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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1116_Библиотеки_им_академика_М_И_Перельмана.pdf
M. Almuhanna and W.-J. Lee274
Fig. 2 CT scan of obese patient with panniculus abdomen and ventral hernia for more than
5 years, with sign of complication as the bowel incarcerated in hernia sac with reactional fluid
Table 1 European Hernia Society (EHS) classification of primary abdominal wall hernias
EHS
Primary abdominal wall
hernia classification
Midline Epigastric
Umbilical
Lateral Spigelian
Lumbar
Diameter in cmSmall < 2 cm Medium ≥ 2–4 cm
Large ≥ 4 cm
– Localization of the hernia two midline (epigastric and umbilical) and two lat-
eral hernias (Spighelian and lumbar)
– Size of the hernia using the diameter (small < 2 cm, medium ≥ 2–4 cm and
large ≥ 4 cm).
Sleeve and Ventral Hernias
275
5 Incisional Hernia
Classification of incisional abdominal wall hernias based on localization of the
hernia: medial or midline zone and the lateral zone (Table 2).
Table 2 European Hernia Society (EHS) classification of incisional abdominal wall hernias
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M. Almuhanna and W.-J. Lee276
5.1 Medial or Midline Zone
The borders of the medial or midline area are defined as:
(1) cranial: the xyphoid
(2) caudal: the pubic bone
(3) lateral: the lateral margin of the rectal sheath.
All incisions made between the lateral margin of the rectus sheath are midline hernias. Midlines hernias are further subdivided into subgroup (5 M zones) as it is
believed that hernias close to bony structures have high risk of recurrence and pose
specific therapeutic approach (Fig. 3).
M1: subxiphoidal (from the xiphoid till 3 cm caudally).
M2: epigastric (from 3 cm below the xiphoid till 3 cm above the umbilicus).
M3: umbilical (from 3 cm above till 3 cm below the umbilicus).
M4: infraumbilical (from 3 cm below the umbilicus till 3 cm above the pubis).
M5: suprapubic (from pubic bone till 3 cm cranially).
5.2 Lateral Hernias (Flank Hernias)
Any incisions lateral to the lateral margin of the rectus sheath are lateral hernias
(Fig. 4).
Fig. 3 Classification of
midline incisional hernias
between the two lateral
margins of the rectus muscle
sheaths, which is divided into
five zones
Sleeve and Ventral Hernias
Fig. 4 Classification of
lateral incisional hernias, four
zones (L1–L4) lateral of the
rectus muscle sheaths
The borders of the lateral hernia are defined as:
(1) cranial: the costal margin
(2) caudal: the inguinal region.
(3) medially: the lateral margin of the rectal sheath
(4) laterally: the lumbar region.
277
So, the four lateral hernia zones on each side are:
L1: Subcostal (between the costal margin and a horizontal line 3 cm above the
umbilicus)
L2: Flank (lateral to the rectal sheath in the area 3 cm above and below the
umbilicus)
L3: Iliac (between a horizontal line 3 cm below the umbilicus and the inguinal
region)
L4: Lumbar (latero-dorsal of the anterior axillary line).
6 Size of the Hernia
Grid format used to describe the size of incisional hernias measure the width and
length. Width of the hernia is defined as the greatest horizontal distance in cm
between the lateral margins of the hernia defect on both sides. In case of multiple
incisional hernia, the width is measured between the two most lateral located hernias with the most lateral edges. The length of incisional hernias is measured by
M. Almuhanna and W.-J. Lee278
the greatest distance in cm vertically between the most cranial and most caudal
margins (Fig. 5). In case of multiple hernia caused by a single incision, the length
measured between the cranial margin of the most cranial defect and distal margin
of the most distal defect (Fig. 6).
To avoid the confusion of incisional hernia size with the size of primary hernia (small, medium and large), code taxonomy was chosen as: W1 < 4 cm,
W2 ≥ 4–10 cm, W3 ≥ 10 cm.
7 Indication and Risks of Ventral Hernia Repair
Indication for ventral hernia repair is for the relief of symptoms (pain, acute
incarceration, enlargement and skin problem). In case of large ventral hernias,
pre-operative optimization of the pulmonary function is very important in order
to reduce the risk of pulmonary complications [16]. Smoking is known to increase
the risk of surgical site infection and recurrence after hernia repair [12, 17]. It is
recommended to stop smoking 4 weeks prior to surgery to decrease the incidence
of pulmonary complications and reduce the incidence of leak in Gastrointestinal
surgery [18, 19]. Poorly controlled diabetes is a risk factor for post-operative complications in ventral hernia repair [11]. Glycosylated hemoglobin (HbA1c) is used
as a test for checking the patients’ diabetic control.
The key for successful outcomes in ventral hernia repair is to reduce the risk
factors of ventral hernia with weight reduction, control of diabetes and cessation
of smoking with optimizing the nutritional parameters.
Fig. 5 Grid format of
incisional hernia for single
defect
Sleeve and Ventral Hernias
Fig. 6 Grid format of
incisional hernia for multiple
defects
279
Laparoscopic or laparoscopic assisted ventral hernia repair is favorable over
open hernia repair in obese patients. Advantages of laparoscopic ventral hernia
repair (LVHR) include fewer surgical site infection, less pain postoperatively,
5 days faster return to work compared to open ventral hernia repair (OVHR),
but no significant difference has been made in recurrence rate between LVHR
and OVHR [20–22]. Prophylactic antibiotics as a single dose of first-generation
Cephalosporin (cefazoline) is recommended to be given pre-operatively, in case
of allergy to Cephalosporin, Clindamycin or Vancomycin can be given. There is
no strong recommendation on bowel preparation or urinary catheterization unless
surgery will take a long time [20]. Deep vein thrombosis prophylaxis is recommended for obese patients as it lowers incidence of pulmonary embolism [23, 24].
Although LVHR is recommended for VH repair in obese patients, there are
some contraindications of LVHR, including defect size greater than 15 cm, high
risk patients, loss of domain (hernia sac contains more 30% of abdominal content
and solid organ), active enterocutaneous fistula, need to remove prosthetic mesh
and small defect but large hernia sac [20, 21, 23]. Patients with small defects but
large hernia sacs maintained for a long period (such as in Fig. 2) may have respiratory distress after repairing the ventral hernia and reducing the sac content into the
abdomen.
M. Almuhanna and W.-J. Lee280
8 Technique of Laparoscopic Ventral Hernia Repair
in Obese Patient [20, 21, 23]
8.1 Position of Trocar and Creation of Pneumoperitoneum
Veress needle or open Hasson’s technique can be used for creation of pneumoperitoneum. It is recommended that Veress needle or first port should be inserted
at Palmer’s point away as much as possible from expected adhesion. First trocar
size should be 10 mm to accommodate the camera and mesh insertion, while other
trocars should be inserted under vision. In dealing with midline incision trocars
inserted on the left side of the patient, ideally 3 or more trocars in line with optimal distance from the defect 16–18 cm to expose the whole hernia sac and allow
accessibility for adhesiolysis and proper fixation of the mesh. Site and size of
trocars can be chosen based on the surgeons preference and expertise. In obese
patients, it is preferable to use long bariatric length instruments.
9 Principles of Adhesiolysis
Limited adhesiolysis is recommended. It should be limited to freeing the adhesion
near the abdominal wall, away from the adherent bowel. Adhesiolysis can be performed using sharp and blunt dissection, limiting the use of energy devices for
hemostasis. Bowel should be inspected at the end of adhesiolysis. In case of iatrogenic bowel injury without significant enteric fluid leakage, it can be repaired followed by hernia repair and mesh fixation.
For safe adhsiolysis, many maneuvers can be used:
• Traction/counter traction technique
• Angled/flexible camera
• Moving scope among ports
• Outside pressure over the abdominal wall to reduce the hernia sac
• Careful sharp dissection under vision and close to abdominal wall
• Limit the use of energy devices
• Reposition patient table and ports if needed
• Maintain the camera clean
• Repeat inspection of bowel at the end of adhesiolysis.
10 Measurement of Hernia Defect
Size of hernia is a significant risk of recurrence. It is important to measure the
size of the hernia defect accurately. Accurate measurement helps to choose the
prober size for the mesh. Dynamic rather than static measurement for ventral
Sleeve and Ventral Hernias
hernia defect is recommended. To determine the size of the defect it should be
measured vertically and transversely. The most accurate method of measurement
of ventral hernia defects is intracorporeal rather than extracorporeal due to the
thickness of the abdominal wall, which can cause an overestimation of the defect
size. Intracorporeal method can be accomplished using two spinal needle placed
through the abdominal wall. Using a sterile ruler, intracorporeal measurement
is done using the largest diameter of the defect transversally and vertically. This
method reduces the overestimation of the hernia defect which may result in large
sized mesh that will be more difficult to handle, allowing the bowel to incarcerate
and bulge into the defect.
281
11 Closure of Hernia Defect and Intraperitoneal Onlay
Mesh (IPOM) Fixation
Suturing the defect in-order to reduce the hernia size to the smallest size possible
thus may reduce the bulging and risk of seroma formation, which may decrease
the risk of infection. The suture material should be nonabsorbable. It is recommended to reconstruct the linea alba or any defect combined to IPOM, this augmentation repair is termed IPOM-PLUS. Mesh size should be used to cover the
defect with an overlap at the edge of the defect by at least 3–4 cm in all directions.
Large mesh size (e.g. 30 cm × 30 cm) can be inserted through 10 or 12 mm ports
by rolling up tightly. For very large size mesh (e.g. 35 cm × 30 cm), a 15 mm port
should be used. It is important to avoid mesh-skin contact. Mesh fixation can be
done by suturing or tacker device with no difference in recurrence rate.
12 Technique of Open Ventral Hernia Repair [10, 25, 26]
Although LVHR for obese patients with ventral hernia is better than open
approach, some scenarios need to be approached using the open technique. These
include emergency surgery for hernias with complications, loss of domain, very
large defects that need component separation and the need for resection panniculus. It is advised that all ventral hernia should be repaired using mesh. There are
four types of mesh placement in open technique, ranked by the best approach with
least recurrence and surgical site infection rates as follow (Fig. 7):
• Retrorecuts also named sublay, retromuscular repair or Rives-Stoppa (preperi-
toneal mesh placement)
• Open intra-peritoneal onlay mesh (underlay)
• Onlay (place the mesh on anterior fascia)
• Inlay (place the mesh on hernia defect).
Fig. 7 Site of mesh
placement in Open and
Laparoscopic Technique of
ventral hernia repair
M. Almuhanna and W.-J. Lee282
13 Concurrent LSG with LVHR
LSG and LVHR can be done during the same procedure in selected patients.
Most cases done in patients with a BMI less than 50 kg/m
than 10 cm (Fig. 1). Raziel A et al. reported a series of 54 cases of concomi-
tant bariatric and ventral/incisional hernia surgeries in morbidly obese patients
with a mean BMI of 44 kg/m2 and a mean age of 50 years, with the majority of
cases being LSG (48 cases). They did not encounter mesh infection or major
complications directly related to LVHR within a 5 year follow up [27]. Moolla
et al. reported on a matched analysis from Metabolic and Bariatric Surgery
Accreditation and Quality Improvement Program (MBSAQIP) database in the
USA of 430,225 cases in which 1.1% (4690) of them had concurrent LVHR. He
was able to find that LVHR is safer with LSG (2718 cases) than with LRYGB
(1930 cases) in terms of readmission, reoperation and major complications with
30 days [28]. Marzouk et al. in their study of LVHR combined with LSG in 15
2
obese patients with a mean BMI 45.2 kg/m
and ventral hernia less than 10 cm,
found that LSG combined with LVHR is safe and feasible in carefully selected
patients [29]. In Praveen Raj P et al.’s retrospective study on 156 cases of bariatric surgery concomitant with LVHR, 120 of them had LSG with an average BMI
2
and a defect size less
Sleeve and Ventral Hernias
Table 3 Details of included studies of Concurrent LSG with LVHR
Author Number
Raziel A
et al.
Muhammad
Moolla et al.
(MBSAQIP)
Marzouk
et al.
Praveen Raj
P et al.
Eid GM
et al.
of LSG +
LVHR
48 53 44.2 – 1.8 –
2718 49 46 – – 3.2
15 42.7 45 2.63 6.6 –
120 43.94 ± 11.41 43.64 ± 6.8 3.58 ± 3.36 <1 –
20 – <50 <8 10 –
Mean age
(years)
Mean
BMI kg/
2
m
S
Size of
defect (cm)
Recurrence
rate (%)
283
Major
complication (%)
of 43 kg/m2 and included both primary and recurrent VH ( average size of hernia
3.58 ± 3.36 cm). After a follow up of 12 months, they were able to demonstrate
that LSG is safe in combination with hernia repair [30] (Table 3).
14 LSG with Sequential LVHR
Eid GM et al. gave a suggested algorithm on how to treat morbidly obese patients
presenting with ventral hernia [31]. The study classified patients on favorable
and unfavorable anatomical hernias. Favorable anatomical hernias are defined as
hernias located in the center, with a size less than 8 cm, BMI less than 50 kg/m2,
body wall thickness less than 4 cm with gynecoid body habit and a reducible hernia. Unfavorable anatomical hernias on the other hand are defined as hernias that
are lateral, size larger than 8 cm, BMI more than 50 kg/m2, body wall thickness
more than 4 cm with android body habit and unreducible hernia. They found that
all symptomatic hernias should have hernia repair first prior to bariatric surgery.
Asymptomatic patients with favorable anatomy can have concomitant LVHR and
bariatric surgery, while patients with unfavorable anatomy should have bariatric surgery followed by LVHR [31]. In Fig. 2, the patient underwent concurrent
LSG and open VHR. However, the patients died 2 months later due to respiratory
failure. Finally, obese patients with asymptomatic VH and unfavorable anatomy
should have LSG first, followed by VHR.
15 Conclusion
There is a strong association between obesity and ventral hernia. The most common type of ventral hernia is incisional hernia followed by umbilical hernia.
Obesity does not only increase the risk of developing ventral hernia, but also