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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1498_Библиотеки_им_академика_М_И_Перельмана.pdf
346
A. Ramaswamy
marked on the abdominal wall, and a ruler used to measure the defect
size. The measurements may be more accurate with the abdomen
desuf fl ated. This external method can be used in most patients with
small- to medium-sized hernias who are not obese. In obese individuals
and/or those with complex hernias, the discrepancy between intra-
abdominal and extra-abdominal measurements may be signi fi cant and
leads to oversizing of the mesh. Mesh should be selected to provide
~5-cm overlap onto healthy tissue. A Swiss cheese defect may require
less, and a large single defect may require a larger piece of mesh. The
mesh should be marked, generally in one location (e.g., top). This will
help orient the mesh internally both in the craniocaudal plane and
with regard to the side which will lie toward the abdominal wall. There
are different methods of mesh fi xation which guide any further
preparation of the mesh prior to insertion. Most experts do feel that
transfascial sutures are necessary and will place four cardinal sutures
through the mesh with the tails being left long to grasp and bring out.
Permanent suture is generally recommended in this situation, and
Gore-Tex
®
suture is used by many. The mesh should then be centered
on the hernia defect, and the abdominal wall marked for location of
suture retrieval. Recently, there have been advocates of midline closure
in laparoscopic ventral hernia repair. This will be discussed elsewhere
in detail, but closure can be accomplished with transfascial sutures.
The width of the mesh when the midline has been closed may not have
to based on the original preclosure hernia defect, though this is not
clear, since some of these sutures placed under tension can be
occasionally be heard breaking when the patient is extubated and
coughs forcefully.
Mesh Insertion and Fixation
The mesh can be rolled tightly and inserted through the 10-mm port
or the incision with the port removed. A laparoscopic grasper inserted
through a trocar on the contralateral side and brought out through the
10-mm port incision can facilitate this task. The mesh can then be
unrolled using two graspers. The cardinal transfascial sutures can then be
retrieved (Fig. 29.5 ). The mesh should be stretched out, after retrieval of
the fi rst two sutures, to con fi rm the position of planned retrieval of the
remaining sutures (Fig. 29.6 ). These can then be tied down, and point
fi xation undertaken around the circumference of the mesh at 1–2-cm
347
29. Technique: Laparoscopic Ventral/Incisional Hernia Repair
intervals (Fig. 29.7 ). Additional transfascial sutures may be placed at
3–5-cm intervals. This basic technique has been described with outcomes
published on a case series of 850 patients with a recurrence rate of 4.7%
and a mesh infection rate of 0.7% [ 13 ] . Others have questioned the need
for transfascial sutures and have described the double-crown technique,
which utilizes two rows of point fi xation without transfascial suture
fi xation. Results have been published demonstrating low recurrence rates
Fig. 29.5. Retrieval of fi rst transfascial suture.
Fig. 29.6. Retrieval of fi nal cardinal transfascial suture.
348
A. Ramaswamy
[ 14, 15 ] , though the purported bene fi t of decreased pain due to lack of
transfascial fi xation has not borne out in a randomized trial [ 16 ] .
Outcomes
Speci fi c complications and their management are discussed elsewhere.
Generally speaking, laparoscopic ventral hernia repair has been increasing
in practice without the bene fi t of impressive randomized trial data. Most
of the randomized studies have been small, so summary measures have
been examined. A meta-analysis of eight randomized trials demonstrated
hospital stay and infection rates (not requiring mesh removal) which
favored laparoscopy but no differences in bowel injury, seroma, and
hernia recurrence [ 17 ] . A systematic review of 11 randomized trials and
comparative studies concluded that there was no evidence that the
laparoscopic approach is better or worse than open, though the data
suggested that the laparoscopic approach is associated with a lower
recurrence rate, shorter hospital stay, and fewer complications [ 18 ] . A
recent Cochrane review identi fi ed 11 randomized trials and concluded
that there appeared to be a lower wound infection rate in the laparoscopic
group, with a shorter hospital stay in the majority of studies, but no
differences were identi fi ed in recurrence rates [ 2 ] . A summary of the
randomized trials is presented in Table 29.1 .
Fig. 29.7 Circumferential tacking.
349
29. Technique: Laparoscopic Ventral/Incisional Hernia Repair
Table 29.1. Comparison of outcomes of randomized trials of laparoscopic versus open ventral hernia repair.
Author Year
No. of
patients
Recurrence
Any
complication Enterotomy
Seroma/
hematoma
Surgical site
infection
Lap Open Lap Open Lap Open Lap Open Lap Open
Itani [
19 ] 2010 146 12.3% 8.2% 31.5% 47.9% 4.1% 0 11.0% 27.4% 5.5% 24.7%
Asencio [
20 ] 2009 84 9.7% 7.9% 33.3% 5.1% 2.2% 0 31.1% 5.1% 0 0
Pring [
21 ] 2008 54 3.3% 4.2% 36.7% 54.2% 0 0 16.7% 33.3% 3.3% 16.7%
Olmi [
22 ] 2007 170 2.3% 1.1% 16.4% 29.4% 0 0 7.1% 4.7% 1.2% 8.2%
Navarra [
23 ] 2007 24 0 0 16.7% 8.3% 0 0 16.7 0 0 8.3%
Misra [
24 ] 2006 62 6.3% 3.3% 21.2% 42.4% 0 0 12.1% 3.0% 6.1% 33.3%
Moreno-Egea [
25 ] 2002 22 0 0 0 36.3% 0 0 0 36.3% 0 0
Carbajo [
26 ] 1999 60 0 6.7% 6.7% 66.7% 0 6.7% 3.3% 36.7% 0 10%
350
A. Ramaswamy
Conclusion
Laparoscopic ventral hernia repair is a procedure which is gaining
popularity. It has an unknown but probably short learning curve for
simple cases; however, atypical locations and complex cases should be
reserved for when expertise has been gained. Level 1 studies have
provided limited evidence of clear superiority over open repair, but many
have been plagued with short follow-up (<2 years).
References
1. Cengiz Y, Mansson P, Israelsson LA. Conventional running suture and continuous double
loop closure: an experimental study of wound strength. Eur J Surg. 2000;166(8):647–9.
2. Sauerland S, Walgenbach M, Habermalz B, Seiler CM, Miserez M. Laparoscopic
versus open surgical techniques for ventral or incisional hernia repair. Cochrane
Database Syst Rev. 2011, (3).
3. Shell D, de la Torre J, Andrades P, Vasconez L. Open repair of ventral incisional
hernias. Surg Clin North Am. 2008;88(1):61–83.
4. Luijendijk RW, Hopp WC, van den Tol MP, et al. A comparison of suture repair with
mesh repair for incisional hernia. N Engl J Med. 2000;343(6):392–8.
5. Rudmik LR, Schieman C, Dixon E, Debru E. Laparoscopic incisional hernia repair: a
review of the literature. Hernia. 2006;10(2):110–9.
6. LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using
expanded polytetra fl uoroethylene: preliminary fi ndings. Surg Laparosc Endosc.
1993;3(1):39–41.
7. LeBlanc KA, Elieson MJ, Corder 3rd JM. Enterotomy and mortality rates of
laparoscopic incisional and ventral hernia repair: a review of the literature. JSLS.
2007;11(4):408–14.
8. Jenkins E, Yom V, Melman L, et al. Clinical predictors of operative complexity in
laparoscopic ventral hernia repair: a prospective study. Surg Endosc. 2010;24:1872–7.
9. Chang EI, Galvez MG, Padilla BE, Freise CE, Foster RD, Hoffman WY. Ten-year
retrospective analysis of incisional herniorrhaphy following renal transplantation.
Arch Surg. 2011;146(1):21–5.
10. Bege T, Berdah SV, Moutardier V, Brunet C. Risks related to tobacco use in general
and intestinal surgery. J Chir. 2009;146(6):532–6.
11. Finan KR, Vick CC, Kiefe CI, Neumayer L, Hawn MT. Predictors of wound infection
in ventral hernia repair. Am J Surg. 2005;190(5):676–81.
12. Tsereteli Z, Pryor A, Heniford BT, Park A, Voeller G, Ramshaw BJ. Laparoscopic
ventral hernia repair (LVHR) in morbidly obese patients. Hernia. 2008;12:233–8.
13. Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic repair of ventral hernias
nine years’ experience with 850 consecutive hernias. Ann Surg. 2003;238(3):391–9.
351
29. Technique: Laparoscopic Ventral/Incisional Hernia Repair
14. Morales-Conde S, Cadet H, Cano A, Bustos M, Morales-Mendez S. Laparoscopic
ventral hernia repair without sutures–double crown technique: our experience after
140 cases with a mean follow-up of 40 months. Int Surg. 2005;90(3 Suppl):S56–62.
15. Baccari P, Nifosi J, Ghirardelli L, Staudacher C. Laparoscopic incisional and ventral
hernia repair without sutures: a single-center experience with 200 cases. J Laparoendosc
Adv Surg Tech A. 2009;19(2):175–9.
16. Wassenaar E, Schoenmaeckers E, Raymakers J, van der Palen J, Rakic S. Mesh- fi xation
method and pain and quality of life after laparoscopic ventral or incisional hernia repair:
a randomized trial of three fi xation techniques. Surg Endosc. 2010;24(6):1296–302.
17. Forbes SS, Eskicioglu C, McLeod RS, Okrainec A. Meta-analysis of randomized
controlled trials comparing open and laparoscopic ventral and incisional hernia repair
with mesh. Br J Surg. 2009;96:851–8.
18. Clarabelle T, Pham C, Perera D, Watkin S, Maddern GJ. Laparoscopic ventral hernia
repair: a systematic review. Surg Endosc. 2009;23:4–15.
19. Itani KM, Hur K, Kim LT, Anthony T, Berger DH, Reda D, Neumayer L, Veterans
Affairs Ventral Incisional Hernia Investigators. Comparison of laparoscopic and open
repair with mesh for the treatment of ventral incisional hernia: a randomized trial.
Arch Surg. 2010;145(4):322–8.
20. Asencio F, Aguilo J, Peiro S, Carbo J, Ferri R, Caro F, Ahmad M. Open randomized
clinical trial of laparoscopic versus open incisional hernia repair. Surg Endosc.
2009;23:1441–8.
21. Pring CM, Tran V, O’Rourke N, Martin IJ. Laparoscopic versus open ventral hernia
repair: a randomized controlled trial. Aust N Z J Surg. 2008;78(10):903–6.
22. Olmi S, Scaini A, Cesana GC, Scaini L, Erba E. Laparoscopic versus open incisional
hernia repair: an open randomized controlled study. Surg Endosc. 2007;21:555–9.
23. Navarra G, Musolino C, De Marco ML, Bartolotta M, Barbera A, Centorrino T.
Retromuscular sutured incisional hernia repair: a randomized controlled trial to
compare open and laparoscopic approach. Surg Laparosc Endosc. 2007;17(2):86–90.
24. Misra MC, Bansal VK, Kulkarni MP, Pawar DK. Comparison of laparoscopic and
open repair of incisional and primary ventral hernia: results of a prospective randomized
study. Surg Endosc. 2006;20(12):1839–45.
25. Moreno-Egea A, Carrasco L, Girela E, Martín JG, Aguayo JL, Canteras M. Open vs.
laparoscopic repair of spigelian hernia: a prospective randomized trial. Arch Surg.
2002;137(11):1266–8.
26. Carbajo MA, del Olmo JC M, Blanco JI, de la Cuesta C, Toledano M, Martín F,
Vaquero C, Inglada L. Laparoscopic treatment vs. open surgery in the solution of major
incisional and abdominal wall hernias with mesh. Surg Endosc. 1999;13(3):250–2.
353
B.P. Jacob and B. Ramshaw (eds.), The SAGES Manual of Hernia Repair,
DOI 10.1007/978-1-4614-4824-2_30,
© Springer Science+Business Media New York 2013
30. Loss of Abdominal Domain
Victor B. Tsirline , Igor Belyansky , David A. Klima ,
and B. Todd Heniford
Over two million laparotomies are performed every year in the United
States. 5% to 20% of these cases lead to incisional hernia formation [ 1 ] ,
some leading to large abdominal wall defects with loss of domain.
Approximately 160,000 ventral hernia repairs are performed annually,
with a recurrence rate of 5–20% in uncomplicated hernias and low-risk
individuals. The success of the hernia operations diminishes with larger
hernia defects, obesity, and multiple reoperations [ 2 ] . In patients with
complex abdominal hernias and loss of domain, recurrence rates of up to
67% have been reported [ 3 ] . Such cases require particular expertise in
evaluation, counseling, and multimodality treatment in order to achieve
long-term success. This chapter will address some of the theoretical
principles and practical considerations in the management of patients
with loss of abdominal domain.
De fi nitions
In 1943, Dr. Ivan Goni Moreno published a paper on the treatment of
chronic abdominal hernias where the visceral contents have lost their
“derecho de domicilio” (right of domain). The literature most commonly
de fi nes loss of abdominal domain as the inability of the abdominal cavity
to accommodate the viscera, without prohibitively high intraabdominal
pressures (>15 mmHg) [ 2 ] . Chevrel in 1987 described abdominal ventral
hernias whose contents were held in place by adhesions and not reducible,
thus losing their right of domain [ 4 ] , as applied to large abdominal
defects >10–15 cm [ 5 ] or areas >100–225 cm
2
[ 6, 7 ] . Others have de fi ned
loss of domain as extrusion of 15–20% or more of abdominal volume
354
V.B. Tsirline et al.
[ 8 ] , as reducing such or greater volume of tissue into the abdominal
cavity is likely to require signi fi cant physiologic adaptation. Most experts
agree that evisceration of more than 50% of abdominal contents into the
hernia requires specialized strategies for successful repair [
9 ] .
Pathophysiology and Biomechanics
Loss of abdominal domain implies the absence of mechanical strength
in the anterior abdominal wall, with unopposed protrusion of the
abdominal viscera, leading to loss of structural integrity of the torso. The
pathophysiology and biomechanics differ from those of ordinary ventral
hernias, where tissue herniates through a well-de fi ned fascial defect due
to increased intraabdominal pressure and may result in incarceration and
strangulation. Patients may experience discomfort due to intermittent
herniation/reduction, acute obstruction, or chronic mental strangulation
in the ventral defect. In contrast, with loss of abdominal domain, there is
lack of con fi nement of the intraabdominal contents, resulting in low
intraabdominal pressure and chronic, gravity-induced stretch of the
viscera. Voluntary straining and postural re fl ex contraction of the residual
abdominal muscles lead to progressive retraction laterally because the
muscles on each side of the hernia are not mechanically coupled.
Causes and Challenges
Ventral hernias of all sizes tend to enlarge over time. As the abdominal
circumference increases, the tension in the abdominal wall and at the
edge of the growing defect increases according to LaPlace’s law.
Eventually, this leads to loss of domain with musculofascial tissues
retracting laterally. The challenge in repairing such defects, rather than
bridging a gap and preventing recurrence, is the restoration of a
physiologic, mechanical, and functional covering around the eviscerated
abdominal structures, if possible.
Patient history is important, as loss of domain often results from an
abdominal catastrophe requiring either extensive abdominal debridement,
such as traumatic injuries or infection, or a prolonged open abdomen,
due to peritonitis and intestinal edema [ 10– 12 ] . In the latter case, the
abdominal wall recedes laterally due to the unopposed lateral forces on
355
30. Loss of Abdominal Domain
the oblique muscles. During the acute hospitalization, the abdominal
wall coverage may be temporized by using an absorbable mesh or a
biologic graft, which usually stretches over time. Epidermal coverage in
the acute setting is often accomplished using split-thickness skin grafts,
which are aesthetically unappealing and lack thermal, mechanical, and
regenerative properties of natural cutaneous and subcutaneous tissues.
Morbidity of Loss of Domain
Loss of abdominal domain is often morbid, and patients usually
describe poor overall quality of life. This comes from a combination of
postural musculoskeletal dysfunction, chronic gastrointestinal pathology,
and psychosocial issues. Lack of abdominal functional musculature
causes signi fi cant activity limitation and leads to chronic progressive
strain on the lumbar spine, often resulting in chronic back pain. Obesity
is commonplace among patients with loss of domain, as a result of
restricted mobility. Gastrointestinal dysfunction with pain and chronic
intestinal incarceration is common. Abdominal wall dysfunction often
produces signi fi cant thoracic impairment. Spinal kyphosis resulting from
loss of anterior torsal integrity can lead to reduced thoracic volume and
decreases the inspiratory capacity. Lack of abdominal muscular function
can also reduce inspired volumes.
Finally, the cosmetic considerations add to the overall morbidity. The
dis fi gured abdomen, distorted by scars, obesity, and inability to exercise
maintain a normal physical appearance, carries a large psychological
burden. Many patients with loss of abdominal domain are signi fi cantly
distressed and unable to change the progressive course of their condition
without surgical intervention.
Evaluation
General Preoperative Considerations
Taking into account preoperative considerations, patients with loss of
abdominal domain may be classi fi ed into discrete categories based on
the following [ 13 ] :
356
V.B. Tsirline et al.
Presence of contamination •
Size of the fascial defect •
Volume of the hernia sac relative to peritoneum •
Patients with loss of domain not only present with dif fi cult to repair
abdominal wall defects but they often have dramatically thin or excess
skin, chronic nonhealing abdominal wounds, fi stulas, and stomas. These
issues signi fi cantly complicate the general problems of returning the
bowel to the peritoneal cavity and closing the abdomen. The issues above
require planning, preparation, and technical factors that exponentially
add to the dif fi culty of the abdominal reconstruction. Management of the
chronic wounds, fi stulas, stomas, etc., requires signi fi cantly greater time
commitment, tools, and frequently a team approach. Each complicating
factor may change the approach, mesh choice, position of the mesh, and
closure techniques.
Volume Measurement
Preoperative physical examination is important; however, it is
somewhat unreliable in estimating the hernia sac volume for multiple
reasons. External circumference of the hernia sac has been shown to
have poor correlation to the hernia sac volume [ 14 ] . Therefore,
preoperative imaging is often helpful. CT of the abdomen may suggest
whether abdominal wall reconstruction will be feasible. There has been
considerable interest in CT volumetric analysis of patients with loss of
domain undergoing abdominal reconstruction [ 15– 17 ] . Both the
peritoneal cavity and the hernia sac can be approximated as ellipse, with
craniocaudal (D
CC
), anteroposterior (D
AP
), and horizontal (D
H
) diameter
measurements from the CT slices [ 17 ] . In this model, the volume of each
compartment can be estimated as
=´ ´ ´Volume D D D .
6
π
CC AP H
Advanced geometric models can be employed in computer-aided CT
volumetrics to yield more accurate results. Incisional hernia volume of less
than 20% of peritoneal volume was found to be highly predictive of being
able to reduce the hernia contents and close the abdomen without causing
a compartment syndrome. Patients whose hernia sac volume was more than
20% of the peritoneal volume could require bridging devices or visceral
resection and risked excessive abdominal pressures postoperatively [ 15 ] .