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Laparoscopic Repair ofPeripheral
Abdominal Wall Hernias
AnilSharma
19
19.1 Introduction
Peripheral abdominal wall hernias are located
in the peripheral zones of the abdominal wall
and include subxiphisternal, subcostal, lumbar,
and suprapubic hernias. These are difcult hernias to repair because of their close proximity
to anatomically important structures like bone,
nerves, major vessels, and bowel. Moreover, it
is difcult to obtain a mesh overlap of more
than 4–5cm from the hernial defect, particularly from the distal margin in these hernias.
Accordingly, the surgical repair of peripheral
hernias would normally involve some additional maneuver to implant the mesh prosthesis
in place.
19.2 Indications
Subxiphisternal, subcostal, lumbar, and suprapubic hernias.
19.3 Contraindications
Absolute Contraindications
• Medically unt for GA.
• Uncontrollable coagulopathy.
• Giant hernia with major loss of abdominal
domain.
• Acute abdomen with abdominal distension
and gross bowel dilatation.
• Major abdominal sepsis.
• Strangulated bowel as hernial content.
• Abdominal wall hernia in children (<12years).
Previous surgery usually produces abdominal
wall musculature denervation causing disruption
of normal anatomy and large bulging defects that
occupy most of the lumbar region [1, 2]. These
patients may not be suitable for laparoscopic
repair.
19.4 Operative Procedure
Bowel preparation is only required if a segment
of large bowel is known to be content or is in
close proximity to the hernial sac.
A. Sharma (*)
Max Institute of Minimal Access, Metabolic and
Bariatric Surgery, Max Super Speciality Hospital
(East Block), Saket, New Delhi, India
© Springer Nature India Private Limited 2020
P. Chowbey, D. Lomanto (eds.), Techniques of Abdominal Wall Hernia Repair,
https://doi.org/10.1007/978-81-322-3944-4_19
Lumbar Hernias
• The patient is placed in a semilateral position
on the OT table.
203
204
A. Sharma
• The ascending/descending colon is reected
medially after incising the fold of peritoneum
on the lateral abdominal wall.
• The medial mobilization of colon is continued
up to the Psoas muscle and longitudinal spinal
muscles. This medial colon mobilization provides enhanced mesh cover posteriorly from
the hernial defect and allows the distal mesh
margin to lie comfortably on the musculature
of the posterior abdominal wall.
• A large mesh is required that is securely xed
to the Cooper ligament and ischium bone inferiorly, the costal margin superiorly, anterior
abdominal wall anteriorly, and overlaps paraspinal muscles posteriorly.
• In some patients with complex hernias, the use
of a double mesh technique may be advisable
[3]. In some other patients sutures with nonabsorbable monolament material may help
restore the normal anatomy, thereby improving muscular function of the area [4].
Subxiphoid and Subcostal Incisional Hernias
• The Falciform ligament should be dissected
up to the hepatic veins providing a generous
retroxiphoid overlap beyond the edge of the
hernial defect [5].
• Avoidance of xation of the cephalad position
of the mesh is thought to be the reason for
higher recurrence rates in these hernias [6–8].
• Additional xation of the mesh transfascial sutures at the subcostal margins is
recommended.
• Endoscopic xating devices may be used to
x the mesh on the costal cartilages avoiding
the area beyond.
Suprapubic Incisional Hernias
• For the purpose of surgical management,
suprapubic incisional hernias are hernias that
are located within 5cm from the pubic arch on
the abdomen.
• A peritoneal ap is raised distally between a
point 2 cm medial to anterior superior
iliac spine to a corresponding point on the
contralateral side. The limit of dissection inferiorly is 2cm below the pubic arch and Cooper
ligaments [9].
• The creation of this extraperitoneal space provides for greater mesh cover distally (at least
7–8cm), secure xation of lower margin of the
mesh to Cooper ligaments (to increase tensile
strength of the repair), and places a substantial
portion of mesh in the extraperitoneal space.
• A large mesh is used to provide optimal mesh
cover on all sides of the hernial defect (at least
5cm).
• Additional transfascial sutures are used to
ensure proper positioning of mesh on abdominal wall and also increase tensile strength of
the repair.
• After mesh placement, the peritoneal ap is
repositioned in place to effectively partially
extraperitonealise the mesh (transabdominal partially extraperitoneal repair, TAPE
technique) [7].
References
1. Suarez S, Hernandez JD. Laparoscopic repair of
a lumbar hernia: report of a case and extensive
review of the literature. Surg Endosc. 2013;27(9):
3421–9.
2. Yavuz N, Ersoy YE, Demirkesen O, Toetum OB,
Erguney S. Laparoscopic incisional lumbar hernia
repair. Hernia. 2009;13(3):281–6.
3. Moreno-Egea A, Mengual-Ballester M, Cases-
Baldo MJ, Aguayo-Albasini JL.Repair of complex
incisional hernias using double prosthetic repair:
single-surgeon experience with 50 cases. Surgery.
2010;148(1):140–4.
4. Sauerland S, Walgenbach M, Habermaiz B,
Seiler CM, Miserez M. Laparoscopic versus
open surgical techniques for vntral or incisional
hernia repair. Cochrane Database Syst Rev.
2011;16(3):CD007781.
5. Eisenverg D, Popescu WM, Duffy AJ, Bell
RL. Laparoscopic treatment of Subxiphoid incisional hernias in cardiac transplant patients. J Soc
Laparoendosc Surg. 2008;12(3):262–6.
6. Varnell B, Bachman S, Quick J, Vitamvas M,
Ramshaw B, Oleynikov D.Morbidity associated with
laparoscopic repair of suprapubic hernias. Am J Surg.
2008;196(6):983–7. (discussion 987-8).
19 Laparoscopic Repair ofPeripheral Abdominal Wall Hernias
205
7. Sharma A, Dey A, Khullar R, Soni V, Baijal M,
Chowbey PK.Laparoscopic repair of suprapubic hernias: transabdominal partial extraperitoneal (TAPE)
technique. Surg Endosc. 2011;25(7):2147–52.
8. Palanivelu C, Rangarajan M, Paethasarathi R,
Madankumar MV, Senthilkumar K. Laparoscopic
repair of suprapubic incisional hernias: suturing and
intraperitoneal composite mesh onlay. A retrospective
study. Hernia. 2008;12:251–6.
9. McKay R, Haupt D. Laparoscopic repair of low
abdominal wall hernias by tack xation to the cooper ligament. Surg Laparosc Endosc Percutan Tech.
2006;16(2):86–90.
Obesity andAbdominal Wall
Hernias
AlfredAllenBuenafe
20
20.1 Obesity/Body Mass Index/ Intra-abdominal Pressure
Obesity is currently a global epidemic. According
to the World Health Organization’s data, the rate
of obesity has been increasing since 1980.
Industrialized nations used to be at the forefront
of this global obesity epidemic; however, developing nations are also reporting growing trend of
their own. Obesity is based on body mass index
(BMI), measured by the weight in kilograms
against the square of the height in meters. The
BMI classication established by the World
Health Organization published in 2000 is commonly used to categorize obesity: underweight
<18.5 kg/m2, normal 18.5–24.9 kg/m2, overweight 25.0–29.9 kg/m2, obesity class I 30.0–
34.9 kg/m2, obesity class II 35–39.9 kg/m2 and
obesity class III ≥40.0kg/m
have dened obesity starting at a lower BMI level
(Japan: >25 kg/m2, and China: >28 kg/m2) in
view of the population developing negative health
consequences at lower levels.
Obese subjects were observed to have elevated
baseline intra-abdominal pressure (IAP) of up to
A. A. Buenafe (*)
Philippine Center for Advanced Surgery,
San Juan, Metro Manila, Philippines
e-mail: abuenafe@csmc.ph
2
. Asian populations
6mmHg, compared to normal weight population
[1], a direct relationship between BMI and IAP
was similarly observed [2]. The increase in each
unit of BMI was associated with an increase in
IAP by up to 0.23±0.07mmHg increments [1].
Higher IAP was observed among obese patients
with pressure-related morbidities (gastroesophageal reux disease, hernia, stress incontinence, diabetes, hypertension and venous
insufciency) [3, 4], but not to the extent of
reaching or going beyond pressure considered as
intra-abdominal hypertension (>12mmHg) [1].
20.2 Obesity andIncidence
ofInguinal Hernias
andInguinal Hernia Repair
Increased IAP is associated with development of
morbidities; theoretically, obesity may be
assumed to result in higher incidence of abdominal wall hernias. Several population-based studies done in Europe and in the United States
showed unexpected contrary ndings to this
assumption, particularly its relation to incidence
of inguinal hernias. The Dutch study by de Goede
etal. [5] and American study by Ruhl etal. [6]
which looked into the incidence of inguinal hernia in the general population, both noted a similar
decreasing trend of hazard rate (HR) for development of inguinal hernia among overweight and
among obese groups compared to the normal-
© Springer Nature India Private Limited 2020
P. Chowbey, D. Lomanto (eds.), Techniques of Abdominal Wall Hernia Repair,
https://doi.org/10.1007/978-81-322-3944-4_20
207
208
A. A. Buenafe
weight group; in the Dutch study, they reported
HR 0.72 (95% CI 0.58–0.89) and HR 0.63 (95%
CI 0.42–0.94), respectively, and in the American
study, they noted HR 0.79 (95% CI 0.66–0.95)
and HR 0.51 (95% CI 0.36–0.71), respectively. A
Swedish study covering over 7000 subjects with
34 years follow-up done by Rosemar et al. [7]
quantied the rate of inverse relationship between
BMI and risk of inguinal hernia, they calculated
that with each increase in BMI unit (3–4kg) it
was associated with 4% decrease in relative risk
for inguinal hernia development. They also
pointed out that despite taking into account factors (age, BMI, smoking and serum cholesterol)
associated with inguinal hernia, the multivariate
analysis did not change the observed risk estimated for BMI and smoking factors. In the study
by Ravanbakhsh etal. [8], employing the regional
database of Kaiser Permanente Southern
California, it pointed out that while obesity was
associated with decreased diagnosis/incidence of
inguinal hernia, it was, however, associated with
increased risk for development of complications:
incarceration and strangulation.
Zendejas et al. [9] reviewed the relationship
between BMI and incidence of inguinal hernia
repair among the population of Olmsted County,
Minnesota; they found a similar trend of higher
incidence of repairs among the normal or overweight population (419.8 and 421.1 per 100,000,
respectively) compared to those who were obese
or morbidly obese (273.5 and 99.4 per 100,000,
respectively). Review [10] by the same group, on
the same population looking into emergent inguinal hernia repairs, pointed out that obesity was
one of the factors (age > 70, high ASA score,
with femoral type hernia, and recurrent hernia)
associated with the need for emergent repairs and
that those with these risk factors may benet
from elective intervention instead of watchful
waiting.
In view of the bafing inverse relationship
between obesity and incidence of inguinal hernia,
the studies [7–9] have suggested explanations for
this observation: the obese body habitus makes
physical examination and self-awareness of
inguinal hernia more challenging, the intraabdominal or pre-peritoneal fat may be acting as
a barrier preventing herniation, and that obese
patients may have obesity-related co-morbidities
thus in poor overall health and likely to be unsuitable for elective surgery.
20.3 Obesity andIncidence
ofVentral Hernias
andVentral Hernia Repairs
Obesity is one of the recognized risk factors for
development of ventral hernia; multiple recent
studies have reafrmed this fact. Study by Itatsu
et al. [11] which prospectively followed up
almost 4000 patients who underwent abdominal
surgery for a period of 180 days estimated the
incidence rate for incisional hernia to be at 5% at
12months and 10% at 24months, through multivariate analyses they identied BMI >25kg/m2 to
be an independent risk factor for development of
incisional hernia with a HR 1.76 (95% CI 1.35–
2.30), other risk factors identied included:
wound classication III and IV, midline incision,
surgical site infection, pre-operative chemotherapy, blood transfusion, increasing age, female
sex, and subcutaneous tissue thickness.
Nakayama et al. [12] who retrospectively analyzed 167 patients who underwent open abdominal surgery noted that 16% developed incisional
hernia at a median of 7months after surgery; the
multivariate analyses identied high BMI as signicant independent risk factor for incisional
hernia development after an abdominal surgery
such as colorectal surgery.
Studies have reported on the advantages of
using the laparoscopic ventral hernia repair
(LVHR) technique in the repair of incisional/ventral hernia among obese patients; LVHR is associated with lower incidence of surgical site infection,
shorter hospital stay, faster return to normal activity, and even lower incidence of recurrence.
Recent studies have reconrmed these benets.
Novitsky etal. [13] in their analysis of over 160
obese patients with mean BMI of 38kg/m
underwent LVHR, reported good outcomes
including low complication rate of 12%, no mortality, short hospital stay of 2.6 days and low
recurrence rate of 5.5% at a mean follow- up of
2
who
20 Obesity andAbdominal Wall Hernias
209
25months. Froylich etal. [14] compared LVHR
against open ventral hernia repair (OVHR) in a
group of 186 patients with BMI >30kg/m2, LVHR
was associated with signicantly longer operative
time (102min vs. 67 min, p<0.01); advantages of
lower peri-operative complications and woundrelated complications were noted, and likewise
the lower recurrence rate among the LVHR (20%
vs. 27.1%) was compared with OVHR, with a
mean follow-up of 58months.
20.4 Obesity andOutcome
inVentral Hernia Repair
Higher BMI is associated with development of
complications following ventral hernia repair.
Several studies [15–19] have shown that higher
BMI was associated with higher rate of recurrence compared to those with lower BMI, even
after LVHR. Aside from higher recurrence rate,
in their study of complex abdominal wall reconstruction among 313 patients with mean follow up of 15.6months, Desai etal. [19] reported that
higher BMI tends to be associated with increased
rate of overall complications of skin necrosis and
of re-operation for recurrence.
that watchful waiting remains an option among
elderly patients and among those with poor surgical risk, who are asymptomatic or have minimally symptomatic hernias, (2) use of diagnostic
investigations (ultrasound, CT scan, MRI, or herniography) for those with vague discomfort and/
or swelling, as obese patients were likely to have
habitus that will hinder physical examination and
result in lower detection of inguinal hernia and
(3) routine antibiotic prophylaxis use is not recommended for neither open nor endoscopic
inguinal hernia repair; however, in the presence
of risk factors for wound and mesh infection
(advanced age, corticosteroid usage, immunosuppressive conditions and therapy, obesity, diabetes and malignancies) the use of antibiotic
prophylaxis should be considered and its use necessary in institutions with high rates of wound
infections (>5%).
In the updated 2015 International Endohernia
Society (IEHS) guidelines [22] on laparoscopic
and endoscopic inguinal hernia repair did not
nd new evidences to alter its previous statement
that routine use of antibiotic and thromboembolic
prophylaxis cannot be routinely recommended
and that its use should be in accordance with the
presence of risk factors for these complications.
20.5 Updated EHS/IEHS
Guidelines forInguinal
Hernia Repair, Application
toObese Patients
The recommendations from the updated 2014
European Hernia Society (EHS) guidelines [20]
with application to treatment of inguinal hernia
among obese patients includes: (1) elective surgical intervention of medically t patients with
asymptomatic inguinal hernias, study cited for
this recommendation was that by Chung et al.
[21] who followed-up two groups of patients randomized to watchful waiting and to surgical
intervention; it noted high conversion rate among
the observed group which was 16% at 1 year,
54% at 5 years and 72% at 7.5 years, with the
chief reason for conversion being development of
pain or of acute hernia. The guideline maintained
20.6 EAES/EHS/IEHS Guidelines
forVentral Hernia Repair,
Application toObese
Patients
The guidelines on laparoscopic repair for incisional/ventral hernia by the European Association
of Endoscopic Surgeons (EAES) and European
Hernia Society (EHS) published in 2015 [23] and
the guidelines by the IEHS published in 2014
[24–26] have similar applicable recommendations for ventral hernia repair in obese patients.
The evidences on the use of diagnostic imaging (CT scan or MRI) for pre-operative diagnosis of ventral hernias are inconsistent; current
recommendation by the IIEHS is that they are
options to consider in situations such as posttraumatic hernias [27, 28], obese patients [29],
large hernias with loss of domain or uncom-
210
A. A. Buenafe
mon/rare hernias. Studies by Gutierrez de la
Pena etal. [30] and Wagenblast et al. [31] on
the value of CT scan in evaluating post-LVHR
patients suspected to have recurrence revealed
that it was better at detecting recurrence and at
differentiating from other conditions such as
seroma than clinical examination; current suggestion is that they should be employed in diagnosing recurrence among post-operative
patients.
LVHR should be the preferred technique for
ventral hernia repair (VHR) among obese patients
and should be offered to them. LVHR is feasible
in obese patients, even among those with large
hernia defects (>15cm). Increasing BMI is associated with increased incidence for complications
(for BMI >40kg/m2) [32] and for recurrence (for
BMI >30kg/m2) [33]. LVHR compared to OVHR
for obese patients is less likely to develop complications and surgical site infection, and is likely
to result in a shorter hospital stay [34].
Antibiotic prophylaxis should be administered
for patients undergoing ventral hernia repair,
especially among patients with risk factors
(advance age, steroid use, immunosuppression,
obesity, diabetes or malignancy) or presence of
surgical risk factors (contamination, long operative time, drain placement or urinary catheter).
Thromboembolic prophylaxis should be considered in the presence of risk factors, though currently no randomized control studies are available
to demonstrate its efcacy in VHR.
20.7 Summary
Obesity is a patient risk factor that has a wide
ranging inuence on every aspect of abdominal
wall hernias (from its development, to disease
progression and on the peri-operative outcomes)
and poses similar inuence on the patient’s health
that further complicates hernia repair. Current
trend of increasing obesity among the world population is likely to further complicate the eld of
abdominal wall hernia repair. Current guidelines
on hernia repair have indirect recommendations
addressing the condition in obese patients, particularly for inguinal hernias.
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Cochrane Database Syst Rev. 2011;(3):CD007781.
Components Separation
Technique forRepair ofComplex
Abdominal Wall Hernia
JonathanFoo andWei-KeatCheah
21
21.1 Introduction
Current management of simple ventral hernia
involves the use of a prosthetic mesh to reconstruct the abdominal wall with a low recurrence
rate. Complex abdominal wall defects, however,
pose a challenge to the surgeon to restore the
structural anatomy and to provide coverage and
good functional outcome using solely a mesh.
Such large and complex abdominal wall defects
often result from trauma, multiple abdominal
operations, infections, resection of tumours and
obesity. Despite advances in surgical technology,
such hernias/defects could be too large or even
impossible to repair with a mesh alone.
In 1990, Ramirez etal. described the component separation technique (CST) that restores the
functional and structural integrity of the midline
abdominal wall defects utilizing a type of rectus
abdominis muscle advancement ap. De Vries
J. Foo
FeM Surgery, Mount Elizabeth Hospital,
Singapore, Singapore
Department of Surgery, Ng Teng Fong General
Hospital, National University Hospital System
(NUHS), Singapore, Singapore
W.-K. Cheah (*)
Department of Surgery, Ng Teng Fong General
Hospital, National University Hospital System
(NUHS), Singapore, Singapore
e-mail: wei_keat_cheah@nuhs.edu.sg
Reilingh TS etal. in 2003 evolved the technique
further to add additional coverage by separation
of the posterior rectus sheath from the rectus
abdominis muscle. The process of separation of
the muscle components is to increase the distance
of coverage of the defect compared to mobilization of the entire abdominal wall that is done in
primary closure of the abdominal wall.
To improve outcomes, an alternative approach,
endoscopic component separation technique
(ECST), was developed, to reduce adverse outcomes by minimizing lengthy undermining,
resulting in less blood loss, perforator division,
less risk of skin ap ischaemia and affording a
quicker recover.
This chapter will focus on contemporary CST
to treat complex ventral hernias and how to avoid
pitfalls associated with this procedure.
21.2 Anatomic Considerations
The skin and subcutaneous tissue plays an important role in reducing the risks of post-operative
infections. They are supplied directly by the
supercial circumex iliac artery, the supercial
inferior epigastric artery, from perforators arising
from the deep epigastric arteries and from
branches of the intercostal arteries. It is vital that
the vasculature in particular the perforators are
preserved during dissection of the skin aps to
© Springer Nature India Private Limited 2020
P. Chowbey, D. Lomanto (eds.), Techniques of Abdominal Wall Hernia Repair,
https://doi.org/10.1007/978-81-322-3944-4_21
213
214
Linea alba
Rectus abdominis
J. Foo and W.-K. Cheah
Fig. 21.1 Abdominal
wall myofascial units
Transversalis fascia
Parietal peritoneum
prevent ischaemia which would lead to subsequent infection and dehiscence.
The musculofascial unit represents the functional component of the abdominal wall. It consists of a medial compartment and a lateral
compartment on each side. The medial compartment comprises the rectus abdominis enveloped
by the anterior and posterior rectus sheath which
ends at the arcuate line posteriorly. The rectus
muscles are innervated by nerves that pierce the
muscle posteriolaterally close to the fusion of the
anterior and posterior sheath. Thus the rectus
muscle can be mobilized posteriorly for extra
length till before the lateral fusion point. The
external oblique muscle (EOM), internal oblique
muscle (IOM) and transversus muscle (TM)
make up the lateral musculofascial unit. An avascular plane is present between the EOM and
IOM, whereas the plane between the IOM and
TM contains neurovascular bundles. Dissection
should be performed in the avascular plane
between the EOM and IOM to preserve the neurovascular bundles (Fig.21.1).
21.3 Indications andPatient
Selection
Indications for component separation include the
following:
1. Large midline ventral hernias and open abdo-
men that cannot be closed primarily.
2. Recurrent large ventral hernias or previous
ventral hernias that have failed with mesh or
suture repair.
External oblique
Internal oblique
Transversus abdominis
3. Large ventral wall defects where mesh deployment is contraindicated e.g. infection.
CST can be utilized for defects up to 20cm in
width at the level of the umbilicus. Defects which
constitute loss of domain and are larger than
20cm may require the concomitant use of a mesh
to provide coverage.
The ideal scenario is to allow the sick patient
to recover from the illness, to control any intraabdominal infection and to repair the hernia
electively.
21.3.1 Contraindications
An absolute contraindication would be extensive
destruction or resection of the abdominal wall
with violation of the rectus musculofascial unit.
Relative contraindications include the presence of contamination or infection, especially if
the defect requires the addition of a mesh in addition to CST.While CST utilizes autologous tissue, it would still be ideal if the infected could be
treated prior to denitive surgical reconstruction.
21.4 Pre-operative Evaluation
Pre-operative workup includes an abdominal CT
scan to identify the magnitude of the defect and to
rule out any ongoing infection. A detailed assessment of the patient’s tness to undergo a major
operation, optimization of any medical conditions
and where possible loss of excess weight prior are
steps to undertake before surgery (Fig.21.2).