 24.9 Onlay mesh placement
24 Lumbar Hernia
Fig. 24.10 Arrows indicate the quilting of the subcutaneous tissue with barbed absorbable
sutures, the process is not completed until the entire layer is done
395
Fig. 24.11 Intracorporeal suturing of the mesh
If the onlay mesh and skin closure has not been done already, the procedure
returns to the open portion. A large onlay of the selected mesh is placed to cover the
entire area as noted above. Quilting is always performed as noted above. The subcutaneous tissue is closed in layers and the skin closed.
Although not mentioned above, it is extremely benecial to inject a long acting
local anesthetic, liposomal bupivacaine into the tissues and as a TAP or erector spinae block during the open portion of the operation. This is a painful operation and
the addition of this drug aids in pain control postoperatively
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M. Harmouch and K. A. LeBlanc
24.4 Conclusion
Lumbar hernia, although rare, can be a signicant cause of chronic lumbar pain,
cosmetic deformity, and potential morbidity from incarceration and strangulation of
retroperitoneal and intraabdominal contents, and all patients diagnosed with lumbar
hernia should be referred for elective repair. The recognition and incidence of these
hernias will continue to increase, and knowledge of repair of these hernias is essential to the practice of hernia specialists. The minimally invasive approach lends
itself well to repair of circumscribed lumbar hernia defects. Adequate mesh overlap
is essential, and repair of these rare hernias can be technically challenging. The
increased freedom of laparoscopic articulation provided by robotic technology
allows the opportunity for these patients with a traditional lumbar hernia to be
treated in the ambulatory setting.
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Robotic-Assisted Parastomal Hernia
Repair: Sugarbaker Repair (With
25
andWithout Component Release)
AlexAddo, RichardLu, IgorBelyansky, andKarlA.LeBlanc
25.1 Background
A parastomal hernia results when there is protrusion of abdominal contents through an
abdominal wall defect adjacent to a stoma. The reported incidence is up to 75% [1, 2].
Risk factors for development include diabetes mellitus, chronic pulmonary disease,
older age, smoking, malnutrition and chronic steroid use [2]. Obesity also signicantly
contributes to the risk of parastomal hernia formation through an increase in intraabdominal pressure and altered maturation of collagen leading to tissue laxity [3].
The two most common types of parastomal hernia repairs are the Sugarbaker and
the keyhole techniques. The purpose of this chapter is to describe the operative
method for the robotic-assisted modied Sugarbaker repair. The original Sugarbaker
method, rst published in 1985, described repairing parastomal hernias with intraabdominal prosthetic mesh placement and lateralization of the bowel conduit [4]. The
mesh was circumferentially secured with interrupted sutures around the defect
except laterally for the bowel conduit to pass through. The bowel conduit was then
secured to the lateral abdominal wall with sutures. Currently, this procedure can be
performed utilizing a minimally invasive approach. Pauli etal. described the Pauli
A. Addo · R. Lu
Department of Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
I. Belyansky (
Department of Surgery, Anne Arundel Medical Center, Annapolis, MD, USA
Abdominal Wall Reconstruction Program, General Surgery, Anne Arundel Medical Center,
Annapolis, MD, USA
e-mail: ibelyansky@aahs.org
K. A. LeBlanc
Our Lady of the Lake Physician Group, Baton Rouge, LA, USA
Department of Surgery, Louisiana State University Health Sciences Center,
New Orleans, 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_25
*)
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