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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_897_Библиотеки_им_академика_М_И_Перельмана.pdf
Enhanced View Totally Extraperitoneal (eTEP) Repair for Iliac Fossa and Lumbar Hernias
ParthasarathiRamakrishnan,
ShankarBalasubramanian,
andChinnusamyPalanivelu
16
16.1 Introduction
Laparoscopic repair of ventral hernia has gained
widespread acceptance among surgeons as well
as patients worldwide for the various benets it
has to offer. Intraperitoneal onlay mesh repair is
the most commonly performed laparoscopic ventral hernia repair with good long-term outcomes
[1]. However, placing the mesh within the peritoneal cavity predisposes to troublesome adhesion
formation which has not been eliminated despite
the use of composite meshes. Also, it is evident
from studies that retrorectus placement of mesh
has biomechanical advantages of distributing the
intra-abdominal pressure on the mesh and tightly
securing it thereby preventing mesh migration
and hernia recurrence [2].
The enhanced view totally extraperitoneal
(eTEP) repair of ventral hernia is the endoscopic
adaptation of Rives-Stoppa technique of retrorectus mesh placement. This technique was initially
described for repairing large inguinal hernias and
was later utilized for repairing midline ventral
hernias [3, 4]. With growing experience in performing endoscopic component separation, surgeons have extended the indications of eTEP for
tackling more complex and atypical hernias
P. Ramakrishnan (*) · S. Balasubramanian
C. Palanivelu
Gem Hospital & Research Center,
Coimbatore, Tamil Nadu, India
including iliac fossa and lumbar hernias. In this
chapter, we will discuss our technique of eTEP
for iliac fossa and lumbar hernias.
16.2 Preoperative Preparation
A thorough preoperative evaluation is needed for
successfully managing atypical hernias. CT scan
of the abdomen and pelvis is a useful tool to
dene the anatomy of the hernia, its contents, and
relationship to surrounding structures. As with
the repair of any incisional hernias, patients who
smoke should be encouraged to stop smoking for
at least 4 weeks before the planned procedure.
Cigarette smoking decreases tissue oxygenation
and impairs wound healing [5]. Strict glycemic
control is another important component of preoperative preparation. Ideally, the HbA1c levels
should be below 7% in the preoperative period
and perioperative blood glucose levels should be
tightly regulated to minimize surgical site infections (SSI). A systematic review of surgical
repairs of incisional hernia identied wound
infection as the most important cause of hernia
recurrence [6]. For elective hernia repairs, obese
patients should be encouraged to lose weight as
morbid obesity is a risk factor for recurrence.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
S. J. Baig et al. (eds.), Newer Concepts and Procedures in Hernia Surgery - An Atlas,
https://doi.org/10.1007/978-981-19-5248-7_16
145
146
16.3 eTEP withTAR forIliac Fossa
Hernias
16.3.1 Patient Position andTeam
Setup
Patient is placed in supine position with both
arms tucked. The monitor is placed at the foot
end of the patient. The surgeon initially stands on
the side opposite to the hernia.
P. Ramakrishnan et al.
A
16.3.2 Operative Procedure
A 12mm incision is placed about 2.5cm above
and lateral to the umbilicus on the side opposite to
the hernia. Using optical trocar (ENDOPATH
XCEL® Trocars with OPTIVIEW®, Ethicon) and
10mm zero-degree telescope the retrorectus space
is entered. Carbon dioxide insufation is started at
an insufation pressure of 12mmHg once the trocar is in the retrorectus plane (Fig.16.1). The retrorectus space is dissected by telescopic dissection
to facilitate the placement of working ports
(Figs.16.2 and 16.3). A 10mm port is placed 5cm
below the camera port at the level of semilunar
line. Further dissection is carried out using monopolar electrocautery with a hook or scissors. The
dissection is carried out as inferiorly as possible
and a 5mm port is placed about 5cm below the
10mm port (Figs.16.4 and 16.5). The camera is
then shifted to the 10mm port and the other two
ports are used as working ports. The posterior rec-
A
B
Fig. 16.2 Creation of retrorectus plane under vision by
telescopic dissection. (A) Posterior rectus sheath
A
C
B
Fig. 16.3 Left retrorectus plane is created. (A) Posterior
rectus sheath. (B) Rectus muscle. (C) Arcuate line
C
B
A
E
D
C
D
Fig. 16.1 Entry into the retrorectus plane with optiview
trocar using 0 degree telescope. (A) Subcutaneous tissue.
(B) Anterior rectus sheath. (C) Rectus muscle. (D)
Posterior rectus sheath
Fig. 16.4 Port position. (A) 10 mm port in the left of
midline for camera and working. (B) 10mm port in the
left lumbar region for camera and working. (C) 5mm port
in the left iliac fossa for working. (D) 5mm port in right
subcostal region for working. (E) Right iliac fossa hernia
tus sheath (PRS) is incised about 5–7mm below
its medial attachment to the linea alba on the cranial side. This exposes the falciform ligament
which is separated from the linea alba by blunt dis-
16 Enhanced View Totally Extraperitoneal (eTEP) Repair for Iliac Fossa and Lumbar Hernias
147
section (Fig.16.6). Care should be taken to avoid
injuring the linea alba. The opposite side PRS is
identied by the color change due to the underlying rectus abdominis muscle and incision is made
on it to enter the contralateral retrorectus space
(Fig. 16.7). An additional 5mm working port is
placed in the subcostal region on the opposite side.
The camera is then shifted to the optical trocar and
utilizing the 10mm port and the 5mm subcostal
port as the working ports, retrorectus space is created on the opposite side as well. The surgeon
stands at the head end of the patient for infra
umbilical retrorectus dissection [7] (Fig.16.8).
A survey of the hernial defect can be done
through the midline opening in the
PRS. Adhesiolysis can be done and hernial
contents can be reduced through the opening
(Figs.16.9, 16.10, and 16.11) and sac excision/
division is done (Figs. 16.12, 16.13, and
16.14).
C
B
A
Fig. 16.7 Entry into the right retrorectus plane by division of right posterior rectus sheath. (A) Falciform ligament. (B) Right posterior rectus sheath. (C) Right rectus
muscle
C
A
Fig. 16.5 Dissection in the space of Retzius, pubic bone
exposed. (A) Symphysis pubis
B
A
Fig. 16.6 Midline crossover by division of left posterior
rectus sheath attachment from linea alba. (A) Left posterior rectus sheath. (B) Falciform ligament
D
B
Fig. 16.8 Midline dissection. (A) Right retrorectus
space. (B) Falciform ligament. (C) Linea alba. (D) Left
posterior rectus sheath
B
Fig. 16.9 Adhesilolysis of omentum from the defect
transabdominally. (A) Right rectus sheath. (B) Defect
A
A
148
P. Ramakrishnan et al.
A
B
D
Fig. 16.10 Retrorectus plane created till the level of
defect on the right side. (A) Left rectus muscle. (B) Left
posterior rectus sheath. (C) Right rectus muscle. (D)
Defect
A
Fig. 16.11 Retrorectus space created all around the
defect. (A) Defect
C
Fig. 16.13 Dissection of sac
A
C
B
Fig. 16.14 Completion of dissection, peritoneum is
mobilized well below the defect. (A) Defect. (B) Posterior
layer of transversalis fascia. (C) Arcuate line
Fig. 16.12 Dissection of posterior layer of transversals
fascia and the peritoneum from the defect
The focus is again shifted to the extraperitoneal space. Inferiorly the preperitoneal spaces of
Retzius and Bogros are dissected (Fig. 16.15).
The spermatic cord structures are parietalized in
A
B
Fig. 16.15 Right Bogras space is being dissected. (A)
Right pubic bone. (B) Round ligament
male patients while the round ligament can be
divided in female patients. TAR is done by incising the posterior lamella of internal oblique and
then the transversus abdominis muscle to enter
A
16 Enhanced View Totally Extraperitoneal (eTEP) Repair for Iliac Fossa and Lumbar Hernias
A
149
B
Fig. 16.16 Release of posterior rectus sheath from the
linea semilunaris. (A) Neurovascular bundle. (B) Posterior
rectus sheath
A
B
Fig. 16.17 Posterior rectus sheath is released from the
linea semilunaris. (A) Neurovascular bundle. (B) Posterior
rectus sheath
A
B
Fig. 16.18 TA muscle is exposed after PRS release. (A)
TA Muscle. (B) PRS release site
A
Fig. 16.19 TAR is being done using Alan vessel sealing
device. (A) Divided edge of TA muscle
the pre-transversalis plane, safeguarding the neurovascular bundles. Initially, TAR is done near the
hernial defect and then continued cranially
(Figs.16.14, 16.16, 16.17, and 16.18). Lateral to
the linea semilunaris, the hernial defect is identied and delineated. The hernia sac is dissected but
preserved to bridge any gaps in the PRS or peritoneum. Further dissection is done all around the
defect area to create a wide space for placement of
the mesh.
Transversus abdominis release (TAR) is an
integral component of eTEP repair for all iliac
fossa hernias. Transversus abdominis muscle can
easily be identied by the transversely oriented
bers just lateral to linea semilunaris. TAR is
done by dividing the transversus abdominis muscle along its entire length using monopolar electrocautery or harmonic shears in cranial to caudal
A
Fig. 16.20 TAR is extended cranially. (A) Divided TA
muscle
direction (Figs. 16.19 and 16.20). This is
facilitated by creating space between the transversus abdominis muscle and transversalis fascia
by blunt dissection.
150
P. Ramakrishnan et al.
Fig. 16.21 Suturing of the defect using Vloc PBT
Fig. 16.22 PRS closure using 0 VLoc PDS
The hernial defect is closed using V-Loc™
PBT nonabsorbable wound closure device No. 1
(Covidien™) (Fig. 16.21). The posterior rectus
sheath is closed with V-Loc™ PDS 0 absorbable
wound closure device (Covidien™) (Fig.16.22).
The hernial sac which was preserved can be utilized to bridge any defects in the PRS or peritoneum. The linea alba is reconstituted using
V-Loc™ PBT nonabsorbable wound closure
device No. 1 (Covidien™). The dissected space is
measured using an umbilical cotton tape
(Fig. 16.23) and an appropriate sized medium
weight macroporous polypropylene mesh is
placed. The mesh is xed to the Cooper’s ligament and the parietal wall anteriorly, laterally as
well as posteriorly using polypropylene 0 sutures
(Figs.16.24 and 16.25). A vacuum suction drain
can be selectively placed if the dissected space is
very large. Pneumo is then deated under vision.
Fig. 16.23 Cotton tape is being used to measure the dissected area
Fig. 16.24 Polypropylene mesh is placed to cover the
dissected area
Fig. 16.25 Mesh is xed to the right cooper’s ligament
All ports 10 mm and wider are closed with transfascial sutures (Fig. 16.26). The port sites are
closed using Vicryl 3-0 subcuticular sutures.
16 Enhanced View Totally Extraperitoneal (eTEP) Repair for Iliac Fossa and Lumbar Hernias
16.4 Unique Features ofeTEP
forIliac Fossa Hernias
• Creation of retrorectus space is fairly straight-
forward in case of iliac fossa hernias. The her-
nial defect is only visible after releasing the
PRS from linea semilunaris.
• The preperitoneal space of Retzius and Bogros
are routinely dissected for iliac fossa hernias
to ensure adequate mesh coverage of the
defect.
• TAR is invariably required for the repair of
iliac fossa hernias. So competence in doing
TAR is a prerequisite for eTEP repair of iliac
fossa hernias.
• Unlike eTEP for midline hernias where the
mesh is placed on the oor of the dissected
space, for iliac fossa hernias, the mesh is xed
to the Cooper’s ligament and to the anterior,
lateral, and posterior aspect of roof of the dis-
sected space.
Fig. 16.26 Transabdominal view at the end of the
procedure
complicated by nerve injuries with resultant
chronic pain and sensory disturbances.
16.6 eTEP forLumbar Hernias
151
16.5 Flank Hernias
Lumbar hernia lie between iliac crest and costal
margin. They can be congenital or acquired.
Congenital lumbar hernias present during early
childhood and are much less common than the
acquired variant. Acquired lumbar hernias can be
primary or secondary. Secondary lumbar hernias
occur following trauma or surgeries on the ank.
Congenital lumbar hernias can occur through
superior or inferior lumbar triangles, two potential sites of weakness in the ank. The superior
lumbar triangle (Grynfeltt) is bounded superiorly
by the 12th rib, medially by quadratus lumborum, and laterally by the posterior border of the
internal oblique muscle. The oor is formed by
transversalis fascia [8]. The inferior lumbar triangle (Petit) is bounded by iliac crest inferiorly,
latissimus dorsi posteriorly, and external oblique
anteriorly. The oor of the triangle is formed by
internal oblique muscle [8].
Lumbar hernia repairs are technically challenging due to the anatomical constraints of the
region. The presence of bones both superiorly
and inferiorly pose difculties with proper mesh
overlap and xation. The repair can further be
16.6.1 Patient Position andTeam
Setup
Patient is placed in supine position with both
arms tucked. The monitor is placed on the side of
the hernia. The surgeon stands on the side opposite to the hernia.
16.6.2 Operative Procedure
For acquired lumbar hernias the ports are placed
close to the midline on the same side of the hernia. The retrorectus space is created only on the
side of the hernia. The PRS is released close to
the linea semilunaris as described for eTEP for
iliac fossa hernias. TAR is performed in a cranial
to caudal direction as described previously. This
is followed by posterior component separation
which involves gentle swiping of the transversalis fascia away from the transversus abdominis
muscle towards the peritoneum taking care to
avoid rents in the peritoneum. The dissection is
continued laterally and posteriorly delineating
the hernial defect. The dissection is carried further posteriorly as far as the psoas major muscle
to ensure adequate mesh overlap all around the
152
hernial defect. The hernial sac is then excised followed by the closure of the defect using V-Loc™
PBT nonabsorbable wound closure device No. 1
(Covidien™). Any defects in the peritoneum are
also closed using PDS 3-0 sutures to prevent
direct contact of bowel with the mesh. The dissected space is measured using umbilical cotton
tape and an appropriate-sized medium weight
macroporous polypropylene mesh is placed. A
vacuum suction drain can be placed if the dissected space is very large. Pneumo is then
deated under vision. The port sites are closed
using Vicryl 3-0 subcuticular sutures (Figs.16.27,
16.28, 16.29, 16.30, 16.31, 16.32, and 16.33).
For primary lumbar hernias, the technique can
be modied by placing the optical view trocar
P. Ramakrishnan et al.
A
Fig. 16.29 Lateral dissection is continued and defect is
reached. (A) Area of the defect
A
B
Fig. 16.27 Retrorectus space created on the side of hernia. (A) Rectus muscle. (B) PRS
A
B
A
Fig. 16.30 Content and sac is mobilized. (A) Sac
Fig. 16.28 PRS is released and lateral space entered. (A)
Rectus muscle. (B) PRS
Fig. 16.31 Defect is closed using Vloc PBT
16 Enhanced View Totally Extraperitoneal (eTEP) Repair for Iliac Fossa and Lumbar Hernias
section may have to be extended beyond the
psoas major muscle posteriorly to facilitate tension-free closure of the hernial defect. Despite
such extensive mobilizations it may at times still
not be possible to close the defect. In such
instances, the defect can be bridged with the
help of a mesh. Such difculties should be
A
anticipated by preoperative imaging to avoid
any intraoperative surprises.
Iliac fossa and lumbar hernias are relatively
rare. Most of the reports in the available literature
are case reports and case series that have adopted
Fig. 16.32 Completion of defect closure. (A) Psoas
muscle
an open method of repair [9, 10]. Laparoscopic
intraperitoneal mesh repair is the commonly
reported minimal access technique for iliac fossa
and lumbar hernias [11, 12]. Some surgeons have
also utilized laparoscopic preperitoneal mesh
repair for tackling such hernias [13, 14]. With
only a small number of patients and retrospective
nature of these studies it is difcult to derive
denitive conclusions. With paucity of literature
evidence, it is vital to adopt a pragmatic approach
based on the individual patient characteristics for
managing these complex hernias.
153
Fig. 16.33 Polypropylene mesh is placed
directly between transversus abdominis muscle
and transversalis fascia lateral to the semilunar
line. Subsequent steps are similar to that described
previously for acquired lumbar hernia.
16.7 Discussion
Iliac fossa and lumbar hernias pose unique challenges to the hernia surgeon. To tackle these
hernias, a sound knowledge of the anatomy of
the lateral and posterior parietal wall is essential. The presence of bony structures on both the
superior and inferior aspects can cause difculties in mesh placement. For very large hernial
defects, it may be necessary to dissect the space
well above the costal margin to all the way
below up to the pubic bone. Similarly, the dis-
16.8 Conclusion
Iliac fossa and lumbar hernias can be successfully managed by eTEP approach. Prociency in
TAR and posterior component separation is
essential for eTEP repair of iliac fossa and lumbar hernias. For obtaining optimum results such
hernias should be repaired by experienced surgeons in high-volume centers.
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