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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_903_Библиотеки_им_академика_М_И_Перельмана.pdf
204
S. P. Carmichael II and J. S. Roth
disease spectrum (“eventration disease”) encompassing multiple factors as follows:
(1) predisposing systemic disorders, (2) injury and atrophic change to subcutaneous
and abdominal wall layers, and (3) disordered ventilation due to loss of complementary abdominal wall and diaphragmatic function [9, 10]. He contended that the
achievement of good operative result required a multidisciplinary approach to medical management with systemic risk reduction prior to the time of surgery [9, 10].
Simple closure of abdominal wall defects >5cm was notably ineffective, and best
results were associated with the use of nonabsorbable macroporous mesh [11].
Thus, the main objectives of mesh herniorrhaphy according to Rives, and synchronously Rene Stoppa, are severalfold: (1) defect closure without tension, (2) anatomic re-approximation of abdominal wall musculature through insertion of a mesh
prosthesis, (3) avoidance of intra-abdominal hypertension upon closure, (4) wide
overlap of mesh within retrorectus (Rives) or preperitoneal (Stoppa) spaces, and (5)
avoidance of intra-abdominal placement of nonabsorbable mesh, given potential for
visceral complication or mesh migration [11, 12].
Utilization of the retrorectus dissection facilitates two notable advantages in IH
repair: (1) approximately 2cm of medial mobilization of the anterior rectus sheath
to facilitate closure and (2) provision of an easily dissectible and well-vascularized
potential space for mesh placement, a discriminating feature from the anterior rectus space [4, 13]. In addition, the retrorectus space provides for a two-layered closure of the abdominal wall [4]. Interestingly, contemporary animal model
preparations of IH demonstrate reversal of the associated rectus muscle atrophy and
brosis described by Rives following mesh herniorrhaphy [14]. Moreover, types I
and III collagen proliferation is more robust within the retrorectus space in comparison with onlay mesh placement [15]. Lastly, insertion of intraperitoneal mesh has
been recently redemonstrated to signicantly increase the rate of subsequent laparotomy versus preperitoneal mesh (76% vs 29%). Of the re-operative group, 21% of
the patients with intraperitoneal mesh required small bowel resections versus none
in the preperitoneal group [16]. Lastly, two patients with intraperitoneal mesh were
also noted to develop enterocutaneous stula at the time of re-laparotomy [16].
Following the pioneering work of Drs. Rives and Stoppa in France, Dr. George
Wantz, a surgeon from Cornell University, studied the retrorectus technique under
Stoppa and Flament, a protégé of Rives. His academic sabbatical in 1985–1986 resulted
in the popularization of the retromuscular IH repair in the United States. In 1991, Dr.
Wantz published his experience in a series of 30 patients with defects >10cm. He
placed overlapping polyester ber (Mersilene) mesh within the retrorectus space,
securing it with interrupted transfascial sutures. He contended that the repair prevented
recurrence via two mechanisms: (1) adherence of the implant to the peritoneum making it “indistensible” and (2) mesh consolidation of the abdominal wall [17].
The major advantage to the retrorectus repair is the creation of a reinforced
abdominal wall with reestablishment of the native anatomic midline. As postulated
by Rives and Stoppa, sizing of the prosthesis for adequate overlap of the defect
facilitates restoration of the abdominal wall as a dynamic functional unit [5]. As
such, Wantz concluded that the retrorectus repair paradoxically exploits the abdominal forces subserving hernia creation to prevent its recurrence.
16 Technique: Posterior Rectus Sheath Release
205
Technique
Preoperative planning for surgery includes optimization of medical comorbidities
and prevention of infection [18]. Patients are counseled for cessation of tobacco and
alcohol usage for a minimum of 4 weeks. Nutritional counseling includes blood
glucose control, weight loss with a goal of BMI<35, and Impact AR TID for 5days
prior to surgery. MRSA prophylaxis includes Hibiclens shower for 5 days and
Mupirocin 2% intranasal ointment BID for 5 days in patients with a history of
MRSA colonization. Postoperatively, pain control is approached via multimodality,
intravenous uids are minimized, and early ambulation is a requirement.
Following intubation, the abdomen is surgically prepared with chlorhexidine and
draped in standard fashion. After sharp incision, dissection is carried out in the midline with Bovie electrocautery, taking care not to violate the hernia sac. Occasionally,
the underlying hernia sac is densely adherent to the deep dermal tissues requiring
sharp dissection for mobilization. A portion of the skin and dermis may need to be
resected in this setting to prevent eventual necrosis following wound closure. Once
the fascial defect and neck of the hernia sac have been dened at the level of the
fascia, rectus musculature is identied via palpation, and the fascia is elevated with
Kocher clamps (Fig.16.1). Anterior rectus sheath is incised medial to the rectus
muscle, and the retrorectus space is opened (Fig.16.2) and inferior epigastric vessels exposed (Fig.16.3). Incision is extended cephalad to the costal margin and
xiphoid with inferior dissection below the arcuate line and into the space of Retzius,
as appropriate for insertion of prosthetic. Lateral dissection is carried out bluntly
with Kittner to the semilunar line, as identied by perforating neurovascular
Fig. 16.1 Fascial incision
for access to retrorectus
space
206
Fig. 16.2 Incision of
the retrorectus space
Fig. 16.3 Exposure of
the inferior epigastric
vessels
S. P. Carmichael II and J. S. Roth
structures (Fig.16.4). This procedure is repeated on the contralateral side. At the
conclusion of this portion of the dissection, the posterior rectus sheath is re-approximated in the midline between Kocher clamps for an estimation of physiologic tension with closure.
If the posterior sheath is unable to be re-approximated without signicant ten-
sion upon the tissues, hernia sac or omentum may be interposed to facilitate separation from viscera. Alternatively, an absorbable mesh may be selected to safely
16 Technique: Posterior Rectus Sheath Release
Fig. 16.4 View of the
retrorectus space upon
completion of lateral
dissection to semilunar
line
207
bridge the posterior rectus sheath for visceral protection from the permanent mesh
[4]. The primary function of this material is to reconstruct the posterior sheaths until
the parietal peritoneum forms and prevents bowel contact with the mesh. When
reconstructing the posterior sheath, it is essential to choose a prosthetic that may be
safely placed adjacent to viscera. It is our practice to avoid permanent synthetic
mesh when reconstructing the posterior sheath as to avoid the potential for chronic
seroma between the denitive hernia repair mesh and the mesh utilized for posterior
sheath reconstruction.
Classically, the Rives-Stoppa technique describes dissection via midline lapa-
rotomy and separation of the posterior rectus sheath from rectus musculature following transgression of the peritoneum. Alternatively, the totally extraperitoneal
(TE) approach, currently performed in our practice, allows for the same dissection
without violation of the peritoneum. Though the transabdominal dissection remains
necessary in several settings (i.e., removal of intra-abdominal mesh or concomitant
intra-abdominal procedure), the TE approach confers the advantage of decreased
operative time with associated benets, as discussed below (Fig.16.5).
The TE approach commences with dissection of the hernia sac from the sur-
rounding subcutaneous tissues. Dissection is continued until the neck of the hernia
sac is fully identied. Although dissection of the hernia sac from the subcutaneous
tissues will result in some undermining of the skin aps, we feel that residual hernia
sac in the subcutaneous tissues is likely to result in prolonged seroma and should be
avoided. All peritoneal defects created during the dissection are closed with absorbable suture prior to completion of fascial closure. This step is imperative for prevention of intraparietal hernia development. Although uncommon, intraparietal
208
Fig. 16.5 Sharp
dissection of the hernia
sac for extraperitoneal
ventral hernia repair
S. P. Carmichael II and J. S. Roth
herniation of viscera through a peritoneal defect may result in pain, obstruction,
incarceration, or strangulation, and therefore it is essential to identify and close any
defects within this peritoneal layer. Intraparietal hernias are generally only detectable by radiographic evaluation due to the intact mesh and abdominal wall musculature above the peritoneum and accordingly should be considered in the event of a
postoperative bowel obstruction.
Following dissection of the hernia sac and retrorectus space, the posterior sheath
is approximated thus imbricating the hernia sac. This is typically performed with a
running 2-0 Vicryl suture (Fig.16.6). As the peritoneum has not been entered and
adhesiolysis has not been performed, it is essential to judiciously place sutures in
the posterior rectus sheath so as to avoid injuring the underlying viscera. In many
cases, it is relatively easy to ascertain the degree of adhesions to the peritoneal layer
based upon palpation. Nevertheless, wide shallow stitches are placed in the posterior sheath to avoid injury to the intestines.
Following closure of the posterior sheath, the retrorectus plane is measured, and
mesh is selected to allow for placement of a prosthetic mesh with a minimum of 5cm
mesh overlap in all dimensions. However, it is our current practice to place the largest
mesh that our dissection will accommodate for maximum coverage in all dimensions. It is important to ensure that the mesh extends not only 5cm laterally beyond
any hernia defect but also 5cm superior and inferior to the hernia defect. Although a
single prosthetic mesh is preferred, occasionally the hernia defect will require the use
of two mesh sheets that can be sutured together with a permanent suture.
Interrupted “U” sutures for transfascial xation consisting of number 1 PDS are
attached to the mesh at superior and inferiormost positions in the midline. An
16 Technique: Posterior Rectus Sheath Release
Fig. 16.6 Closure of
the posterior rectus
sheath with hernia sac
imbrication
Fig. 16.7 Completion
view of mesh placement in
the retrorectus space. Note
transfascial sutures placed
circumferentially around
periphery of mesh
209
additional six sutures are evenly spaced along the lateral portion of the mesh,
approximately 1–2cm from the mesh edge. Small skin incisions are created on the
abdominal wall skin with the 11 blade scalpel at points corresponding to the periphery of the mesh. Subsequently, the Reverdin needle is used to pass suture through
the abdominal wall to xate the mesh. It is essential that individual sutures should
pass through the abdominal wall via separate tracts, exiting across a common stab
incision to provide adequate xation of the mesh (Fig.16.7). Suture knots are tied
loosely in the subcutaneous tissue so as to prevent supercial nerve entrapment
which may result in chronic pain.
A single channel drain is placed in the retrorectus space overlying the mesh and
exteriorized through the anterior sheath and subcutaneous tissue in the left upper quadrant. The use of a drain is controversial and some surgeons will omit this step. It is our
210
Fig. 16.8 Closure of the
anterior rectus sheath
S. P. Carmichael II and J. S. Roth
practice to leave a single drain in this space with drain removal prior to hospital discharge. The linea alba or anterior rectus sheath is then re-approximated in the midline
with interrupted single-armed number 1 PDS suture in gure-of-eight fashion (Fig.16.8).
It is not uncommon that, upon completion of hernia repair, redundant skin and
subcutaneous tissue are present at the midline. As such, abdominoplasty is performed following marking skin with tension in apposition (Fig.16.9). Excess tissue
is resected and passed off the eld. Depending upon the extent of the redundancy,
skin excision may be accomplished via a vertically oriented ellipse or a transverse
incision. When signicant skin redundancy is anticipated, it is our practice to orient
the initial skin incision transversely so as to facilitate subsequent skin resection. In
the event that the hernia sac has created signicant undermining of the skin aps
resulting in potential space, a channel drain is placed in the subcutaneous space and
externalized in right upper quadrant. Approximation of the overlying dermis to the
fascia utilizing progressive tension sutures will help reduce drain output and seroma
formation. Scarpa’s fascia and dermal tissues are approximated using interrupted
absorbable sutures, and the skin is closed with a running absorbable monolament
suture and a skin adhesive (Fig.16.10). Drains are generally removed once output
from each is less than 30–40mL per day for 2 consecutive days.
Patient Selection
The Rives-Stoppa repair is suitable for the majority of incisional hernias, both primary and recurrent, and is ideally suited for moderately sized midline defects.
However, many factors including patient goals, comorbidities, and surgical history
16 Technique: Posterior Rectus Sheath Release
Fig. 16.9 Abdominoplasty
with excision of excess
skin and subcutaneous
tissue
211
Fig. 16.10 Completion of
repair
212
S. P. Carmichael II and J. S. Roth
will inuence our decision to perform this technique. Although many patients will
undergo imaging prior to ventral hernia repair, we typically reserve CT scan for
those patients with complex or recurrent hernias. In our experience, the RivesStoppa approach will generally be suitable for hernias with a transverse dimension
up to approximately 8cm. The cranio-caudal dimensions of the hernia do not inuence our decision to utilize this technique. However, intraoperative assessment of
midline tension and ability to close the linea alba is performed after completion of
the dissection bilaterally. In the event that the midline is either not amenable to closure or creates unacceptable tension, additional releases can be performed (i.e.,
transversus abdominis release, external oblique release). Patients with combined
midline and off-midline hernias (e.g., parastomal hernias) are not well suited for the
Rives-Stoppa approach and are generally considered for posterior component separation via transversus abdominis releases. Patients with small hernia defects or
those with multiple honeycomb defects may also be considered for a Rives-Stoppa
approach but are better suited for a laparoscopic repair, in our opinion. However,
patients with small defects requiring scar excision or excision of redundant soft tissues (i.e., panniculectomy) are also good candidates for the Rives-Stoppa repair.
The extended-view totally extraperitoneal ventral hernia repair (eTEP, Chapter 20)
has evolved as a minimally invasive approach to performing a Rives-Stoppa repair
or a traditional laparoscopic repair with intraperitoneal mesh. This eTEP technique
is best suited for small to moderate hernias with a more limited surgical history. The
eTEP technique combines the advantages of the dissection of the Rives-Stoppa
repair with the patient benets of a laparoscopic hernia repair. However, at the present time, this technique is performed in limited centers and thus conclusions regarding its efcacy remain speculative.
Outcomes
In a recent review of the American College of Surgeons National Surgical Quality
Improvement Program (NSQIP) database, the incidence of major operative morbidity after abdominal wall reconstruction is 13.4% (n=1706) with return to the operating room in 7.7% and readmission after discharge in 5–11% [19, 20]. Patient
factors associated with postoperative morbidity included advanced age, functional
status, malnutrition, anemia, obesity, smoking, diabetes, organ failure, and hypertension. Skin and soft-tissue infections (SSI) are the commonest postoperative complications overall at 8.9% (range in the literature 0–18%) and are the most common
reasons for readmission [19–21]. Operative factors correlating to postoperative
morbidity and cost included concurrent procedure, preoperative open wound, CDC
wound class (>1), American Society of Anesthesiologists (ASA) tness classication (>3), and operative time [19, 20].
Outcomes data from Rives and colleagues’ original operations with retrorectus
mesh prosthesis demonstrated an overall recurrence of 2.6% in a review of 388
patients by Flament and 8.6% by the Congrès Français de Chirurgie between 3 and
10years postoperatively [11]. Wantz published a comprehensive summary of his
16 Technique: Posterior Rectus Sheath Release
213
experience in 1999, following practice implementation of the retrorectus technique
in 1991. Of his 206 repairs for incisional hernia, 106 were performed for midline
defects (61% primary IH, 39% recurrent IH). Mersilene mesh was used in 89% and
polypropylene mesh in 11%. Of these, he reported hernia recurrence in two midline
hernias and one lumbar hernia [22].
Recurrence rates after Rives-Stoppa sublay repair in contemporary review of the
literature range from 0 to approximately 4% [21]. These outcomes are consistent
when the procedure is performed in the re-operative abdomen and in special surgical populations (i.e., inammatory bowel disease) [23, 24]. A recent meta-analysis
comparing sublay versus onlay techniques revealed fewer infections and IH recurrence in the sublay group [25]. Furthermore, wound complications and seroma formation were higher in a single-center prospective experience of onlay versus sublay
repair (49% vs 24% and 45% vs 24%, respectively) [26]. Of the four available locations for mesh herniorrhaphy (i.e., onlay, inlay, sublay, and underlay), the RivesStoppa repair confers superior protection from SSI and intra-abdominal complication
while demonstrating lowest overall recurrence [24].
In review of our own 5-year experience (2009–2013), approximately equal num-
bers of transabdominal (TA, n=45) versus TE (n=40) Rives-Stoppa repairs were
performed. Groups were matched by age and comorbidity. Findings revealed no
difference in enterotomy frequency between the two groups and that the TE
approach confers reduced operative duration. Notably, more patients in the TA
group had undergone prior hernia repair (73% vs 45%). Overall mesh size was
2
larger in the TE group (625±234 cm
vs 424 ± 214 cm2), as accounted for by
change in practice from 5-cm overlap to placement of largest mesh possible within
the dissected plane [27].
Overall, unplanned enterotomy or bowel resection (EBR) complicates 7.3% of
mesh herniorrhaphy and is associated with an increased rate of 30-day complications, including SSI, return to the operating room, hernia recurrence, and enterocutaneous stula formation [28–30]. The incidence of EBR is increased in re-operative
abdominal wall reconstruction and chronic steroid use [29]. There was a reduction
in EBR within our series of TE herniorrhaphy; however this difference was not
statistically signicant. Though theoretical concern exists for a change in geometry
of intra-abdominal adhesions in the absence of transgression of the peritoneum,
adhesiolysis is known to increase both operative time and the risk of intestinal injury
[29]. Moreover, equal mobility of the visceral sac may still be achieved with preperitoneal dissection. Neither TA or TE groups were complicated by postoperative
bowel obstruction in our cohort.
We found seroma formation to be twice as common in the TE group, likely
owing to intact peritoneum precluding intra-abdominal drainage. However, this difference was not signicant in comparison with the TA repair and did not correlate
with return to the operating room. Arguably, the greatest advantage of the TE
approach is decreased operative times due to avoidance of adhesiolysis. Given that
prolonged surgical duration causes increased physiologic stress and is associated
with an increased risk of postoperative SSI, reduction in OR time provides potential
benet of decreased major complication [19, 31].