Laparoscopic Hernia Surgery This Page Intentionally Left Blank Laparoscopic Hernia Surgery an Operative Guide

Laparoscopic hernia surgery This page intentionally left blank Laparoscopic hernia surgery An operative guide

Edited by

Karl A. LeBlanc MD MBA FACS Minimally Invasive Surgery Institute, Inc. Baton Rouge, Louisiana, USA Clinical Assistant Professor, Surgery, Louisiana State University School of Medicine, New Orleans, Louisiana, USA Past President of the American Hernia Society

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What do you think about this book? Or any other Arnold title? Please send your comments to [email protected] I wish to dedicate this book to Zinda, my wife. Please forgive my absence in so many things in our lives so that this textbook could become a reality. Your support and love is never forgotten and always appreciated. This page intentionally left blank Contents

Contributors xi

Preface xiii

Abbreviations xv

Manufacturers xvii

PART 1 OVERVIEW 1

1 Laparoscopic general surgery 3 Roger K.J. Simmermacher 2 Technological and instrumentation aspects of laparoscopic hernia surgery 7 Gina L. Adrales and Adrian E. Park 3 Prosthetic biomaterials for hernioplasty 17 Karl A. LeBlanc 4 Fixation devices for laparoscopic hernioplasty 25 Karl A. LeBlanc

PART 2 LAPAROSCOPIC INGUINAL/FEMORAL HERNIOPLASTY 31

5 History 33 Michael S. Kavic and Stephen M. Kavic 6 Anatomy and physiology 41 B. Page and Patrick J. O’Dwyer 7 Intraperitoneal onlay mesh approach 47 Morris Franklin 8 Transabdominal pre-peritoneal approach 53 Reinhard Bittner, Claus-Georg Schmedt and Bernhard Josef Leibl 9 Totally extraperitoneal approach 65 Ed Felix 10 Femoral and pelvic herniorrhaphy 75 Christine A. Ely and Maurice E. Arregui 11 Results of laparoscopic inguinal/femoral hernia repair 83 Ketan M. Desai and Nathaniel J. Soper 12 Complications and their management 89 Ricardo V. Cohen, Carlos A. Schiavon, Sérgio Roll and José C.P. Filho viii Contents

PART 3 LAPAROSCOPIC INCISIONAL AND VENTRAL HERNIOPLASTY 97

13 History 99 Kristi L. Harold, Brent D. Matthews and B. Todd Heniford 14 Anatomy and physiology 103 Karl A. LeBlanc 15 Laparoscopic repair in the emergent setting 111 Guy R. Voeller 16 Herniorrhaphy with the use of transfascial sutures 115 Karl A. LeBlanc 17 Pre-peritoneal herniorrhaphy 125 Sérgio Roll, Wagner C. Marujo and Ricardo V. Cohen 18 Hernioplasty with the double-crown technique 133 Salvador Morales-Conde and Salvador Morales-Méndez 19 Parastomal hernia repair 143 Karl A. LeBlanc 20 Lumbar hernia and ‘denervation’ hernia repair 151 Karl A. LeBlanc 21 Results of laparoscopic incisional and ventral hernia repair 155 Rodrigo Gonzalez and Bruce J. Ramshaw 22 Complications and their management 161 Samuel K. Miller, Stephen D. Carey, Francisco J. Rodriguez and Roy T. Smoot, Jr

PART 4 LAPAROSCOPIC TREATMENT OF DIAPHRAGMATIC HERNIATION 171

23 History 173 Raymond C. Read 24 Anatomy and physiology 179 Mark A. Reiner 25 Preoperative evaluation 187 Marco G. Patti and Piero M. Fisichella 26 Gastroesophageal reflux disease 193 J. Barry McKernan and Charles R. Finley 27 Para-esophageal hernias 201 Hugo Bonatti, Beate Neuhauser and Ronald A. Hinder 28 Traumatic and unusual herniation 209 Sergio G. Susmallian and Ilan Charuzi 29 Etiology of recurrent gastroesophageal reflux disease 217 Ziad T. Awad and Charles J. Filipi 30 Reoperation for recurrent gastroesophageal reflux disease 227 Thomas R. Eubanks 31 Results of laparoscopic treatment of hiatal hernias 235 Patrick R. Reardon and Stirling E. Craig 32 Complications and their management 239 Santiago Horgan and Robert Berger Contents ix

PART 5 LAPAROSCOPY IN THE PEDIATRIC HERNIA PATIENT 249

33 History 251 Rajeev Prasad and Thom E. Lobe 34 Anatomy and physiology 255 Rajeev Prasad and Thom E. Lobe 35 Diaphragmatic herniation 257 Rajeev Prasad and Thom E. Lobe 36 Complications and their management 261 Rajeev Prasad and Thom E. Lobe

PART 6 FUTURE CONSIDERATIONS 263

37 Robotics and hernia surgery 265 Amit Trivedi and Garth H. Ballantyne 38 Socioeconomic issues 273 Karl A. LeBlanc, Andrew N. Kingsnorth and Zinda Z. LeBlanc Index 283 This page intentionally left blank Contributors

Gina L. Adrales MD Ed Felix MD Clinical Instructor, University of Kentucky Medical Center; and California Institute of Minimally Invasive Surgery, Fresno, Research Fellow, Center for Minimally Invasive Surgery, CA, USA

University of Kentucky, Lexington, KY, USA José Carlos Pinheiro Filho MD Maurice E. Arregui MD FACS Department of Surgical Endoscopy, Sao Camilo Hospital, Sao Director of Fellowship in Laparoscopy, Endoscopy and Paulo, Brazil

Ultrasound, St. Vincent Hospital and Health Care Center, Charles J. Filipi MD Indianapolis, IN, USA Professor, Department of Surgery, Creighton University, Omaha, Ziad T. Awad MD FRCSI FICS NE, USA General Surgery Resident, Omaha, NE, USA Charles R. Finley MD FACS Garth H. Ballantyne MD FACS FASCRS Videoscopic General Surgeon, Atlanta, GA, USA Professor of Surgery, Division of Minimally Invasive and Piero M. Fisichella MD Telerobotic Surgery, Hackensack University Medical Center, Fellow, Swallowing Center, University of California, San Hackensack, NJ, USA Francisco, CA, USA Robert Berger MD Morris Franklin MD Fellow in Laparoscopic Surgery, Department of Surgery, Professor of Surgery, University of Texas Health Science Center, University of Illinois, Chicago, IL, USA and Director, Texas Endosurgery Institute, San Antonio, Reinhard Bittner MD FRCS TX, USA Head of Department of General and Visceral Surgery, Rodrigo Gonzalez MD Marienhospital Stuttgart, Stuttgart, Germany Fellow, Emory Endosurgery Unit, Surgery Department, Emory Hugo Bonatti MD University School of Medicine, Atlanta, GA, USA Department of Surgery, Mayo Clinic, Jacksonville, USA Kristi L. Harold MD Stephen D. Carey MD FACS Laparoscopic Fellow, Carolinas Laparoscopic and Advanced Nanticoke Surgical Associates, Seaford, DE, USA Surgery Program, Carolinas Medical Center, Charlotte, Ilan Charuzi MD NC, USA Chairman, Department of Surgery, Wolfson Medical Center, B. Todd Heniford MD Holon, Israel Chief of Minimal Access Surgery, Co-Director Carolinas Ricardo V. Cohen MD FACS Laparoscopic and Advanced Surgery Program, Carolinas Medical Department of Surgical Endoscopy, Sao Camilo Hospital, Sao Center, Charlotte, NC, USA Paulo, Brazil Ronald A. Hinder MD PhD Stirling E. Craig MD BA Professor and Chairman, Department of Surgery, Mayo Clinic, Research assistant, Methodist Reﬂux Center, The Methodist Jacksonville, FL, USA Hospital, Texas Medical Center, Houston, Texas Santiago Horgan MD Ketan M. Desai MD Director of Minimally Invasive Surgery and Assistant Professor Department of Surgery, Washington University School of of Surgery, Department of Surgery, University of Illinois, Medicine, St Louis, MO, USA Chicago, IL, USA

Christine A. Ely MD Michael S. Kavic MD Fellow in Laparoscopy and Endoscopy, St Vincent Hospital and Professor of Clinical Surgery and Vice Chair, Department of Health Care Center, Indianapolis, IN, USA Surgery, Northeastern Ohio Universities College of Medicine, Thomas R. Eubanks MD DO and Director of Education, General Surgery, St Elizabeth Health Portland Surgical Specialists, Portland, OR, USA Center, Youngstown, OH, USA xii Contributors

Stephen M. Kavic MD Marco G. Patti MD Department of Surgery, Yale University School of Medicine, Associate Professor of Surgery, Director, Swallowing Center, New Haven, CT, USA University of California, San Francisco, CA, USA

Andrew N. Kingsnorth BSc MD MS FRCS FACS Rajeev Prasad MD Professor of Surgery and Consultant Surgeon, Plymouth Fellow in Pediatric Surgery, University of Tennessee College of Postgraduate Medical School, Derriford Hospital, Plymouth, UK Medicine, and Le Bonheur Children’s Medical Center, Memphis, Karl A. LeBlanc MD MBA FACS TN, USA Minimally Invasive Surgery Institute, Inc. Baton Rouge, Bruce J. Ramshaw MD FACS Louisiana, USA. Clinical Assistant Professor, Surgery, Louisiana Director of Education, Emory Endosurgery Unit, and Assistant State University School of Medicine, New Orleans, Louisiana, Professor, Surgery Department, Emory University School of USA. Past President of the American Hernia Society Medicine, Atlanta, GA, USA Zinda Z. LeBlanc RN BSN MD MBA Raymond C. Read MD FACS FRCS Director of Surgical Services/AICU/PACU/TX Rm., Professor of Surgery Emeritus, University of Arkansas for Woman’s Hospital, Baton Rouge, LA, USA Medical Sciences, Rockville, MD, USA Bernhard Josef Leibl MD Department of General and Visceral Surgery Marienhospital Patrick R. Reardon MD Stuttgart, Stuttgart, Germany Director, Texas Institute for Advanced Minimally Invasive Surgery Training, Texas Medical Center, Houston, Texas and Thom E. Lobe MD Surgical Director, Methodist Reflux Center, The Methodist Chairman, Section of Pediatric Surgery, and Chairman, Task Hospital, Texas Medical Center, Houston, Texas Force on Complementary and Alternative Medicine, and Professor of Surgery and Pediatrics, University of Tennessee Mark A. Reiner MD College of Medicine and Le Bonheur Children’s Medical Center, Assistant Clinical Professor of Surgery, Laparoscopic Surgical Memphis, TN, USA Center of New York, Mount Sinai School of Medicine, New York, NY, USA Wagner C. Marujo MD Attending Surgeon, Liver Transplantation Unit, Hospital Albert Francisco J. Rodriguez MD FACS Einstein, Sao Paulo, and Faculty of Medicine, University of Sao Nanticoke Surgical Associates, Seaford, DE, USA Paulo, Sao Paulo, Brazil Sérgio Roll MD Brent D. Matthews MD Director of Laparoscopic Surgery, Department of General Chief of Research, Carolinas Laparoscopic and Advanced Surgery, Heliopolis Hospital, University of Santos School of Surgery Program, Carolinas Medical Center, Charlotte, NC, USA Medicine, Sao Paulo, Brazil J. Barry McKernan MD PhD FACS Carlos A. Schiavon MD Clinical Professor of Surgery, Medical College of Georgia, Department of Surgical Endoscopy, Sao Camilo Hospital, Augusta, GA, USA Sao Paulo, Brazil Samuel K. Miller MD FACS Claus-Georg Schmedt MD Nanticoke Surgical Associates, Seaford, DE, USA Department of General and Visceral Surgery Salvador Morales-Conde MD Marienhospital Stuttgart, Stuttgart, Germany Laparoscopic Surgery Unit, University Hospital Virgen Roger K.J. Simmermacher MD PhD Macarena, Seville, Spain General Surgeon, University Medical Centre, Utrecht, Salvador Morales-Méndez MD The Netherlands Digestive and General Surgery Unit, University Hospital Virgen Del Rocío, Seville, Spain Roy T. Smoot, Jr MD FACS Nanticoke Surgical Associates, Seaford, DE, USA Beate Neuhauser MD Department of Surgery, Mayo Clinic, Jacksonville, FL, USA Nathaniel J. Soper MD Department of Surgery, Washington University School of Patrick J. O’Dwyer MB BCh MD FRCSI MCh FRCS Medicine, St Louis, MO, USA Professor of Gastrointestinal Surgery, University Department of Surgery, Western Infirmary, Glasgow, UK Sergio G. Susmallian MD Department of Surgery, Wolfson Medical Center, Holon, Israel B. Page BSc MD MBChB MRCS Research Fellow, University Department of Surgery, Western Amit Trivedi MD Infirmary, Glasgow, UK Division of Minimally Invasive and Telerobotic Surgery, Hackensack University Medical Center, Hackensack, NJ, USA Adrian E. Park MD FRCS FACS Department of Surgery, Center for Minimally Invasive Surgery, Guy R. Voeller MD FACS University of Kentucky Chandler Medical Center, Lexington, KY, Associate Professor, Surgery, University of Tennessee, Memphis, USA Memphis, TN, USA Preface

The laparoscopic repair of inguinal hernias quickly fol- world, the availability of the pediatric surgeon is quite lowed the development of the laparoscopic approach to uncommon. The information imparted in these chapters the cholecystectomy. This operation was, and continues should provide guidance to the general laparoscopic sur- to be, a controversial subject. In contrast, the adoption of geon in this setting. the laparoscopic methodology for the treatment of the The era of robotics is also upon us. It may be surpris- other hernias of the abdominal wall has experienced con- ing to many of us but there is utility in the repair of her- tinued growth. While there are textbooks that have dealt nias also. with general laparoscopic surgical techniques and others The final chapter on socioeconomics is needed to that are comprehensive texts on the subject of hernias, educate the surgeon as he or she makes the operative none have been dedicated solely to the laparoscopic treat- choices that are available. Many issues will be regional ment of this malady in all aspects of the abdomen. while others are national and international. We are all A review of the authors that have contributed to this continually faced with the economic realities of the prac- work is a testament of my efforts to provide a true “oper- tice of surgery. More attention should be given to this ative guide” to those surgeons-in-training and those who subject in the training programs. It is hoped that this desire more detailed information on this subject matter. book provides a sound basis to begin this process. An international representation is evident. These are the I wish to thank all of the contributors for their persist- opinion leaders and the surgeons that have helped to ence in this work. It is rather difficult and time-consum- develop this field. I appreciate their efforts to share their ing to provide a chapter of the detail and with the knowledge. significant references that I desired. It is the expertise of I have tried to provide the reader with the different these authors that will truly make this text a reference techniques that are currently being used to repair the source. I would also express my appreciation of all of the hernias in the inguinal region, the incisional and hiatal staff from Arnold Publishers and Naughton Management locations. I have also relied on different authors to pro- that have helped in the production of this text. I hope that vide the details of the pertinent anatomy, the current the reader will realize the goals that I set forth upon the results and the various complications and the manage- commencement of this operative guide to laparoscopic ment. The segregation of these topics should remove any hernia surgery. bias that may be seen in the usual textbooks of this type. A section on the use of the laparoscope in the pedi- Karl A. LeBlanc Louisiana atric hernia patient is also included. In many areas of the July 2003 This page intentionally left blank Abbreviations

CGRP calcitonin gene-related peptide CT computerized tomography DES diffuse esophageal spasm DPL diagnostic peritoneal lavage ECG electrocardiogram ECMO extracorporeal membrane oxygenation EGD esophagogastroduodenoscopy ePTFE expanded polytetrafluoroethylene GER gastroesophageal reflux GERD gastroesophageal reflux disease GPRVS giant prosthetic reinforcement of the visceral sac HAL hand-assisted laparoscopy IEM ineffective esophageal motility IPOM intraperitoneal onlay of mesh LES lower esophageal sphincter LIVH laparoscopic incisional and ventral hernioplasty MIS minimally invasive surgery MRI magnetic resonance imaging NSEMD non-specific esophageal motility disorder PCA patient-controlled analgesia PEH para-esophageal hernia PFA platelet function assay PONV postoperative nausea and vomiting PPM polypropylene mesh PTFE polytetrafluoroethylene TAPP transabdominal pre-peritoneal TEP total extraperitoneal TLESR transient lower-esophageal sphincter relaxation This page intentionally left blank Manufacturers

Angiologica, S. Martino Sicc., Italy Applied Medical, Rancho Santa Margarita, CA, USA Atrium Medical Corp., Hudson, NH, USA Autosuture, Norwalk, CT, USA BARD, Loomis, CA, USA Brennen Medical, Inc., St Paul, MN, USA Coalescent, Sunnyvale, CA, USA Cook Surgical, Inc., Bloomington, IN, USA Computer Motion, Inc., Santa Barbara, CA, USA Cousin Biotech, Wervicq-Sud, France C. R. Bard, Inc., Cranston, NJ, USA Curon Medical, Sunnyvale, CA, USA Ethicon, Inc., Somerville, NJ, USA Ethicon Endosurgery, Inc., Cincinnati, OH, USA Genzyme Corp., Cambridge, MA, USA HerniaMesh, S.R.L., Turin, Italy Intuitive Surgical, Mountain View, CA, USA Lifecell, Inc., Branchburg, NJ, USA Louisville Laboratories, Inc., Louisville, KY, USA 3M Healthcare, St Paul, MN, USA Meadox Medical Corp., Oakland, NJ, USA Onux Medical, Inc., Hampton, NJ, USA Organogenesis, Inc., Canton, MA, USA Origin Medsystems, Menlo Park, CA, USA Phillips Petroleum Co., Bartlesville, OK, USA Sanoﬁ Winthrop Pharmaceuticals, New York, NY, USA Sofradim International, Villfranche-sur-Saône, France Storz Endoscopy, Los Angeles, CA, USA Tissue Science Laboratories plc, Covington, GA, USA U.S. Surgical Corp./Tyco International, Inc., Norwalk, CT, USA W. L. Gore & Associates, Inc., Flagstaff, AZ, USA This page intentionally left blank PART 1

Overview

1 Laparoscopic general surgery 3 3 Prosthetic biomaterials for hernioplasty 17 2 Technological and instrumentation aspects of 4 Fixation devices for laparoscopic hernioplasty 25 laparoscopic hernia surgery 7 This page intentionally left blank 1

Laparoscopic general surgery

ROGER K.J. SIMMERMACHER

References 5

Fortunately the time when many surgeons and their mention thoracoscopy, a procedure that he initially felt had patients thought that laparoscopy should be a purpose a better chance than laparoscopy for further development. rather than a means to an end has passed. Although the In 1927, the first textbook dealing with thoracoscopy ‘scopic’ approach has become the gold standard for some and laparoscopy was published by Korbsch in Munich, indications, it has not brought completely new ideas on Germany. After World War II, the development of laparo- how to handle surgical diseases, but it has changed our scopic investigations into the human body was led mainly certain approach in order to facilitate the postoperative by European gynecologists. An extensive overview of their recovery of the patient. Principally, a surgical disease contributions into the development of endoscopic sur- should be managed by a surgeon. Who, in order to treat gery is beyond the scope of this chapter, but some of their his or her patient optimally, is not limited by technology advancements are interesting and worth consideration.7 (a scalpel for open surgery or the laparoscope for some of Once technical innovations allowed more than one per- us) rather than trying to find the best treatment modal- son to view through the laparoscope at the same time, it ity by chance, which might include techniques still to be was only a few years before Phillipe Mouret of Lyon, envisioned.1 For many of us, laparoscopy is, or was, the France performed the first human laparoscopic chole- first expansion of our rather limited armamentarium. cystectomy in 1987. This event initiated an explosion of As with many things in surgery, Hippocrates is credited experiments that has brought us to the current position of as the first physician to have used a tool to obtain a better laparoscopy as an important part of the surgical arma- view of the human interior, in his case the rectum.2 Fur- mentarium. Nowadays, laparoscopic cholecystectomy, by ther development of this idea, however, was hampered for far the most extensively described and most frequently nearly 2000 years due to a lack of progression in techno- performed laparoscopic procedure, is the gold standard logical innovation.3 The evolution of laparoscopic surgery treatment for most diseases that merit removal of the parallels the evolution of two distinct technical factors, gallbladder,8 irrespective of age and comorbidity.9 Addi- which are the basis for all current endoscopic interven- tionally, cholecystectomy is very often the first laparo- tions: the invention and development of a lens system that scopic operation that trainees are taught. It should could be connected to a computer-chip television camera be emphasized that the principles and indications for and an effective lighting system via fiber-optic delivery cholecystectomy have not changed because of the laparo- were the essential prerequisites for the current possibilities scopic approach. However, the old controversy of whether of laparoscopic technology. This allowed other surgeons intraoperative cholangiography should be a routine part and their assistants to handle the endoscope while actively of the procedure returned early in the development of this participating and assisting in the scopic procedures. It is procedure.10 Additional concerns were exposed, partly difficult to state with certainty who should be credited with because the laparoscopic exploration of the common bile performing the first human laparoscopy, complete with duct was in its infancy.11,12 Even today, these arguments pneumoperitoneum. However, at the beginning of the are not resolved.10 twentieth century, three names are mentioned: Kelling,4 Within a short period of time, the scopists turned their Jacobaeus5 and Ott.6 Jacobaeus was the first physician to interest towards another frequent surgical procedure, 4 Overview appendectomy.13 Laparoscopic appendectomy had been Introduction of improved techniques for intracorpo- reported as early as 1977 in a paper from The Netherlands,14 real hemostasis, stapling and knot-tying make it possible and since then there has been an ongoing discussion about to treat many colorectal diseases laparoscopically,37 even the merits of the laparoscopic approach in the surgical in the presence of generalized peritonitis.38 Despite ini- treatment of appendicitis. A recent review by Fingerhut tial doubts about the maintenance of oncological resec- concluded that because many of the surgical aspects of tion principles, it has been shown that both types of the open appendectomy have improved so greatly, the operations, laparoscopic and open, do not differ greatly apparent advantages of a laparoscopic approach are hard in this respect.39 The incidences of anastomotic leakage, to demonstrate.15 It is acknowledged, however, that local morbidity and mortality are not significantly different cultural factors, as well as operative experience, are impor- between the two methodologies, but the laparoscopic tant considerations that should dictate the strategic approach requires more operative time.39 decisions of any individual surgeon and/or hospital.15 Laparoscopic resection of cystic and solid liver tumors, Recently, a randomized clinical trial in children, which curative or palliative, is receiving increasing interest compared both approaches, demonstrated clearly that as reports of the different techniques and their pitfalls laparoscopic appendectomy did not offer advantages are accumulating.40–43 Staging, of course, has also been over the open method.16 These findings are disputed shown to be feasible.44 The spleen has also been the target heavily by others.17 Advantages of laparoscopic appen- of the laparoscopist. Currently, open splenic resection is dectomy appear to be limited to obese patients and usually reserved for treating a very large spleen with hyper- patients whose preoperative diagnosis is not clear-cut.18 splenism and in the acute trauma setting.45 Another organ system that received a lot of attention Retroperitoneal organs, such as the pancreas, adrenal in the early years of laparoscopy was the upper gastro- glands and prostate, have also become the domain of intestinal tract.19 The initial interest began with the treat- laparoscopically trained surgeons.46–49 Admittedly, these ment of duodenal ulcers and gastroesophageal reflux more advanced procedures require sufficient training disease.20 Since its introduction of laparoscopic surgery of and skills in both laparoscopic and open surgery. the upper gastrointestinal tract, has become the gold stan- Vascular surgeons are now evaluating the newest dard for the surgical treatment of gastroesophageal reflux treatment modalities of endovascular procedures and disease (GERD).21 It is frequently performed in daycare endoscopic techniques. Veins50 and the aorta51 can be situations,22 although there can be persistent complaints handled via a laparoscope, although this is still experi- years after the operation.23 mental in most cases.52 According to the French literature, gastric ulcers Future developments will probably focus on the should be approached laparoscopically at the initial oper- improvement of intraoperative imaging techniques, ation,24 as both retrospective25 and prospective26 analyses improved tactile feedback through the so-called ‘endo- have shown excellent results and low conversion rates.25 hand’,53 navigation,54 and robotic assistance.55 The pri- Other diseases of the stomach for which laparoscopy is mary efforts of the developments of laparoscopic surgery frequently performed in some centers with standardized focused upon the improvements for the care of the laparoscopic methods include achalasia,26,27 perforated patients, which of course continues today (e.g. the devel- peptic ulcer,28 and gastric cancer. With respect to bariatric opment of gasless pneumoperitoneum by lifting of the surgery, there appear to be current differences between abdominal wall).42,53 Current innovative attention seeks the use of the gastric bypass (more popular in the USA) to improve the range of motion, precision and control of and the application of adjustable bands on the stomach the surgeon through the development of intracorporeal (more popular in Europe). The laparoscopic approach for instruments that are handled via the endo-hand or revo- both procedures continues to grow rapidly, but random- lutionary improvements of the tip of the laparoscopic ized controlled trials comparing the different methods are instruments53 as the ‘endo-wrist’ of the da Vinci® robotic needed urgently.29 system.55 Furthermore, gastroenterologists might be chal- Laparoscopy offers an important advantage in the lenged as some surgeons turn their interest into endo- treatment of many types of intra-abdominal cancers, as organ laparoscopic management. However, there are it allows staging of the disease prior to any intended only limited anecdotal reports of resections of gastric resection. However, careful patient selection is necessary leiomyomas56 or small neoplasms, which predicts that to effectively limit the number of unnecessary laparo- further investigations will be undertaken in the future.57 tomies.30,31 Additionally, intraoperative laparoscopic ultra- In conclusion, it is evident that laparoscopy is cur- sonography may become mandatory in the future because rently part of the surgical armamentarium as much as it allows more accurate pretreatment staging.32 Preopera- the hand and scalpel have always been. Due to the cur- tive staging will allow the correct operation to be chosen rent availability of rapid communication facilities,58 the from one of the many different types of resections that development of laparoscopy has been quicker than that are feasible.33–36 of any other innovation within surgery. In fact, this may Laparoscopic general surgery 5 have pushed some surgeons to use laparoscopy for very 11 Phillips EH, Rosenthal RJ, Caroll BJ, Fallas MJ. Laparoscopic trans- many different indications with, in some cases, less than cystic common bile duct exploration. Surg Endosc 1994; 8: 1389. 59 12 Berci G, Morgenstern L. Laparoscopic management of common bile optimal preparation. Laparoscopy is well established duct stones. A multi-institutional SAGES-study. Surg Endosc 1994; 18 for cholecystectomy and gastric fundoplication, but for 8: 1168. many other indications its position still has to be deter- 13 Schreiber JH. Early experience with laparoscopic appendectomy in mined, because many reports of successful laparoscopic women. Surg Endosc 1987; 1: 211–16. management for various indications are either from 14 Kok HJ. A new technique for resecting the non-inflamed not-adhesive appendix through a mini-laparotomy with the aid anecdotal or personal experiences. The following chap- of the laparoscope. Arch Chir Neerl 1977; 29: 195–8. ters of this book indicate the current state of the art con- 15 Fingerhut A, Millat B, Borrie F. Laparoscopic versus open cerning hernia surgery. Certainly, there is enough evidence appendectomy: time to decide. World J Surg 1999; 23: 835–45. to direct a choice. Thus far, the discussion regarding the 16 Little DC, Custer MD, May BH, Blalock SE, Cooney DR. Laparoscopic value of laparoscopy in trauma has yet to be finalized with appendectomy: an unnecessary and expensive procedure in 60,61 62 children? J Pediatr Surg 2002; 37: 310–17. respect to its indications and its potential risks. The 17 Garbutt JM, Soper NJ, Shannon WD, et al. Meta-analysis of alleged or partly demonstrated advantages of laparoscopic randomized controlled trials comparing laparoscopic and open surgery, such as reductions in postoperative morbidity,63 appendectomy. Surg Laparosc Endosc 1999; 9: 17–26. postoperative intra-abdominal adhesions,64 postoperative 18 Tittel A, Schumpelick V. Laparoskopische Chirurgie: Erwartungen analgesia requirements, sleep disturbances,65 blood loss, und Realität. Chirurg 2001: 72: 227–35. 19 Katkhouda N, Moniel J. A new technique of surgical treatment of and moderate immunological responses, and, increas- chronic duodenal ulcer without laparotomy by videocoelioscopy. 66 18 ingly, lower costs are not proven completely, despite the Am J Surg 1991; 161: 361–4. fact that others test endoscopic surgery in rather extreme 20 Dallemagne B, Weerts JM, Jehaes C, et al. Laparoscopic Nissen circumstances.67 Training of our future colleagues should fundoplication: preliminary report. Surg Laparosc Endosc 1991; 1: be standardized with well-organized hands-on courses 138–43. 21 Booth MI, Joines L, Stratford J, Dehn TCB. Results of laparoscopic combined with pelvic trainers and animal models. This Nissen fundoplication at 2–8 years after surgery. Br J Surg 2002; 68 issue is a matter of concern that still needs attention. In 89: 476–81. order to convince the surgical community of its advan- 22 Trondsen E, Mjåland O, Raeder J, Buanes T. Day-case laparoscopic tages, randomized clinical trials and thorough analyses of fundoplication for gastro-esophageal reflux disease. Br J Surg the outcomes from these procedures are mandatory. 2000; 87: 1708–11. 23 Liu JY, Woloshin S, Laycock WS, Schwartz LM. Late outcomes after Nevertheless, one must not forget the real experts’ wisdom laparoscopic surgery for gastroesophageal reflux. Arch Surg 2002; 1 and warnings. 137: 397–401. 24 Yahchouchy E, Debet A, Fingerhut A. Crack cocaine-related prepyloric perforation treated laparoscopically. Surg Endosc 2002; 16: 220. REFERENCES 25 Cougard P, Barrat C, Gayral F, et al. Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery. Ann Chir 2000; 1 Scott-Conner CEH, Arregui M. Visions of things that will come to 125: 726–31. pass. Surg Laparosc Endosc Percutan Tech 1999; 9: 85–6. 26 Alamowitch B, Aouad K, Sellam P, et al. Laparoscopic treatment of 2 Edmondson JM. History of the instruments for gastrointestinal perforated duodenal ulcer. Gastroenterol Clin Biol 2000; 24: endoscopy. Gastrointest Endosc 1991; 37: S27–57. 1012–17. 3 Gunning JE. The history of laparoscopy. J Reprod Med 1974; 12: 27 Spiess A, Kahrilas P. Treating achalasia: from whalebone to 222–6. laparoscope. JAMA 1998; 280: 638. 4 Kelling G. Über Oesofagoscopie, Gastroscopie und Kölioscopie. 28 Sunderland GT, Chisholm EM, Lau WY, et al. Laparoscopic repair of Munch Med Wochenschr 1902; 41: 259–71. perforated peptic ulcers. Br J Surg 1992; 79: 785. 5 Jacobaeus HC. Über die Möchligkeit die Zystoscopie bei 29 Gentileschi P, Kini S, Catarci M, Gagner M. Evidence-based Untersuchung seröser Höhingen auszuwenden. Munch Med medicine: open and laparoscopic bariatric surgery. Surg Endosc Wochenschr 1910; 57: 2090–92. 2002; 16: 736–44. 6 Ott D. Die direkte Beleuchtung der Bauchhöhle, der Harnblase, des 30 Lehnert T, Rudek B, Kienle P, et al. Impact of diagnostic laparoscopy Dickdarms und des Uterus zu diagnostischen und operativen on the management of gastric cancer: prospective study of 120 Zwecken. Rev Med Tcheque 1901; 2: 27–9. consecutive patients with primary gastric adenocarcinoma. 7 Taniguchi E, Ohashi S, Takiguchi S, Kanno H, Oriyama T, Ikuma K, Br J Surg 2002; 80: 471–5. et al. Laparoscopic surgery assisted by a transvaginal approach. 31 Böhm B, Ablassmaier B, Müller JM. Laparoscopische Chirurgie am Surg Laparosc Endosc 1999; 9: 53–6. oberen Gastrointestinaltrakt. Chirurg 2001; 72: 349–61. 8 Zacks SL, Sandler RS, Rutledge R, Brown RS, Jr. A population- 32 Feussner H, Omote K, Fink U, et al. Pretherapeutic laparoscopic based cohort study comparing laparoscopic cholecystectomy and staging in advanced gastric carcinoma. Endoscopy 1999; 31: open cholecystectomy. Am J Gastroenterol 2002; 97: 334–40. 342–7. 9 Ludwig K, Patel K, Wilhelm L, Bernhardt J. Prospective study on 33 Ohgami M, Otani Y, Kumani K, et al. Curative laparoscopic surgery patients outcome following laparoscopic vs. open for early gastric cancer: 5 years experience. World J Surg 1999; cholecystectomy. Zentralbl Chir 2002; 127: 41–6. 23: 187. 10 Podnos YD, Gelfand DV, Dulkanchainun TS, et al. Is intraoperative 34 Zornig C, Emmermann A, Blöchle C, Jackle S. Laparoscopische cholangiography during laparoscopic cholecystectomy cost 2/3-Resektion des Magens mit intracorpaoraler Anastomose nach effective? Am J Surg 2001; 182: 663–9. Roux-Y. Chirurg 1998; 69: 467. 6 Overview

35 Uyama I, Sugioka A, Fujita J, et al. Laparoscopic total gastrectomy 52 Dion YM, Hartung O, Gracia C, Doillon C. Experimental laparoscopic with distal pancreatosplenectomy and D2 lymphadenectomy for aortobifemoral bypass with end-to-side aortic anastomosis. advanced gastric cancer. Gastric Cancer 1999; 2: 230–34. Surg Laparosc Endosc 1999; 1: 35–8. 36 Adachi Y, Suematsu T, Shiraishi N, et al. Quality of life after 53 Cuschieri A. Neue Technologien in der laparoskopischen Chirurgie. laparoscopy-assisted Billroth I gastrectomy. Ann Surg 1999; 229: 49. Chirurg 2001; 72: 252–60. 37 Szinicz G, Riegler M, Müller W, Beller S. Minimally invasive surgery 54 Van der Peet DL, Berends FJ, Klinkenberg-Knol EC, Cuesta MA. (MIC) in the area of the colon and rectum: technique of minimally Endoscopic treatment of benign esophageal tumors. Surg Endosc invasive colorectal surgery. Chirurg 2001; 72: 362–7. 2001; 15: 1489. 38 Faranda C, Barrat C, Catheline JM, Champault GG. Two-stage 55 Ruurda JP, Broeders IAMJ, Simmermacher RKJ, et al. Feasibility of laparoscopic management of generalized peritonitis due to robot-assisted laparoscopic surgery. An evaluation of 35 robot- perforated sigmoid diverticula: Eighteen cases. Surg Laparosc assisted laparoscopic cholecystectomies. Surg Laparosc Endosc Endosc Percutan Tech 2000; 3: 135–8. Percutan Tech 2002; 12: 41–5. 39 Milsom JW, Böhm B, Hammerhofer KA, Fazio V. A prospective 56 Seelig MH, Hinder RA, Floch NR, et al. Endo-organ and laparoscopic randomized trial comparing laparoscopic versus conventional management of gastric leiomyomas. Surg Laparosc Endosc 1999; techniques. In colorectal cancer surgery: a preliminary report. 9: 78–81. J Am Coll Surg 1998; 187: 46. 57 Mittal SK, Filipi CJ. Indications for endo-organ gastric excision. Surg 40 Zacherl J, Scheuba C, Imhof M, et al. Long-term results after Endosc 2000; 14: 318–25. laparoscopic unrooﬁng of solitary symptomatic congenital liver 58 Allen JW, Finch RJ, Coleman MG, et al. The poor quality of cysts. Surg Endosc 2000; 14: 59. information about laparoscopy on the World Wide Web as 41 Katkhouda N, Hurwitz M, Gugenheim J, et al. Laparoscopic indexed by popular search engines. Surg Endosc 2002; 16: management of benign solid and cystic lesions of the liver. 170–72. Ann Surg 1999; 229: 460. 59 Liberman MA, Greason K. Residency training in advanced 42 Intra M, Viani MP, Ballarini C, et al. Gasless laparoscopic resection laparoscopic surgery: how are we doing? Surg Laparosc Endosc of hepatocellular carcinoma in cirrhosis. J Laparoendosc Surg Percutan Tech 1999; 9: 87–90. 1996; 6: 263. 60 Cottom D, Gorecki PJ, Curvelo M, Shaftan GW. Laparoscopic repair 43 Antonetti MC, Killelea B, Orlando R, 3rd. Hand-assisted laparoscopic of traumatic perforation of the urinary bladder. Surg Endosc 2001; liver surgery. Arch Surg 2002; 137: 407–11. 15: 1488–9. 44 Montorsi M, Santambrogio R, Bianchi P, et al. Perspectives and 61 McKinley AJ, Mahomed AA. Laparoscopy in a case of pediatric blunt drawbacks of minimally invasive surgery for hepatocellular abdominal trauma. Surg Endosc 2002; 16: 358. carcinoma. Hepatogastroenterology 2002; 49: 56–61. 62 Howells GA, Uzieblo MR, Bair H, Boyer MD. Tension 45 Klingler PJ, Tsiotos GG, Glaser KS, Hinder RA. Laparoscopic pneumopericardium during laparoscopy for trauma. Surg Laparosc splenectomy: evolution and current status. Surg Laparosc Endosc Endosc Percutan Tech 2000; 10: 44–6. 1999; 9: 1–8. 63 Langebrekke A, Istre O, Hallqvist AC, et al. Comparison of 46 Arca MJ, Gagner M. Minimal-invasive Verfahren am Pankreas. laparoscopy and laparotomy in patients with endometrial cancer. Chirurg 1998; 69: 621–7. J Am Assoc Gynecol Laparosc 2002; 9: 152–7. 47 Walz MK. Minimal-invasive Nebennierenchirurgie. Chirurg 1998; 64 De Wilde RL. Goodbye to late bowel obstruction after 69: 613–20. appendicectomy. Lancet 1991; 338: 1012. 48 Turk I, Deger S, Winkelmann B, et al. Radical prostatectomy in 65 Gogenur I, Rosenberg-Adamsen S, Kiil C, et al. Laparoscopic clinically localized prostate carcinoma. Pro laparoscopic approach cholecystectomy causes less sleep disturbance than open [in German]. Urologe A 2002; 41: 48–54. abdominal surgery. Surg Laparosc 2001; 15: 1452–5. 49 Sirén J, Haglund C, Huikuri K, et al. Laparoscopic adrenalectomy for 66 Hawkins J, Dube D, Kaplow M, Tulandi T. Cost analysis of tubal primary aldosteronism: clinical experience in 12 patients. Surg anastomosis by laparoscopy and by laparotomy. J Am Assoc Gynecol Laparosc Endosc 1999; 1: 9–13. Laparosc 2002; 9: 120–24. 50 Maghraby HA. Laparoscopic varicocelectomy for painful varicoceles: 67 Campbell MR, Kirkpatrick AW, Billica RD, et al. Endoscopic surgery merits and outcomes. J Endourol 2002; 16: 107–10. in weightlessness. Surg Endosc 2001; 15: 1413–18. 51 Silva L, Kolvenbach R, Pinter L. The feasibility of hand-assisted 68 Shalhav AL, Dabagia MD, Wagner TT, et al. Training postgraduate laparoscopic aortic bypass using a low transverse incision. Surg urologists in laparoscopic surgery: the current challenge. J Urol Endosc 2002; 16: 173–6. 2002; 167: 2135–7. 2

Technological and instrumentation aspects of laparoscopic hernia surgery

GINA L. ADRALES AND ADRIAN E. PARK

Instrumentation 7 Ergonomics 13 Fixation 11 Conclusion 13 Videoendoscopic system 12 References 14 Other enabling technologies 12

Laparoscopic hernia surgery, like other types of minimally invasive approaches to a variety of surgical therapies. The invasive surgery (MIS), has been shaped and impacted development of new dissecting tools and the incorpora- by the emergence of new surgical techniques and the tion of various energy sources into laparoscopic proce- assimilation of new and evolving medical technologies. dures have greatly enhanced the physician’s capability for To address the technological and instrumentation aspects fine dissection and rapid hemostasis. Despite these achieve- of laparoscopic herniorrhaphy comprehensively could ments, the basic design of laparoscopic instruments and extend the discussion from a macro-perspective dealing the associated ergonomic constraints have evolved little with issues of operative suite design and integration of over the past century. Laparoscopic instrument design is technology to a micro-view focusing on, for example, the still based upon a template consisting of a handle con- tines of a dissecting instrument. Such a dissertation is nected to a long, slender shaft, which then engages an end- beyond the scope of this chapter. Instead, we will focus effector unit. Like all surgical instruments, laparoscopic upon the instruments, equipment and material used in instruments should be cost-effective, low-maintenance, laparoscopic hernia surgery and the related technological functional tools that achieve the intended purpose safely, advances that have facilitated a widening adoption of easily and reliably, as Melzer has stipulated.1 Over the past various laparoscopic hernia procedures. Some topics that two decades, an abundance of end-effectors with varied are dealt with in greater detail in later chapters, such as functions has been developed. As a result, a wide array of methods of mesh fixation and surgical energy sources, will instruments is currently available to the surgeon per- receive more cursory mention in this chapter, in the con- forming laparoscopic hernia repair. A brief discussion of text of specific instrument use and development. Ergono- the various characteristics and distinguishing features of mic considerations in surgical instrument and equipment laparoscopic instrumentation relevant to hernia repair design, so often overlooked yet so vital to optimal surgical follows. performance, will also be addressed. Disposable instruments INSTRUMENTATION Disposable instruments may increase operative efficiency by eliminating the need for sterilization of reusable The rapid expansion of available laparoscopic instrumen- instruments perioperatively. This convenience comes at a tation has fueled the widespread application of minimally significant cost in terms of equipment expenditure and environmental impact. In a cost-comparison of pro- Supported in part by an educational grant from Tyco/US Surgical cedural equipment, the cost of disposable equipment Corporation. exceeded that of reusable instrumentation by a factor of 8 Overview

10–20.2 Although reusable instrumentation is subject or ratcheted instruments may reduce muscular fatigue to the wear and tear of repeated use and sterilization, during grasping, but they are not appropriate for dissec- disposable instruments may be imprecise.3 Reposable tion, which requires more dynamic handling. Similarly, instruments, which combine reusable and disposable single-action jaws, in which one jaw remains fixed, are components, represent a compromise between the two effective for grasping but less so for dissection. Further- instrument types. more, the symmetry of double-action jaws makes these instruments better suited for fine dissection. The diameter of the instrument also affects function Laparoscopic dissecting and grasping and performance. Micro-instruments (2–3 mm diame- instruments ter) have been applied to a variety of minimally invasive procedures, including laparoscopic hernia repair.4,5 These Although laparoscopic dissectors and graspers conform ‘needlescopic’ dissectors have relatively elastic shafts and to a basic design, the configurations of the end-effectors short end-effectors with limited spread. Thus, limitations vary in terms of size, shape and surface. Different types inherent in the design of 2-mm graspers and dissectors of dissection (sharp or blunt dissection, micro- or have in turn limited the use of such needlescopic instru- macro-exposure) require instruments with different dis- ments in laparoscopic hernia surgery. secting tips. Sharp-tipped instruments, including laparo- Unique to laparoscopic totally extraperitoneal inguinal scopic shears and needle-nose dissectors, facilitate fine hernia repair is the balloon dissector, commonly used in spreading and micro-dissection. Blunt dissectors, such as North America to develop the pre-peritoneal plane. A the Reddick-Olsen, may reduce the risk of inadvertent variety of balloon dissectors are available, most furnished injury to adjacent structures, but their utility in fine dis- with a guiding trocar and obturator for initial placement section and micro-exposure is limited. Tapered tips that beneath the rectus muscle. With inflation of the balloon, fall somewhere in the continuum from sharp to blunt a pre-peritoneal working space is created. Although this end-effectors constitute the majority of commonly used device provides a simpler and more timely alternative dissectors. Tapered, narrow-tipped dissectors, such as the to manual dissection, it is imperative that the surgeon is Maryland/Kelly or DeBakey laparoscopic instruments, familiar with the laparoscopic pre-peritoneal anatomy to have proved useful during laparoscopic hernia repair, from recognize the appropriate plane of dissection and to avoid dissection in para-esophageal herniorrhaphy to creation associated complications. of the peritoneal flaps in transabdominal pre-peritoneal inguinal herniorrhaphy. Additionally, the Maryland/Kelly dissectors have curved jaws, which facilitate dissection Trocars around structures. The curved tips of the Maryland/Kelly dissector allow clear visualization of the operative target Careful consideration of trocar type and placement is and the tip of the instrument, unlike the shadowing that imperative in the successful conduct of laparoscopic her- may occur about the symmetrically tapered, flat-tipped, nia repair. Quite simply, trocars are the portals through duckbill dissector. which the laparoscopic instruments are passed. At the Effective tissue grasping is made possible by the surface same time, trocars represent potential weapons, and their topography of the instrument tips. The fine ridges and misplacement can contribute to the morbidity and even grooves provide friction during grasping, limiting slippage mortality of a laparoscopic procedure. The incidence of and therefore tissue trauma. The delicate serrations of the trocar-related injury is low but significant. The incidence DeBakey clamp provide atraumatic tissue handling. This of hollow viscus perforation varies between 0.04 and curved instrument is thus ideally suited for the fine dissec- 0.14 per cent.6–13 Major retroperitoneal vascular injury has tion and the gentle manipulation of the bowel required been reported in 0.03–0.1 per cent, carrying a substantial during adhesiolysis and reduction of hernia contents. In mortality rate of nine per cent.9–12,14 Major vascular contrast, ratcheted instruments with thick serrations are injury is a very common cause of death in laparoscopy, poorly suited for bowel handling, but they are designed for second only to anesthetic complications.14 In an effort to constant grasping, such as gallbladder retraction. Other increase the safety of trocar insertion, a variety of trocar dissectors have tines that appose incompletely along the designs has been introduced. proximal jaws of the instrument, allowing the instrument The previously stated pros and cons of reusable to hold tissue atraumatically in that space. instrumentation also hold for trocars. Reusable, metal The laparoscopic handle and the hinge mechanism trocars may provide better grip to the skin and abdomi- of the jaws greatly impact the function of grasping and nal wall compared with plastic, disposable trocars. dissecting instruments. Instruments with coaxial or Several trocar designs have been developed to prevent articulating shafts provide the surgeon with greater free- slippage and leakage of pneumoperitoneum. The Hasson dom of movement in restricted working spaces. Locking trocar, typically used as an initial trocar after peritoneal Technological and instrumentation aspects 9 access via an open technique, has threads along the end of has been implemented in trocar design to reduce insertion- its shaft. Much like the configuration of a screw, these associated injury. The optical view trocar was developed as threads assist in securing the trocar in the abdominal an alternative to Hasson trocar placement. This single-use, wall. Balloon trocars utilize an attached, inflatable, intra- plastic trocar has a clear shaft and conical tip, allowing abdominal balloon after insertion to bolster the trocar visualization of the abdominal wall layers as they are tra- against the abdominal wall. While these balloons add versed while inserting the laparoscope. This trocar design is security, they are subject to breakage and may decrease the well suited for insertion after pneumoperitoneum has been radial mobility often required during ventral hernia repair established using a Veress needle. to visualize and operate on the anterior abdominal wall. While the optical trocar capitalizes on the benefit of Safe peritoneal entry is a particular concern during inci- direct visualization, other trocar designs are centered on sional hernia repair, where there is a considerable risk of the tip configuration for injury prevention (Figure 2.1). In injury to adherent loops of bowel. A variety of measures an effort to circumvent visceral damage, the shielded trocar

(a) (b) (c) (d)

(e)

Figure 2.1 A variety of trocars is available for use during laparoscopic ventral herniorrhaphy. (a) The Hasson trocar has threads to prevent slippage from the abdominal wall (Ethicon Endosurgery, Inc.). (b) The non-cutting trocar tip is designed to split the musculature in an effort to decrease bleeding and other trocar-related injuries (Ethicon Endosurgery, Inc.). (c) The plastic shield of this trocar retracts during insertion to expose a cutting blade then deploys upon peritoneal entry to protect the viscera from injury (U.S. Surgical Corp., Inc.). (d) The bladed trocar features a blade that retracts upon peritoneal entry (Ethicon Endosurgery, Inc.). (e) The laparoscope is housed in the optical trocar to provide visual guidance during insertion of this non-cutting trocar. This is particularly useful in the reoperative abdomen after insufflation via the Veress needle technique (Ethicon Endosurgery, Inc.). 10 Overview consists of an exposed blade for abdominal wall entry and Similarly, other non-bladed trocars have also been a plastic shield that is released upon peritoneal entry to demonstrated to cause smaller abdominal wall defects safely cover the cutting blade. Many disposable trocars that do not require closure.25 In contrast to cutting incorporate this mechanism. Importantly, this feature does trocars, non-bladed trocars split the musculature rather not guarantee protection against trocar entry injuries. than cut through the abdominal wall, a technique that Pyramidal and conical trocar tips have also been may also be associated with less minor bleeding.16 examined for safety and efficacy. When use of a conical, non-cutting reusable trocar was compared with that of a cutting, disposable trocar during transperitoneal Energy sources inguinal herniorrhaphy, the reusable trocar resulted in a lower complication rate.15 Trocar vascular and visceral Advances in the use of energy sources have increased the injuries are thought to be related to the force required ease and feasibility of performing MIS. While energy for trocar insertion. However, the size of the abdominal sources are used largely for hemostasis, increasingly they wall defect created by the trocar has been shown to be are employed in tissue dissection as well. Available energy inversely proportional to the entry force.16 In an animal sources include both thermal and mechanical energy study, it was demonstrated that conical tips require devices. greater entry force than pyramidal trocars yet subsequently produce smaller abdominal wall defects. Electrosurgery To decrease the insertion force and possibly reduce visceral injury, innovative trocar designs have been Thermal energy sources rely on the passage of electrical coupled with various energy sources. However, these new current through tissues and the subsequent production of designs have not yet been proven in human application heat. Applying high-radiofrequency alternating current in laparoscopic hernia surgery; studies have been limited results in the excitation of cellular ions and the conversion almost entirely to animal models. Electrosurgical trocars of electrical energy to mechanical energy. The degree of utilize thermal energy to create the abdominal wall open- the thermal response is directly proportional to the inhe- ing for passage of the trocar. This has been found to rent resistance of the tissues, with little heat production reduce the force required for entry without detrimental in plasma but significant heat production in bone. The effects on wound healing at the trocar site after lap- electrical current can be applied with a bipolar or mono- aroscopic cholecystectomy.17 Taking advantage of the polar electrode, the most common method in general decreased thermal spread associated with ultrasonic dis- surgery.26 Bipolar electrosurgery confines the electrical section, an ultrasonically activated trocar has been designed current to the tissue between the forceps and consequently with an associated decrease in insertion time and force as offers the added safety of decreased thermal spread. well as a smaller increase in abdominal pressure during Electrothermal injury is a substantial concern, with the insertion compared with conventional conical trocars.18 incidence of laparoscopic electrosurgery-associated com- The applicability of these trocars is yet to be seen in plications numbering two to five per 1000 cases.27 patients with multiple previous surgeries or with ventral hernias, where the proximity of adhered bowel may Ultrasonic dissection predispose the patient to thermal visceral injury. Another substantial concern in the treatment of Ultrasonic dissection is a form of mechanical dissection, hernia patients is recurrent herniation. In a retrospective like scissor or water-jet dissection, that has gained review of 320 patients (including two patients with popularity in laparoscopy. Mechanical energy is created concomitant para-esophageal hernia repair), the overall by high-frequency sound-wave vibration. The high- incidence of trocar site herniation after laparoscopic fun- frequency vibration produces denatured collagen and doplication was found to be three per cent.19 As hernia- effectively vaporizes cells. The ultrasonically activated tion at trocar sites has been reported repeatedly in the scalpel, the ultrasonic instrument used most commonly literature,19–21 the size of the defect created by trocars is a in laparoscopy, has been shown to seal vessels at diameters key factor. The size of the trocar site defect is influenced up to 5 mm. However, it is recommended that its use is by the tip shape, trocar size, and mechanism of entry. limited to vessels 3 mm or less in diameter.28 At 80°C, the The radially expanding trocar utilizes a needle puncture ultrasonically activated scalpel operates at a lower tem- followed by insertion of a blunt, radially expanding perature than electrosurgery (100°C).3 Ultrasonic dis- obturator through the needle tract. This alternative to section is reported to produce decreased lateral thermal the traditional cutting trocar has been associated with spread when compared with traditional electrosurgery.29 less postoperative pain, improved postoperative patient- However, identification of intestinal or biliary duct rated wound scores, decreased intraoperative and post- injury due to the ultrasonic dissector may be delayed. operative complications, and smaller fascial defects.22–24 Anecdotally, the dissector may temporarily seal the Technological and instrumentation aspects 11 injury site, such as an enterotomy, only to open days later thin arm that is then covered by a retractable sheath with devastating consequences. during insertion. The operation of this device is rather In summary, electrosurgical and ultrasonic dissection counterintuitive, as retraction of the handle is required dur- instruments minimize blood loss and may reduce opera- ing insertion. Proper handling of the device is essential to tive time in a variety of laparoscopic procedures. However, protect the delicate mechanism responsible for securing the very judicious and limited use of energy sources in ventral suture. A more cost-effective method of suture introduc- and incisional hernia repair is encouraged. A higher toler- tion has been illustrated elegantly by Park and colleages31 ance for a small amount of oozing is accepted in exchange and Rosenthal and Franklin.32 Rather than employing a for a reduced risk of intestinal, spermatic cord, or nervous suture passer, the suture is introduced on a Keith needle and thermal injury. The morbidity of intestinal injuries, par- extracted through a large-gauge spinal needle. ticularly missed enterotomies, is remarkably high, with a mortality rate of at least 25 per cent.30 Fixation devices

FIXATION In an effort to secure the prosthetic material and to facilitate its incorporation, several fixation methods have been developed. The need for prosthetic fixation by Needle drivers and suture passers sutures, tacks and/or staples has been well demonstrated for ventral and incisional herniorrhaphy, and it is now The employment of needle drivers and suture passers dur- considered indispensable to the long-term durability of ing laparoscopic hernia repair will be discussed in more the repair.33,34 The picture is less clear with regard to detail in subsequent chapters. A variety of needle drivers inguinal herniorrhaphy, where data regarding the utility and aids to suturing (e.g. Endostitch, Surg-assist) is avail- of tissue adhesives or even non-fixation continue to able for use during laparoscopic hiatal hernia repair. These emerge. In contrast, primary suture closure is the most devices were developed to assist the surgeon with intra- significant component of hiatal hernia repair, as pros- corporeal suturing, an advanced laparoscopic technique. thetic mesh is seldom used. Sutured mesh fixation is imperative in laparoscopic ven- The development of staples and spiral tacks has tral hernia repair. This crucial component of ventral increased operative efficiency in ventral and incisional herniorrhaphy can be accomplished via various suture- hernia repair. A variety of tacking devices is now avail- passing devices. These reusable, low-profile, sharp instru- able, including a reusable device, the Salute™ (Onux ments pierce the abdominal wall through small stab Medical, Inc.). This innovative device delivers a stainless- incisions and transfer the suture to secure the mesh to the steel construct that is not preformed but assumes the abdominal wall (Figure 2.2). The suture is held in place by a final shape of a keyring. Traditional spiral tacks are approximately 3–4 mm in length, limiting the depth of fixation of the prosthetic patch into the abdominal wall. In a study comparing titanium stapling and Prolene suture fixation of mesh, the burst strength of mesh fixed with suture was significantly greater (1461.7 mmHg) than that of staple fixation with two different delivery systems (885.5 mmHg, 665.2 mmHg).35 It is thus recommended that tack or staple fixation of the mesh be combined with nonabsorbable suture fixation in laparoscopic ventral hernia repair. The development of effective bioadhesives and tissue substitutes may facilitate mesh fixation in ventral and inguinal hernia repair and offer an alternative to prosthetic mesh in crural closure for large hiatal hernias. Several adhesives have been studied. Fibrin sealant or fibrin glue, a hemostatic agent derived from human plasma, has been evaluated as an alternative prosthetic fixation tool in ventral and inguinal hernia repair. However, fibrin application has been associated with a greater inflammatory reaction compared with staple fixation.36 In another animal study, the incorporation of fibrin glue in ventral Figure 2.2 Gore suture passer (W.L. Gore & Associates, Inc.). hernia repair resulted in reduced intra-abdominal 12 Overview adhesions.37 While an inflammatory reaction was also this distortion, but they remain cost-prohibitive in noted in this study, the density of adhesions and the many institutions and may provide poorer resolution and percentage of expanded polytetrafluoroethylene (ePTFE) movement lag. prosthetic patch coverage by adhesions was decreased in Advances in imaging technology have led to the devel- the fibrin glue cohort. The majority of fibrin sealant opment of new systems to address current optical and studies associated with hernia repair have been con- ergonomic limitations. Head-mounted displays reduce ducted in animal models. The hemostatic properties of the displacement associated with standard video towers fibrin glue in hernia repair were notable in one of the few positioned at a distance from both the surgeon and the published human studies. In patients with coagulopathic operative field. However, the results of head-mounted disorders, fibrin glue was noted to reduce postoperative displays have been mixed; at least one report notes bleeding after inguinal herniorrhaphy.38 decreased eyestrain and improved operative efficiency, The cyanoacrylates, a class of tissue adhesives tradi- but another study fails to duplicate these results.40,41 tionally used in wound management, have been examined Three-dimensional imaging systems have also been for use in laparoscopic hernia repair. Internal use constructed to provide stereoscopic perceptual cues. of this tissue adhesive was previously limited due to However, the spacing between the component imaging sys- the potential toxicity associated with early formulations. tems is generally limited and is significantly smaller than However, newly designed formulations have been studied the normal interpupillary distance. This restriction limits for their applicability in hernia repair, although these stud- the depth perception provided by the three-dimensional ies remain limited to animal models. In an examination of optical systems. Additionally, the accompanying head- octylcyanoacrylate tissue adhesive for fixation of ePTFE in mounted display results in degradation in image quality, a rabbit incisional hernia model, less force was required for limiting the widespread incorporation of this innovative displacement of adhesive-fixed mesh than for suture or system. spiral tack fixation.39 In addition, the octylcyanoacrylate It is hoped that with the adoption of high-definition adhesive stimulated an inflammatory reaction that television standards and new research in advanced delayed cellular migration into the ePTFE interstices, so digital signal processing technology, many limitations of the clinical implications of this finding are unclear. videoendoscopic imaging will be eliminated.42 This has important implications for laparoscopic hernia surgery. Real-time reversal of the video display could avoid the VIDEOENDOSCOPIC SYSTEM mirror-image effect of working against the camera in ventral herniorrhaphy. These new systems could also correct for perceptual distortion, such as the lack of shadowing The videoendoscopic system has become the eyes of and other depth cues, and could facilitate the perform- the laparoscopic surgeon. With the limited tactile feed- ance of more complex laparoscopic procedures. back inherent in MIS, the quality of the surgical image is crucial. The present limitations of the imaging system include detrimental reductions in resolution, field of OTHER ENABLING TECHNOLOGIES view, contrast, and depth perception. These limitations are the result of optical distortion by the camera and monitor systems, and the loss of monocular and stereo- Hand-assisted laparoscopy scopic visual cues. The current videoendoscopic system begins with a The technique of hand-assisted laparoscopy (HAL) has rod-lens laparoscope with coaxial illumination and fiber- been applied to a variety of laparoscopic procedures, in optic light bundles. Illumination is provided by a high- some cases avoiding certain laparotomy. With HAL, the intensity but ‘cold’ broadband light source. Most systems surgeon’s hand is inserted into the peritoneal cavity to employ a high-quality solid-state camera equipped with assist in dissection and retraction. Various port systems a charged-coupled device and a three-chip array for that maintain pneumoperitoneum are used for hand color separation (red, green, blue). This provides optimal placement. In HAL, the incision size is limited to the color fidelity. Standard display systems utilize National surgeon’s hand size, and this incision may be later used Television Committee Standard video with a resolution for specimen extraction. of no less than 640 ϫ 480 pixels. Improving upon stan- The application of the hand-assisted technique in dard composite video systems, which combine luminance laparoscopic hernia repair has been limited. In 2000, Litwin and chrominance signals, S-video separates the signals and and colleagues reported one repair of a post-traumatic offers superior color saturation. Most cathode-ray tube left diaphragmatic hernia in a series of HAL cases.43 The monitors in use are curved and are therefore associated patient was noted to have incarcerated colon, spleen and with a degree of distortion. Flat-screen monitors eliminate small intestine. This repair was facilitated by the entry Technological and instrumentation aspects 13 of the surgeon’s hand via an upper midline incision with a resultant operative time of 206 minutes, estimated blood loss of 50 ml, and a length of stay in hospital of four days. Hand-assisted ventral herniorrhaphy has not been reported. There does not appear to be a clear role for HAL in the repair of ventral or inguinal hernias.

Robotic surgery

The feasibility of robotic-assisted surgery has been examined for a variety of laparoscopic procedures. In 2001, Cadiére and colleagues published a robotic-assisted laparoscopic surgery series using the Da Vinci system (Intu- itive Surgical), including three inguinal hernia repairs.44 Although the robotic articulating instruments facilitated dissection in a variety of procedures, one system limita- Figure 2.3 Minimally invasive surgery often requires awkward tion noted by the authors was the narrow field of vision positioning. provided by the three-dimensional optical system. the patient, the surgical staff, and the equipment. Within ERGONOMICS the current ergonomic constraints of laparoscopy, changes can and should be made to increase the comfort of the surgeon and reduce muscular fatigue. Instrumentation Research in the field of surgical ergonomics may have should be selected not only for function but also for ease of a far greater impact on MIS than will some of the tech- use and proper individual surgical fit. Currently, this selec- nological advancements addressed previously. In the tion may not be accomplished easily for surgeons with manufacturing industry, it is well recognized that paying smaller hands. The operating table should be positioned proper attention to postural mechanics and the health so that the instrument handles are at the surgeon’s elbow impact of instrumentation and machinery can signifi- level.46 Similarly, the video monitor should be positioned cantly increase the productivity, efficiency and longevity at or slightly above eye level. Suspended mobile monitors of workers. There are comparatively few available data on may facilitate this adjustment. The monitor should be in the ergonomic risk factors associated with surgery. The alignment with the operative target and the surgeon. Foot performance of surgery can be both mentally and physi- pedals that control energy sources should be placed within cally demanding, and there is an alarming incidence of a small radius from the surgeon’s feet to avoid stiffening musculoskeletal complaints among laparoscopic sur- and straining to maintain balance. geons.45 Ergonomic risk factors (prolonged static pos- Patient position is also crucial. The patient should tures, awkward stances, extreme joint angles, pressure be positioned to allow gravity to assist with operative points from instrumentation, etc.) are pervasive in MIS exposure, reducing the exertion needed from the surgeon as a result of long instrumentation with reduced degrees and assistants for retraction. For example, the patient of freedom and displaced imaging (Figure 2.3). More is placed in mild reverse Trendelenburg position dur- specifically, there are ergonomic issues that are unique to ing para-esophageal hernia repair. Similarly, the patient’s laparoscopic hernia repair, such as the strain of working arms should be tucked during ventral herniorrhaphy to against the camera (mirror-image effect) and the com- provide freedom of movement by the surgeon and assis- plex movements required to repair hernia defects from tants about the operating table. Attention to these details underneath the anterior abdominal wall during ven- in positioning and operative set-up should greatly tral herniorrhaphy. While changes in instrument design improve operative efficiency. and imaging are forthcoming, the incorporation of these changes will take time and the ergonomic hazards will persist until they take effect. In the interim, attention to the CONCLUSION current operative environment and the selection of appropriate available instrumentation may improve operative efficiency and protect the health of the surgeon. As with other types of MIS, laparoscopic hernia repair The etiology of the ergonomic problem in laparo- evolved through the merger of innovative technology scopy is multifactorial. Consideration should be given to and new surgical techniques. The wide array of available instrumentation, image quality, and the positioning of instrumentation for tissue dissection, the development of 14 Overview new tools for mesh fixation, and the application of novel 20 De Giuli M, Festa V, Denoye GC, Morino M. Large postoperative techniques have all facilitated and expanded the role of umbilical hernia following laparoscopic cholecystectomy. A case report. Surg Endosc 1994; 8: 904–5. laparoscopy in the treatment of a variety of hernia defects. 21 Patterson M, Walters D, Browder W. Postoperative bowel With continuing technological advances and attention to obstruction following laparoscopic surgery. Am Surg 1993; 59: ergonomic factors, the outcome and efficiency of laparo- 656–7. scopic hernia repair are certain to improve. 22 Bhoyrul S, Payne J, Steffes B, et al. A randomized prospective study of radially expanding trocars in laparoscopic surgery. J Gastrointest Surg 2000; 4: 392–7. 23 Yim SF, Yuen PM. Randomized double-masked comparison of REFERENCES radially expanding access device and conventional cutting tip trocar in laparoscopy. Obstet Gynecol 2001; 97: 435–8. 24 Lam TY, Lee SW, So HS, Kwok SP. Radially expanding trocar: a less 1 Melzer A. Endoscopic instruments: conventional and intelligent. painful alternative for laparoscopic surgery. J Laparoendosc Adv In: Toouli J, Gossot D, Hunter J, eds. Endosurgery. New York: Surg Tech A 2000; 10: 269–73. Churchill Livingstone, 1996: 69–95. 25 Liu CD, McFadden DW. Laparoscopic port sites do not require 2 Fengler TW, Pahlke H, Kraas E. Sterile and economic fascial closure when nonbladed trocars are used. Am Surg 2000; instrumentation in laparoscopic surgery. Surg Endosc 1998; 12: 66: 853–4. 1275–9. 26 Tucker RD. Laparoscopic electrosurgical injuries: survey results and 3 Park AE, Mastrangelo MJ, Jr, Gandsas A, et al. Laparoscopic their implications. Surg Laparosc Endosc 1995; 5: 311–17. dissecting instruments. Semin Laparosc Surg 2001; 8: 42–52. 27 Nduka CC, Super PA, Monson JR, Darzi AW. Cause and prevention 4 Tagaya N, Aoki H, Mikami H, et al. The use of needlescopic of electrosurgical injuries in laparoscopy. J Am Coll Surg 1994; 179: instruments in laparoscopic ventral hernia repair. Surg Today 2001; 161–70. 31: 945–7. 28 Mueller W, Fritzsch G. Medicotechnical basics of surgery using 5 Ferzli G, Sayad P, Nabagiez J. Needlescopic extraperitoneal repair invasive ultrasonic energy. Endosc Surg Allied Technol 1994; 2: of inguinal hernias. Surg Endosc 1999; 13: 822–3. 205–10. 6 Zaraca F, Catarci M, Gossetti F, et al. Routine use of open 29 Birch DW, Park A, Shuhaibar H. Acute thermal injury to the canine laparoscopy: 1,006 consecutive cases. J Laparoendosc Adv Surg jejunal free flap: electrocautery versus ultrasonic dissection. Tech A 1999; 9: 75–80. Am Surg 1999; 65: 334–7. 7 Catarci M, Carlini M, Gentileschi P, Santoro E. Major and minor 30 El-Banna M, Abdel-Atty M, El-Meteini M, Aly S. Management of injuries during the creation of pneumoperitoneum: a multicenter laparoscopic-related bowel injuries. Surg Endosc 2000; 14: study on 12,919 patients. Surg Endosc 2001; 15: 566–9. 779–82. 8 Bonjer HJ, Hazebroek EJ, Kazemier G, et al. Open versus closed 31 Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional establishment of pneumoperitoneum in laparoscopic surgery. hernias. Surg Laparosc Endosc 1996; 6: 123–8. Br J Surg 1997; 84: 599–602. 32 Rosenthal D, Franklin ME. Use of percutaneous stitches in 9 McMahon AJ, Baxter JN, O’Dwyer PJ. Preventing complications of laparoscopic mesh hernioplasty. Surg Gynecol Obstet 1993; 176: laparoscopy. Br J Surg 1993; 80: 1593–4. 491–2. 10 Saville LE, Woods MS. Laparoscopy and major retroperitoneal 33 LeBlanc KA. The critical technical aspects of laparoscopic vascular injury. Surg Endosc 1995; 9: 1096–100. repair of ventral and incisional hernias. Am Surg 2001; 67: 11 Loffer FD, Pent D. Indications, contraindications and complications 809–12. of laparoscopy. Obstet Gynecol Surg 1975; 30: 407–27. 34 Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral 12 Deziel DJ, Millikan KW, Economou SG, et al. Complications of and incisional hernia repair in 407 patients. J Am Coll Surg 2000; laparoscopic cholecystectomy: a national survey of 4,292 6: 645–50. hospitals and analysis of 77,604 cases. Am J Surg 1993; 35 Dion YM, Charara J, Guidoin R. Bursting strength evaluation. 165: 9–14. Comparison of 0-Prolene sutures and endoscopic staples in an 13 Penfield AJ. How to prevent complications of open laparoscopy. experimental prosthetic patch repair of abdominal wall defect. J Reprod Med 1985; 30: 660–63. Surg Endosc 1994; 8: 812–16. 14 Hashizume M, Sugimachi K. Needle and trocar injury during 36 Katkhouda N, Mavor E, Friedlande MH, et al. Use of fibrin sealant laparoscopic surgery in Japan. Surg Endosc 1997; 11: 1198–201. for prosthetic mesh fixation in laparoscopic extraperitoneal 15 Leibl BJ, Schmedt CG, Schwarz J, et al. Laparoscopic surgery inguinal hernia repair. Ann Surg 2001; 1: 18–25. complications associated with trocar tip design: review of 37 Toosie K, Gallego K, Stabile BE, et al. Fibrin glue reduces literature and own results. J Laparoendosc Adv Surg Tech A 1999; intra-abdominal adhesions to synthetic mesh in a rat ventral 9: 135–40. hernia model. Am Surg 2000; 66: 41–5. 16 Bohm B, Knigge M, Kraft M, et al. Influence of different trocar tips 38 Canonico S, Sciaudone G, Pacifico F, Santoriello A. Inguinal hernia on abdominal wall penetration during laparoscopy. Surg Endosc repair in patients with coagulation problems: prevention of 1998; 12: 1434–8. postoperative bleeding with human fibrin glue. Surgery 1999; 17 Waxman K, Birkett DH, Sackier JM, et al. Clinical and laboratory 125: 315–17. evaluation of an electrosurgical laparoscopic trocar. Surg Endosc 39 Birch DW, Park A. Octylcyanoacrylate tissue adhesive as an 1994; 8: 1076–9. alternative to mechanical fixation of expanded 18 Gossot D, Validire P, Matsumoto S, et al. Development of an polytetrafluoroethylene prosthesis. Am Surg 2001; 67: 974–8. ultrasonically activated trocar system. Surg Endosc 2002; 16: 40 Geis WP. Head-mounted video monitor for global visual access in 210–14. mini-invasive surgery. An initial report. Surg Endosc 1996; 10: 19 Bowrey DJ, Blom D, Crookes PF, et al. Risk factors and the 768–70. prevalence of trocar site herniation after laparoscopic 41 Herron DM, Lantis JC, 2nd, Maykel J, et al. The 3-D monitor fundoplication. Surg Endosc 2001; 15: 663–6. and head-mounted display. A quantitative evaluation of Technological and instrumentation aspects 15

advanced laparoscopic viewing technologies. Surg Endosc 1999; 44 Cadiére GB, Himpens J, Germay O, et al. Feasibility of robotic 13: 751–5. laparoscopic surgery: 146 cases. World J Surg 2001; 25: 1467–77. 42 Park A, Charash WF, Shaw M. The future of imaging in minimally 45 Berguer R, Forkey DL, Smith WD. Ergonomic problems associated invasive surgery. Surg Endosc 2000; 14: 517–19. with laparoscopic surgery. Surg Endosc 1999; 13: 466–8. 43 Litwin DEM, Darzi A, Jakimowicz J, et al. Hand-assisted 46 Berguer R, Smith WD, Davis S. An ergonomic study of the laparoscopic surgery (HALS) with the HandPort System: initial optimum operating table height for laparoscopic surgery. Surg experience with 68 patients. Ann Surg 2000; 231: 715–23. Endosc 2002; 16: 416–21. This page intentionally left blank 3

Prosthetic biomaterials for hernioplasty

KARL A. LEBLANC

Synthetic prosthetic biomaterials: ﬂat, single-component Non-synthetic prosthetic biomaterials 22 products 17 Conclusion 24 Synthetic prosthetic biomaterials: preformed products 21 References 24 Synthetic prosthetic biomaterials: composite products 21

Almost all hernia repairs that are performed laparoscop- Table 3.1 Flat, single-component polypropylene biomaterials ically utilize some form of prosthetic biomaterial. One and manufacturers notable exception is the infrequent small hernias found Biomaterial Manufacturer during laparoscopic incisional and ventral hernioplasty, which are merely sutured. The early pioneers in laparo- Angimesh Angiologica scopic inguinal hernia repair generally used polypropy- Biomesh P1 Cousin Biotech lene mesh (PPM) products, but a few attempted to use Biomesh P3 Cousin Biotech expanded polytetrafluoroethylene (ePTFE). Incisional Biomesh 3D Cousin Biotech Hertra 1, 2 HerniaMesh and ventral hernioplasty utilized ePTFE when it was first Hermesh 3, 4, 5 HerniaMesh described. Currently, PPM and ePTFE prostheses are Intramesh NK1, NK2, NK8 Cousin Biotech the preferred biomaterials for the laparoscopic repair of Marlex C. R. Bard, Inc. inguinal and incisional hernias, respectively. The pre- Parietene Sofradim International ferences for each of these operations and the choice of Prolene Ethicon prostheses are described in the following chapters. This Prolene Soft Mesh Ethicon chapter will present the currently available materials that Prolite Atrium Medical Corp. are used for the laparoscopic repair of hernias. Prolite Ultra Atrium Medical Corp. The biomaterials can be subdivided into many classes. Surgipro (Monofilament) U.S. Surgical Corp., Inc./Tyco The broadest distinction is between synthetic and non- Surgipro (Multifilament) U.S. Surgical Corp., Inc./Tyco synthetic products. These can be subdivided further into Trelex Meadox Medical Corp. products used for inguinal and non-inguinal hernia repair. While any prosthetic biomaterial could be used in the repair of any hernia, the common preferences noted itself (i.e. the weight of the mesh). These two factors influ- above will be assumed. ence the thickness, stiffness, shrinkage rates, inflammatory response, potential for development of adhesions to the SYNTHETIC PROSTHETIC BIOMATERIALS: product, and resulting changes in the elasticity of the FLAT, SINGLE-COMPONENT PRODUCTS abdominal wall. These products are listed in Table 3.1,and the differences in the weave and pore sizes of some of them are noted in Figure 3.1. Most of these products are manufactured from poly- One of the problems that has been seen in the past propylene. The major differences between the meshes are with the repair of incisional hernias is fistulization.1 This the size of the monofilaments used in the structure of the has also been seen with laparoscopic inguinal repair.2 mesh and the size of the pores (interstices) of the mesh These real and potential complications of PPM may be 18 Overview

(a) (b) (c)

(e) (f)

Figure 3.1 Comparison of the weaves of PPM products: (a) Hetra 1, (b) Hetra 2, (d) (c) Prolene, (d) Prolene Soft Mesh, (e) Marlex, and (f) NK Mesh.

related to the weight of the polypropylene within the Table 3.2 Polyester prostheses and manufacturers mesh. Newer, lighter-weight meshes have been developed Biomaterial Manufacturer (Table 3.1) that, theoretically, are designed to overcome many of the adverse effects of the heavier meshes. Biomesh A1 Cousin Biotech However, the lighter products are very soft and pliable, Biomesh A3 Cousin Biotech and consequently the use of them within the pre-peri- Biomesh 3D Cousin Biotech toneal space created for the repair of inguinal hernias can Mersilene Ethicon Parietex® TEC Sofradim International be somewhat difficult. Manipulation can be particularly Parietex® TECR Sofradim International troublesome because of other difficulties, such as obtain- Parietex® TET Sofradim International ing the correct spatial and linear orientation. To overcome this, innovations such as Prolene Soft Mesh have blue lines incorporated within the biomaterial, which provides a degree of ease for laparoscopic inguinal hernia patches compromises about 85 per cent of the published repair. reports on the repair of incisional and ventral hernias. Although not as prevalent or plentiful as PPM, poly- The prevalence of use of ePTFE is based upon the fact ester products are used in the repair of inguinal hernia in that there has never been a reported case of fistulization several countries (Table 3.2). The use of polyester is gen- subsequent to the intraperitoneal placement of this erally prescribed because of its pliability and conforma- product. In addition, ePTFE results in very minimal bility to the inguinal floor. However, the use of polyester adhesions to itself. The currently available products biomaterial has been associated with fistulas.3 Figure 3.2 are listed in Table 3.3 and shown in Figure 3.3. There shows the differences between the polyester products. has been some concern regarding the extent and nature The Parietex and Biomesh meshes are woven into a three- of tissue penetration into ePTFE. However, this was dimensional weave rather than the two-dimensional based upon an earlier product that is no longer used in weave that is most familiar to flat meshes. This is said to the laparoscopic arena. Recent studies have confirmed make them even more pliable and to allow a greater that the level of tissue penetration and attachment degree of tissue penetration. strength of the newer DualMesh® is superior to that of As with other biomaterials, ePTFE products were PPM at only three days post-implant.4 Other postopera- initially developed many years ago for open repair of tive data also support the inhibition of adhesions to inguinal hernias. The use of these single-component ePTFE.5 Prosthetic biomaterials for hernioplasty 19

Table 3.3 ePTFE biomaterials and manufacturers Biomaterial Manufacturer DualMesh W. L. Gore & Associates DualMesh Emerge W. L. Gore & Associates DualMesh Plus W. L. Gore & Associates DualMesh Plus Emerge W. L. Gore & Associates DualMesh with Holes W. L. Gore & Associates DualMesh Plus with Holes W. L. Gore & Associates Dulex C. R. Bard, Inc. Mycromesh W. L. Gore & Associates Mycromesh Plus W. L. Gore & Associates (a) Reconix C. R. Bard, Inc. Soft Tissue Patch W. L. Gore & Associates

There is a distinctive difference between DualMesh and Dulex products. As can be seen in Figure 3.3, the rough surface of the latter is more like that of sandpaper than the corduroy appearance of the former. Close-up views reveal that these differences in appearance are due to the laminar construction of the Dulex and the transverse interstices of the DualMesh. Collagen penetration will be throughout the entire structure of the latter and will be stopped at the visceral surface of the biomaterial. Another unique feature of the DualMesh is that it is available impregnated with silver and chlorhexidine, antimicrobial agents that are added for the obvious purpose of preventing infection. Long-term data on the benefits of impregnating these substances into the product are difficult to document due to the low rate of infection (b) that is associated with laparoscopic hernioplasty. The brown color of the material does, however, present a significant improvement in the use of the prosthesis, as it results in a reduction in the glare that is apparent with the non-impregnated product; this eases its use during laparoscopy. DualMesh Emerge and DualMesh Plus Emerge com- prise DualMesh standard or DualMesh Plus biomaterial that has an attached removable layer of silicone on its surface (Figure 3.4a). This is currently available on the 15 ϫ 19-cm patch, but other sizes should become available soon. This stiffens the product significantly, such that it cannot be inserted into the abdomen via a 5-mm port site. The purpose of this additional layer is to act as an aid in the manipulation and fixation of the DualMesh during incisional hernia repair. Once the product is secured to the abdominal wall, the silicone layer is peeled off the ePTFE and removed (Figure 3.4b). DualMesh with Holes and DualMesh Plus with Holes are similar to the above products but with perforations at (c) evenly spaced intervals throughout the biomaterial. These Figure 3.2 Comparison of polyester biomaterials: (a) Mersilene, products are 1.5-mm thick, compared with the DualMesh (b) Parietex TEC, and (c) Parietex TET. products without holes, which are 1-mm thick. 20 Overview

(a)

(b)

(d)

Figure 3.3 ePTFE biomaterials: (a) DualMesh, (b) DualMesh Plus, (c) (c) DualMesh Plus with Holes, and (d) Dulex.

(a) (b) Figure 3.4 Emerge biomaterial (a) with the silicone unpeeled and (b) as it is peeled off the DualMesh. Prosthetic biomaterials for hernioplasty 21

Figure 3.6 Anatomical Mesh.

Table 3.4 Composite biomaterials and manufacturers Biomaterial Manufacturer Composix C. R. Bard, Inc. Composix EX C. R. Bard, Inc. Paritex® Composite Sofradim International Paritene® Composite Sofradim International Sepramesh® Genzyme Corp. Figure 3.5 3D Max. Glucamesh Brennen Medical, Inc. Glucatex 3D Brennen Medical, Inc. SYNTHETIC PROSTHETIC BIOMATERIALS: PREFORMED PRODUCTS SYNTHETIC PROSTHETIC BIOMATERIALS: COMPOSITE PRODUCTS These products have been manufactured to conform, in one way or another, to the inguinal floor. They are placed specifically via the laparoscopic approach, either by a The introduction of the laparoscopic approach to inci- transabdominal or a totally extraperitoneal technique. sional hernioplasty has identified the need to protect the The most common of these prostheses is the 3D Max intra-abdominal viscera from contact with the mesh (C. R. Bard, Inc.) (Figure 3.5). This polypropylene prod- materials that are used in the repair. Table 3.4 lists the uct is available in two sizes. Because of the curve within products that are composed of two different biomaterials. the product, left and right prostheses are available for use The construction of these biomaterials is designed to allow on the left and right sided inguinal hernia, respectively. the in-growth of tissue while protecting the opposite sur- The orientation of this biomaterial is critical to ensure face from adhesion formation during the healing phase. adequate coverage of the myopectineal orifice. The larger The concept differs in the individual products. product may be used without the need for fixation; the The first of these to be manufactured was that of the intra-abdominal pressure and the stickiness of the PPM Composix mesh (Figure 3.7a). A thin layer of ePTFE is are said to allow for this.6 The smaller biomaterial does heat-sealed on to two layers of Marlex mesh. This is a very require fixation because of its potential to migrate within thick product that requires at least a 12-mm trocar site the pre-peritoneal space. hole in which to introduce it. There have been reports of Another preformed device is the Anatomical Mesh adhesion formation and postoperative pain with the use (Sofradim International) (Figure 3.6). The flat portion of of this biomaterial.7 A thinner product, Composix EX the prosthesis is made of PPM, while the portion that is (Figure 3.7b), is comprised of one layer of Marlex and a made to lie over the iliac vessels is made of polyester. The thicker layer of ePTFE. The ePTFE on this prosthesis is sutures intertwined into the mesh are drawn together to sutured on to the PPM to provide secure fixation between compress the product to ease its introduction through a the two products. There is an overlap of the ePTFE past trocar. This is then cut to deploy the full surface of the the PPM to minimize the risk of exposure of the edges biomaterial. At the time of writing, there are no long- of the PPM to the viscera. Therefore, one should avoid term follow-up data on the use of this product. cutting the mesh to conform to a non-standard shape, 22 Overview

(a)

Figure 3.8 Sepramesh.

PPM similar to the other two products above. The manufacturer recommends that the mesh be covered by the omentum at the completion of the laparoscopic incisional hernia repair. There is some dispute as to the success of this biomaterial in the prevention of adhesions.8,9 Glucamesh and Glucatex 3D are, at the time of writing, very new polypropylene and polyester biomaterials that are impregnated with oat beta glucan. Oat beta glucan is a puriﬁed complex carbohydrate that is isolated from the cell wall of oats. It is absorbed following introduction of the product.

(b) Figure 3.7 Comparison of (a) Composix and (b) Composix EX. NON-SYNTHETIC PROSTHETIC BIOMATERIALS which could expose the PPM. The products are available in numerous sizes, so cutting will seldom be necessary. Several products based upon biological materials are The last ﬁve products listed in Table 3.4 have absorbable now available (Table 3.5). The use of a non-synthetic components. Parietex composite consists of a three- biomaterial for the repair of hernias may be the better dimensional polyester mesh (listed in Table 3.3) that has approach. However, long-term studies and biocompati- been incorporated by hydrophilic collagen. Paritene com- bility evaluations will be needed to conﬁrm their useful- posite uses the PPM that is listed in Table 3.1 and has the ness. All have been processed to eliminate the risk of same collagen layer as Parietex composite. The absorbable transmission of viral or other diseases. These generally collagen is no longer present by the fourteenth postoper- are pure or nearly pure collagen that will be incorporated ative day. At the time of writing, long-term studies using and/or replaced by the patient’s own collagen over time. these biomaterials are in progress. The hernia is repaired by the neofascia that subsequently Sepramesh (Figure 3.8) is PPM coated on one surface develops. The majority of implantations of these bio- with carboxymethylcellulose and hyaluronate foam. This materials have been via open operation, but their use foam will be absorbed in about seven days to leave the with laparoscopic technique is undergoing evaluation. Prosthetic biomaterials for hernioplasty 23

Table 3.5 Biological prosthetic biomaterials and manufacturers Biomaterial Manufacturer Surgisis ES® and Surgisis Gold® Cook Surgical, Inc. FortaPerm™ Organogenesis, Inc. FortaGen™ Organogenesis, Inc. Permacol™ Tissue Science Laboratories plc Alloderm® Lifecell, Inc.

(a)

Figure 3.9 Alloderm.

(a) (b)

Figure 3.11 (a) Fortagen and (b) Fortaperm.

(b) Figure 3.10 (a) Surgisis ES and (b) Surgisis Gold.

Figure 3.12 Permacol. Alloderm (Figure 3.9) is manufactured from cadaveric skin. Its width is limited by the size of the der- matome that is used to harvest the material. Surgisis ES in appearance. They are ﬁve layers thick, the layers being and Surgisis Gold (Figure 3.10) are four- and eight-ply, cross-linked together to provide greater strength. Fortagen respectively, porcine small-intestinal submucosa. The will be replaced by the native collagen, similar to Surgisis, manufacturing process causes the nodules that are seen but Fortaperm becomes a permanent prosthetic similar on the Surgisis Gold. Fortagen and Fortaperm are also to that of the synthetic biomaterials described above. processed porcine submucosa of the small intestine Permacol (Figure 3.12) is porcine dermis with indica- (Figure 3.11). These latter two products are very similar tions similar to the other products. 24 Overview

At the time of writing, all of these biomaterials are rel- REFERENCES atively new and clinical experience is generally limited. There may be particular application in the site of infections 1 Losanoff JE, Richman BW, Jones JW. Entero-colocutaneous fistula: a that are associated with tissue loss or following hernia late consequence of polypropylene mesh abdominal wall repair: repair with synthetic meshes. These cannot be used in case report and review of the literature. Hernia 2002; 6: 144–7. the presence of an intestinal fistula because the enteric 2 Klein AM, Banever TC. Enterocutaneous fistula as a postoperative contents will dissolve the collagen in the product. complication of laparoscopic inguinal hernia repair. Surg Laparosc Endosc 1999; 9: 60–2. 3 Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg CONCLUSION 1998; 133: 378–82. 4 LeBlanc KA, Bellanger DE, Rhynes VK, et al. Tissue attachment strength of prosthetic meshes used in ventral and incisional hernia Laparoscopic hernioplasty is dependent upon the use of repair. Surg Endosc 2002; 16: 1542–6. 5 Koehler RH, Begos D, Berger D, et al. Adhesion formation to prosthetic biomaterial and the in-growth that ensues. A intraperitoneally-placed mesh: reoperative clinical experience after variety of synthetic and non-synthetic biomaterials are laparoscopic ventral incisional hernia repair. Am J Surg; in press. available for implant. Surgeons should be aware of all of 6 Pajotin P. Laparoscopic groin hernia repair using a curved prosthesis the available products. The selection of the ideal prosthe- without fixation. J Coelio-Chir 1998; 28: 64–8. sis should be based upon experimental, clinical and long- 7 LeBlanc KA. ‘Tack hernia’ – a new entity. JSLS 2003; in press. 8 Kramer K, Senninger N, Herbst H, Probst W. Effective prevention of term follow-up data. Newer biomaterials will probably adhesions with hyaluronate. Arch Surg 2002; 137: 278–82. be developed in the future that may enhance the repair of 9 Amid P. Hyaluronate does not prevent adhesions. Arch Surg 2002; hernias. 137: 1313–14. 4

Fixation devices for laparoscopic hernioplasty

KARL A. LEBLANC

Early devices 25 Conclusion 28 Later devices 27 References 28 Latest devices 27

Laparoscopic hernioplasty requires the use of a pros- a series of 13 patients in whom he closed the peritoneal thetic biomaterial. Consequently, a method of fixation opening of the sac using Michel clips. All but the last will be necessary for all but the smallest of incisional and patient in this series were repaired through an open inci- some of the inguinal hernia prostheses. The earliest sion. The thirteenth patient was repaired in 1979 under attempts to repair inguinal hernias laparoscopically were laparoscopic guidance with a special stapling device. The performed with the suture fixation of the mesh to the three-year follow-up of this patient revealed him to be structures of the inguinal floor. This was a very tedious free of an identifiable recurrence. Ger and colleagues task, which greatly hindered the adoption of this new continued their efforts to repair these hernias laparo- technology. Manufacturers of instruments responded scopically. They reported the closure of the neck of the with the development of different devices that delivered hernia sac using a prototypical instrument called the metal fixation to secure the biomaterial to the inguinal Herniostat in beagles (Figure 4.1).2 This device was never floor. The use of these devices is, of course, an integral produced commercially, but it was certainly ahead of part of all laparoscopic hernia repairs. There have been a its time. number of these products that have not been successful Schultz and colleagues published the first patient or even brought to large-scale production. These and the series of laparoscopic herniorrhaphy in 1990.3 Rolls newer instruments are discussed below. of polypropylene were stuffed into the hernial orifice, The classification of these devices is arbitrary. Regard- which was then covered by two or three flat sheets of less of the product that is used by the surgeon, it is criti- polypropylene mesh (2.5 ϫ 5 cm) over the defect. These cal that each is used properly. Few surgeons are afforded rolls of mesh were not secured to either the fascia or the opportunity to use these instruments for the first time peritoneum. The peritoneum, however, was closed using in the laboratory setting. Therefore, it is recommended clips that were commonly used for hemostasis. Corbitt that the surgeon experiences the mechanism of delivery of each device before using it in the operating room. Proper surgical technique is critical for the correct application of these devices without exposing the patient to untoward consequences.

EARLY DEVICES

Ger, in 1982, was the ﬁrst to report the use of the laparo- Figure 4.1 Ralph Ger’s ‘Herniostat’. (Photograph used with scope in the repair of an abdominal hernia.1 He reported permission of Ralph Ger, MD.) 26 Overview

Figure 4.2 Ethicon EMS stapler and the staples that it fired. Figure 4.3 Nanticoke Hernia Stapler and staples. These devices are conformed into a more rounded shape than the modified this technique by inverting the hernia sac and EMS staples. performing a high ligation with sutures or with an endoscopic stapling device used for transection of tissues similar to that used for open bowel resection.4 A similar concept was applied in the intraperitoneal onlay patch (IPOM) technique. This repair, originally investigated by Salerno and coworkers, used a polypropylene patch material in a porcine model.5 They placed rectangular pieces of the prosthesis against the abdominal wall covering the internal inguinal ring and secured it with a stapling device. The success of these repairs led Figure 4.4 Endopath EMS stapler. them to apply this method in clinical trials. This early stapling device was the EMS stapler (Figure 4.2). It was a reusable instrument that had to be reloaded following the placement of every staple. This placed a box type of staple similar to that which is used commonly for skin closure. This was a 10-mm instrument that greatly improved and decreased the time required for the inguinal hernia repair technique. At about the same time, Toy and Smoot reported on Figure 4.5 Endo-universal stapler of USSG. their first ten patients repaired with the IPOM technique.6 They secured an expanded polytetrafluoroethylene (ePTFE) patch to the inguinal floor with staples that were introduced by a prototypical stapling device of their own design, which they called the Nanticoke Hernia Stapler (Figure 4.3). They used this fixation device successfully without adverse results in 20–30 patients. The device did not become available commercially. A subsequent report of their first 75 patients was published in 1992.7 In this later series, the same prosthetic biomaterial Figure 4.6 Endopath EAS stapler. was attached with the Endopath EMS® stapler (Ethicon Endosurgery, Inc.) (Figure 4.4). After a follow-up of up device, however, allowed the articulation of the end of to 20 months, the recurrence rate was 2.4 per cent. They the instrument, giving the surgeon the capability to place noted a significant decrease in postoperative pain and an the staples more accurately against the abdominal wall earlier return to normal activity compared with the open and the ligament of Cooper. repair of the hernia defect. Ethicon responded with the release of the EAS device, These early hernia repairs continued to become mod- which also has an articulating head (Figure 4.6). Both the ified in many different aspects, including approaches to U.S. Surgical Corporation stapler and the Ethicon EAS the inguinal area, prosthetic biomaterials, and fixation allowed 360-degree rotation of the shaft of the device devices. The devices that followed, such as the EMS, and articulation of the end of the shaft to place staples. In allowed the placement of multiple staples without the most cases, these movements in these two different planes need to reload after each use. U.S. Surgical Corporation, allowed exact delivery of the staple to the prosthesis and Inc. released its stapler, which was similar in concept tissue. At about this time, there was an increasing use of (Figure 4.5). This device required a 12-mm trocar rather laparoscopic repair of not only inguinal but also inci- than the 10-mm trocar used by the EMS staplers. The sional hernias subsequent to the first report in 1993.8 The Fixation devices for laparoscopic hernioplasty 27

Figure 4.8 Origin Tacker. Figure 4.7 Omni-Tack. delivery of the staples for this operation was not always ideal because of the lack of further rotation of the end of the head of the stapler. Because of this limitation, the staple could not always be placed exactly perpendicular to the edge of prosthesis, which resulted in fixation that was not always flat against the abdominal wall. This problem was solved with the release of the Omni-Tack by Ethicon Figure 4.9 ProTack. Endosurgery (Figure 4.7). Despite its innovative design and increased ability of accurate staple placement, this a part of the coil could remain exposed to the intestine. product was never distributed widely. At least one report has documented the development of a colocutaneous fistula that is presumed to be due to a tack.9 LATER DEVICES

LATEST DEVICES As laparoscopic surgery expanded into the many areas of general surgery, there was an unsatisfactory realization that hernias developed in trocar sites that were larger Newer products have recently been introduced into the than 5 mm. Because of this, the trocar sites of the larger hernia repair market. Like their predecessors, these have ports required fascial closure to prevent these hernias. In unique characteristics. Onux Medical, Inc. has produced an effort to decrease this risk, the use of 5-mm instead the Salute fixation device (Figure 4.10). Unlike all of the of 10-mm trocars, wherever possible, became more fre- products discussed above, which used titanium as the quent. However, all of the instruments mentioned above metal for the device, this construct is made of stainless required access with trocars that were at least 10 mm. steel. This is the only reusable fixation device that has Further engineering refinements in all laparoscopic been available commercially. Unlike the other products, instruments provided the surgeon with 5-mm instru- it does not deliver a preformed device into the tissues. ments and laparoscopes. Origin Medsystems introduced A construct is formed into a keyring shape as the trigger the first successful 5-mm fixation device (Figure 4.8). The is fired (Figure 4.11). This motion also cuts the wire at method of fixation of this new helical coil was a signifi- the same time. While the device does require the use of cant departure from the previous staples. Delivery with counter-pressure for placement, its method of delivery the 5-mm size was accepted quickly. The apparent disad- makes it appealing for use in the upper abdomen, on vantage of the inability to rotate or articulate the device the diaphragm or at the esophageal hiatus. Although the did not prove to be important to the vast majority of sur- device does not seem to have as deep a penetration geons. This method of fixation was quite secure. into the tissues as the tack, experimental evidence has U.S. Surgical Corporation introduced a similar shown that it is an effective method of fixation.10 Two product, the ProTack, shortly thereafter (Figure 4.9). The slightly different heads are available with this instru- ProTack is almost identical, conceptually, to the Origin ment. Some surgeons find the use of one or the other tacker. Both deliver a 5-mm titanium helical coil that preferable, in that the depth of penetration (depending is screwed through the prosthesis and into the tissues. upon the particular surgeon’s technique) is affected by The ProTack, however, allows the surgeon to unscrew the the shape of the head. Because of the shape of the head, tack after it is introduced if the placement is deemed to the thickness of the wire is greater in the newer design. be inadequate or inappropriate. Because the ends of Therefore, there are two different thicknesses of these these devices cannot be manipulated, it is important to wires. Consequently, the spools of wire that are used use significant counter-pressure during the implantation to deliver the coil are not interchangeable between these of these tacks. If not, poor placement can result and devices. 28 Overview

Figure 4.10 Salute instrument.

Figure 4.13 EndoAnchor with the inner needle shaft exposed by squeezing the trigger of the device.

Figure 4.11 Salute construct.

Figure 4.14 EndoAnchor device.

CONCLUSION

Laparoscopic hernioplasty requires fixation of the biomaterial. The devices described above are almost all in use today. The effectiveness of the newer products will Figure 4.12 EndoAnchor instrument. become known with the passage of time. Whichever product is chosen in the laparoscopic repair of hernias, it is critical to use the device properly. Knowledge of the The most recently developed product is the Endo- mechanism of delivery and the concept that is applied in Anchor by Ethicon Endosurgery, Inc. (Figure 4.12). This the shape of the final delivered device is important. allows the entire device to be loaded into either a Emerging technologies will continue to deliver newer 3-mm or a 5-mm shaft. To place this product into the products for this operation. tissues, the trigger is fired first. Unlike all of the other products, this maneuver does not deploy the device. A large needle-like shaft is moved forward from inside the REFERENCES end of the outer shaft (Figure 4.13). The anchor is contained within the end of the needle. The anchor is released 1 Ger R. The management of certain abdominal herniae by into the tissues as the trigger is released. Once this occurs, intra-abdominal closure of the neck of the sac. Ann R Coll Surg the nitinol anchor assumes its shape after that movement Engl 1982; 64: 342–4. (Figure 4.14). The upper protrusions of the shaft of the 2 Ger R, Monro K, Duvivier R, et al. Management of inguinal hernias nitinol are the portion of the device that remains in by laparoscopic closure of the neck of the sac. Am J Surg 1990; 159: 370–73. the tissues. The lower, larger hooks are positioned over 3 Schultz L, Graber J, Pietrafitta J, et al. Laser laparoscopic the prosthesis to hold it in place. Currently, there is only herniorrhaphy: a clinical trial, preliminary results. J Laparoendosc a limited release of this device. Surg 1990; 1: 41–5. Fixation devices for laparoscopic hernioplasty 29

4 Corbitt J. Laparoscopic herniorrhaphy. Surg Laparosc Endosc 1991; preliminary findings. Surg Laparosc Endosc 1993; 1: 23–5. 3: 39–41. 5 Salerno GM, Fitzgibbons RJ, Filipi C. Laparoscopic inguinal hernia 9 DeMarie EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal repair. In: Zucker KA, ed. Surgical Laparoscopy. St Louis: Quality polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral Medical Publishing, 1991: 281–93. hernia. Surg Endosc 2000; 14: 326–9. 6 Toy FK, Smoot RT. Toy–Smoot laparoscopic hernioplasty. Surg 10 LeBlanc KA, Stout RW, Kearney MT, Paulson DB. Comparison of Laparosc Endosc 1991; 1: 151–5. adhesion formation associated with Pro-Tack (US Surgical) versus 7 Toy FK, Smoot RT. Laparoscopic hernioplasty update. a new mesh fixation device, Salute (ONUX Medical). Surg Endosc J Laparoendosc Surg 1992; 2: 197–205. 2003; in press. 8 LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: This page intentionally left blank PART 2

Laparoscopic inguinal/femoral hernioplasty

5 History 33 10 Femoral and pelvic herniorrhaphy 75 6 Anatomy and physiology 41 11 Results of laparoscopic inguinal/femoral 7 Intraperitoneal onlay mesh approach 47 hernia repair 83 8 Transabdominal pre-peritoneal approach 53 12 Complications and their management 89 9 Totally extraperitoneal approach 65 This page intentionally left blank 5

History

MICHAEL S. KAVIC AND STEPHEN M. KAVIC

Hernia paradigm 33 Laparoscopic hernia repair 37 Open hernia repair 33 Conclusion 39 Genesis of hernias 36 References 39

A hernia has been defined as the protrusion of a loop or the papyrus in 1875, which was later completed by knuckle of an organ or tissue through an abnormal Bendix Ebbell, a Norwegian physician. Ebbell’s study of opening.1 In their earliest state, hernias of the abdomen the papyrus suggested that the ancient Egyptians had and pelvic side wall begin as a protrusion of peritoneum attained a high level of surgical skill and had developed through a fascial defect. They are rarely symptomatic, procedures for hernia and aneurysm management.2 and typically they are undetectable on physical examina- Interestingly, then, in the first preserved written record of tion. In order to understand the development of laparo- medical practice, the paradigm for hernia management scopic hernia repair, it is necessary to review how the included surgical intervention. approach to hernias and hernia repair has evolved Surgical intervention for hernia, and almost any other throughout history. disease, was mercifully rare before the modern era. Without anesthesia, operative pain was real and fearsome. In addition, infection almost inevitably followed a surgi- HERNIA PARADIGM cal procedure and frequently was life-ending. Because of this, the religious proscriptions against human dissection, and technological immaturity, progress in the surgical Before recorded or written history, humans are thought sciences stagnated. The discovery of anesthesia and the to have managed hernia with taxis. From its Greek origin, development of antiseptic methods in the mid-nineteenth meaning ‘the drawing up in rank and file’,taxis for hernia century revolutionized the practice of surgery. Operative involved the use of finger or hand pressure to reduce the intervention without the twin specters of agonizing opera- displaced organ or tissue. Support after reduction, utiliz- tive pain and postoperative infection became possible, and ing a belt or girdle to maintain the herniated content, the abdominal cavity no longer remained terra incognita. would have been a logical extension of taxis. Thus the first Along with that for many other diseases, the paradigm for paradigm for hernia management is most likely to have hernia changed. been one of conservative, nonoperative management. The date of the first operation for hernia and change in the nonoperative paradigm is unknown. However, OPEN HERNIA REPAIR allusion to an operative procedure for hernia was made in one of the earliest written medical records, an ancient Egyptian medical text known as the Ebers Papyrus. Henry O. Marcy (1837–1924), a surgeon from the USA George Moritz Ebers (1837–98), a professor of Egypt- and a disciple of the English surgeon Joseph Lister, ology at the University of Berlin, purchased an ancient described two cases of incarcerated hernia that he treated papyrus while traveling in Egypt in 1873. The papyrus surgically in 1871.3 Marcy, using Listerian antiseptic contained a collection of older works dating back to techniques, performed the standard operation of the day 3000–2500 BC. Ebers prepared a partial translation of on these two patients: he divided the hernia ring ‘in the 34 Laparoscopic inguinal/femoral hernioplasty usual way with the hernial knife’ and reduced the incar- USA, failed to appreciate the importance of dividing the cerated hernia. However, Marcy went a step further and transversalis fascia to expose all layers, and a true triple- expanded the hernia technique then in vogue. Rather layer repair was often not accomplished. Bassini’s opera- than open the hernia sac, he reduced it and repaired the tion was modified and simplified by not dividing the defect by closing the ‘constricting ring’ with carbolized transversalis fascia, but it was also diminished. Bassini catgut suture. initially reported a recurrence rate of about three per cent.5 Marcy, in his report of these procedures, emphasized In the USA, experience with the Bassini repair, which was the use of Lister’s antiseptic technique and a new form of frequently modified, differed from the Italian master, and sterile (carbolized catgut) suture. He stressed that the recurrence rates ranged from five to ten per cent in most two patients healed without infection. Almost as an hands.6 afterthought, he noted that both patients were ‘cured’ of Although Annandale, in 1876, was the first to enter their hernias. In truth, Marcy may have been the first to the pre-peritoneal space for hernia repair,7 Cheatle, in have closed the internal ring for hernia repair and prob- 1920, is generally credited with being the first to intro- ably helped initiate the modern age of hernia repair.4 duce a pre-peritoneal (otherwise known as pro-peritoneal, Although Marcy made significant contributions to extraperitoneal, or posterior) approach.8 Cheatle des- herniology, it is generally agreed that the Italian surgeon cribed his procedure as follows: ‘an incision is made to Eduardo Bassini (1844–1924) is the progenitor of mod- one side of the middle line, the rectus abdominus is split ern hernia repair (Figure 5.1). Bassini, in 1884, devised a longitudinally and the abdominal wall is retracted to the method of hernia repair that called for a three-layer side of the operation’. The hernia sac was ligated ‘as low reconstruction of the inguinal floor.5 After division of the down as possible’ and the internal ring closed by sutur- posterior wall of the inguinal canal and herniotomy (high ing ‘the muscle fibres and their sheath’. ligation and excision of the sac), Bassini performed a For femoral hernia, Cheatle recommended that a ‘triple layer’ repair of the inguinal floor. He approximated flap of pubic bone periosteum be secured to Poupart’s the internal oblique muscle, transversus abdominus ligament to secure the femoral orifice. In 1936, Arnold muscle, and transversalis fascia to the inguinal ligament. Henry described a similar extraperitoneal approach to According to Bassini, this herniorrhaphy technique (suture hernia repair in which he secured the femoral canal with reinforcement of the floor of the inguinal canal) repaired a flap of pectineus fascia to Poupart’s ligament ‘without the inguinal defect(s), re-established the obliquity of the tension’.9 The internal ring was repaired ‘from within’. inguinal canal, and reconstructed the internal and external Nyhus and colleagues later adopted and further inguinal rings, restoring all to competency. refined the open pre-peritoneal repair.10 They recom- The Bassini repair was logical from an anatomic per- mended that the pre-peritoneum be approached via a spective, and it worked in practice. It was also radical, as suprainguinal incision and that suture plasty (hernior- the patient did not have to wear a truss after the proce- rhaphy) be performed to secure the defects of indirect, dure as in other repairs popular at the time. sliding, and recurrent inguinal hernias. Bassini’s operation was a marked improvement over Because of the significant recurrence rate after what had preceded it. Unfortunately, the sound proce- herniorrhaphy, many surgeons recalled a quote attrib- dure that Bassini devised became corrupted during its uted to Theodore Billroth (1829–94): ‘If we could artifi- dissemination worldwide. Surgeons, particularly in the cially produce tissues of the density and toughness of fascia and tendon, the secret of the radical cure of hernia would be discovered.’11 The earliest use of synthetic material to substitute for living tissues in herniorrhaphy occurred in 1894, and involved the use of silver wire coils placed in the inguinal canal to induce fibrosis and strengthen the hernia repair.12 A few years later, German surgeons Goepel13 and Witzel14 independently utilized handmade silver wire filigrees to serve as a prosthetic ‘mesh’ for difficult or recurrent hernias. Silver wire, however, lacked pliability and caused patient discomfort. It was not inert, and metal fatigue led to disintegration of the silver wires. Infection and sinus tract formation with persistent drainage occurred, and silver wire was eventually abandoned as prosthesis for hernia repairs. Despite a genuine need for fascial substitutes, investi- Figure 5.1 Eduardo Bassini. gation of prosthetics for hernia repair was unfocused History 35 until the seminal work of Francis Usher (1908–80). tissue disruption and hernia recurrence. He reported Usher, in the 1950s, became interested in hernia recur- that tension-free repair with mesh prosthesis had been rence and attempted to repair hernias with freeze-dried employed in more than 300 consecutive cases of direct homographs and lyophilized dura mater.15 None of these and indirect inguinal hernia without complication or materials proved satisfactory, so Usher turned his atten- recurrence. tion to synthetic materials. Various forms of plastic had Lichtenstein’s genius was not that he introduced been tried before, but because of their rigidity, tendency polypropylene mesh for inguinal hernia repair; he did to fragment, and susceptibility to infection, none was not. Nor was his concept of a tension-free repair new; it found to be satisfactory for hernia repair. Usher persisted was not. Usher deserves primacy in both of these matters. in his investigation of plastic materials and learned of a Lichtenstein’s insight was in understanding the work that new polyolefin plastic (polypropylene, i.e. Marlex) that had gone on before and building on it. He helped could be extruded as a monofilament, did not fragment, popularize the concept of ambulatory hernia surgery and and was inert. Usher worked closely with the company advocated a tension-free onlay of polypropylene mesh that produced Marlex (Phillips Petroleum Co.), and had for all groin hernias, regardless of size or complexity. He the material woven into a mesh and tested in animal stud- stressed the use of local anesthesia and the importance of ies. He found that polypropylene mesh was tolerated well immediate resumption of normal activity. Lichtenstein in sterile and infected fields, and he began to use Marlex and colleagues reported on the technique in 1989.23 They mesh in humans in 1958.16,17 Usher made many original described over 1000 cases of hernias repaired with a contributions to the field of hernia repair, which Read ‘tension-free hernioplasty’ technique and followed for lists elegantly in a scholarly retrospective of Usher’s life:15 one to five years with no recurrences or mesh infections. This paper described hernia repair with elegant simplicity The development of polypropylene mesh and • and took the surgical world by storm. Not only were the suture for repair of abdominal-thoracic defects. results excellent, but the operation was easy to perform Improved techniques for mesh placement. A • and patients underwent a rapid recovery. In a study of prosthetic bridge was placed deep and under lapped more than 16 000 tension-free mesh repairs performed by the hernia defect. 72 surgeons, the recurrence rate was reported to be less Anterior, pre-peritoneal placement of the prosthesis • than 0.5 per cent and the incidence of infection was 0.6 for large, primary, direct or recurrent groin herniae per cent.24 For the last quarter of the twentieth century, a without suture closure of the defect. mantra for hernia repair might have been ‘tension-free, Elimination of tension in hernia repair, which • tension-free, tension-free’. facilitated early ambulation. In referring to hernia procedures, Halsted noted that Demonstrated that infected prosthesis could remain • surgical skeptics at the turn of the nineteenth century in situ and heal after open drainage. exclaimed: ‘Why take so much trouble, when such good The use of unsplit groin mesh with overlap and • results, as are published, may be obtained by simpler interrupted suture lateral to the internal inguinal methods?’25 This at a time when William T. Bull, a ring to allow extended pre-peritoneal obliquity of prominent New York surgeon, reported recurrence rates the spermatic cord. This provided a shelf for the cord of 40 per cent in the first year after hernia repair and to rest on and preserved the normal obliquity of almost 100 per cent within four years.26 Indeed, many the internal ring. surgeons at the turn of the twentieth century held a sim- The use of bilaminar mesh to bridge a hernia defect • ilar view regarding a change of technique for open hernia and suture of the two lamina and encompassed repair: ‘If it ain’t broke, why fix it?’ tissue laterally to prevent the suture from tearing Groin hernias originate in the abdomen and traverse out weakened structures. a myopectineal orifice between abdomen and thigh to These contributions were significant advances in the present in the inguinal region (Figure 5.2). The myopec- field of herniology.16–21 However, like so many other pio- tineal opening, as described by Fruchaud (Figure 5.3), is neers, Usher did not receive the recognition he deserved. bounded by the rectus sheath medially, internal oblique It remained for others to build on his work and advance and transversus abdominus muscles superiorly, the the science of hernia repair. iliopsoas muscle laterally, and pubis inferiorly.27 It is an In the 1986 edition of his textbook Hernia Repair irrefutable anatomic structure whose entire opening must Without Disability, Irving L. Lichtenstein stated that he be addressed before a complete cure of inguinal-femoral was performing a tension-free repair utilizing synthetic hernia can be anticipated. mesh to bridge the hernia defect and that he had discarded The Lichtenstein operation is an excellent procedure. older classical techniques of suture repair (herniorrha- However, it is not perfect. The Lichtenstein technique phy).22 Tension, as noted by Lichtenstein, was ‘the bête of open anterior repair does not allow for the entire noire of the hernia surgeon’ and could lead to suture or myopectineal orifice to be addressed easily. There is 36 Laparoscopic inguinal/femoral hernioplasty

prosthesis that would functionally replace the transversalis fascia.29,30 Stoppa advocated an extensive reinforcement of transversalis fascia without repair of the hernia defect. Whereas the goal of surgical therapy had always been to achieve parietal repair, i.e. closure of the hernia defect, Stoppa’s revolutionary concept was to render the peritoneal envelope inextensible without mandatory repair of the deteriorated abdominal wall and hernia defect. The operation has become known as the giant prosthetic reinforcement of the visceral sac (GPRVS) or Stoppa procedure, and has worked quite well, with low recurrence rates reported for even very large, complex, recurrent hernias.

GENESIS OF HERNIAS

For thousands of years, adult groin hernias were thought to result from a physical rupture or tear of the abdominal- wall supporting tissues. In the late 1960s, Read noted that Figure 5.2 Myopectineal orifice. during a pre-peritoneal approach for hernia repair, the rectus sheath above the hernia defect appeared thin and felt greasy, particularly with direct hernia defects.31 He followed up this observation with other studies in which he biopsied and weighed constant-area rectus sheath samples of patients operated on for hernia and compared them with samples from patients operated on for intra-abdominal conditions other than herniation. The weight of the biopsy specimens, especially of chronic smokers, was less per unit area in patients with direct hernia than in controls and did not relate to the patient’s age or muscle mass.32 Read and others have suggested that there is an increased number of circulating white blood cells in the blood and lungs of smokers that discharge free, unbound, active protease and elastase compounds.33 These proteo- lytic enzymes disturb the normal protease/anti-protease balance and contribute to the damage of elastin and colla- Figure 5.3 Henri Fruchaud. gen in the fascia transversalis and rectus sheath of smokers, which leads to direct inguinal herniation.34 It has been shown that purified human neutrophil polymorpho- limited exposure of the inferior aspect of the myopectineal nuclear leukocyte elastase can induce pulmonary emphy- orifice. Moreover, it should be noted that performance of sema.35 There are other conditions of systemic illness and an anterior repair requires the spermatic cord and its stress (pulmonary emphysema, ruptured abdominal aor- structures to be mobilized circumferentially before the tic aneurysm, burns) that cause an enhanced leukocyte mesh can be positioned. Circumferential cord mobilization count and the discharge of proteases and oxidants from and manipulation can lead to spermatic venous throm- leukocytes. These conditions may, in part, be responsible bosis, ischemia of the testicle, and testicular atrophy.28 for the biochemical changes that lead to damage of the Lichtenstein in 1986 reported his incidence of testicular collagenous connective tissues in the groin and cause atrophy to be one per cent.22 hernia formation in non-smokers in a manner similar to During the latter third of the twentieth century, René smokers. Because of these findings and the work of others, Stoppa and colleagues performed much of the innovative it was Cannon and Read’s opinion that: ‘The surgeon’s work that ultimately formed the foundation for a suc- approach to inguinal herniation should consider more cessful laparoscopic approach to hernia repair. Stoppa’s than the anatomic and technical detail. It must now contribution to herniology was that he suggested manag- embrace biochemistry, because he is dealing with a local ing hernias of the groin with a very large, permanent manifestation of a generalized lesion of connective tissue.’36 History 37

LAPAROSCOPIC HERNIA REPAIR Both Schultz and Corbitt abandoned the technique of plug- and-patch repair because of excessive hernia recurrence and changed their technique to one that utilized a large With little fanfare and without much notice, Ger prosthesis of polypropylene mesh in the pre-peritoneal reported the first laparoscopic hernia repair in a paper space that covered the entire myopectineal orifice. published in 1982.37 This study conducted from August Toy and Smoot42 in 1991, along with Salerno and through November 1977 examined the effectiveness of colleagues,43 took a somewhat different approach to stainless-steel clips to secure the peritoneal opening of laparoscopic hernia repair. Both groups reported on an known abdominal hernias during laparotomy for other intra-abdominal onlay technique subsequently dubbed the major abdominal procedures. In the thirteenth and final intraperitoneal onlay of mesh (IPOM) procedure.42–44 case of the series, an operating laparoscope was used to This technique involved a transabdominal examination visualize the peritoneal defect of a right indirect inguinal of the hernia defect and placement of synthetic mesh hernia. The neck of the hernia sac was closed with a directly on the peritoneal surface about the hernia defect. specially devised stapling device passed through a port Salerno and colleagues, in an animal model, investi- placed in the right iliac fossa. The staple was constructed gated polypropylene as an onlay prosthesis.43 Toy and of tantalum and measured 12.5 mm long in the open Smoot utilized a prosthesis of expanded polytetrafluoro- position. Ger reported that the first patient to be treated ethylene (ePTFE) stapled to the peritoneal surface.42 by laparoscopic closure of the neck of the sac was under In the Toy–Smoot modification, no attempt was made the care of Dr P. Fletcher of the University of the West to shield the graft from intra-abdominal content for Indies, Jamaica.37 the reason that previous animal studies suggested that Gynecologists have been responsible for many of the adhesions between ePTFE graft and abdominal viscera innovations in laparoscopy, and hernia repair has been were thin and inconsequential. The IPOM procedure no exception. In 1990, Popp published a report of the was satisfactory for small to moderately sized defects. coincidental repair of an inguinal hernia during laparo- However, because staple bites were shallow (grasping scopic uterine myomectomy.38 In this paper, Popp principally peritoneum) and because of difficulties in related that the hernia margins were apposed and visualizing substantial pre-peritoneal structures (Cooper’s secured by endosutures tied extracorporeally. A patch of ligament, iliopubic tract, transversalis fascia, transversus dehydrated dura mater was applied to the sutured area to abdominus aponeurosis, etc.), larger hernias repaired further cover the repair site. with this technique frequently recurred. With increased Early on, several prominent laparoscopic surgeons intra-abdominal pressure, such as with coughing, strain- advocated repair of inguinal hernia by ‘plugging’ the ing or exercise, the mesh (attached principally to peri- hernia defect. At the annual meeting of the American toneum) would slide into the hernia defect and the repair Association of Gynecological Laparoscopists (AAGL) in would fail. 1989, Bogojavlensky showed a video that demonstrated The early 1990s were a time of great intellectual repair of an indirect inguinal hernia with a laparoscopic ferment in laparoscopic hernia surgery. While the intra- stuffing technique.39 The hernia canal was filled with a abdominal onlay technique was being developed, several plug of polypropylene mesh, and the internal ring was groups, led most notably by Arregui45 and Dion,46 closed with suture placed laparoscopically. reported on a transabdominal pre-peritoneal patch tech- In 1990, Schultz and colleagues reported on a plug- nique that eventually became adopted widely. In no small and-patch technique for hernia repair that expanded on measure, this technique relied on the principles of hernia the initial work described by gynecologists.40 In their tech- repair established by Stoppa and his GPRVS. nique, the sac of an indirect inguinal hernia was visualized After pneumoperitoneum was established, a laparo- with a laparoscope and grasped on its superior margin scope was inserted into the abdominal cavity, typically with forceps. The peritoneum was incised, and the sac was via an umbilical port, and both groin areas were exam- removed from the musculofascial defect. The hole in the ined. Two additional ports, each placed lateral to the muscle was then filled with rolls of polypropylene mesh rectus sheath and on a plane level with the umbilicus, tied with dissolvable suture. It was thought that the rolled provided access for laparoscopic instrumentation. If an polypropylene mesh would expand to completely fill the inguinal hernia was identified, then an incision was made canal once the suture tie was absorbed.After the defect was into the peritoneum several centimeters above the supe- filled with rolled mesh, one or two pieces of 1 ϫ 2-inch rior margin of the inguinal hernia defect. The indirect or mesh were laid over the defect, and the cut edges of peri- direct hernia sac was reduced, and wide dissection of the toneum were brought together (over the mesh patch) and pre-peritoneal space was performed. No attempt was secured with endoclips. In 1991, Corbitt independently made to obliterate the inguinal canal as in the plug-and- described a similar technique; however, he further ligated patch technique. Rather, a large portion of mesh, com- the inverted hernia sac with an endoscopic linear stapler.41 monly 8 ϫ 13 or 10 ϫ 15 cm in size, was used to cover 38 Laparoscopic inguinal/femoral hernioplasty the myopectineal orifice of Fruchaud. The mesh was mesh, usually polypropylene, is then positioned to cover fixed to the transverse abdominus aponeurotic arch and the femoral canal and the indirect and direct inguinal Cooper’s ligament and lateral to the internal ring with spaces with a 3–5 cm overlap. The mesh is secured with staples or tacks. The peritoneum was closed over the mesh suture, staples or tacks, and the pneumoperitoneum is with suture or staples. deflated. No incision is made into the peritoneum, and the The transabdominal pre-peritoneal application of mesh is completely shielded from intra-abdominal con- synthetic graft, later dubbed the transabdominal pre- tent. Although an additional cost is engendered with the peritoneal (TAPP) patch procedure, was elegant in concept. use of the balloon dissector, its employment has simplified The entire opening between abdomen and thigh through the technique and encouraged many more surgeons to which all hernias of the groin originate (the myopectineal perform laparoscopic repair. Additionally, recent long- orifice of Fruchaud) was bridged in a tension-free manner. term outcome studies have suggested that laparoscopic Intra-abdominal content was protected from contact with extraperitoneal hernia repair has outcomes similar to the graft by placing the mesh in a pre-peritoneal position. open hernia repair.52 Several benefits were accrued with this technique, and One of the major frustrations encountered while were summarized in a 1993 paper:47 performing laparoscopic abdominal wall repair has been manipulation of the mesh prosthesis. A bitter lesson Expose and reconstitute the entire myopectineal • learned early on was that there must be adequate overlap orifice. of mesh (usually 3–5 cm) beyond the perimeter of the Examine both groin areas and repair bilateral • hernia defect. An adequate overlap demands a large por- inguinal hernias as required. tion of mesh, and the larger the mesh the more difficult it Perform repair with little disturbance of cord • is to manipulate in a laparoscopic environment. Several structures with a likely reduction in the incidence ‘pearls’ have been developed to ease mesh deployment of ischemic orchitis. and assure adequate tension-free repair. Marking the Avoid transgression of the scarred tissue of a • mesh with a sterile pen has been of help in orienting the recurrent hernia and the potential for nerve or prosthesis. Rolling up the mesh like a cigarette and secur- spermatic cord injury. ing the rolled mesh with suture has simplified initial mesh Permit a thorough diagnostic abdominal • placement. Using this technique, an edge of the rolled laparoscopic examination. mesh is first secured with tacks or staples. The remainder Reduction in the incidence of hernias ‘missed’ • of the mesh is then unfurled, finessed into position, and on external physical examination. anchored with tacks or staples. Repair of an inguinal hernia from a transabdominal An intriguing use of mesh for groin hernioplasty, first approach, however, exposed the patient to theoretical proposed by Felix and Michas, was that of a ‘double- complications, including postoperative adhesions, postop- buttress’ repair using two sheets of polypropylene mesh.53 erative ileus, bowel obstruction, and intra-abdominal organ In this variation, the authors suggested using two pieces injury.48 To reduce the potential for complications asso- of mesh, typically 8 ϫ 13 cm (in a pre-peritoneal position), ciated with a peritoneal incision or the intra-abdominal one overlying the other at an oblique angle, thus creating application of a synthetic prosthesis, several authors, a ‘double buttress’ of mesh over the mid-portion of the including McKernan and Laws,49 Dulucq,50 and Phillips,51 myopectineal orifice. While application of two layers of discussed a totally extraperitoneal approach to laparo- mesh undoubtedly bolstered the mid-portion of the scopic groin hernia repair. This method, which would orifice, this methodology had the additional benefit of become known as the total extraperitoneal (TEP) patch increasing the diameter of the area repaired far in excess procedure, deployed all laparoscopic instrumentation, of 8 ϫ 13 cm, widely overlapping the entire myopectineal cannulae, and camera in a working pre-peritoneal space orifice. outside of the peritoneal cavity. Laparoscopic access has also been proposed for repair The entire TEP procedure is performed in an extra- of ventral incisional hernias. In 1993, LeBlanc and Booth peritoneal space, a pneumoextraperitoneum, between the described their experience with repair of incisional hernia peritoneum and abdominal wall musculature. An initial using ePTFE prosthetic graft.54 Franklin and colleagues incision is made at the umbilicus, and the anterior rectus reported on the use of open-weave polypropylene mesh sheath on the side of the hernia defect is incised. A cannula for repair of ventral hernias.55 Notably, no fistula forma- is inserted and passed caudally along the intact posterior tion or significant adhesive bowel complications were rectus sheath, and the extraperitoneal space is developed found in their study. Kavic commented on the use of with blunt dissection or a balloon dissector. Additional dual-mesh ePTFE (Gore-Tex) for abdominal-wall ventral cannulae are placed in this pre-peritoneal space under hernia repair.56 Dual-mesh has a rough side and a smooth direct laparoscopic vision, and extraperitoneal dissection side. The smooth side of the ePTFE graft is intended to of the myopectineal orifice is completed. A large piece of interface with intra-abdominal content and to not excite History 39 adhesion formation. The rough side is placed in apposi- complex pathophysiological, biochemical, molecular, and tion to the abdominal wall, where its rough surface perhaps genetic derangements that are, even today, not encourages tissue adhesion. The graft is fixed circumfer- well understood. Study of the groin by several generations entially with staples or tacks and anchored with trans- of surgeon-scientists has provided an appreciation of the fascial stay sutures placed at the four cardinal points of dynamic mechanisms that protect the myopectineal ori- the graft. Carbajo and colleagues prospectively compared fice in the normal state. Current understanding suggests laparoscopic with open prosthetic repair of large inci- that the entire myopectineal window must be secured if a sional hernias.57 Their study suggested that laparoscopic complete cure of groin hernia is to be accomplished.56 repair reduces complication rates and hernia recurrence Achievement of the perfect operation may be an compared with open methods. unobtainable goal, but pursuit of the perfect operation is neither unreasonable nor undesirable. CONCLUSION REFERENCES The successful repair of groin hernia can be accomplished in many ways. Conventional anterior herniorrhaphy, as described by Bassini and Shouldice, or 1 Dorland’s Illustrated Medical Dictionary, 28th edn. Philadelphia: Saunders, 1994: 756. anterior hernioplasty, as advocated by Lichtenstein, are 2 Ebbell B (transl.). The Ebers Papyrus. The Greatest Egyptian Medical effective procedures. These repairs, however, limit their Document. London: H. Milford and Oxford University Press, 1937: focus to the upper aspect of the myopectineal orifice and 17 and 123. neglect the lower aspect. They have been successful in 3 Marcy HO. A new use of carbolized catgut ligatures. Boston Med large measure because of the application of sound surgi- Surg J 1871; 85: 315. 4 Ponka JL. Significant contributions toward understanding and cal principles to secure the hernia defect and because the sound treatment of hernias. In: Ponka JL, ed. Hernias of the large majority of groin hernias pass through the indirect Abdominal Wall. Philadelphia: W.B. Saunders Co; 1980: 1–17. or direct inguinal ring. 5 Bassini E. Nuovo metodo per la cura radicale dell’ernia inguinale. Laparoscopic access has advanced the art of hernia Arch F Klin Chir 1890; 40: 429–76. repair, as the entire myopectineal orifice with its multiple 6 Heydorn W. Hernia. In: James EC, Corry RJ, Perry JF, eds. Principles of Basic Surgical Practice. St Louis: Mosby, 1987: 351–2. openings can be approached and exposed. Bilateral groin 7 Annandale T. A case in which a reducible oblique and direct hernias can be repaired without a large incision or multi- inguinal and femoral hernia existed on the same side and were ple incisions. Hernias that may have been missed during successfully treated by operation. Edinburgh Med J 1876; 21: anterior repair (contralateral inguinal, femoral, occult 1087–91. hernias) can be examined and repaired.58 Surgical 8 Cheatle GL. An operation for the radical cure of inguinal and femoral hernia. Br Med J 1920; 2: 68–9. trauma to skin, subcutaneous tissue, fascia and muscle is 9 Henry AK. Operation for femoral hernia by a midline reduced. Moreover, the spermatic cord is not manipu- extraperitoneal approach. Lancet 1936; 1: 531–3. lated circumferentially, offering the possibility that 10 Nyhus LM, Stevenson JK, Listerud MB, Harkins HN. Preperitoneal testicular vein thrombosis and testicular atrophy will be herniorrhaphy. A preliminary report in fifty patients. Western J lessened. Hernias that recur after open procedures can be Surg 1959; 67: 48–53. 11 Billroth T, ed. Czerny V. Beiträge zur Operativen Chirurgie. repaired laparoscopically without transgressing scarred Stuttgart: F Enke, 1878. tissue of the previous procedure. 12 Phelps AM. A new operation for hernia. N Y Med J 1894; 60: 291. Over the past two decades, laparoscopic hernioplasty 13 Goepel R. Ueber die Verschliessung von Bruchpforten durch has evolved from an experimental procedure to one of Einheilung geflochtener, fertiger Silberdrahtnetze proven efficacy. Groin hernia repair is not a simple exer- (Silberdrahtpelotten). Verh Dtsch Ges Chir 1900; 19: 174. 14 Witzel O. Ueber den Verschluss von Bauchwunden und cise, and its practice requires skill and attention to detail. Bruchpforten durch versenkte Silberdrahtnetze (Einheilung von Differing clinical situations demand different anatomic Filigranpelotten). Centralbl Chir Leipz 1900; 27: 257. approaches. Anterior open repair should probably be 15 Read R, Francis C. Usher, herniologist of the twentieth century. considered for pediatric patients and for patients with Hernia 1999; 3: 167–71. severe cardiopulmonary compromise, when repair may 16 Usher FC. Hernia repair with knitted polypropylene mesh. Surg Gynecol Obstet 1963; 117: 239. be performed under local anesthesia. Bilateral inguinal 17 Usher FC, Gannon JP. Marlex mesh: a new plastic mesh for hernias, recurrent hernias, and unilateral hernias with a replacing tissue defects: I. Experimental studies. Arch Surg 1959; suspected contralateral hernia, however, suggest that a 78: 131. laparoscopic approach be considered. 18 Usher FC, Cogan JE, Lowry TI. A new technique for the repair of The modern herniologist should be proficient in both inguinal and incisional hernias. Arch Surg 1960; 81: 847. 19 Usher FC. Hernia repair with Marlex mesh. Arch Surg 1962; 84: 73. laparoscopic and open repair techniques. The myth that 20 Usher FC, Allen Jr, Crosthwait RW, et al. Polypropylene the least skilled surgeon or resident can perform hernia monofilament: a new biologically inert suture for closing repair should be laid to rest. Hernia genesis involves contaminated wounds. JAMA 1962; 179: 780. 40 Laparoscopic inguinal/femoral hernioplasty

21 Usher FC, Wallace SA. Tissue reaction to plastics; comparison of 40 Schultz L, Graber J, Pietrafitta J, Hickok D. Laser laparoscopic nylon, Orlon, Dacron, and Teflon. Arch Surg 1958; 76: 997. herniorrhaphy: a clinical trial preliminary results. J Laparoendosc 22 Lichtenstein IL. Hernia Repair Without Disability, 2nd edn. St Louis: Surg 1990; 1: 23–5. Ishiyaku Euroamaerica, Inc., 1986. 41 Corbitt JD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc 23 Lichtenstein IL, Shulman AG, Amid PK, Montilier MM. The tension- 1991; 1: 23–5. free hernioplasty. Am J Surg 1989; 157: 188–93. 42 Toy FK, Smoot RT, Jr. Toy–Smoot laparoscopic hernioplasty. 24 Shulman AG, Amid PK, Lichtenstein IL. A survey of non-expert Surg Laparosc Endosc 1991; 1: 151–6. surgeons using the open tension-free mesh repair for primary 43 Salerno GM, Fitzgibbons RJ, Filipi C. Laparoscopic inguinal hernia inguinal hernia. Int Surg 1995; 80: 35–6. repair. In: Zucker KA, ed. Surgical Laparoscopy. St Louis: Quality 25 Halsted WS. Bull Johns Hopkins Hosp 1903; 149: 211. Medical Publishing, 1991: 281–93. 26 Zimmerman LM, Zimmerman JE. The history of hernia treatment. 44 Fitzgibbons RJ. Laparoscopic inguinal hernia repair. New Frontiers In: Nyhus LM, Condon RE, eds. Hernia, 2nd edn. Philadelphia: in Endoscopy, Nationwide Satellite Teleconference, May 1991. JB Lippincott Co., 1978: 3–13. 45 Arregui ME, Davis CD, Yucel O, et al. Laparoscopic mesh repair of 27 Fruchaud HR. Anatomie chirurgicale des hernies de l’aine. Paris: inguinal hernia using a preperitoneal approach: a preliminary G. Doin, 1956. report. Surg Laparosc Endosc 1992; 2: 53–8. 28 Wantz GE. Testicular atrophy as a risk of inguinal hernioplasty. 46 Dion YM, Morin J. Laparoscopic inguinal herniorrhaphy. Can J Surg Surg Gynecol Obstet 1982; 154: 570–1. 1992; 35: 209–12. 29 Stoppa RE, Petit J, Henry X. Unsutured Dacron prosthesis in groin 47 Kavic MS. Laparoscopic hernia repair. Surg Endosc 1993; 7: 163–7. hernias. Int Surg 1975; 60: 411–15. 48 MacFayden B, Arregui M, Corbitt J, et al. Complications of 30 Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron laparoscopic hernia. Surg Endosc 1993; 7: 155–8. in the repair of hernias of the groin. Surg Clin N Am 1993; 49 McKernan BJ, Laws HL. Laparoscopic preperitoneal prosthetic 73: 571–81. repair of inguinal hernias. Surg Rounds 1992; 7: 579–610. 31 Read RC. Preperitoneal exposure of inguinal herniation. Am J Surg 50 Dulucq JL. Traitement des hernies de l’aine par mise en place d’un 1968; 116: 653–8. patch prothétique sous-péritonéal en rétropéritonéoscopie. 32 Read RC. Attenuation of the rectus sheath in inguinal herniation. Cahiers Chir 1991; 79: 15–16. Am J Surg 1970; 120: 610–14. 51 Phillips EH, Carroll BJ, Fallas MJ. Laparoscopic preperitoneal 33 Read RC. The metabolic role in the attenuation of transversalis inguinal hernia repair without peritoneal incision. Surg Endosc fascia found in patients with groin herniation. Hernia 1998; 1993; 7: 159–62. 2 (suppl 1): 17. 52 Wright D, Paterson C, Scott N, et al. Five-year follow-up of 34 Read RC. Blood protease/antiprotease imbalance in patients with patients undergoing laparoscopic or open groin hernia repair. Ann acquired herniation. Prob Gen Surg 1995; 12: 41–6. Surg 2002; 235: 333–7. 35 Senior RM, Tegner H, Kuhn C, et al. The induction of pulmonary 53 Felix E, Michas C. The double-buttress laparoscopic herniorrhaphy. emphysema with human leukocyte elastase. Am Rev Resp Dis J Laparoendosc Surg 1993; 1: 1–8. 1977; 116: 469–75. 54 LeBlanc KA, Booth WV. Laparoscopic repair of incisional 36 Cannon DJ, Read RC. Metastatic emphysema. A mechanism for abdominal hernias using expanded polytetrafluoroethylene: acquiring inguinal herniation. Ann Surg 1981; 194: 270–8. preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. 37 Ger R. The management of certain abdominal herniae by 55 Franklin ME, Heniford BT, Arca MJ, et al. Laparoscopic ventral and intra-abdominal closure of the neck of the sac. Ann R Coll Surg incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. Engl 1982; 64: 342–4. 56 Kavic MS. Laparoscopic Hernia Repair. Amsterdam: Harwood 38 Popp LW. Endoscopic patch repair of inguinal hernia in a female Academic Publishers, 1997. patient. Surg Endosc 1990; 4: 10–12. 57 Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic 39 Bogojavlensky S. Laparoscopic treatment of inguinal and femoral treatment vs. open surgery in the solution of major incisional and hernia. Video presentation presented at the 18th Annual Meeting abdominal wall hernias with mesh. Surg Endosc 1999; 13: 250–2. of the American Association of Gynecological Laparoscopists, 58 Crawford DL, Hiatt JR, Phillips EH. Laparoscopy identifies Washington, DC, 1989. unexpected groin hernias. Arch Surg 1998; 64: 976–8. 6

Anatomy and physiology

B. PAGE AND PATRICK J. O’DWYER

View from the peritoneal cavity 41 Myopectineal oriﬁce 44 Pre-peritoneal space 42 Femoral canal and sheath 45 Transversalis fascia 43 Nerves 45 Oblique muscles 44 Pathophysiology and conclusion 45 Inguinal canal 44 References 46 Spermatic cord 44

A thorough knowledge of the anatomy and function of the VIEW FROM THE PERITONEAL CAVITY pre-peritoneal space and groin region is required by any surgeon with a special interest in treating hernias. Lack of knowledge of the basic pre-peritoneal anatomy has almost A starting point for any surgeon contemplating laparo- certainly led to injuries to vessels and nerves in this region, scopic hernia repair is to view the normal anatomy of which otherwise could have been avoided. In addition, the pelvis through the laparoscope (Figure 6.1) of a failure to recognize the importance of the anatomy by sur- patient undergoing another laparoscopic procedure, e.g. gical trainees and practicing surgeons has slowed progress cholecystectomy. With a head-down tilt of 15–30 degrees, in minimal-access approaches to hernia repair via the ﬁrst observe the natural boundaries between the pelvic pre-peritoneal space. and abdominal cavity. In the midline, one will see the symphysis pubis, the superior pubic ramii bilaterally, and the iliopubic tract laterally, traversing out as far as the

Median umbilical ligament Lateral fossa (urachus) Medial fossa Medial umbilical ligament Supravesical fossa Lateral umbilical ligament

Deep inguinal ring

Ileopubic tract Testicular vessels

Vas deferens Bladder

Figure 6.1 View of the pelvic anatomy observed through a laparoscope. 42 Laparoscopic inguinal/femoral hernioplasty anterior superior iliac spines. The iliopubic tract is a condensation of the fascia transversalis and lies deep to the inguinal ligament. Anterior to this natural division, in the midline, the median umbilical ligament is observed, which represents the obliterated remnant of the urachus and extends from the fundus of the bladder to the umbilicus. On either side and lateral to this are the medial umbilical ligaments, which represent the peritoneal folds around the obliterated embryonic umbilical arteries. Further laterally, one can observe the inferior epigastric vessels, sometimes referred to as the lateral umbilical ligament. The inferior epigastric vessels are important landmarks for the hernia surgeon, as indirect inguinal hernias pass lateral to them on their way through the internal ring Figure 6.2 The avascular plane immediately posterior to the to the inguinal canal, while direct hernias pass medially rectus muscle in a patient undergoing open surgery. Note on their way through the transversalis fascia. the transverse ﬁbers pointed out with tissue forceps below Posterior to the natural division between the abdomen the arcuate line. and pelvis, the bladder is noted in the midline and on either side the venous pulsation of the external iliac vein and the arterial pulsation of the external iliac artery. From this view, it should also be possible, in male patients, to note the vas deferens on its course through the internal ring over the external iliac vessels and down the pelvic side well, where it disappears to join the seminal vesicles on their way into the prostatic urethra. The testicular artery and vein should also be noted coursing lateral to the external iliac artery. If at this stage one is performing laparoscopy under local anesthesia, then it is worth asking the patient to cough. It will be noted that the internal inguinal ring is suddenly pulled upwards and laterally by the fascia transversalis sling, thus shutting the door to the inguinal canal.

Figure 6.3 The vascular plane between the pre-peritoneal fat PRE-PERITONEAL SPACE and the deep layer of fascia transversalis. This membranous layer is in continuity with the posterior rectus sheath. The allis forceps nearest the umbilicus marks the level of the arcuate line. The laparoscopic surgeon enters the pre-peritoneal space either transperitoneally or totally extraperitoneally. Getting into the right plane (i.e. immediately posterior to the rectus the midline, it is seen to fuse with the linea alba and can muscle) is important (Figure 6.2), otherwise the space be difficult to separate from that structure when moving between the pre-peritoneal fat and the deep layer of fas- to the contralateral side in bilateral hernia repair. cia transversalis is entered (Figure 6.3). This space con- The pre-peritoneal space is in direct communication tains numerous small blood vessels and is associated with with the retropubic space of Rietzius.1 Following the pubic troublesome bleeding, while the space posterior to the arch around on either side, the pectineal (Cooper’s) liga- rectus muscle is avascular. The deep layer of fascia trans- ment comes into view (Figure 6.4). This is usually crossed versalis lies between the rectus muscle and the peritoneum, by the anastomotic pubic artery and vein, tributaries from with pre-peritoneal fat sandwiched between them. The the inferior epigastric vessels, which course towards the fascia transversalis extends laterally beyond the inferior obturator foramen, where they join with their respective epigastric vessels and can be observed surrounding the pubic branch of the obturator vessels. An abnormal obtu- sac of an indirect hernia. It is particularly strong lateral to rator artery arising from the inferior epigastric will be the inferior epigastric vessels, and as it is pulled down to seen in a similar location; observed in about 30 per cent open the space lateral to this it can be seen to inter- of cases, this is larger than the aforementioned vessels. digitate with the fibers of transversus abdominus muscle. The pectineal ligament itself fans out over a broad area Inferiorly, in the midline, the fascia transversalis fuses of the superior pubic ramus, where medially it forms with the pubis, but it is quite flimsy here and breaks the lacunar ligament and anteriorly it continues as the easily with posterior movement of the laparoscope. In iliopubic tract. The latter structure goes from the pubic Anatomy and physiology 43

Medial limb of transversalis sling Inferior epigastric vessels Rectus muscle Aponeurotic arch Transversus abdominus muscle Hasselbach's triangle Internal ring Ileopubic tract Femoral branch of Deep circumflex iliac genitofemoral nerve artery and vein Iliacus muscle Lateral cutaneous Transversalis fascia nerve of thigh Genital branch of Femoral nerve genitofemoral nerve Lacunar ligament Psoas mucle Femoral canal Ileopsoas fascia (cut) Anastomotic pubic artery and vein Bladder Pectineal ligament Testicular vessels Vas deferens Obturator foramen Obturator vessels and nerve External iliac artery and vein Figure 6.4 The pre-peritoneal pelvic anatomy with the iliopsoas fascia partially excised to expose the femoral nerve on the right side. tubercle to the anterior iliac spine and is a condensation femoral branches at a variable distance along the psoas of the anterior layer of fascia transversalis. The iliopubic muscle. The femoral nerve lies deep to the iliopsoas fas- tract thus forms the posterior margin of both direct and cia and is again lateral to the iliac artery and runs along indirect hernias while it is anterior to a femoral hernia. the lateral border of the psoas muscle. Further lateral is The femoral canal is bounded by iliopubic tract anteri- the lateral cutaneous nerve of thigh, which can be seen orly, the pectineal ligament posteriorly, the lacunar liga- crossing the iliacus muscle and which passes below the ment medially, and the iliac vein laterally. Likewise, the iliopubic tract just medial to the anterior superior iliac triangular area bounded by the deep epigastric vessels spine. The deep circumflex iliac artery and vein cross over laterally, the lateral margin of the rectus muscle medially, the lateral cutaneous nerve on their course parallel and and the iliopubic tract posteriorly (Hesselbach’s triangle) superior to the iliopubic tract. These vessels can easily is the area through which direct hernias are formed. be injured at this site and cause some nuisance bleeding More precisely, from the pre-peritoneal view, the medial during laparoscopic hernia repair. limb of the fascia transversalis U-sling forms the lateral margin of a direct hernia, while the medial margin is TRANSVERSALIS FASCIA formed by the aponeuroses of the transversus abdominus muscle. The former can be seen easily at laparoscopic surgery with a large direct hernia, where the defect This fascial layer, which is thought to invest the entire extends lateral to the deep epigastric vessels. The fascia abdominal cavity, is a source of controversy for surgeons transversalis forms a U-shaped sling around the cord, and anatomists. Some argue that it is a weak layer with no with the two limbs extending anteriorly and laterally to intrinsic strength, while others regard it as essential both fuse with the posterior aspect of the transversus muscle. in the origin and repair of groin hernias. It is likely that This sling is responsible for the shutter mechanism, both of these statements are true and almost certainly which, for practical purposes, closes off the inguinal represent observations from different groups of patients canal with sudden increases in intra-abdominal pressure. or cadavers. Some regard it as a bilamellar structure with The iliopubic tract is an important landmark for the a strong anterior layer and a membranous deep layer.2 surgeon, for as well as having the femoral canal posterior There is little doubt from the laparoscopist’s point of view to it, the external iliac vein and artery pass behind the that a two-layer fascial structure exists. The anterior layer iliopubic tract and inguinal ligament to become the of transversalis fascia can be seen easily when reducing a femoral vessels. Both run on the medial aspect of the psoas direct hernia as an attenuated fascial structure that lines muscle and can be seen easily during a totally extra- the defect. The deep layer is observed when entering the peritoneal laparoscopic hernia repair. It goes without pre-peritoneal space subumbilically and immediately saying for surgeons who continue to use staples or other posterior to the rectus muscle (Figure 6.3). Both struc- fixation methods for laparoscopic hernia repairs that tures appear strong and difficult to break through in the placement of these devices in this area should be avoided. young patient with an indirect hernia; in older patients, As stated already, the vas deferens runs over the iliac both are flimsy, presumably because of a deficiency of col- vessels on its course from the prostatic urethra to the lagen.3 Some regard the deep layer as a distinct structure internal ring. The testicular artery and vein course just from the transversalis fascia. However, as it is followed lateral to the iliac artery, while the genitofemoral nerve laterally it appears to interdigitate with the abdominal runs a similar course, having split into its genital and muscles, making it likely that it is attenuated posterior 44 Laparoscopic inguinal/femoral hernioplasty rectus sheath and will thus contain a fascial contribution INGUINAL CANAL from the transversalis fascia.4 It is also likely that the so- called anterior layer of transversalis fascia is merely an attenuation of the aponeuroses of the internal oblique The inguinal canal is an oblique intermuscular slit about and transversus abdominus muscles. Evidence for this 6 cm long, lying above the medial half of the inguinal comes from children and young adults, in whom this ligament. It begins at the deep (internal) ring and ends at layer is mainly muscular or musculotendinous.5 the superficial (external) ring. It transmits the spermatic The transversus abdominus muscle is the deepest cord and the ilio-inguinal nerve in the male, and the round of the three abdominal muscle layers and the one seen by ligament and the ilio-inguinal nerve in the female. The the laparoscopic surgeon. It arises from the costal carti- anterior wall is formed by the external oblique aponeuro- lages of the lower six ribs, the vertebral column and the sis medially and the internal oblique laterally. Its floor is iliac crest. Its fibers run transversely, except in the lower made up of the rolled edge of the inguinal ligament. The abdomen, where they arch over the inguinal canal as an lower edges of the internal oblique and the aponeurotic aponeurotic arch, which is inserted into the pubic crest arch of the transversus muscle form the roof of the canal. and iliopectineal line. The transverse fibers proceed hor- These muscles arch over from in front of the cord laterally izontally to their insertion in the rectus sheath and linea to behind the cord medially. In adults, the posterior wall is alba. Below the aponeurotic arch, the posterior wall of thus strong medially and weak laterally, where it is formed the inguinal canal is closed by transversalis fascia only in by the transversalis fascia only. In children, however, the adults and is the site through which direct hernias occur. inguinal canal is short (1–1.5 cm) and the internal and When the aponeuroses of the transversus and the inter- external rings are almost superimposed on each other. nal oblique muscle are fused lateral to the rectus sheath, the term ‘conjoined tendon’ is used. This is a variable SPERMATIC CORD structure, however, and does not exist in all patients.6

The spermatic cord leaves the abdominal cavity via the OBLIQUE MUSCLES superficial ring. The coverings of the spermatic cord are formed by the local muscles and fascia. The internal sper- In addition to the transversus abdominus muscle, the matic fascia is derived from fascia transversalis, cremas- abdominal wall is composed of the internal and external ter muscle from internal oblique muscle, and external oblique muscles. The external oblique arises from the lower spermatic fascia from external oblique aponeurosis. The eight ribs. From its fleshy origin, the muscle spans widely to spermatic cord contains the testicular artery and vein, the an aponeurotic insertion. Superiorly, the aponeurosis is ductus deferens and its accompanying vessels, the cremas- very thin and is attached to the xiphoid process. Inferiorly, teric artery, lymphatics, and the genital branch of the it is thick and inserts into the anterior superior iliac spine genitofemoral nerve. Until birth, the processus vaginalis, and pubic tubercle as the taut inguinal ligament. In the the portion of the peritoneum that accompanies the testis midline, the aponeurosis forms the anterior rectus sheath on its descent into the scrotum in embryonic life, remains and is inserted into the linea alba. Posteriorly, the external opened. In some children, delay in closure may result in oblique is not attached and forms part of the lumbar trian- the development of a pediatric hernia. Although patent in gle. This, on occasion, may be a site for a lumbar hernia. some adults, the role of the processus vaginalis in the The internal oblique muscle arises from the lumbar development of an indirect inguinal hernia is not certain. fascia, from the anterior two-thirds of the iliac crest, and It is likely that failure of the sphincter mechanism of the from the lateral part of the inguinal ligament. The muscle inguinal region, the transversalis U-sling, combined with fibers run parallel to the costal cartilages until they reach contraction and flattening of the transversalis arch and the ninth rib, where they become aponeurotic. Above the internal oblique muscle, which essentially closes the umbilicus, the tendinous aponeurosis of the internal inguinal canal, is more important. oblique splits to encircle the rectus muscle. At a point 2.5 cm below the umbilicus lies the arcuate line, the pos- MYOPECTINEAL ORIFICE terior layer that was once thought to not exist. It is now recognized that the arcuate line merely marks the point where the posterior rectus sheath goes from a strong fas- Fruchaud emphasized that all groin hernias originate from cial structure to a more attenuated membranous struc- a single weak area (Figure 6.5).7 This area is formed by the ture (Figure 6.3). The lower fibers of the internal oblique abdominal wall muscles above, the arching fibers of the originate at the inguinal ligament and arch downward transversus abdominus, the internal and external oblique and medially with the fibers of transversus abdominus to muscles, the bony pelvis below, ilium covered by the pec- insert into the pubic crest anterior to the rectus muscle. tineal ligament, the rectus muscle medially, and the fascia Anatomy and physiology 45

Ilio-hypogastric nerve

Ilio-inguinal nerve

Inferior epigastric vessels

Cremasteric vessels Spermatic cord Genital nerve Inguinal ligament Ileopsoas muscle Figure 6.6 Position of the nerves in the right inguinal canal.

Inguinal ligament region. It passes obliquely through the substance of the psoas major muscle and emerges from this crossing deep Femoral vessels to the peritoneum and the ureter. It splits behind the

Spermatic cord deep inguinal ring into the genital and femoral branches. The genital branch lies on the floor of the inguinal canal Myopectineal orifice behind the spermatic cord and supplies the cremasteric Figure 6.5 The myopectineal orifice. muscle via its motor branches and the scrotal skin via its sensory branches. The femoral branch contributes to the covering the iliopsoas muscle laterally. The myopectineal sensation of the anterior thigh. The lateral cutaneous orifice is divided into two levels by the inguinal ligament. nerve of the thigh crosses the iliacus muscle after emerg- The superior, inguinal level provides a passage for the ing from the lateral border of the psoas muscle. It passes spermatic cord or round ligament; the inferior, femoral beneath the iliopubic tract just medial to the anterior level provides a passage for the femoral vessels. superior iliac spine and innervates the skin on the anterior and lateral surface of the thigh. The femoral nerve is the largest of the three nerves and lies deep to the iliop- FEMORAL CANAL AND SHEATH soas fascia. It can be seen emerging between the psoas and iliacus muscle, passing beneath the iliopubic tract, and innervating the muscles in the anterior compart- The femoral canal contains fatty tissue, lymph nodes and ment of the thigh and the skin of the anteriomedial lymphatics. The boundaries of the canal include the femoral aspect of the lower thigh and leg. vein and connective tissue laterally, the aponeurotic inser- Also of importance to the hernia surgeon are the ilio- tion of the transversus abdominus and lacunar ligament inguinal and ilio-hypogastric nerves (Figure 6.6). The medially, the iliopubic tract and inguinal ligament anteri- former is usually smaller than the latter and is sometimes orly, and the pectineal ligament posteriorly. The entrance to absent. These are both sensory nerves that arise from the canal, the femoral ring, is a little over 1 cm in diameter, the first lumbar nerve. The ilio-inguinal nerve passes while the canal itself is 1–2 cm long with its apex at the fossa through the inguinal canal and becomes superficial at the ovalis. The femoral sheath is an extension of the transver- external ring to innervate the skin of the scrotum and the salis fascia and envelops the femoral artery, vein and canal. medial upper thigh. Damage to the ilio-inguinal nerve in The sheath is divided into three compartments by septa of the inguinal canal causes sensory loss as the motor fibers connective tissue between each compartment. are already given off to the conjoint tendon. The ilio- hypogastric nerve emerges through the external oblique aponeurosis to innervate the suprapubic skin. NERVES PATHOPHYSIOLOGY AND CONCLUSION The nerves of most importance to the laparoscopic surgeon are the genitofemoral nerve, the lateral cutaneous nerve of the thigh, and the femoral nerve. The genito- A better understanding of the physiology of the inguinal femoral nerve comes from the first and second lumbar region may lead ultimately to novel methods of preventing nerves and completes the innervation of the groin and treating inguinal hernias. In children, fusion of the 46 Laparoscopic inguinal/femoral hernioplasty processus vaginalis is thought to be hormone-related.8 muscle to its aponeurosis on the rectus sheath. This sug- This is supported by the fact that inguinal hernias are gests an inherited anatomical variation that predisposes associated with an undescended testis and gonadotropin certain individuals to the development of an inguinal administration results in a significantly higher rate of hernia and helps explain why one-third of patients will closure of the processus vaginalis. Since androgen recep- have or develop a contralateral hernia while a similar tors are not present in the processus vaginalis, it has been number will have a family history of a hernia.16 postulated that their effect is on the genitofemoral nerve. Although we have made significant progress in the This releases calcitonin gene-related peptide (CGRP), understanding of the anatomy and physiology of the which has been shown to fuse the inner mesothelial layer inguinal region, there is still a lot to learn. Advancements of the processus vaginalis.9 Hepatocyte growth factor/ in these areas will undoubtedly lead to the prevention of scatter factor (HGF/SF) has also been found to induce some groin hernias and better treatment of existing fusion of the processus, suggesting that local administra- symptomatic hernias in the future. tion of these agents may lead to a non-surgical treatment of an inguinal hernia in neonates.9 While the presence of a patent processus vaginalis is a REFERENCES key element in the development of pediatric hernias, its role in adults is less certain. Autopsy studies reveal that 15–35 per cent of adults have a patent processus vaginalis 1 Bouchet Y, Voilin C, Yver R. The peritoneum and its anatomy. In: 10 Bengmark S, ed. The Peritoneum and Peritoneal Access. London: without ever developing a hernia. A more likely cause, Wright, 1989: 1–13. given the increasing incidence with age, is a relative 2 Cooper A. The Anatomy and Surgical Treatment of Abdominal reduction in connective tissue in the inguinal region.11 In Hernia. London: Longman, 1804. addition, there is evidence that altered collagen synthesis 3 Wagh PV, Read RC. Collagen deficiency in rectus sheath of patients may weaken the fascia transversalis in patients with an with inguinal herniation. Proc Soc Exp Biol Med 1971; 37: 382–4. 4 Arregui ME. Surgical anatomy of the preperitoneal fascia and inguinal hernia. In a study by Klinge and colleagues, posterior transversalis fascia in the inguinal region. Hernia 1997; immunohistochemical and Western blot analysis showed 1: 101–10. that the ratio of type I to type III collagen was decreased 5 Bendavid R. The transversalis fascia: new observations in significantly in the fascia transversalis of patients with an abdominal wall hernias. In: Bendavid R, Abrahamson J, inguinal hernia.12 The tensile strength of tissues depends Arregui ME, et al., eds. Abdominal Wall Hernias: Principles and Management. New York: Springer-Verlag, 2001: 97–100. on the proportion of type I and III collagen, and the 6 Sorg J, Skandalakis JE, Gray SW. The emperor’s new clothes or the authors postulated that the relative increase in type III myth of the conjoined tendon. Ann Surg 1979; 45: 588–9. collagen, thin, immature fibers might be responsible for a 7 Fruchaud H. Anatomie chirurgicale des hernies de l’aine. Paris: reduction in mechanical strength of the collagen matrix G Doin, 1956. of the abdominal wall. 8 Clarnette TD, Hutson JM. The development and closure of the processus vaginalis. Hernia 1999; 3: 97–102. The lack of strength in the supporting structures is 9 Sugita Y, Uemura S, Hasthorpe S, Hutson JM. Calcitonin gene- probably only part of the puzzle that leads to failure of the related peptide (CGRP) – immunoreactive nerve fibre and receptors inguinal region in adults. Anatomically, Hessert’s triangle in the human processus vaginalis. Hernia 1999; 3: 113–16. is a weak area that has the internal ring as its apex, the rec- 10 Read RC. Historical survey of the treatment of hernia. In: tus abdominus as its base, and the inguinal ligament and Nyhus LN, Condon RE, eds. Hernia, 3rd edn. Philadelphia: JB Lippincott, 1989: 3–17. aponeurotic arch of the transversus abdominus and inter- 11 Conner WT, Peacock EE. Some studies on the aetiology of inguinal 13 nal oblique as its sides. This area is normally closed by hernia. Am J Surg 1973; 126: 732–5. the contraction of the transversus and internal oblique 12 Klinge U, Zheng H, Si Zy, et al. Altered collagen synthesis in fascia muscular arch, which flattens out this arch and causes it to transversalis of patients with an inguinal hernia. Hernia 1999; approach the inguinal ligament. This essentially occludes 4: 181–7. 13 Hessert W. Some observations on the anatomy of the inguinal the triangle and is referred to as the inguinal shutter by region, with special reference to absence of the conjoined tendon. 14 Keith. Recent evidence indicates that in patients with an Surg Gynecol Obstet 1913; 16: 566–8. inguinal hernia, this triangle is larger than usual and thus 14 Keith A. On the origin and nature of a hernia. Br J Surg 1973; 11: closure of the shutter may be incomplete.15 The authors of 455–75. the latter study concluded that the greater area was a cause 15 Abdalla RZ, Mittlestaedt WE. The importance of the size of Hessart’s triangle in the aetiology of inguinal hernia. Hernia 2001; 5: 110–23. and not a consequence of inguinal herniation because the 16 Hair A, Paterson C, Wright D, et al. What effect has the duration reason for the increase in this area was a higher intersec- of an inguinal hernia on patient symptoms? J Am Coll Surg 2001; tion of the internal oblique and transversus abdominus 193: 125–9. 7

Intraperitoneal onlay mesh approach

MORRIS FRANKLIN

Patient selection 48 Postoperative management 51 Operating room set-up 48 Conclusion 51 Operative technique 49 References 51

It has been over 100 years since Bassini ushered in a new The three most popular procedures to emerge were the era of hernia surgery with the introduction of his triple- transabdominal pre-peritoneal (TAPP) patch, the totally layer technique to repair the inguinal floor. Since then, extraperitoneal (TEP) patch, and the intraperitoneal surgeons have developed a myriad of new methods of her- onlay mesh (IPOM) repairs. In the TAPP technique, nia repair in an attempt to improve the results. However, the peritoneum is incised intra-abdominally and a pre- despite a century of advances in hernia surgery, recur- peritoneal space is developed. A prosthetic mesh is then rence continues to plague the general surgeon and is the introduced into this space, placed over the abdominal wall primary reason why no single technique of herniorrhaphy defect, and stapled into place. The peritoneum is then has become universally accepted. The repair of inguinal re-approximated over the mesh so that there is no exposure hernias has probably produced more variety in technique of synthetic material to the intra-abdominal contents. than any other operation performed by the general sur- In the TEP approach, the peritoneal space is never geon today. Complexity of the anatomy, the variety in size entered. Dissection is carried out in the extraperitoneal and location of the defect, and the multiplicity of the space just below the fascia of the abdominal wall. A presentations of a hernia have contributed to this pre-peritoneal space is created using blunt dissection uncertainty regarding the optimal repair.1 and carbon dioxide insufflation. Synthetic mesh is then After minimally invasive surgery proved to be success- placed over the defect and fixed into place with staples or ful in the treatment of biliary, gastric and colon diseases, tacks, as in the TAPP procedure. surgeons attempted to find a method of successfully The potential drawback of both the TAPP and the TEP repairing inguinal hernias laparoscopically. It was felt that procedures is that they require considerable dissection to the attendant benefits of decreased postoperative pain and create the pre-peritoneal space, which can result in periop- disability seen in other minimally invasive procedures erative discomfort and complications, such as hematoma could be realized in hernia patients as well. The first report formation or injury to the vas deferens, vascular structures, of a laparoscopic technique of inguinal herniorrhaphy was or nerves. The TEP technique in particular is technically by Ger and colleagues in 1990,2 who advocated simple clo- more demanding, and the pre-peritoneal dissection can sure of the neck of the hernia sac. This was soon followed be very difficult to perform, particularly in large inguino- by reports of plugging of the inguinal canal or direct defect scrotal hernias. As a result, a third laparoscopic repair with a prosthetic mesh, as described by Schultz and col- was developed, which involves placing the mesh on the leagues3 in 1990 and by Corbitt4 in 1991. After unaccept- intra-abdominal side of the peritoneum, rather than pre- able early recurrence rates, these methods were abandoned peritoneally, thus avoiding the radical dissection of the in favor of newer techniques that combined the advan- pre-peritoneal space. This method of repair – the IPOM tages of a tension-free repair utilizing a synthetic mesh technique – was concurrently investigated in the Laboratory with the transabdominal approach of laparoscopy. for Experimental Laparoscopic Surgery at Creighton 48 Laparoscopic inguinal/femoral hernioplasty

University and at the Texas Endosurgery Institute, San PATIENT SELECTION Antonio.5 Yorkshire cross-feeder pigs with congenital indirect inguinal hernias underwent intraperitoneal herniorrhaphy with placement of Prolene mesh either All adult patients with inguinal hernias and who are fit laparoscopically or via laparotomy. At six weeks, all pigs for general anesthesia are considered candidates for a were sacrificed and an intra-abdominal exploration was laparoscopic IPOM procedure. Those patients with an carried out to confirm the success or failure of the repair, to obliterated pre-peritoneal space secondary to radiation stage the development of any adhesions to the mesh, to or previous surgery (radical retropubic prostatectomy, examine the prostheses for infection, and to evaluate the bladder surgery, vascular procedures, cesarean section, erosion of the prosthesis into neighboring structures. All etc.) are particularly good candidates in that a laparo- hernia repairs in both groups were successful. In addition, a scopic TAPP or TEP procedure would be technically significant reduction in adhesion formation was noted difficult or even impossible in this setting. Additionally, when the mesh was placed laparoscopically rather than by those patients with a failed TAPP or TEP are ideal candi- laparotomy. There was no evidence of intra-abdominal dates for this approach, which allows for recurrent hernia infection or erosion of the prosthesis into adjacent struc- repair in virgin territory. tures in either group. These findings parallel those of Relative contraindications include severe intra- Franklin6 and Layman and colleagues,7 who found that the abdominal adhesions due to prior surgery, ascites, coagulo- use of intraperitoneal material in swine models resulted pathy, severe underlying medical illness precluding general in good in-growth of peritoneum over the mesh with anesthesia, and lack of appropriate laparoscopic skills. minimal adhesion formation. We performed the first IPOM procedure in a human patient at the Texas Endosurgery Institute in 1990. Since OPERATING ROOM SET-UP then, we have repaired over 550 direct, indirect, and recurrent inguinal hernias using the IPOM technique, with an overall complication rate of 7.5 per cent and a recur- The operating room set-up for the IPOM procedure on a rence rate of 0.96 per cent.8 These results are compar- left-sided inguinal hernia can be seen in Figure 7.1. The able to those of Toy and colleagues,9 who reported 441 operating surgeon stands on the contralateral side of the IPOM repairs with a complication rate of 8.0 per cent table from the hernia, while the assistant is positioned on and a recurrence rate of 3.8 per cent, and Fitzgibbons the side ipsilateral to the hernia site. With the patient and colleagues,10 who detailed 217 IPOM repairs with a under general anesthesia, a catheter is placed in the blad- recurrence rate of 5.1 per cent. der and a nasogastric tube is introduced into the stomach.

Anesthesia Suction irrigation Cautery

Camera holder Assistant surgeon

Surgeon

Scrub table nurse Laparoscopy

Mayo stand

Hot plate sequential Primary Secondary compression Figure 7.1 Operating room set-up video cart video cart devices for left-sided hernia repair. Intraperitoneal onlay mesh approach 49

After insufflating the peritoneal cavity to 14 mmHg using space. Division of the sac also gives access to the properi- a Veress needle, a 5-mm trocar is introduced into the toneal area where a ‘lipoma’ of the cord, if present, can be abdomen on the side opposite the hernia, just lateral to the excised. When operating for left-sided hernias, we often rectus sheath at the level of the umbilicus. After a general- find it necessary to divide the embryonic adhesions that ized inspection of the abdominal cavity and lysis of adhe- the sigmoid colon maintains with the parietal peritoneum sions if necessary, a 10/12-mm trocar is placed at the adjacent to the hernia defect. We excise the sac using umbilicus and a 5-mm trocar is placed on the ipsilateral laparoscopic scissors connected to an electrosurgical unit. side of the hernia, exactly opposite the initial trocar. Trocar First, the sac is inverted progressively into the peri- placement is outlined in Figure 7.2. For bilateral repairs, toneal cavity using gentle traction. Once the inversion is the same configuration of trocar placement is utilized. completed, the sac is incised, starting 1 or 2 cm from its base at the 12 o’clock position and proceeding clockwise to about the 4 o’clock position. The incision is then restarted OPERATIVE TECHNIQUE at the ‘top’ and carried in an anticlockwise fashion until approximately the 8 o’clock position. The inversion of an indirect inguinal hernia sac drags within it the fatty areo- After inspection of the entire peritoneal cavity and lysis lar tissue in which the gonadal vessels and the vas may be of any remaining adhesions, the hernia site and the con- embedded. This tissue must be bluntly and carefully swept tralateral inguinal area are evaluated carefully. For proper away from the sac anteriorly. Once separated fully from orientation, the surgeon should recognize the median, the elements of the cord, the sac can then be safely excised medial and lateral umbilical ligaments. Just below the circumferentially and removed through a 10/12-mm port. posterior parietal peritoneum, the external iliac vein Small or capillary vessel bleeding during this phase of and artery, the gonadal vessels, and, in males, the vas the operation is controlled easily by pinpoint electro- deferens should be identified. The hidden course of the coagulation. Large inguinoscrotal sacs and sacs in multi- genitofemoral nerve and the approximate course of the ple recurrent hernias are ringed at the neck (incision of lateral femoral cutaneous nerve should be recalled and the peritoneum circumferentially) and are left in place. care taken to avoid rough dissection in this area. The exact Bleeding and extensive edema may ensue if these sacs are location of the ureter bilaterally should also be noted. pursued aggressively. We now routinely remove direct and indirect hernia Once the sac is removed, a piece of Polypropylene sacs, since in our experience leaving the sac may perpetu- mesh is prepared. The size of the mesh should be such ate a bulge in the groin – a bulge that patients and inexpe- that it covers the hernia defect and extends 3 cm beyond rienced surgeons interpret as an operative failure despite its rim in all directions at a minimum. We have found that repeated assurances that no bowel can enter the sac or a 12 ϫ 15-cm portion of mesh covers most defects adequately. The folded mesh is introduced into the abdominal cavity. We have found that if the mesh is folded rather than rolled, it will not have a tendency to curl once opened and it will be much easier to manipulate and hold in place. Once the mesh is unfolded, it is placed over the defect and held there with grasping forceps. The superior border of the mesh at its mid-portion is then held tightly against the anterior abdominal wall. A Keith needle attached to a 2-0 strand of Prolene, Ethicon, Somerville, NJ is pushed through the abdominal wall and through the mesh (Figure 7.3). Pressing gently on the abdominal wall with one’s finger and visualizing the inden- tation laparoscopically can establish the spot where the 1 mm incision is to be made and where the needle is to 10/12mm port pierce the abdominal wall. Through the same incision, a 13-gauge needle is then placed through the abdominal wall and the mesh, parallel to the Keith needle. Once the Keith 5mm port 5mm port needle is passed through the abdomen and mesh, it is grasped, turned through 180 degrees, and pushed back Hernia through the lumen of the 13-gauge needle, exiting through the small skin incision (Figure 7.4). A clamp is applied to the Prolene suture at skin level, which holds the mesh Figure 7.2 Trocar configuration for IPOM inguinal hernia repair. tightly against the abdominal wall. The same procedure is 50 Laparoscopic inguinal/femoral hernioplasty

Figure 7.5 Mesh stapled securely to Cooper’s ligament. Figure 7.3 Keith needle passing through mesh and abdominal wall adjacent to 13-gauge spinal needle. Once placed, these three sutures hold the mesh securely in place, spreading it out evenly and allowing for the rest of the mesh to be precisely and easily stapled in place. The staples are initially placed approximately 1–1.5 cm apart along the lateral edges of the mesh. Around the inferolateral aspect of the mesh, care should be taken to place the staples parallel to the course of the lateral femoral cutaneous nerve or the femoral branch of the genitofemoral nerve to minimize the chance of their entrapment, especially if these are placed lateral to the internal spermatic vessels and inferior to the iliopubic tract.12 Along the lower margin of the mesh, staples (a) should be placed lightly and further apart (2 cm) to avoid damage to the iliac vessels and the vas deferens. A few 13G needle staples are also used to fix the superior and central portion of the mesh to the anterior abdominal wall. Medi- ally, every effort should be made to secure the mesh to Cooper’s ligament (Figure 7.5). The anteriorly positioned inferior epigastric vessels, immediately beneath the peritoneum, should be avoided in the stapling process. Staples should not be used near the inferior or infero- Skin lateral aspect of the internal ring because of the risk of injuring the structures passing through it. The area is irrigated with saline solution and inspected for hemostasis. The subcutaneous fat below the skin Mesh incisions through which the Prolene sutures were placed Peritoneum is spread with a fine-tip hemostat, allowing the sutures to be tied over the external oblique aponeurosis. In our opinion, firm anchoring of the mesh by transabdominal stitches and staples in Cooper’s ligament prevents displacement of the mesh when the abdomen is deflated and (b) when the patient assumes the erect position. We firmly Figure 7.4 (a) Keith needle being passed back through abdominal believe that recurrent herniation is the result of early wall via 13-gauge needle. (b) Diagrammatic representation. migration of the mesh away from its intended position. To repair a contralateral hernia, the same procedure repeated at both upper corners of the mesh. This method is performed on the opposite side. Initially, we did not of percutaneous fixation of mesh for inguinal hernia repair combine this type of surgery with operations on the bowel was first described by Rosenthal and Franklin in 1993.11 We or biliary tree. However, these are no longer contraindi- do not rely solely on staples, which grasp only mesh and cations to the simultaneous repair of these hernias with peritoneum, to hold the prosthesis in place. bowel or biliary surgery subsequent to the development Intraperitoneal onlay mesh approach 51 of biosynthetic mesh materials such as Surgisis™ anesthesia, higher costs, the potential problems inherent (Cook Surgical), which have demonstrated high resist- to laparoscopy, and the need for technical expertise in ance to infection, even in contaminated fields.13 (See laparoscopic surgery. Potential complications due to the Chapter 4.) mesh’s direct contact with abdominal viscera have yet to As the trocars are sequentially removed, the trocar be realized in the laboratory or in clinical practice. sites are examined to ensure that no bleeding is present. The laparoscopic IPOM technique of hernia repair Finally, the umbilical insertion site is observed by slowly is a safe and relatively easy procedure to perform, with withdrawing the camera and its cannula in unison. To good results and low morbidity. It can be a particularly prevent potential herniation, all 10-mm trocar sites are effective technique for laparoscopic repair of recurrent closed by repairing the underlying fascia or aponeuro- inguinal hernias or for hernia repair in the setting of an sis with the aid of a Carter-Thomason® suture passer obliterated pre-peritoneal space. (Louisville Laboratories) using 0 Vicryl® (Ethicon) or Polysorb® (U.S. Surgical) sutures. The skin edges are then re-approximated with 3-0 Monocryl® (Ethicon) subcuti- REFERENCES cular sutures or Steri-strips® (3M Health Care).

1 Ramshaw R, Shuler FW, Jones HB, et al. Laparoscopic inguinal hernia repair: lessons learned after 1224 consecutive cases. Surg POSTOPERATIVE MANAGEMENT Endosc 2001; 15: 50–54. 2 Ger R, Monroe K, Duvivier R, Mishriek A. Management of indirect inguinal hernia by laparoscopic closure of the neck of the sac. Patients are generally discharged the evening of surgery Am J Surg 1990; 159: 370–73. or after a 23-hour observation period, depending on age, 3 Schultz L, Graber J, Pietrafitta JJ, Hickok D. Laser laparoscopic comorbidities, and difficulty of operation. They are herniorrhaphy: a clinical trial preliminary results. J Laparoendosc Surg 1990; 1: 41–5. scheduled for follow-up office visits one to two weeks 4 Corbitt JD. Laparoscopic herniorrhaphy. Surg Laparosc Endosc following discharge and are instructed to be aware of uri- 1991; 1: 23–5. nary retention, neuralgia (from damage to the lateral 5 Fitzgibbons RJ, Salerno GM, Filipi CJ, et al. A laparoscopic femoral cutaneous nerve), and scrotal swelling in men. intraperitoneal onlay mesh technique for the repair of an indirect We ask that they avoid heavy lifting (Ͼ9 kg) for five inguinal hernia. Ann Surg 1994; 219: 144–56. 6 Franklin ME. Animal studies and rationale for intraperitoneal to seven days following surgery. However, after this repair. In: Arregui ME, Nagan RF, eds. Inguinal Hernia: Advances brief time period, they are allowed to perform activity as or Controversies? Oxford: Radcliffe Medical Press Ltd, 1994: tolerated. 241–4. 7 Layman ST, Burns RP, Chandler KE, et al. Laparoscopic inguinal herniorrhaphy in a swine model. Am J Surg 1993; 59: 13–19. 8 Franklin ME, Diaz-Elizondo JA. The intraperitoneal onlay mesh CONCLUSION procedure for groin hernias. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and Condon’s Hernia. Philadelphia: Lippincott Williams & Wilkins, 2002: 269–76. The transabdominal approach to inguinal hernia repair 9 Toy FK, Moskowitz M, Smoot RT, Jr, et al. Results of a prospective is not a new concept. Advocated by Marcy14 in 1887 and multicenter trial evaluating the ePTFE peritoneal onlay laparoscopic 15 inguinal hernioplasty. J Laparoendosc Surg 1996; 6: 375–86. by LaRoque in 1932, the transabdominal approach for 10 Fitzgibbons RJ, Camps J, Comet DA, et al. Laparoscopic inguinal inguinal herniorrhaphy allows greater ease in identifica- herniorrhaphy: results of a multicenter trial. Ann Surg 1995; tion of groin anatomy, determination of the type of her- 221: 3–13. nia defect, and separation of incarcerated and adherent 11 Rosenthal D, Franklin ME, Jr. Use of percutaneous stitches in structures to the sac.16,17 However, the morbidity asso- laparoscopic mesh hernioplasty. Surg Gynecol Obstet 1993; 176: 491–2. ciated with a laparotomy is far too great for repair of 12 Eubanks S, Newman L, Goehring LM, et al. Meralgia paresthetica: an uncomplicated inguinal hernia. With the advent of a complication of laparoscopic herniorrhaphy. Surg Laparosc laparoscopic surgery, the benefits of the intra-abdominal Endosc 1993; 3: 381–5. approach to inguinal herniorrhaphy can be enjoyed 13 Franklin ME, Gonzalez JJ. Preliminary experience with new without the morbidity of a laparotomy. bio-active prosthetic material for repair of hernias in infected fields. Presented at the American Hernia Society meeting, The IPOM procedure is relatively simple to perform Tucson, AZ, USA, May 8–12, 2002. and carries with it all the potential advantages of a mini- 14 Marcy HO. The cure of hernia. JAMA 1887; 8: 589–92. mally invasive procedure with respect to the open inguinal 15 LaRoque GP. The intra-abdominal method of removing inguinal hernia repair, including less postoperative pain, earlier and femoral hernia. Arch Surg 1932; 24: 189–203. return to normal activities, ability to clearly visualize 16 Read RC. Preperitoneal herniorrhaphy: a historical review. World J Surg 1989; 13: 532–40. and repair all hernia defects bilaterally, easier repair of 17 Nyhus LM, Condon RE, Haskins HN. Clinical experiences with recurrent hernias, and improved cosmesis. Disadvantages preperitoneal hernia repair for all types of hernia of the groin. of the IPOM technique include the necessity for general Am J Surg 1960; 100: 234–44. This page intentionally left blank 8

Transabdominal pre-peritoneal approach

REINHARD BITTNER, CLAUS-GEORG SCHMEDT AND BERNHARD JOSEF LEIBL

Principles 53 Special remarks 61 Preoperative management 54 Postoperative management 63 Instrumentation 55 Conclusion 63 Operative room set-up 55 References 63 Operative technique 56

The introduction of laparoscopic operating techniques sufficiently large, then laparoscopic pre-peritoneal hernio- opened up the possibility of using this method to plasty can be seen as a completely tension-free method of implant mesh into the pre-peritoneal space to repair an hernia repair, which dispenses with any and all kinds inguinal hernia. By sparing the patient a large abdominal of fixation. In contrast to this, the success of an anterior incision in the inguinal region1 or in the midline,2 one mesh implant (Lichtenstein) depends on a strong external can expect a decrease in the number of wound complica- oblique aponeurosis and on a row of well-placed fixation tions, less postoperative pain, and consequently a faster sutures. recovery of normal physical activity and return to work. Laparoscopic hernioplasty can be used on any type of In contrast to pre-peritoneal mesh insertion via a mini- hernia, with the exception of huge, non-reducible scrotal mized anterior approach,3 the laparoscopic method hernia (more than double the size of a man’s fist). In our provides clear visibility when dissecting the inguinal patient pool of more than 1100 hernia repairs yearly, region with safe, wrinkle-free placement of a large mesh.4 TAPP is used in 99 per cent of repairs.5 Conventional her- Laparoscopic hernioplasty with pre-peritoneal placement nia repair operations are carried out only in young of a large mesh (transabdominal pre-peritoneal (TAPP) patients (Ͻ20 years of age), in patients at high cardiopul- repair) represents a synthesis between proven conven- monary risk where a general anesthetic is refused, and in tional operative techniques and the advantages of a mini- patients who decline to accept implantation of prosthetic mally invasive approach. materials. Preferred indications are hernias recurring after conventional operations (with the advantage of avoiding 6 PRINCIPLES anterior scar areas), bilateral hernia (both sides can be treated through the same three trocar incisions), and hernias with extensive destruction of the rear wall of the Indications hernial canal (Nyhus type 3 with a defect diameter of more than 3 cm, pantaloon hernia).7,8 Other accepted The mode of operation of TAPP follows the law of indications are inguinal pain in athletes,9 after eliminat- physics according to Pascal.2 As a result of pre-peritoneal ing other possible causes, and hernias in patients who placement of the prosthesis, i.e. between abdominal wish to return to normal physical activity as quickly as pressure and the weak point in the abdominal wall, the possible. pressure that initially caused the hernia now acts as a Pain in the inguinal area with no clinically or sono- stabilizer for reconstruction. If the mesh chosen is graphically proven hernia sac or lipoma of the spermatic 54 Laparoscopic inguinal/femoral hernioplasty cord is not seen as an indication for laparoscopic hernio- between anterior and posterior implant techniques.10 The plasty. Painstaking neurological (inguinal nerve neural- same meta-analysis confirmed that in comparison with gia?) and orthopedic investigation is necessary. Strong anterior mesh implants, laparoscopic/endoscopic tech- selection for operation is the only way to reduce signifi- niques provide a clearly higher patient comfort and a cantly the frequency of postoperative chronic pain for significantly faster resumption of normal physical activity. these patients. However, a clinically proven hernia, even It was observed, however, that the risk of severe complica- though a hernia sac may not have been identified laparo- tions is higher when using the laparoscopic technique scopically, does necessitate complete dissection of the (4.7/1000 v. 1.1/1000). Furthermore, the laparoscopic inguinal region. As a rule, very often one will find a cir- technique means longer operating times and significantly cumscribed lipoma of the inguinal canal or a fatty mass higher costs. There is no doubt that the laparoscopic tech- that has moved into the inguinal canal. The operation is nique is more difficult to learn. This is, to some extent, then identical to a hernia repair. related to the fact that many clinics do not routinely Advantages of the TAPP technique over the totally perform videoendoscopic operations, and therefore there extraperitoneal (TEP) approach include the following: is no structured training curriculum available. In the authors’ hospital, with the experience that comes from After insertion of the laparoscope, one can assess • more than 8000 hernia repairs, a median operating time of immediately the hernial situation on both sides and 40 minutes is sufficient for experienced surgeons, while recognize the landmarks that are important for trainees need 55 minutes. These times are completely in dissection. the range of those for open repair.5 A decisive factor con- Intestinal adhesions in the hernial sac (sliding hernia) • cerning the costs is whether disposable or non-disposable can be recognized immediately. instruments are used, and whether, or how, the mesh is Control of any bleeding is possible by appropriately • fixed in place. A high potential cost-saving is possible here. aimed electrocoagulation, thereby avoiding injury to The experience of our clinic is that the costs for the oper- the adherent intestinal wall. ating theatre alone (personnel and instruments) are only It is possible to diagnose accompanying pathological • about $75 higher than those of the Lichtenstein operation, conditions as well as to carry out additional surgery assuming that an anesthetist is required for the local in the abdominal space (e.g. cholecystectomy) anesthesia. Furthermore, the total costs for employees are without conversion to an open procedure. lower with the laparoscopic technique when the costs of lost work days are factored into overall expense.11 All in all, Contraindications the literature and our own results show that a well-trained surgeon can perform a cost-effective laparoscopic hernio- The only absolute contraindication is for patients at high plasty in a period of time that is well within the range of cardiopulmonary risk who cannot be subjected to general that for conventional open surgery. anesthesia or a pneumoperitoneum. A relative contraindication is seen in patients after extensive abdominal surgery, especially after a lower abdominal laparotomy through a PREOPERATIVE MANAGEMENT midline incision as well as after surgery in the space of Retzius (transabdominal prostate resection, bladder resection), after previous laparoscopic or endoscopic hernio- Anatomy/pathology plasty with mesh implant, and in patients with large, old, irreducible scrotal hernia. Patients who have undergone the Clinical examination of the patient is indispensable. An above operations tend to develop extensive adhesions in experienced examiner can diagnose correctly inguinal her- the abdominal space as well as substantial scarring between nia with a total accuracy rate of 0.93. An additional sono- 12 the retroperitoneal structures. These patients present a risk graphic examination can increase this figure to 0.94. not only of increased bleeding but also of injury to the Classification of the hernia into medial or lateral, or in intestinal organs and the bladder, as well as the large respect to the size of the defect, can be estimated only abdominal vessels. approximately, both clinically and sonographically, achieving a total accuracy rate of correct diagnosis of only 0.62 and 0.53, respectively. Exact classification of the hernia is Laparoscopic versus open repair therefore only possible intraoperatively. Precise knowledge of anatomy is indispensable for According to a meta-analysis of the EU Hernia Trialists a successful laparoscopic hernia operation, especially Collaboration covering a total of 58 randomized studies, concerning the course of the epigastric vessels, the large recurrence rates can be reduced by about 50 per cent by pelvic vessels, the corona mortis, and the inguinal nerves implanting prosthetic materials, with no difference noted (Figure 8.1). Transabdominal pre-peritoneal approach 55

with a blunt, conical tip and a radially expanding effect. Endo-Overholt and endo-scissors have a connection for monopolar electrocoagulation. In the case of large hernia sac, dissection is carried out using two Endo-Overholts. A 30-degree angled laparoscope is used. We recommend using Reddick–Olsen atraumatic forceps to push an umbrella-like mesh through the 12-mm trocar. The handles of the instruments mentioned above should not be lockable; the dissection forceps (Kelly) is the only exception, where a lockable handle is useful. The peritoneum is closed with a running stitch (Lahodny-Suture, Ethicon, PDS 3/0) with clip ﬁxation. An endoscopic needle-holder and a clip-application forceps are necessary for this suture.

Figure 8.1 Complete dissection of the pelvic floor. All OPERATIVE ROOM SET-UP important anatomical structures are visible. The patient is supine and flat on the operating table. After Preoperative testing setting up the pneumoperitoneum, the patient is placed into the Trendelenburg position and turned at an angle of In patients who are old (Ͼ60 years) or who have an about 15 degrees towards the surgeon, so that the surgeon increased cardiopulmonary risk, an electrocardiogram can approach the inguinal region without being hindered (ECG) and thoracic X-ray are essential. Additionally, if by intestinal loops. The patient’s arms are at his or her side, necessary, blood and clotting tests should be run. Patients so that the operator can change sides easily in cases of a should be asked whether they have taken aspirin and, if bilateral hernia. The surgeon stands on the side opposite necessary, platelet function assay (PFA) values should be the hernia; the camera operator is positioned on the ipsilat- determined. eral side of the hernia. The monitor is placed at the foot of Some authors recommend evaluation of the colon for the patient. The assisting nurse with the instruments is pathology to eliminate a symptomatic hernia, especially always to the left of the patient, between the surgeon and in older patients. If the patient’s history is uneventful, the camera operator. The anesthetist looks after the patient however, this is not considered a routine examination. as usual, from the head of the operating table, so that each A preoperative urethral catheter is not necessary. It member of the team can follow the progress of the opera- is usually sufficient to request that the patient empties tion on the monitor at any time (Figures 8.2–8.4). their bladder before being transported to the operating theater. Should a full bladder be found during laparoscopy, however, a suprapubic urinary catheter can be laid MCL MCL via percutaneous puncture.

INSTRUMENTATION

The following instruments are needed for a laparoscopic hernioplasty: Assistant Surgeon (camera) Veress needle for creating a pneumoperitoneum; • 10mm • 10-mm trocar at the navel for insertion of the optics; 5mm • 5-mm trocar in the left mid-abdomen for insertion 12mm of the Endo-grasper (Overholt); Scrub • 12-mm trocar in the right mid-abdomen for the hernia nurse stapler, the mesh and the Metzenbaum endo-scissors. A dissection swab (forceps according to Kelly) and/or a gauze for hemostasis can also be inserted. Monitor All the trocars and operating instruments are reusable instruments. It is important that the trocars do not Figure 8.2 Localization of ports for TAPP repair of left-sided cut through the tissues; our preference is to use trocars inguinal hernia. MCL, medioclavicular line. 56 Laparoscopic inguinal/femoral hernioplasty

MCL MCL abdominal surgery, then we prefer the Veress needle technique. Initially, a longitudinal skin incision about 1 cm long is made along the upper border of the umbilicus. The abdominal layers are held under maximum tension (the umbilical area is lifted with two Backhaus clamps in the corners of the incision), and the Veress needle is inserted into the abdominal space under careful monitoring, as described by Semm.13 At the beginning of insuffla- Assistant tion, the intra-abdominal pressure and the rate of gas flow Surgeon (camera) must be monitored carefully. Pressure must initially be 10 mm 0 mmHg and the gas flow must be 2–3 liters CO2/min. If 12 mm the pressure is initially too high or the gas flow too low, 5mm then the position of the needle must be checked and/or an Scrub open approach into the abdominal space should be chosen. nurse If the patient has an umbilical hernia, we make a 2–3-cm-long horizontal incision at the upper border of the umbilicus, dissect the hernial sac, and then use the Veress needle or the optical trocar to gain entry to the abdominal Monitor space through the hernial gap (fascial closure in these patients follows at the end of the operation in the same Figure 8.3 Localization of ports for TAPP repair of right-sided way as for umbilical hernias). If intra-abdominal pressure inguinal hernia. MCL, medioclavicular line. reaches 12 mmHg and the aspiration test is regular, then the optical trocar is inserted. The abdominal wall should again be held under maximum tension. The optical trocar is then inserted into the abdominal cavity in the direction MCL MCL of the center of the navel with slightly rotating movements, the most effective way to avoid slipping on the fascia. By using this technique, the danger of inadvertent injury to the small or large intestines or large vessels is kept Assistant changes Surgeon changes position for repair position for repair at a negligible minimum. of contralateral side of contralateral side If intra-abdominal adhesions are expected, especially after prior median laparotomy, then the open technique Assistant Surgeon according to Hasson should be chosen to insert the opti- (camera) cal trocar. After the somewhat larger skin incision has 10 mm 12 mm been made, the linea alba is dissected and opened up far 5mm enough between two Kocher clamps to allow insertion of a finger. After opening the peritoneum, the finger is Scrub nurse inserted into the abdominal space to check for and/or eliminate possible adhesions. The optical trocar can then be inserted and the pneumoperitoneum created. Now the further steps of the operation are under direct Monitor view. In cases of a bilateral hernia, both the working trocars, 5 mm left, 12 mm right, are introduced into the mid- Figure 8.4 Localization of ports for TAPP repair of bilateral clavicular line at the level of the umbilicus. If the hernia is inguinal hernias. MCL, medioclavicular line. unilateral, then we recommend inserting the ipsilateral working trocar about 1–2 cm above the navel area and/or the contralateral working trocar about 1–3 cm below the OPERATIVE TECHNIQUE navel region (Figures 8.2–8.4). In this way, collisions with the optical trocar can be avoided. In order to dissect the inguinal region, the surgeon uses the right hand to oper- The operation begins with the creation of the pneumo- ate the Metzenbaum Endo-scissors, which are connected peritoneum and insertion of the camera trocar. The to monopolar electrocautery. The left hand operates the pneumoperitoneum can be installed with the help of the Endo-Overholt. Veress needle or after open insertion of the optical trocar The transabdominal technique allows immediate assess- (Hasson technique). If a patient has had no previous ment of the hernia situation. The operative procedure is Transabdominal pre-peritoneal approach 57

Figure 8.6 Partly blunt, partly sharp dissection in the mostly Figure 8.5 Generous arcuate incision of the peritoneum about avascular, cobweb-like tissue layer between the peritoneum and 3–4 cm above the transverse arcade and the inner inguinal ring, the abdominal wall. beginning at the anterior superior iliac spine and leading to the medial umbilical fold. initially not dependent on the type of hernia because the aim is to completely dissect the inguinal region and all possible hernial orifices. Adhesions between the omentum or intestine within the inguinal region or the hernial sac (e.g. sliding sigmoid hernia) are not detached but removed en bloc with the peritoneum from the abdominal wall or from the hernial orifices. The operation then begins by determining the site of the anterior superior iliac spine using the bimanual method – the palpating finger of the left hand on the outside, the tip of the scissors on the inside. Regardless of the type and size of the hernial orifice, starting at this point a generous curving incision of the peritoneum is performed, well above the internal inguinal ring and above the rear wall of the Figure 8.7 In very obese patients, early preparation of the inguinal canal as far as the median umbilical ligament anatomical landmarks (e.g. epigastric blood vessels, symphysis) (Figure 8.5). It is usually not necessary to divide this liga- is very important. Dissection then follows these landmarks ment, even in the case of a prominent ligament, i.e. when strictly, which have to be prepared absolutely free of fatty tissue. this structure projects far into the abdominal space or has a large component of adipose tissue, nor if the hernial sac During this phase, early identification of some anatom- is found to be located very medially. Division of this liga- ical structures (landmarks), including the epigastric ves- ment can lead to unnecessary bleeding from umbilical sels, symphysis and Cooper ligament, and iliopubic tract, vessels that remain patent. If the peritoneal incision needs is important, especially in obese patients or in unclear to be extended, then this is carried out parallel to the hernia situations (Figure 8.7). Only when these structures ligament in the cranial direction. The peritoneal and/or have been identified properly can dissection continue, fol- subperitoneal small blood vessels are coagulated immedi- lowing the structures in the direction of the hernial orifice/ ately with monopolar current, so that the site is always hernial sac. Special attention must be paid to dissection absolutely free of blood and has a yellowish-pink color. underneath the iliopubic tract, in order to avoid injury to Dissection continues strictly in the mostly avascular, nerves (N. cutaneus femoris lateralis, N. genitofemoralis) cobweb-like zone, whereby the procedure is mainly blunt, or vessels (Figure 8.8). Clumsy and obscure use of electro- and the peritoneum with its surrounding pre-peritoneal coagulation and placement of clips are strictly prohibited. fatty tissue can be pushed away from the fascia transver- Any bleeding that occurs must be controlled immedi- salis and the rectus muscle (Figure 8.6). The few blood ately to keep the site clearly visible and to avoid increased vessels that may be encountered are coagulated. light absorption, which would cause insufficient lighting 58 Laparoscopic inguinal/femoral hernioplasty

Figure 8.10 Dissection of the medial compartment has to be carried beyond the middle of the symphysis so that a supra- Figure 8.8 Avoiding rough dissection in the lateral caudal symphytic defect, especially in recurrent hernias, is not missed. compartment, below the iliopubic tract and lateral to the testicular blood vessels, endangering the inguinal nerves, which may have a very variable course. slightest points of bleeding. In this way, the formation of extensive postoperative sero-hematoma can be largely avoided. Furthermore, two basic principles are to be taken into account when dissecting the medial compartment: 1 Dissection has to reach past the middle of the symphysis to the opposite side in order to identify a suprasymphytic hernial orifice (Figure 8.10), not uncommon in recurrent hernias, and also to create a large enough space for wrinkle-free placement of the mesh. Usually, this preparation is simple and carries no risk of injury to the bladder wall. Problems may be expected, however, in cases of previous operations in this area (e.g. prostate resection). Due to the significant risk of bladder injury, operations on such patients should be performed only by very experienced laparoscopic surgeons, otherwise a Figure 8.9 Dissection of a direct hernia in a case of bilateral conventional anterior approach should be selected hernias, where the opposite mesh is already in place. In order from the start. to avoid the formation of seroma, generous use of 2 In a lateral direction, the medial compartment electrocoagulation in hemostasis is recommended. should be dissected as far as the iliac vessels, in order to eliminate the possibility of a femoral hernia. Preparation should be carried out very carefully to of the operative field. Control of any bleeding can be avoid injury not only to the iliac vessels but also carried out with the aid of a dissection swab in the right to the corona mortis, which is found in about hand or with a small gauze that is inserted easily via the 20–30 per cent of patients (Figure 8.11). 12-mm trocar. The electrocoagulator is then connected to the Endo-Overholt in the left hand, allowing accurate Dissection of the lateral compartment is significantly coagulation. more difficult, especially in patients with a large amount In most cases of direct herniation, the lipomatous her- of adipose tissues with a large indirect hernial sac and in nial content will be dissected from the extended transver- patients with severe scar contractions between hernial sac salis fascia and removed from the hernial orifice during and cremaster muscle. These problems are not uncom- dissection of the Hesselbach triangle, i.e. the level between mon, especially in recurrent hernias after previous con- epigastric vessels, the transversus arcade, and the liga- ventional operation. A basic consideration in an indirect mentum inguinale/tractus iliopubicus (Figure 8.9). This hernia is that the hernia sac should be located cranially dissection is almost completely blunt. Careful hemostasis and laterally to the spermatic cord, whereas the vas defer- is important to ensure that the part of the fascia transver- ens should be most caudal, stretching over the iliac ves- salis that forms the hernial sac is totally free of even the sels in a medial direction, while the testicular vessels can Transabdominal pre-peritoneal approach 59

Figure 8.11 During medial dissection, the iliac vein has to be prepared in order to recognize femoral defects. Care: corona mortis! Figure 8.13 In case of a tangled situation around the inner inguinal ring because of fatty tissue, we ﬁrst prepare the testicular blood vessels, caudal and lateral, and then dissect in a cranial and medial direction.

carefully and pushed aside easily. If the hernial sac is very long, it may need a strong tug with the left hand holding the Endo-Overholt to remove the hernial sac from its bed in the inguinal canal. To prevent the hernial sac from slipping back into the inguinal canal, e.g. when adjusting the Endo-Overholt, we recommend dissection with two Endo-Overholts following the rope-ladder principle. It is important to identify the testicular vessels as early as possible during dissection. This is usually done easily in the region of the base of the hernial sac as far as possible laterally and dorsal-caudally (Figure 8.13). Further dissection is carried out parallel to the testicular vessels in a medial-ventral direction to the angle between iliop- Figure 8.12 Tip of the hernia sac clearly visible in front of the ubic tract and epigastric vessels. It can sometimes be left Endo-Overholt. Strong adhesions to the cremasteric bundle helpful to create a dorsocaudal window between hernial (in front of the right Endo-Overholt) can be removed after sac and spermatic cord, especially in the case of a scrotal careful electrocoagulation. hernia. If complete removal of a hernial sac may seem too difﬁcult regarding risk of injury to the spermatic be followed in a lateral direction. Detachment of the her- cord, then the hernial sac can be severed. If the hernial nial sac from the internal inguinal ring in the region of its sac stays in situ, however, the risk of postoperative hydro- upper circumference can therefore be carried out rela- cele may be higher. tively quickly, as there is usually no danger of injury to Our experience in more than 450 scrotal hernias the spermatic cord (Figure 8.12). If an accompanying shows that the hernial sac can almost always be removed lipoma of the spermatic cord is present, this can usually completely without risk of injury to the testicular vessels be mobilized out of the inguinal canal relatively easily; or extensive postoperative hematoma, as long as the fol- sometimes, only then is it possible to make an approach lowing principles are observed:14 early identiﬁcation of to the hernial sac. the testicular vessels laterally and caudally of the hernial Dissection is mainly blunt, adhering strictly to the sac, dissecting from caudal-lateral to ventral-medial, care- hernial sac with careful hemostasis. If there are irremov- ful hemostasis, strict dissection while the hernial sac is able adhesions between the hernial sac and the cremaster held under tension, and severing stronger adhesions with tube or spermatic cords, then these are electrodissected the aid of electrocoagulation. Once the point of the top of 60 Laparoscopic inguinal/femoral hernioplasty

Figure 8.14 Partly blunt, partly sharp removal of the hernia sac Figure 8.15 End of dissection: the peritoneal sac is removed towards the abdomen while performing meticulous hemostasis beyond the middle of the psoas muscle. All anatomic structures of the spermatic structures (parietalization). are recognizable and freed of fatty tissue. the hernial sac has been reached, the rest of the procedure is simple (Figure 8.14). Partly blunt, partly sharp (electrocoagulation) dissection is now carried out in the direction of the abdominal cavity, and the hernial sac is detached completely from the spermatic cords. This procedure is known as parietalization. Parietalization (i.e. detachment of the hernial/peritoneal sac from the retroperitoneum and/or from the spermatic fascia covering the retroperitoneum and the spermatic cord) is performed in the direction of the head, as far as the mid-psoas muscle, so that there is no longer any contact between the peritoneum and the vas deferens medially and between the testicular vessels and the peritoneum laterally. Manipulation of the peritoneum should no longer lead to changes in the position of the spermatic cords. Extensive parietalization is especially important when an unslitted mesh is to be inserted. This is the only way to ensure that when the peri- ϫ toneum is closed, any adhesions that may be left behind Figure 8.16 A 10 15-cm polypropylene mesh is placed do not displace the mesh into a position that could lead to without folds. All potential hernia openings are overlapped by a recurrence. If extensive parietalization is not possible, at least 3 cm. which does happen very rarely (sometimes in a patient with a recurrence after TAPP), then a slitted mesh can be out wrinkles, overlapping all possible hernial orifices introduced, causing the dorsal portion of the mesh to take by at least 3 cm (Figure 8.16). Using such a large mesh up a position behind the spermatic cords. means that fixation is necessary only to facilitate posi- After this dissection, the entire myopectineal orifice is tioning (e.g. in very shallow curved inguinal areas or to free of peritoneum and fatty tissue, thereby allowing com- avoid mesh dislocation in the immediate perioperative plete identification of the epigastric vessels, the internal phase). Fixation is carried out with a few clips or staples. inguinal ring, Hesselbach’s triangle, Cooper’s ligament, We recommend using two clips in both the areas of the the iliopubic tracts, the testicular vessel bundle, and the symphysis and/or Cooper’s ligament, two clips to fix the vas deferens (Figure 8.15). A 10 ϫ 15-cm polypropylene upper border of the mesh to the rectus muscle medial to mesh can now be inserted. The mesh is folded like an the epigastric vessels, and two clips lateral to the epi- umbrella over the Reddick–Olson Endo-forceps and gastric vessels into the fascia transversalis (Figure 8.17). pushed through the 12-mm working trocar into the Before the clips are fixed at the ligament of Cooper, a inguinal region, where, due to the memory effect, it can possible corona mortis and/or the iliac vessels should be be spread out easily. The mesh should be positioned with- identified. After the iliopubic tract is identified, the lateral Transabdominal pre-peritoneal approach 61

Clip position in TAPP technique

Figure 8.17 Presentation of clip ϭ Clip position positions and the endangered regions: triangle of pain and triangle ϭ Forbidden area of doom. (a) Medial defect; (b) lateral defect; (c) femoral defect. clips are placed, keeping a minimum cranial distance of about 2–3 cm. If these basic guidelines are followed strictly, injury to the large vessels or the inguinal nerves can be avoided completely. We almost always use an unslitted mesh for the following two reasons: • The slit can cause a recurrence because it weakens the stability of the mesh. • In contrast to the keyhole technique, there is no need for circular dissection of the spermatic cord with the risk of damaging some small vessels, and there is also no close contact between the spermatic cord and the mesh, thus eliminating the possibility of it becoming involved in scar tissue. Before the peritoneum is closed, it is lifted and the extent of parietalization is checked. The covering peri- Figure 8.18 The peritoneal fold should be 1–2 cm proximal to toneal fold should be at least 1–2 cm above the upper end the caudal edge of the mesh. of the mesh (Figure 8.18). Finally, the peritoneal incision is closed carefully with resorbable sutures (PDS, Lahodny). To facilitate tension-free closure, the intra- Suturing of the lateral fascial openings is not neces- abdominal pressure should be reduced to 6–8 mmHg. sary when blunt, radially expanding trocars are used, When using this technique, a tight and secure seal is pos- because the rectus muscle covers these openings. The sible even with scarred peritoneum, a task that is occa- fascial opening for the camera trocar should always sionally difficult when clips are used. The suture closure be closed with suture to avoid the occurrence of a late is technically more difficult, however, and needs practice. postoperative trocar hernia. After carrying out five to ten operations, however, even a relative beginner should be able to perform it efficiently. Finally, the working trocars are removed under direct SPECIAL REMARKS visualization. Even though blunt trocars are used, bleeding from the epigastric vessels does occur on occasion and must be recognized and controlled. In such cases, A drain is generally not necessary, but in the case of large hemostasis is simple to carry out with electrocoagulation scrotal hernias, a retroperitoneal closed suction drain and can be performed with an Endo-Overholt intro- ought to be used, placed between the mesh and the duced via the contralateral trocar. abdominal wall. 62 Laparoscopic inguinal/femoral hernioplasty

Bilateral hernia vessels, so that the former is displaced medially and the latter are displaced in a very lateral direction. Very rarely, The identical standard technique is used separately the testicular vessels may be looped around the sper- for each side, with implantation of a 10 ϫ 15-cm poly- matic cord in a medial and ventral direction. Whereas propylene mesh on each side.15 these problems occur mostly in indirect recurrent hernias, operation of a direct recurrent hernia is much easier because, as a rule, there are no structures nearby that Recurrent hernia after conventional may be injured. It must be taken into account, however, operation that the tranversalis fascia should not be perforated during dissection, as one would then enter into the inguinal An essential advantage of the laparoscopic technique in canal and possibly damage the testicular vessels. recurrent hernias after anterior conventional repair is that dissection can be shifted into the pre-peritoneal space, which is mostly free of scar tissue, allowing the use of an Recurrent hernia after pre-peritoneal almost standard primary hernia technique. The results patch hernioplasty (operating time, morbidity, return-to-work times, recurrence rate) are consequently not significantly different to Laparoscopic operation of a recurrent hernia after those of a primary hernia operation (Table 8.1). The only pre-peritoneal hernioplasty is technically possible, but exception is the situation after previous hernioplasty operation time will be significantly longer, and there will according to Lotheisen. In this case, significant scarring be a risk of higher morbidity.16 However, the time needed can be expected at Cooper’s ligament, and it is difficult to to regain physical activity is the same as for the standard operate laparoscopically in this area. This situation can be technique in primary hernias. overcome by choosing a peritoneal incision caudal to Operation of a recurrent hernia after pre-peritoneal the Cooper ligament. After the usual dissection of the hernioplasty is extremely difficult and should be carried peritoneum, which has been described above, in an area out only by very experienced laparoscopic hernia sur- somewhat medial to the Cooper ligament a whetstone-like geons. As a rule, extensive scarring can be found between incision is made around the ligament itself at the peritoneal the abdominal layer and mesh, and/or mesh and peri- level. This method allows renewed access to the scar-free toneum, and can only be dissected sharply. Dissection pre-peritoneal space caudally, where further dissection can begins in the scar-free areas, with early identification of now take place undisturbed. Although this leaves a small, the landmarks (epigastric vessels, symphysis, Cooper’s scarred peritoneal section on the Cooper’s ligament, the ligament). Medial dissection should adhere strictly to the polypropylene mesh can nevertheless be anchored safely. rectus muscle and/or the fascia transversalis in order to In the area of the internal inguinal ring, it is not avoid damage to the bladder. In 80 per cent of cases, we uncommon to find scar formation 1–2 mm thick sur- found a dissection layer between abdominal wall and rounding both the hernia sac and the spermatic cord. mesh, and in about 20 per cent of cases between peri- Once this cuff-like scarred ring of tissue is cut with elec- toneum and mesh. As noted earlier, reoperation upon a trocautery in the neighborhood of the epigastric vessels direct hernia is significantly easier than on an indirect her- (which may involve the cremasteric muscle), standard nia. Operation of an indirect hernia is extremely compli- dissection can continue. cated, but once the scar areas have been overcome and It must be taken into consideration that the previous direct access gained to the hernial sac, the rest of the oper- operation may have resulted in an atypical localization of ation is not too different to that of a primary hernia. The the spermatic cord. The recurrent hernia can occasion- mesh is usually left in place; parietalization, however, is ally develop between the vas deferens and the testicular possible in only the rarest of cases. As a rule, a slitted mesh

Table 8.1 Operative results in 8050 consecutive laparoscopic hernia repairs Median Median operation Morbidity Reoperation Recurrence return to time (min) rate (%) rate (%) rate (%) work (days) Unilateral primary hernia (n ϭ 4222) 47 3.0 0.4 0.8 14 Bilateral primary hernia repair (n ϭ 1341)* 35 2.2 0.5 0.6 15 Recurrent hernia (n ϭ 1146) 45 4.5 1.0 1.1 21 Scrotal hernia (n ϭ 440) 65 4.8 1.1 2.7 19

*Results related to 2682 repaired hernias. Transabdominal pre-peritoneal approach 63 will have to be inserted. In such cases, we do, however, simple. Sometimes external pressure may be required. The secure the slit with a second, smaller mesh using the hernial content can now be reliably assessed for viability. so-called double-buttress technique. In case of a direct The further procedure again correlates to the standard hernia and stable conditions in the area of the lateral technique. If the intestine shows signs of gangrene, then compartment, lateral dissection is not necessary. It suf- a primary mesh implant is not recommended due to the ﬁces to implant a piece of mesh that is appropriately sized risk of infection. Thorough rinsing of the inguinal region so that it overlaps the hernial defect by at least 3 cm and and the insertion of a drain is recommended. Defect can be anchored to the original mesh, which is located reconstruction, however, should not be performed; an laterally. option here is open repair with sutures.

Scrotal hernia POSTOPERATIVE MANAGEMENT In comparison to the TEP technique, the advantage of the TAPP technique on scrotal hernia is the immediate identification of adhesions of the intestinal loops within On the evening after the operation, the patient is allowed the hernial sac, so that trauma to the wall of the bowel to get up and use the toilet. The patient may drink freely (e.g. by electrocoagulation on the hernia sac) can be and may have a light meal if desired. A diclofenac 100 mg avoided completely. The operation is performed strictly suppository is provided as needed. A one-night stay in according to the standard technique, as mentioned above, the hospital is obligatory for insurance reasons in almost exclusively using the two Endo-Overholt tech- Germany, where the authors of this chapter work. On the nique and the rope-ladder principle. Especially important following morning, we recommend that the patient in this kind of hernia is the fat-free dissection of the moves around freely and begins light stretching exercises internal inguinal ring, the detachment of all lipomatous for the inguinal region. The patient should decide when masses from the inguinal canal, the spermatic cord and to be discharged. As a rule, patients leave the hospital the hernial sac, early preparation of testicular vessels, and between the second and fourth postoperative day. Before carefully controlled hemostasis.14 In the case of a very discharge, sonography of both inguinal regions and large internal inguinal ring, a 10 ϫ 15-cm standard mesh scrotum is performed routinely. Sutures are removed (as may be too small because it is not possible to overlap the an outpatient) on the sixth postoperative day. From the upper border of the hernial ring by the required mini- eighth to the tenth postoperative day, we recommend mum 3 cm. Therefore, in these patients we prefer to use a return to work and resumption of normal physical activ- 15 ϫ 15-cm mesh. ity. All patients are included in a follow-up program and requested to attend a specific hernia consultation four weeks and one, three and five years postoperatively. Irreducible/incarcerated inguinal hernia

Irreducible and especially acute incarcerated hernias present a good indication for the laparoscopic tech- CONCLUSION nique.17 An exception, however, is the very large, chronically irreducible scrotal hernia, as the relationship Laparoscopic hernia repair is a well-standardized repair between operative effort and result are out of propor- technique, suitable for all types of inguinal and femoral tion. Although an open approach is also difﬁcult in such hernias. The procedure combines highest patient comfort patients, the few cases that do come into question should with low morbidity and recurrence rates. However, fun- opt for this technique. In contrast, the laparoscopic tech- damental training in laparoscopic surgery is an important nique offers advantages in acute incarcerated hernias. It prerequisite for good results. When laparoscopic proce- may be possible to avoid resection of the intestine, as dures are established in a surgical department, this tech- there is more time available to observe how the damaged nique can be performed on a routine basis, even as a intestinal wall recovers. If a resection does prove neces- teaching operation. sary, then the required laparotomy can be kept small, or it may even be possible for the whole operation to be carried out via laparoscopy. The operation begins in the standard way, with the REFERENCES aim of completely exposing the hernial ring in the pre- peritoneal space. Reduction of the hernial contents via 1 Rives J, Nicaise H, Lardennois B. A propos du traitment chirurgical traction should be avoided. If the exposed hernial ring des hernies de l’aine. Orientation nouvelle et perspectives is split in a ventral-cranial direction, then reduction is thérapeutiques. Ann Med Reims 1965; 2: 193–200. 64 Laparoscopic inguinal/femoral hernioplasty

2 Stoppa RE, Rives JL, Warlaumont CR, et al. The use of Dacron in 11 Heikkinen TJ, Haukipuro K, Hulkko A. A cost and outcome repairs of hernias of the groin. Surg Clin N Am 1984; 64: 269–85. comparison between laparoscopic and Lichtenstein hernia 3 Ugahary F, Simmermacher RKJ. Groin hernia repair via a gridiron operations in day-case unit. A randomized prospective study. Surg incision: an alternative technique for preperitoneal mesh insertion. Endosc 1998; 12: 1199–203. Hernia 1998; 2: 123–5. 12 Bittner R, Kraft B, Kuckuk B, et al. Ultrasound examination in 4 Arregui MD, Davis CJ, Yucel O, Nagan RF. Laparoscopic mesh repair laparoscopic/endoscopic hernia surgery. In: Fitzgibbons RJ, Jr, of inguinal hernia using a preperitoneal approach: a preliminary Greenburg AG, eds. Nyhus and Condon’s Hernia, 5th edn. report. Surg Laparosc Endosc 1992; 2: 53–8. Philadelphia: Lippincott Williams & Wilkins, 2002: 95–102. 5 Bittner R, Leibl BJ, Kraft K, et al. Laparoscopic transperitoneal 13 Semm K. Operative Manual for Endoscopic Abdominal Surgery – procedure for routine repair of groin hernia. Br J Surg 2002; 89: Operative Pelviscopy – Operative Laparoscopy. Chicago: Year Book 1062–6. Medical Publishers, 1985. 6 Felix EL, Michas C, McKnight RL. Laparoscopic repair of recurrent 14 Leibl BJ, Bittner R, Schmedt CG. Scrotal hernias: a contraindication groin hernia. Surg Laparosc Endosc 1994; 4: 200–4. for an endoscopic procedure? Surg Endosc 2000; 14: 289–92. 7 Nyhus LM. Individualization of hernia repair: a new era. Surgery 15 Schmedt CG, Däubler P, Leibl BJ, et al. Simultaneous bilateral 1993; 114: 1–2. laparoscopic inguinal hernia repair: an analysis of 1336 8 Schumpelick V, Treutner KH, Arlt G. Inguinal hernia repair in consecutive cases at a single center. Surg Endosc 2002; 16: 240–4. adults. Lancet 1994; 344: 375–9. 16 Leibl BJ, Schmedt CG, Kraft K, et al. Recurrence after endoscopic 9 Ingoldby CJH. Laparoscopic and conventional repair of groin transperitoneal hernia repair (TAPP): causes, reparative techniques disruption in sportsmen. Br J Surg 1997; 84: 213–15. and results of the reoperation. J Am Coll Surg 2000; 190: 651–5. 10 EU Hernia Trialists Collaboration. Repair of groin hernia with 17 Leibl BJ, Schmedt CG, Kraft K, Bittner R. Laparoscopic synthetic mesh – meta-analysis of randomized controlled trials. transperitoneal hernia repair of incarcerated hernias: is it feasible? Ann Surg 2002; 235: 322–32. Surg Endosc 2001; 15: 1179–83. 9

Totally extraperitoneal approach

ED FELIX

Principles 65 Postoperative management 73 Preoperative management 66 References 74

The surgical approach to inguinal hernia repair has method, and the potential complications and their undergone a slow evolution since Bassini introduced the management will be described. first true anatomical repair over 100 years ago.1 Initially, surgeons were fixated on tissue to tissue repairs. Then, 2 3 Lichtenstein and coworkers and Stoppa and colleagues PRINCIPLES demonstrated that tension-free reinforcement of the abdominal wall with mesh eliminates one of the major causes of recurrence, the intrinsic or acquired weakness A surgeon must be experienced in conventional anterior of the groin; the emphasis of hernia repair then switched approaches as well as both laparoscopic approaches dramatically. Ten years later, laparoscopic surgeons took (TAPP and TEP) in order to make a rational decision on the tension-free repair one step further by introducing a which hernioplasty best fits an individual patient and her- repair that reinforced the groin, avoided missed hernias, nia. The laparoscopic approach that is chosen depends and reduced postoperative recovery. upon the surgeon’s level of experience, the type of hernia Many early attempts at a laparoscopic approach, how- present, and the patient’s past history. For most patients, I ever, fell quite short of this lofty target. There seemed to be favor the TEP approach because it avoids entering the a wide variability in the results reported by surgeons. peritoneal cavity, it requires less operative time, and it has Many complications as well as early failures were reported. less potential for complications than the TAPP approach. It quickly became apparent, however, that success with this There are, however, a few exceptions. The TAPP approach approach was dependent upon the level of laparoscopic is preferred if the patient has an incarcerated hernia, expertise of the surgeon and the ability of the surgeon to because this approach allows for an accurate analysis of apply proper techniques to appropriate patients.4 what is incarcerated and its viability, as well as safe and At first, the majority of surgeons were limited to a single usually easy reduction of the contents of the hernia. laparoscopic approach, the transabdominal pre-peritoneal When the hernia is incarcerated, balloon dissection of the (TAPP) approach, but soon the totally extraperitoneal extraperitoneal space may lead to a large tear in the (TEP) approach became a viable alternative. Arguments peritoneum or injury to incarcerated omentum, bowel or between laparoscopic surgeons on which approach was bladder. The extraperitoneal approach and especially the better were common, but now most surgeons realize that use of a balloon dissector should be avoided if the hernia each approach works well when applied appropriately in cannot be reduced after the induction of anesthesia. the hands of an experienced laparoscopic surgeon.5 In female patients with abdominal pain, the etiology The purpose of this chapter is to describe an approach of the pain may be in question. When a surgeon needs to to the laparoscopic TEP repair of inguinal hernias that has differentiate between pain secondary to a groin hernia resulted in a recurrence rate of less than one per cent in and other possible causes, such as endometriosis, one over 2000 repairs in our center. The indications and should perform a diagnostic laparoscopy followed by a contraindications to the use of the approach, the operative TAPP repair when indicated. For female patients where 66 Laparoscopic inguinal/femoral hernioplasty the diagnosis is certain, a TEP technique is preferred. The elected in children. At the other extreme are patients over presence of a Pfannenstiel incision is common in many 70 years of age. Some have suggested that laparoscopic female patients because of a previous cesarean section or repair should be limited to working younger adults. It is pelvic surgery, but this should not interfere with the TEP our experience, however, that patients of all ages benefit dissection because a Pfannenstiel incision is really a mid- from the laparoscopic approach, especially regarding the line fascial incision. rapid recovery and return to normal activity. Some previous operations, abdominal incisions, or We recommend that patients who are not candidates treatments may preclude adequate or safe dissection of for general anesthesia should have an open hernioplasty the extraperitoneal space. Previous pelvic irradiation or under a local anesthetic. Although several centers have radical prostatectomy can prevent separation of the peri- reported success using local and regional anesthesia for toneum from the abdominal wall. Balloon dissection of extraperitoneal repairs,7 it has been our experience that the extraperitoneal space may result in injury to the blad- some patients will become anxious if carbon dioxide der or a large rent in the peritoneum. A lower-abdominal enters the peritoneal cavity, necessitating conversion to a incision crossing the rectus sheath can obstruct the safe general anesthetic. We would reserve laparoscopic repair passage of the dissector. If the dissector is forced through for patients who are candidates for general anesthesia, the obstruction, the peritoneum will tear and an intra- even if the case is to be performed using a local or regional abdominal visceral injury may result. A transverse incision technique. An absolute contraindication to laparoscopic is not a contraindication to the use of the extraperitoneal hernioplasty is the presence of infection. Neither the approach, but if resistance is experienced when passing the TAPP nor the TEP approach should be used in the face of dissector, then the procedure should be converted to a local or systemic infection because of the risk of infecting TAPP approach. A midline incision is usually not a prob- the mesh. lem when using the TEP approach. The dissector slides toward the pubis parallel to the incision. The peritoneum along the midline will separate from the abdominal wall PREOPERATIVE MANAGEMENT when the balloon is inflated, or it can be dissected manually after the trocars are placed. If bilateral repairs are planned, however, then there is a small chance that a Anatomy and pathology previous midline incision will prevent dissection of the opposite side. In this case, the surgeon may initiate the Understanding the anatomy of the groin has never been procedure as a TEP approach and convert to the TAPP easy, but it has always been important to the performance approach when, or if, this becomes necessary. of a successful inguinal hernia repair. Because the post- The laparoscopic approach is ideally suited for recur- erior anatomy of the groin is being viewed in an unfamil- rent hernias. The surgeon’s view of the posterior wall is iar way, it can be even more difficult to understand it. unobstructed and allows for complete identification of Consequently, without a complete knowledge of the the site of recurrence and repair of the entire posterior normal and pathological anatomical structures of the floor. The decision of whether a TAPP or TEP approach posterior groin, any laparoscopic posterior repair will should be employed is dependent upon the expertise of be doomed to failure. (See Chapter 6 for an overview of the the surgeon. The dissection of the recurrent indirect sac anatomy/physiology of the inguinal region.) The easiest can be difficult using the extraperitoneal technique and way to learn the normal anatomy of the posterior wall is to requires more skill than that of a primary repair. With first view it through a transabdominal route (Figure 9.1). experience, however, this difference in degree of diffi- Once the surgeon understands the normal and pathologi- culty disappears, and the surgeon should base the hernio- cal aspects of the posterior anatomy via a TAPP approach, plasty choice on other factors. then dissection of the extraperitoneal space and exposing The extraperitoneal dissection of large scrotal hernias the anatomy of the posterior space via a TEP approach can is similar to that of recurrent hernias, in that the separa- be undertaken. Because the anatomical structures are not tion of the indirect sac can be quite difficult.6 To avoid obvious until the dissection is completed, it is key that the problems, the surgeon should use the TAPP approach surgeon understands what is being dissected in order to until he or she has adequate mastery of some of the spe- prevent becoming lost or confused. Serious complications cial maneuvers required to deal with a long scrotal sac. to major vessels and nerves can occur, especially when The age of the patient may influence the type of there is a large indirect or femoral hernia. hernioplasty chosen. In general, laparoscopic hernio- To proceed without injuring normal structures, plasty should be reserved for adults. In a few cases, the the surgeon must identify certain landmarks. Once the patient that is a minor by chronological age may be fully extraperitoneal space is developed, identification of the mature and have an adult-type hernia or even a recurrent pubis will allow proper orientation of the other struc- hernia. Only then should the laparoscopic approach be tures. The next landmark is the inferior epigastric vessels, Totally extraperitoneal approach 67

(a) (a)

(b)

(b) Figure 9.1 (a) Indirect hernia viewed via the intraperitoneal approach. (b) Peritoneum opened. IND, indirect hernia; INF, inferior epigastric vessels; IPT, iliopubic tract; TV, testicular vessels; VAS, vas deferens.

which separate the indirect from the direct hernia and lead the surgeon to the major vessels of the pelvis (Figure 9.2). Sometimes, a large femoral hernia can obscure the major vessels, but the surgeon can become reoriented by locating the inferior epigastric vessels (Figure 9.3). Additionally, these vertical structures mark the location of where the lateral dissection of the indirect hernia begins. The ﬁnal important landmark is the iliopubic Figure 9.2 Extraperitoneal view of the groin. C, cord; DIR, direct tract (Figure 9.4). The identiﬁcation of this is essential to hernia; IL, iliac vessels; IND, indirect hernia; INF, inferior avoid injury to several cutaneous nerves and dissection epigastric vessels. of any cord lipoma that may be present. 68 Laparoscopic inguinal/femoral hernioplasty

Figure 9.5 Balloon dissector and Hasson trocar. Figure 9.4 Recognizing the iliopubic tract. CL, Cooper’s ligament; DIR, direct hernia; INF, inferior epigastric vessels; to ligate an indirect sac or a peritoneal tear are suggested. IPT, iliopubic tract. Rarely, a suction irrigator will be needed to clear blood from the extraperitoneal space and decrease groin and Preoperative testing perineal ecchymosis postoperatively. A full laparotomy set-up is not required, but a Mayo or Inguinal hernia repair does not require extensive pre- 6–8 inch curved clamp is needed to dissect the fat and operative testing, but it does require determination of muscle at the umbilicus. A number 11 scalpel blade is used whether the patient is a candidate for general anesthesia. to incise the fascia, and two ‘S’ retractors facilitate the dis- If general anesthesia is thought to be safe, then the sur- section and retraction of the fascia and muscle. Two 5-mm geon’s next step is to make sure that there are no other trocars are used for the placement of the instruments that contraindications to laparoscopic hernia repair. If there are used in the dissection of the pre-peritoneal space. are none, then the most appropriate laparoscopic Polypropylene mesh is the mainstay of the laparo- approach can be selected, as outlined earlier. Before scopic repair. Usually, a 15 ϫ 15-cm mesh is used and proceeding to the operating room, however, a complete trimmed to fit the posterior wall. The mesh is anchored to examination of both groins by the operating surgeon is the abdominal wall with 5-mm tacks supplied in a multi- essential. If the surgeon actively looks for a possible fire gun. Recently, however, we have used a preformed hernia on the contralateral side, then we have shown in a mesh that does not require fixation of any kind. The recur- prospective study that very few contralateral hernias will rence rate remains the same, but the risk of nerve injury is 8 be missed. It is not necessary to expose the opposite side lowered. In a small number of cases in which we feel fixa- to look for a second hernia during a TEP repair if the sur- tion is required, such as multi-recurrent hernias or where geon has performed a proper preoperative examination. the mesh will not lay flat against the wall, we use a regular In addition, the surgeon should determine whether the mesh and cut it to fit the space. hernia is reducible. If it is incarcerated, then a TAPP approach should be chosen. This avoids complications caused by the blind dissection of the incarcerated hernia Operative room set-up sac. The TAPP approach also allows the surgeon’s ability to evaluate the viability of the incarcerated contents. The room set-up is simple, requiring one surgeon, a nurse and a video monitor. The patient is positioned Instrumentation with both arms tucked at his or her side and with a slight head-down position. The surgeon stands on the side of TEP hernioplasty does not require many specialized the patient opposite the hernia and the scrub nurse/assis- instruments. A balloon dissector and balloon Hasson tant stands on the opposite side. The monitor is placed trocar (Figure 9.5) make the extraperitoneal dissection at the foot of the operative table and the Mayo stand is easier and simpler for most surgeons, but they are not over the legs. The insufflator should also be in plain view mandatory. We use a straight 10-mm endoscope, but of the surgeon. A single light is positioned directly over some surgeons prefer an angled scope. Unipolar scissors the periumbilical incision to help with the initial expo- for dissection and a bipolar coagulator to control bleed- sure of the fascial layers. ing are useful. At least two atraumatic graspers are Very few instruments are required for extraperitoneal needed to perform the dissection, and endoloop sutures dissection and hernia repair. They should be set up on the Totally extraperitoneal approach 69

Mayo stand so that either the surgeon or the nurse can the procedure should be converted to a TAPP approach. reach them readily. If a preformed mesh is used, then both When the pubis is palpated with the dissector, the balloon left- and right-sided meshes must be kept in the room. is inflated. The operator views the progress of the dissection directly via the laparoscope in the dissector.After completing the balloon dissection, the balloon is removed and Operative technique replaced with a specialized Hasson trocar that seals the extraperitoneal space. The dissected space is then insuf- We begin the procedure with a small transverse skin inci- flated with carbon dioxide up to 12 mmHg. We use lower sion 2.5 cm lateral to and just below the umbilicus on the pressures (8–10 mmHg) if the patient is thin or elderly. side of the hernia (or the dominant hernia if bilateral The anterior and posterior rectus sheaths create a tunnel hernias are present). By avoiding the midline of the that opens into the dissected extraperitoneal space. When fascia, we avoid entering the peritoneal cavity where the the tunnel is short, it does not interfere with exposure or anterior and posterior rectus sheaths merge. We choose placement of the other midline trocars; if it is very long, the side of the dominant hernia because we use a balloon the available space will be limited and the exposure will be dissector that will dissect more completely on the side poor. In this case, the sheath should be cut back with that it is placed. This makes the rest of the dissection sim- laparoscopic scissors. This maneuver will open up the pler. We identify the anterior rectus sheath by carefully exposure, greatly facilitating the rest of the repair. spreading the subcutaneous fat with a Mayo clamp. The Three trocars are placed in the midline: a 10-mm small vessels in the fat should not be torn at this point, Hasson just below the umbilicus for the camera, a 5-mm because bleeding in the tiny hole will make identification trocar just above the pubis, and a second 5-mm trocar of the anterior rectus sheath difficult. Two ‘S’ retractors between these two trocars in the midline. The second are placed in the wound and used to expose the white trocar is positioned as close as possible to the subumbili- fibers of the fascia. An 11 blade is used to incise the fascia cal camera trocar in order to leave space between the exposing the rectus muscle. One of the ‘S’ retractors is lowest trocar and the pubis. The inferior trocar is posi- placed under the muscle like a shoehorn; the muscle is tioned approximately three fingers below the middle elevated, thereby allowing visualization of the posterior trocar to prevent ‘sword fighting’ of the instruments and sheath. A finger is used to dilate the space in preparation still allowing the lowest trocar to be above the level of the for the placement of a balloon dissector. mesh. The surgeon must watch the entry of each trocar Because the posterior rectus sheath usually ends at the into the extraperitoneal space in order to prevent the lac- line of Douglas, an instrument such as the balloon dissec- eration of a small branch of the inferior epigastric vessels tor can be passed on top of the sheath, allowing it to auto- or penetration into the peritoneal cavity. We anchor each matically fall into the extraperitoneal space. The dissector is trocar to the skin with a specialized adhesive strip to placed behind the rectus muscle with its tip on the poste- prevent them from slipping in and out of the abdominal rior rectus sheath.Aiming it slightly upward, we gently slide wall during instrument manipulation. on top of the sheath toward the pubis until the pubic bone The exposure of Cooper’s ligament begins with the is palpated. If resistance is encountered, then the dissector dissection of the posterior aspect of the abdominal wall must not be forced into the space because it will tear the by the gentle sweeping off of any tissue remaining on the peritoneum. A second attempt to pass the instrument can pubis. If a direct hernia is present (Figure 9.6), it is com- be tried after dilating the space with a finger, but if that fails pletely reduced at this point. This can be accomplished

(a) (b) Figure 9.6 Reducing the direct hernia. INF, inferior epigastric vessels. 70 Laparoscopic inguinal/femoral hernioplasty

as possible. This maneuver allows the mesh repair to be covered by the peritoneum and not be lifted by it when the carbon dioxide is evacuated. To prevent the peritoneum from lifting the mesh on the medial aspect, the peritoneum must also be dissected off the vas deferens, as originally described by Stoppa in the open posterior repair. When an indirect hernia is present, the sac will be found anterior and lateral to the cord structures (Figure 9.8). If the sac is broad-based, it may extend medially to involve the vas deferens. We use a hand-over-hand technique to dissect the sac off the cord structures. The peritoneum must be dissected cephalad so that it does not contact the inferior edge of the mesh. If the peritoneum or any of its filamentous attachments to the canal are left under the mesh, they will elevate the mesh and lead to an early recurrence. A short or small sac is easily delivered out of the Figure 9.7 Lipoma of the cord. internal ring, but it may be difficult and traumatic to completely dissect off the cord a very long sac that descends with gentle traction on the peritoneal attachments to the into the scrotum. In the latter case, the sac should be defect. The peritoneum usually peels away from the trans- transected. The superior lateral edge of the peritoneum is versalis fascia, allowing it to balloon into the direct defect. incised first because the testicular vessels and the vas def- When the direct hernia is not reduced by these maneu- erens may be quite adherent to the undersurface of the sac. vers, we incise the fascial defect on the superior aspect to The vas deferens will be on the medial side and the testic- release the incarcerated hernia contents. The direct sac ular vessels on the lateral side. To avoid injury to these cord should not be ligated because the bladder may make up structures, they must be identified before the inferior peri- the medial aspect of the sac. In this situation, ligation of toneal surface is cut. A mass ligation of the sac should be this sac could result in an injury to the bladder. avoided because the spermatic cord could be inadvertently After dissection of the direct floor, the femoral area incorporated into the ligated tissue. must be examined. The iliac vein will be visible just lateral After the proximal sac is completely separated from to Cooper’s ligament. If it is not visible, then an incarcer- the distal sac, it is dissected off the cord structures and ated femoral hernia is probably covering the vein. The ligated with an endoloop. If the intraperitoneal carbon surgeon must reduce the hernia carefully so that the small dioxide causes the peritoneum to balloon outward into vessels in the femoral canal are not avulsed. If the hernia the operative field, the surgeon can usually dissect the is stuck in the canal, then an incision in the medial and peritoneum further cephalad in order to hold it out of superior edge of the femoral ring will release the hernia. the field of vision. Before ligating the indirect sac, it is The dissection of the lateral floor is initiated with probably better to wait until the mesh is in place because identification of the inferior epigastric vessels. The fat this will allow the peritoneal pressure to be in equilib- and loose connective tissues are dissected off the poste- rium with the extraperitoneal space and exposure will rior abdominal wall just lateral to these vessels until the not be compromised. At the end of the procedure, the peritoneum is identified. If there is a lipoma of the cord, indirect sac and any other tears in the peritoneum are then it will be lateral to the peritoneal sac and cord closed to prevent the development of internal hernias or (Figure 9.7). It is pulled out of the internal ring and left adhesions to the mesh. If carbon dioxide is trapped in the in the retroperitoneum, out of the operative field. peritoneal cavity, it is vented with a Veress needle to pre- Sometimes, only a slip of fat will be covering the ilio- vent postoperative shoulder discomfort at this point. pubic tract, but it may lead to a very large lipoma in the At the onset of a TEP repair, one cannot tell whether scrotum. The fibers of the iliopubic tract must be identi- there is an indirect component to the hernia until the fied to prevent leaving behind a lipoma. Cautery should lateral dissection is completed. This is in contrast to the be avoided in this part of the dissection because the TAPP approach, in which an indirect hernia is almost lateral femoral cutaneous nerve and femoral branch of always obvious on the initial inspection of the pelvic the genitofemoral nerve are directly under the lipoma. floor. Because of this, it is mandatory that the entire Dissection of the cord and possible indirect hernia is posterior floor be dissected in every TEP repair, even if a now started. If there is no indirect hernia, then the peri- direct or femoral hernia is not immediately apparent. toneal edge will be set back from the internal ring. The This is critically important because up to 30 per cent of edge of the peritoneum is lifted off the testicular vessels patients will have an indirect hernia in addition to the with atraumatic graspers and dissected cephalad as far obvious direct or femoral hernia defect.9 Historically, Totally extraperitoneal approach 71

(a) (b)

14 per cent of recurrent hernias after open repairs are due to missed hernias, and the laparoscopic approach potentially eliminates this cause of failure. The mesh repair is begun after dissection of all potential hernias. A 15 ϫ 15-cm sheet of polypropylene flat mesh is cut to fit the pelvic floor and anchored to the wall. Conversely, a preformed mesh can be used without anchors. Because the pelvic floor is wider from top to bottom medial to the iliac vessels, the medial half of the mesh is wider than the lateral side. The mesh drapes over Cooper’s ligament when it is placed into the pelvis. We place a colored absorbable stitch at the bottom of the medial side of the mesh as a marker. We do this with both our flat tailor-cut mesh and our preformed mesh to make orientation of the mesh much simpler and quicker. We place the polypropylene mesh into the extraperitoneal space by removing the laparoscope, grasping the Figure 9.9 Mesh placement. mesh on one end with a 5-mm instrument, and dragging it into the extraperitoneal space via the 10-mm port. We mesh is large enough to cover all three potential hernia do not find it necessary to roll up the mesh tightly before sites in every patient. The total size of the mesh must be placing it, as some have described. The laparoscope is tailored to the size of the patient’s pelvis. When the mesh replaced and the mesh pushed gently through the 10-mm is smoothed out, it overlaps the pubic bone and crosses port the rest of the way into the pelvis with the scope. the midline (Figure 9.9). Folds or wrinkles in the mesh Once the mesh is fully in the extraperitoneal compart- should be avoided because they lead to increased scar or ment, it is rotated using two graspers until the tagged adhesion formation and can be the cause of chronic pain corner is in place below Cooper’s ligament or pubis. The in the future. 72 Laparoscopic inguinal/femoral hernioplasty

The peritoneum and any lipomas of the cord must be well behind the inferior edge of the mesh before the mesh is fixed in place and/or the carbon dioxide is evacuated. As noted above, if tissue attachments of the sac to the distal cord remain under the mesh after the mesh is positioned, then the mesh may be lifted laterally in the postoperative period. The creation of a window between the vas deferens and the testicular vessels will allow the surgeon to be certain that a tail of sac has not been left behind. To accomplish this, the peritoneum on the vas deferens must be dissected completely from underneath the mesh. A large sac or lipoma should be placed on top of the mesh after the mesh is anchored and before the carbon dioxide is evacuated. These maneuvers prevent the mesh from being lifted up by (a) the peritoneal edge when the carbon dioxide is released. If the testicular vessels do not lie flat against the pelvic floor, as happens most often in very thin patients and patients with recurrent hernias, a double-buttress repair, as originally described for the TAPP hernioplasty, can be utilized.10 In this technique, a polypropylene mesh with a slit in the lower third is used to secure the indirect defect. The slit is placed around the cord and loosely re-approximated over Cooper’s ligament (Figure 9.10). A second mesh, like that described for conventional TEP repair, is placed over the mesh with the slit. Both meshes are cut from 15 ϫ 15-cm sheets of polypropylene and each measures approximately 14 ϫ 10 cm. The second mesh is placed to prevent a recurrence through the slit and completes the (b) repair of the direct and femoral areas. Figure 9.10 TAPP double-buttress mesh approach. If fixation of the mesh is to be used, this is the next step. The number of points of fixation has decreased since our technique was first described.11 It is important to recognize that the iliopubic tract is essential in the placement of these anchors. This tract is a white fibrous band running transversely along the lower edge of the internal ring. In some patients it is quite prominent and obvious, while in others it is subtle and barely visible (Figure 9.11). We confirm the location of the tract by placing one hand externally on the abdominal wall while the other hand presses the stapler internally against the wall. If the tip cannot be felt with the opposite hand, then it is unsafe to place a staple or tack at that site. The instrument is below the iliopubic tract and in an area where the nerves (femoral, genital branch of the genitofemoral, lateral femoral cutaneous) are at high risk of injury. No anchor should be inserted into the mesh and the posterior wall unless the anchoring device can be felt with the opposite hand. It is important not to Figure 9.11 Mesh anchored with tacks. press so hard as to force the staples (or other fixation device) deep into the muscle layers because this can that any wrinkles or folds are removed. If aberrant obtu- result in an injury to a more superficial nerve, such as the rator vessels are present coursing over the pubis, they ilio-inguinal. must be avoided otherwise serious bleeding can result. The first tacks or staples are placed through the mesh Other anchors are placed into the mesh and transversalis into Cooper’s ligament to stabilize the mesh, which allows fascia medial to the inferior epigastric vessels, whereupon the surgeon to fan out the mesh in a lateral direction so the mesh is smoothed out in a lateral direction, making Totally extraperitoneal approach 73

Mesh Mesh placement

Spermatic cord

Iliac vessels Vas deferens

Figure 9.12 Preformed mesh (3D Max, BARD).

POSTOPERATIVE MANAGEMENT sure that the peritoneum and lipoma of the cord are well cephalad to the posterior edge of the mesh. Lateral anchors are inserted using the bimanual technique Postoperative management for patients undergoing described above, so that damage to the neural structures laparoscopic inguinal hernioplasty is fairly standardized. below the iliopubic tract is prevented. The purpose of the The surgery is usually performed under general anesthe- fixation is not to strengthen the repair but rather to keep sia and patients are observed for approximately two to the mesh in place until natural in-growth occurs. The three hours before discharge. They are allowed to resume number of fixation points has therefore decreased as our normal activities as soon as they feel that they are understanding of this repair has grown. capable. No restrictions are placed upon the patients. We More recently we have begun using a preformed mesh allow patients to return to work and physical activity as that does not require fixation (Figure 9.12) (see Chapter 3). soon as their pain tolerance allows them to do so. On The results over the last two years equaled our earlier average, patients are back to 80 per cent of full activity in results with anchors. In the newer technique, the mesh, less than a week and are able to perform fairly physical which has a molded contour, fits into the pelvis and is activity, such as riding a bicycle, by the second week. not fixed with anchors. Care must be taken to use a mesh Some patients develop a seroma at the site of the hernia. that is large enough to be held in place once the carbon This, in fact, may mimic a recurrence, but it will reabsorb in dioxide is removed. 90 per cent of patients by six weeks. If it is not uncomfort- The final phase of the procedure is evacuation of the able for the patient, it is observed and then aspirated only carbon dioxide. It is released slowly through one of the if it is present after six weeks and if it appears that it is 5-mm ports while the lateral inferior corner of the mesh not resolving. We have not found it necessary to use is held against the wall with a grasper in the other 5-mm ultrasonography to diagnosis a seroma, but rather have port. This procedure ensures that the peritoneum will been able to rely on physical exam alone. On only one occa- cover the mesh rather than lift the inferior edge. The sion did we misinterpret the findings as a recurrent hernia peritoneum will rest on top of the mesh, holding it in when it was actually a contained fluid collection.12 place. If the peritoneum lifts the mesh, the mesh must be Using our extraperitoneal technique with and, more manipulated or trimmed until it is covered properly by recently, without anchors, we have maintained a recur- peritoneum. If there are bilateral hernias, we release the rence rate of less than 0.5 per cent over the last ten years. gas very slowly while watching both meshes and holding Short- and long-term morbidity, convalescence and sat- the corners of each mesh with a grasper as needed. The isfaction of all patients have been excellent. Because the small trocars are removed, and the rest of the extraperi- procedure can be performed rapidly and in an outpatient toneal gas is evacuated through the umbilical port. If car- setting, the overall cost has remained comparable to bon dioxide is trapped within the peritoneal cavity, it is other methods of hernia repair. The keys to a successful evacuated from the peritoneal cavity with a Veress laparoscopic technique are an understanding of the needle. The fascia of the 10-mm port is re-approximated posterior anatomy, perfection of the laparoscopic skills with absorbable suture. Gas trapped in the scrotum can required to perform advanced laparoscopic surgery, also be eliminated with a small needle at the end of the and knowledge of the limitations of the laparoscopic procedure, if deemed necessary. approach to inguinal hernia repair. 74 Laparoscopic inguinal/femoral hernioplasty

REFERENCES 7 Ferzli G, Sayad P, Huie F, et al. Endoscopic extraperitoneal herniorrhaphy. A 5 year experience. Surg Endosc 1998; 12: 1311–13. 1 Bassini E. Nuovo me todo cura radicale dell’ernia inguinale. Arch 8 Felix E. Laparoscopic approach to bilateral hernias. Sages abstracts Soc Ital Chir 1887; 4: 380. 1999. 2 Lichtenstein IL, Shulman AL, Amid PK, et al. The tension-free 9 Felix E, Michas C, Gonzalez H. Laparoscopic hernioplasty: why it hernioplasty. Am J Surg 1989; 157: 188–93. works. Surg Endosc 1997; 11: 36–41. 3 Stoppa R, Rives JL, Walamount C. The use of Dacron in the repair 10 Felix EL, Michas C. Double-buttress laparoscopic herniorrhaphy. of hernias of the groin. Surg Clin N Am 1984; 64: 269–85. J Laparoendosc Surg 1993; 3: 1–8. 4 Felix E, Scott S, Crafton B, et al. Causes of recurrence after 11 Felix E, Michas C, Mcknight R. Laparoscopic herniorrhaphy. laparoscopic hernioplasty – a multicenter study. Surg Endosc 1998; Transabdominal preperitoneal ﬂoor repair. Surg Endosc 1994; 12: 226–31. 8: 100–3. 5 Felix E, Michas C, Gonzalez H. Laparoscopic hernioplasty. Tapp vs. 12 Felix E. A uniﬁed approach to recurrent laparoscopic hernia Tep. Surg Endosc 1995; 9: 984–9. repairs. Surg Endosc 2001; 15: 969–71. 6 Felix E, Michas C, Gonzalez H. Laparoscopic repair of recurrent hernia. Am J Surg 1996; 172: 580–4. 10

Femoral and pelvic herniorrhaphy

CHRISTINE A. ELY AND MAURICE E. ARREGUI

Demographics 75 Rare and unusual hernias 77 History of repair 76 Conclusion 81 Techniques 76 References 82 Postoperative care 77

Femoral and pelvic hernias are much less common than In this chapter, we will focus on our technique of inguinal hernias. If these hernias are diagnosed pre- repair of femoral and obturator hernias, since the obtu- operatively, they are certainly amenable to laparoscopic rator hernia is by far the most common of the pelvic repair. However, if they are not diagnosed preoperatively, hernias (Figure 10.1). Our technique and postoperative these cases are the perfect situation for the application of care will be reviewed. In addition, we will comment on diagnostic laparoscopy followed by laparoscopic repair. some other unusual hernias that may be encountered, such as sciatic, supravesicular and perineal hernias, as well as prevascular hernias, lipomas of the cord, and low Inguinal ligament Spigelian hernias. Less common Femoral hernia (anatomically less weak) DEMOGRAPHICS

Most common Inguinal hernia Femoral hernias are much less common than inguinal (Anatomically hernias, with an incidence of two to four per cent of all weakest) groin hernias.1 They are more common in women, with reported male/female ratios of 1 : 1.6 to 1 : 3.1,2 The incidence and rate of repair increase with age.1 The femoral hernia is located most frequently on the right.1 Obturator hernias, although extremely rare, are the most common of the pelvic hernias. Their incidence is reported to be Pectineus muscle 0.05–0.07 per cent of all groin hernias. They typically occur in an emaciated, dehydrated, multiparous female Rare patient. The patients may have a positive Howship– Obturator hernia Romberg sign or a palpable upper-thigh mass. The (Anatomically least weak) Howship–Romberg sign is positive when medial thigh and Figure 10.1 Surgical anatomy of the obturator and inguinal hip pain is created or exacerbated by adduction and region. Lateral view of the right side of the pelvis, showing the medial rotation of the thigh and relieved by thigh ﬂexion.3 sites of inguinal, femoral and obturator hernias. From Carter JE. More often, however, symptoms are vague, and patients Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic frequently present with small-bowel obstruction with Pain: Diagnosis and Management. Philadelphia: Lippincott either intermittently incarcerating or strangulated small Williams & Wilkins, 2000: 385–413, with permission. bowel. One’s level of suspicion, therefore, needs to be high. 76 Laparoscopic inguinal/femoral hernioplasty

These vague symptoms and small-bowel obstructions can occur with both femoral and obturator hernias.

d b HISTORY OF REPAIR

Femoral hernias have been repaired anteriorly with and without mesh, or with a mesh plug, as well as via the a e suprainguinal ligament approach or the infrainguinal approach. They have been repaired posteriorly via open c pre-peritoneal approaches and, most recently, laparoscopically using the transabdominal pre-peritoneal (TAPP) or totally extraperitoneal (TEP) approach. Reports have varied with regards to complications, with the rate of recurrences varying from poor to good.4–8 Reports are now emerging regarding the success of the laparoscopic 8 Figure 10.2 Transperitoneal view of (a) indirect inguinal hernia, repair of these hernias. (b) direct inguinal hernia, (c) femoral hernia, (d) inferior A variety of approaches for repair of the obturator epigastric vessels, and (e) median umbilical ligament. hernia has been used. The abdominal, inguinal (extraperitoneal or retroperitoneal), retropubic, and obturator approaches have been described, as well as different com- binations of these incisions. The abdominal approach has seemed to be the best approach because it provides simul- b taneous diagnosis and repair and allows the resection of compromised bowel if necessary. The obturator defect has a been closed with sutures or mesh, or with tissue, such as a ﬂap of adductor longus, the round ligament, or a portion c of the bladder wall.9,10 Most recently, the laparoscopic approach has been applied to these hernias (Figures 10.2 d and 10.3). The reports are few but the results are favorable, and this approach also affords the above-mentioned beneﬁts of the open abdominal approach.

TECHNIQUES

Figure 10.3 Intraoperative view of obturator foramen. (a) Plug If the hernia is discovered preoperatively, our approach of fat in obturator foramen, (b) Cooper’s ligament, (c) obturator of choice is the extraperitoneal approach. If the hernia is nerve, and (d) obturator artery. discovered during diagnostic laparoscopy, either it may be repaired via the TAPP approach or the pre-peritoneal space may be insufflated and an extraperitoneal approach with a 5-mm, 30-degree viewing laparoscope. Using the may be used, as described below. transperitoneal view, an additional 5-mm trocar is We perform extraperitoneal repair of indirect and placed on the ipsilateral side about one finger’s breadth direct inguinal hernias. Femoral hernias and obturator below the level of the umbilicus over the lateral aspect of hernias are repaired in a similar fashion. As we will point the rectus muscle just above the arcuate line of the poste- out, the most important concept is wide coverage of all rior rectus sheath. The trocar is introduced carefully into hernia orifices with mesh to prevent recurrence. the posterior rectus space to avoid perforation of the General endotracheal anesthesia is used. After infil- peritoneum. Dissection of this space is then carried out trating with 0.5 per cent bupivacaine with epinephrine with a long, blunt grasper inserted through the trocar. (adrenaline), a 5-mm incision is made in a skin fold in For unilateral repair, a second 5-mm trocar is inserted in the inferior portion of the umbilicus. A Veress needle the midline at the midpoint between the symphysis pubis is introduced for insufflation of carbon dioxide to a and umbilicus. For bilateral repair, the second trocar is pressure of 15 mmHg. A 5-mm trocar is then inserted, placed on the opposite side, in the lateral rectus space, followed by a general inspection of the peritoneal cavity again just above the arcuate line. Femoral and pelvic herniorrhaphy 77

After dissection with the blunt grasper, an additional are given a prescription for propoxyphene for pain con- 5-mm incision is made below the umbilicus, through trol. The patient is restricted only from driving for two to which a 5-mm trocar is placed. The 5-mm, zero- or 30- three days, or until they are pain-free and not requiring degree viewing laparoscopes are then used. The dissection narcotic analgesics. Patients may bathe the same day and of the pre-peritoneal space is carried beyond Cooper’s lig- may return to work or full activity without restrictions ament into the space of Retzius below the obturator fora- when they feel ready.11 men. Once dissection is complete, the symphysis pubis, the rectus muscle medially, the anatomic landmarks surrounding Hesselbach’s triangle (including Cooper’s RARE AND UNUSUAL HERNIAS ligament and the medial iliopubic tract), the transversus abdominus musculo-aponeurotic arch, and the inferior In this section, we will mention some unusual hernias epigastric vessels will be identified. Laterally, the dissec- that may be encountered and the principles and tech- tion will have exposed the cord structures, the underlying niques for their management and repair. femoral vessels, and the lateral iliopubic tract. The direct, indirect and femoral hernial orifices should be identified easily. The obturator orifice should be seen inferior to Sciatic hernia Cooper’s ligament. Subsequent to the reduction of the herniated contents Sciatic hernias are very rare. A literature search on and sac, the femoral hernia defect and the entire Medline from 1966 to 1996 generated only 57 reported myopectineal orifice of Fruchaud will be covered with cases of sciatic hernias.12 A sciatic hernia is a protrusion Mersilene mesh. A 15 ϫ 15-cm mesh is trimmed to of a peritoneal sac and its contents through the greater or 13 ϫ 15 cm. It is introduced by rolling it, grabbing one lesser sciatic foramen. They may be congenital or, more end with grasping forceps, and pushing it through the commonly, acquired. The defect usually results from 5-mm trocar. The mesh is unrolled and positioned over weakness of the piriformis muscle from a chronic the entire area, thereby covering the hernia defect and increase in the intra-abdominal pressure, such as in preg- all other potential sites of herniation. The mesh is not nancy, severe constipation, surgery or trauma. It can also sutured or tacked into place. In the case of an obturator occur because of atrophy of the muscle caused by neuro- hernia, the mesh can be smaller and limited to a wide muscular or hip disease.13 The hernia sac can protrude coverage of the obturator foramen with or without fixa- through one of three openings: the greater sciatic foration. We would choose to fashion the size of the mesh so men above the piriformis muscle, the greater sciatic fora- that it overlaps the defect by 3–4 cm. Others have fixated men below the piriformis muscle, or the lesser sciatic the mesh, which can be done with either sutures or tacks. foramen (Figure 10.4). Typical symptoms include inter- Based on the above principles, however, we would not mittent pain radiating to the buttocks and/or posterior fixate the mesh. After making sure that the prosthesis is thigh, with or without a palpable mass deep to the glu- lying flat and in the correct space, the pre-peritoneal tro- teus maximus muscle. The most common contents of a cars are removed and the pre-peritoneal space is desuf- sciatic hernia are small bowel, ovary (with or without the flated. The laparoscope is then placed in the peritoneal adjacent fallopian tube), and ureter.13 cavity and the mesh is observed as the peritoneum lies on The sciatic hernia has traditionally been approached top of it, making sure that there is no buckling of the transabdominally, with reduction of the hernia, excision mesh. Then, while still under direct vision, the peritoneal of the sac, and either suture closure or mesh coverage of cavity is desufflated and the final trocar is removed. The the defect. Alternatively, if it is diagnosed preoperatively positive intra-abdominal pressure that took part in and it is easily reducible, the hernia could be repaired creating the hernia itself is now used to secure the mesh from a transgluteal approach. in place, obviating the need for fixation of the prosthetic The largest series of patients who underwent laparo- biomaterial. The subcutaneous tissue at all trocar sites is scopic repair of a sciatic hernia consisted of 20 women closed with 3-0 Vicryl (Ethicon). Collodian is applied to who underwent diagnostic laparoscopy for pelvic pain the skin for dressing.11 and were found to have a sciatic hernia, which was then repaired via laparoscopic approach.14 When a sciatic hernia was identified, the contents were reduced. The peri- POSTOPERATIVE CARE toneum was elevated and transected transversely with endoscopic scissors. The obturator internus and coccygeus muscles were identified with the use of blunt dis- The patient is observed in the recovery room for one to section. A 6.0 ϫ 12.5-cm piece of Surgipro mesh (U.S. two hours. The majority of electively repaired patients Surgical) was then folded and placed into the space that are then discharged home on the same day. Most patients had been created by the atrophic piriformis muscle. 78 Laparoscopic inguinal/femoral hernioplasty

The authors do not describe it exactly as a ‘plug’; this is contained an ovary and/or the fallopian tube, which left the only description that they gave. A second, smaller little room for the distention of the peritoneum con- piece of mesh, trimmed to the size of the peritoneal defect, tained within the hernia sac by the intra-abdominal car- was placed over the folded mesh. The second piece of mesh bon dioxide. However, the authors felt that in other cases was secured to the obturator internus fascia laterally and the increased intra-abdominal pressure could be helpful the coccygeus medially with a stapler. The peritoneum in the detection of sciatic hernias because of the actual was then closed over the mesh.12 If the peritoneum is stretching of the peritoneum to its limit of support, such not closed, then an inert mesh, such as DualMesh® as the bone or muscle.12 (W. L. Gore & Associates) could be used to prevent morbidity due to adhesions.15 The repair was very successful, with 14 patients reporting complete pain relief, and the Supravesical hernia other six individuals noting continuing improvement over a median follow-up of 13 months. Supravesical hernias are rare hernias that herniate Laparoscopy is a great adjunct in the diagnosis of this through the supravesical fossa of the anterior abdominal hernia because of the excellent view of the pelvis that wall. They are classiﬁed as either external (those that pass it affords. In this series of patients, all of the hernias downward through the supravesical fossa to become

Anterior sacroiliac ligament

Piriformis muscle

Sacrospinous ligament b

Sacrotuberous ligament c

Ischial tuberosity and spine (a)

Posterior sacroiliac Posterior inferior ligament iliac spine

Greater sciatic foramen Piriformis muscle

Sacrospinous ligament Capsule of hip joint Figure 10.4 Sites of potential hernias through the sciatic foramina: Sacrotuberous ligament (a) suprapiriformis sciatic hernia, (b) infrapiriformis sciatic hernia, and Greater trochanter (c) subspinous sciatic hernia through the Lesser sciatic foramen lesser sciatic foramen. From Carter JE. Quadratus femoris Hernias. In: Howard FM, Perry CP, Carter JE, Ischial tuberosity muscle et al., eds. Pelvic Pain: Diagnosis and Management. Philadelphia: Lippincott Sciatic nerve Williams & Wilkins, 2000: 385–413, with (b) permission. Femoral and pelvic herniorrhaphy 79 direct inguinal or femoral hernias) or internal (those may be especially well suited for the laparoscopic approach that pass downward to enter the space of Retzius) because of the better visualization of the entire pelvis.16 (Figure 10.5). While the external hernias may be much easier to diagnose, an internal hernia may present with Perineal hernia non-specific clinical findings, such as pelvic pain or bladder symptoms, or, as in other hernias, it may present as Perineal hernias are very rare true hernias, which are usu- small-bowel obstruction with its attendant symptoms. ally found in women. These defects are characterized by a Open repair has been described for these hernias, either peritoneal sac that has herniated between the muscles and with or without mesh, particularly for the external her- fascia of the perineal floor.16 They can be categorized as nias. Laparoscopic repair, however, is again applicable either anterior or posterior to the superficial transverse to such hernias, using the same technique as described perineus muscle. Anterior perineal hernias pass through above for sciatic hernias. The internal supravesical hernia the pelvic and urogenital diaphragms, lateral to the urinary bladder and vagina and anterior to the urethra (Figure 10.6). They have also been referred to as pudendal, labial, lateral and vaginal-labial hernias. These hernias are e unique to women and may contain intestine or bladder. Posterior perineal hernias pass directly through the d components of the pelvic diaphragm. Their content is a usually omentum or small bowel, which lie between the rectum and uterus. The hernia usually remains lateral to c the uterosacral ligament and posterior to the broad liga- b ment. There are two possible locations, an upper posterior hernia between the pubococcygeus and iliococcygeus muscles, and a lower posterior hernia between the iliococcygeus and coccygeus muscles, below the lower margin of the gluteus maximus muscle. Posterior perineal Figure 10.5 External supravesical hernia: (a) external hernias may occur in men or women, but they are more supravesical hernia orifice, (b) Hesselbach’s triangle, common in men.13,17 (c) transversus abdominus aponeurotic arch, (d) rectus muscle, Laparoscopic repair of these hernias has been and (e) inferior epigastric vessels. described as an approach for maximum visualization of

Ischiocavernous muscle

Bulbocavernosus muscle

Superficial transverse perineal muscle a External anal sphincter b Levator ani muscle

c Coccygeus muscle Gluteus maximus muscle d

Figure 10.6 The female perineum, showing possible sites of perineal hernias. A primary perineal hernia may occur anterior or posterior to the superficial transversus perineal muscle. An anterior hernia protrudes through the urogenital diaphragm, lateral to the urinary bladder and vagina (a, b). Anterior hernias occur only in women. A posterior perineal hernia may merge between bundles of levator ani muscle (c), or between that muscle and the coccygeus muscle, midway between the rectum and the ischial tuberosity (d). From Carter JE. Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic Pain: Diagnosis and Management. Philadelphia: Lippincott Williams & Wilkins, 2000: 385–413, with permission. 80 Laparoscopic inguinal/femoral hernioplasty the pelvic cavity. The hernia is identified, the hernia eight-year period, ten (9.5 per cent) of the hernias were of contents are reduced, and a pre-peritoneal dissection is the prevascular type.20 Repair of these hernias can be dif- performed to define the boundaries of the hernia ring. ficult because, if repaired anteriorly, the iliopubic tract Permanent prosthetic mesh is used to cover and overlap must be sutured to the vascular adventitia, which obvi- the defect. The mesh is tacked or stapled in place, and ously holds inherent danger. The pre-peritoneal approach reperitonealization is performed.16 has therefore been recommended as the safest and preferred approach.20 In the previously mentioned study, Prevascular hernia all ten of the prevascular hernias were repaired using the TEP laparoscopic technique, with good results, no complications, and no recurrences to date. Prevascular hernias are a variation of the femoral hernia in which the sac is situated in the femoral sheath, but anterior to the femoral vessels rather than medial to Lipoma of the cord them as in the ‘usual’ fashion.18 This hernia was originally described by Teale in 1846. Other related hernias A lipoma of the spermatic cord or the round ligament is an have been described that protrude through the femoral isolated discrete collection of fatty tissue arising from the sheath in strict continuity with the femoral vessels but in retroperitoneal tissue, which protrudes through the inter- various locations and are separated from the vessels only nal ring and is easily separated from the cord structures by adventitia (Figure 10.7). There is one report of a (Figure 10.8). These tissues can cause symptoms similar to patient who simultaneously had two bilateral femoral a true hernia. Lipomas can occur with or without a coex- hernias (total of four femoral hernias).18 isting peritoneal defect. In a retrospective review of 280 This group of hernias is rare, with a reported incidence hernia repairs, the incidence of lipoma of the cord was of 1.7–2.5 per cent of all femoral hernias.19 However, found to be 22.5 per cent (63/280).21 Eighteen of these recent reports suggest that these hernias may be more lipomas were found in groins without hernias. Fourteen common than originally recognized. In a retrospective of the patients with lipomas presented with groin pain, study in which 105 femoral hernias were identified in an and four were asymptomatic. The authors believe that a lipoma can be the cause of a patient’s groin pain, and also can be a predisposing factor to formation or recurrence of a hernia, possibly by insinuating itself into the internal ring and dilating it over time. They recommend removal of all lipomas, with or without a hernia, in symptomatic patients and documenting in detail those found incidentally in asymptomatic patients because of the possibility of future symptoms.21

Hesselbach (lateral femoral)

Teale (prevascular)

Serafini (retrovascular)

Femoral

Callisen-- Cloquet Laugier Figure 10.7 The various paravascular hernias. From Bocchi P. Paravascular hernias. In: Bendavid R, ed. Prostheses and Abdominal Wall Hernias. Austin, TX: RG Landes Co., 1994: Figure 10.8 Laparoscopic view of lipoma of the cord. Cord 415–16, with permission. structures can be seen medially. Femoral and pelvic herniorrhaphy 81

Contrary to the advantage that laparoscopy adds in all aponeurosis. This aponeurosis, or fascia, is defined as the of the above-mentioned hernia surgeries, lipomas of the region between the semilunar or Spigelian line (the tran- cord or round ligament are more difficult to visualize sition from muscle to aponeurosis in the transversus with the laparoscope. A maneuver that is useful to help abdominus muscle) and the lateral border of the rectus visualize the lipoma is external compression with the muscle. The usual Spigelian hernia refers to a hernia hand at the inguinal canal, thus pushing back the lipoma located above the inferior epigastric vessels. Hernias that through the internal ring. This should be done in any penetrate the Spigelian fascia inferior to the inferior epi- patient who is undergoing laparoscopic evaluation for gastric vessels are called low Spigelian hernias (Figure groin pain when a hernia is not found.21 Herniated pre- 10.9). These hernias are actually traversing through peritoneal fat can also be found in the femoral canal, Hesselbach’s triangle, which includes part of the Hasselbach’s triangle, or obturator foramen, or alongside Spigelian aponeurosis caudal and medial to the inferior the pre-peritoneal nerves. We have seen small herniations epigastric vessels. One can easily appreciate that these along the lateral femoral cutaneous nerve, which, when hernias are very easily confused with direct inguinal her- reduced, relieved the patient of the preoperative pain over nias and most likely are underreported because of mis- the distribution of that nerve. representation as direct inguinal hernias. Low Spigelian When a lipoma is discovered and requires removal, it is hernias, if diagnosed properly, are usually diagnosed not always easy to pull it through a 5-mm or 10-mm trocar. intraoperatively. The hernial orifice is usually small and The available options are piecemeal removal of the lipoma has rigid, sharply defined edges. These hernias may also (which can be tedious), allowing it to remain attached at be repaired laparoscopically, which can be done in a pre- the base and placing it between the mesh and the peri- peritoneal fashion, as described for repair of a direct toneum, or separation of the lipoma from the cord, leaving inguinal hernia.22,23 the lipoma in situ. The latter option is not recommended as the lipoma may re-herniate into the inguinal canal.21 CONCLUSION Low Spigelian hernia We have described in detail our approach for laparoscopic A Spigelian hernia is a rare hernia that protrudes repair of femoral and obturator hernias. The repair is no through a congenital or acquired defect in the Spigelian different in principle to that of direct or indirect inguinal hernias. The most important step to remember is that (c) wide coverage of all of the possible hernia orifices is necessary to prevent recurrence. In addition, we have stressed the usefulness of the laparoscopic approach because it gives a better total visualization of the entire inguinal and (a) pelvic regions than the open technique. This is especially helpful when one encounters some of the more unusual (d) (f) hernias that have been mentioned in this chapter. Finally, we have described some of the unusual inguinal and pelvic hernias that may be encountered and the basic principles of management of them.

(b) REFERENCES (e) 1 Rutkow I. Epidemiologic, economic, and sociologic aspects of hernia surgery in the United States in the 1990s. Surg Clin N Am 1998; 78: 941–51. 2 Sandblom G, Haapaniemi S, Nilsson E. Femoral hernias: a register analysis of 588 repairs. Hernia 1999; 3: 131–4. Figure 10.9 Anatomy of the low Spigelian hernia. Shaded area: 3 Haith LR, Simeone MR, Reilly KJ, et al. Obturator hernia: Spigelian aponeurosis. (a) Region of Spigelian hernia; (b) region laparoscopic diagnosis and repair. JSLS 1998; 2: 191–3. of low Spigelian hernia; (c) Spigelian line; (d) lateral border of 4 Koontz AR. Femoral hernia. Arch Surg 1952; 64: 298–308. rectus abdominus muscle; (e) inferior epigastric vessels; and 5 Glassow F. Femoral hernia: review of 2,105 repairs in a 17 year (f) transversus abdominus muscle. Modiﬁed from Bennett D. period. Am J Surg 1985; 150: 353–6. 6 Bendavid R. A femoral ‘umbrella’ for femoral hernia repair. Surg Spigelian hernias. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus Gynecol Obstet 1987; 165: 153–6. & Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & 7 Lichtenstein IL, Shore JM. Simpliﬁed repair of femoral and inguinal Wilkins, 2002: 405–13, with permission. hernia by a ‘plug’ technique. Am J Surg 1974; 128: 439–44. 82 Laparoscopic inguinal/femoral hernioplasty

8 Hernandez-Richter T, Schardey HM, Rau HG, et al. The femoral 16 Kavic MS. Chronic pelvic pain in women. In: Bendavid R, hernia: an ideal approach for the transabdominal preperitoneal Abrahamson J, Arregui ME, et al., eds. Abdominal Wall Hernias technique (TAPP). Surg Endosc 2000; 14: 736–40. Principle and Management. New York: Springer-Verlag, 2001: 9 Marchal F, Parent S, Tortuyaux JM, et al. Obturator hernias – 636–8. report of seven cases. Hernia 1997; 1: 23–6. 17 Skandalakis JE. Perineal hernia. In: Skandalakis JE, Gray SW, 10 Skandalakis LJ, Skandalakis PN, Colborn GL, Skandalakis JE. Mansberger AR, et al., eds. Hernia Surgical Anatomy and Obturator hernia: embryology, anatomy, surgery. Hernia 2000; 4: Technique. New York: McGraw-Hill, 1989: 185–206. 121–8. 18 Harkins HN. In: Nyhus LM, Condon RE, eds. Hernia, 3rd edn. 11 Arregui ME, Navarrete J, Davis CJ, et al. Laparoscopic inguinal Philadelphia: JB Lippincott, 1989: 302–3. herniorrhaphy – techniques and controversies. Surg Clin N A 1993; 19 Bocci P. Paravascular hernias. In: Bendavid R, ed. Prostheses 73: 513–27. and Abdominal Wall Hernias. Austin, TX: RG Landes Co., 1994: 12 Miklos JR, O’Reilly MJ, Saye WB. Sciatic hernia as a cause of 415–16. chronic pelvic pain in women. Obstet Gynecol 1998; 91: 998–1001. 20 Spurbeck WW, Voeller GR. Prevascular and retropsoas hernias: 13 Carter JE. Sciatic, obturator, and perineal hernias: a view from the incidence of rare abdominal wall hernias. Abstract presented at gynecologist. In: Fitzgibbons RJ, Greenburg AG, eds. Nyhus and American Hernia Society Hernia Conference, Tucson, AZ, May Condon’s Hernia, 5th edn. Philadelphia: Lippincott Williams & 2002. Wilkins, 2002: 539–49. 21 Lilly MC, Arregui ME. Lipomas of the cord and round ligament. 14 Kavic MS. Chronic pelvic pain in females and obscure hernias. Ann Surg 2002; 235: 586–90. Hernia 2000; 4: 250–4. 22 Spangen L. Spigelian hernia. Surg Clin North Am 1984; 64: 351–66. 15 Chaudhuri A, Chye KK, March SK. Sciatic hernias: choice of 23 Bennett D. Spigelian hernia. In: Fitzgibbons RJ, Greenburg AG, eds. optimal prosthetic repair material in preventing long-term Nyhus and Condon’s Hernia, 5th edn. Philadelphia: Lippincott morbidity. Hernia 1999; 4: 229–31. Williams & Wilkins, 2002: 405–13. 11

Results of laparoscopic inguinal/femoral hernia repair

KETAN M. DESAI AND NATHANIEL J. SOPER

TEP versus TAPP repair 83 Laparoscopic femoral hernia repair 86 Laparoscopic versus open tissue repair 84 References 86 Laparoscopic versus open mesh repair 85 Further reading 87 Summary 86

Over 750 000 inguinal hernia repairs are performed in the approaches for the repair of inguinal hernia include the USA annually. Historically, many techniques for the tissue transabdominal pre-peritoneal (TAPP) and the totally repair of groin hernias have been used, including the extraperitoneal (TEP) approaches. These two laparo- Bassini, McVay, Cooper and Shouldice repairs. Currently, scopic procedures, based upon the open Stoppa repair, the tension-free repair of Lichtenstein and the mesh-plug provide pre-peritoneal mesh reinforcement of the ilio- procedure dominate the majority of surgical practices. pubic tract. Since the introduction of laparoscopic cholecystectomy in the late 1980s, advancements in minimally invasive surgery have led surgeons to investigate laparoscopic tech- TEP VERSUS TAPP REPAIR niques for treating inguinal hernia while still providing a durable repair. Accepted indications for laparoscopic hernia repair are recurrent and bilateral inguinal hernias in a TAPP repair requires entry into the peritoneal cavity. patient at low anesthetic risk. However, considerable debate Following placement of trocars, the peritoneum is divided over laparoscopic inguinal hernia repair, not seen with transversely anterior to the internal ring, wide peritoneal other laparoscopic procedures, has diminished the enthu- flaps are raised, and the hernia sac is reduced. A large siasm for adopting this technique for unilateral, primary prosthetic mesh is stapled into place, widely overlapping inguinal hernias. the defect and buttressing the iliopubic tract. Similarly, The emergence of laparoscopic groin hernia surgery is TEP repair requires advanced knowledge of the anatomy multifactorial. Following open repair, high rates of post- of the inguinal floor. However, access to the pre-peritoneal operative patient discomfort, pain, and increased time space is achieved without incision of the peritoneal mem- away from work, coupled with recurrence rates that brane. Following balloon or blunt dissection of the pre- ranged from one to ten per cent, influenced surgeons to peritoneal space, the cord structures are dissected, and explore alternative repair methods. Early attempts at indirect or direct hernias are reduced. The inguinal floor laparoscopic inguinal hernia repair included intraperi- is covered with a large prosthetic mesh and secured with toneal onlay mesh (IPOM) techniques, simple inguinal staples or another fixation device. Potential early postop- ring closure, and plug-and-patch repair. However, these erative complications include bowel injury from trocar early laparoscopic approaches were abandoned secondary insertion (TAPP), bowel obstruction from adhesion for- to an unacceptable rate of recurrence and the formation mation (TAPP), nerve entrapment from staple placement of intra-abdominal adhesions, except at a few centers (see (TAPP and TEP), and mesh infection (TAPP and TEP). Chapter 7). Today, the two predominant laparoscopic The extraperitoneal approach avoids a number of these 84 Laparoscopic inguinal/femoral hernioplasty

Table 11.1 Recurrence rates of laparoscopic repairs Follow-up Recurrence Study Procedure Number (months) rate (%) Aeberhard et al. (1999)3 TEP 1605 12 1.3 Katkhouda et al. (1999)4 TEP 99 24 0 Farinas and Griffen (2000)5 TEP 96 12 0 Knook et al. (1999)6 TEP 256 40 5 Ferzli et al. (1999)7 TEP 100 8 0 Frankum et al. (1999)8 TEP 779 30 0.2 Halkic et al. (1999)9 TEP 118 22 0 Lucas and Arregui (1999)10 TEP 199 36 0 O’Riordain et al. (1999)11 TEP 71 12 0 Juul et al. (1999)1 TAPP 138 12 2.9 Knook et al. (1999)12 TAPP 34 35 0 Smith et al. (1999)13 TAPP 536 17 0.6 Johansson et al. (1999)14 TAPP 204 12 2 pitfalls that are unique to entry into the peritoneal cavity. invasive repairs, due to conversions and recurrences However, early problems with nerve entrapment and requiring the alternative procedure. hernia recurrence secondary to inadequate mesh size following either procedure have resulted in significant morbidity. LAPAROSCOPIC VERSUS OPEN Outcome measures following groin hernia repair TISSUE REPAIR include postoperative pain, complications, return to work, patient satisfaction, and cost, as well as long-term hernia recurrence rates. Comparisons of laparoscopic approaches Although we currently use the Lichtenstein (tension-free) have revealed lower rates of postoperative pain following repair for open inguinal herniorrhaphy, the Shouldice TEP repair; however, operating times and return to nor- technique appears to have similar advantages in terms of mal activity were generally similar. Recurrence rates fol- short recovery time and low recurrence rates. Laparo- lowing either laparoscopic repair were variable (Table 11.1). scopic repair has been compared with a number of open Non-randomized (usually sequential) trials comparing repair methods, with varying results. A number of early, TEP versus TAPP approaches have reported lower recur- small trials failed to demonstrate a clear benefit following rence rates following the TEP technique. However, in a laparoscopic repair. More recent randomized trials com- number of these trials the differences were not statistically paring laparoscopic and open suture repair have reported significant, with subsequent randomized studies report- superior outcomes following the laparoscopic approach ing similar recurrence rates irrespective of laparoscopic in terms of less postoperative pain and a faster return to procedure. normal activity. Although operative times of the laparo- Evaluations of these two laparoscopic techniques have scopic approaches have been reported to be significantly demonstrated a slightly lower complication rate following longer than with open suture methods in a number of TEP repair. Reports of bowel injury and small-bowel studies, wound complications and overall recurrence obstruction secondary to intra-abdominal adhesions were rates were similar (Table 11.2). In addition, general anes- more common following the TAPP approach than the TEP thesia was used in the vast majority of laparoscopic cases approach. The difference in complication rates between the as opposed to local, epidural or spinal anesthesia in the two accepted laparoscopic approaches may result from open group. Despite this, several trials have shown earlier remaining completely extraperitoneal during TEP dissec- hospital discharge and less postoperative pain (early tion and repair. However, initial experience with TAPP may and late) in patients undergoing laparoscopic repair. A have provided surgeons with the additional skills and randomized comparison of extraperitoneal laparoscopic knowledge to perform a superior TEP repair. repair with various open approaches by Liem and col- In general, due to the small number of comparative leagues revealed longer procedure times for the laparo- studies, firm conclusions on the relative merits of the dif- scopic repair.13 However, the laparoscopy group had ferent techniques are difficult to obtain. However, TEP lower analgesia requirements, less postoperative pain, and repair may have some advantages regarding complica- an earlier return to work. The recurrence rate was slightly tions and postoperative pain. Despite these potential dif- lower in the laparoscopy group, as were wound infections ferences, surgeons should be skilled in both minimally and chronic postoperative pain. Results of laparoscopic inguinal/femoral hernia repair 85

Table 11.2 Comparison of open versus laparoscopic repair Recurrence (%) No. Study randomized Open Laparoscopic Open Laparoscopic Liem et al. (1997)15 994 Various TEP 6 3 Juul and Christensen (1999)1 268 Shouldice TAPP 2 3 Fleming et al. (2001)2 200 Shouldice TEP 5 2 Paganini et al. (1998)16 108 Mesh TAPP 0 4 Zieren et al. (1998)17 240 Mesh TAPP 0 0 Koninger et al. (1998)18 280 Mesh TAPP 1 1 Payne et al. (1994)19 100 Mesh TAPP 0 0 Heikkinen et al. (1997)20 38 Mesh TAPP 0 0 Beets et al. (1999)21 79 Mesh TAPP 3 14 Filipi et al. (1996)22 53 Mesh TAPP 7 0 Johansson et al. (1999)14 613 Mesh TAPP 5 2 Aitola et al. (1998)23 60 Mesh TAPP 8 13 Wellwood et al. (1998)24 403 Mesh TAPP 0 0 Champault et al. (1997)25 100 Mesh TEP 2 6 Khoury (1998)26 292 Mesh TEP 3 2

Laparoscopic repair of groin hernias is generally A number of prospective non-randomized studies reserved for bilateral and recurrent hernias. However, the have compared laparoscopic and open mesh repair. benefits of laparoscopic repair for primary, unilateral her- Objective pain scoring, analgesia use, and complication nias have been demonstrated. Patients with primary, uni- rates were similar. Laparoscopic repair was shown to be lateral hernias may recover more rapidly after TAPP repair superior to open mesh repairs in terms of faster return to than after an open approach, as assessed by analgesia normal activity and return to work. Although recurrence requirement and functional status. In a randomized clinical rates did not differ significantly, a short duration of trial by Juul and coworkers of laparoscopic (TAPP) versus follow-up and small cohort numbers were potential lim- open (Shouldice) inguinal hernia repair, complication rates iting factors to a number of these studies. Laparoscopic were similar, whereas the laparoscopic repair resulted in repair required longer operating times and, in general, less postoperative pain, shorter analgesia requirement, was more expensive; however, more rapid return to work and an earlier return to work.1 At postoperative follow- may result in lower overall societal costs following the up, there were similar rates of recurrences. Comparison laparoscopic approach. of Shouldice and TEP repairs by Fleming and colleagues Randomized clinical trials of open versus laparo- also demonstrated the potential benefits of the laparoscopic repair of primary, unilateral inguinal hernias have scopic approach. TEP repair led to a more rapid return to shown comparable results with respect to overall compli- work, with fewer complications at one-year follow-up, cations and recurrences (Table 11.2). Major intraopera- when compared with the open group.2 tive and postoperative complications were uncommon in both groups. However, severe visceral and vascular injuries were more frequent following the laparoscopic LAPAROSCOPIC VERSUS OPEN MESH REPAIR approach. Postoperative pain was shown to be less among the laparoscopic groups, possibly contributing to the earlier return to regular activity in patients undergo- The practice of tension-free groin hernia repair using ing laparoscopic hernia repair. However, length of hospi- prosthetic mesh materials has become increasingly popu- tal stay was similar in patients undergoing open mesh lar over the last decade. Laparoscopic inguinal hernia sur- and laparoscopic repair, with no difference in recurrence gery should be comparable to the standard Lichtenstein rates between open mesh and laparoscopic repair at repair, which has a reported recurrence rate of 0.1–1 per short- to medium-term follow-up (Table 11.2). cent. Multiple small studies with relatively short-term Outcomes of randomized trials comparing laparo- follow-up have reported that laparoscopic repair can be scopic and open herniorrhaphies have shown less pain performed safely with results that equal or surpass open and faster recovery following laparoscopic approaches, hernia repair. Although the laparoscopic approach may but at increased cost and slightly greater risk. However, offer shorter recovery time owing to less pain, only a few prospective, randomized data comparing laparoscopic large studies have investigated overall differences in versus open bilateral hernia repair are lacking. It would complication and recurrence rates. be expected that bilateral open repairs would result in a 86 Laparoscopic inguinal/femoral hernioplasty doubling of operative time and postoperative pain when Table 11.4 Perceived disadvantages of laparoscopic compared with laparoscopic repair. The laparoscopic inguinal hernia repair approach for repair of unilateral or bilateral hernias Requirement for general anesthesia utilizes the same ports, thereby limiting additional time Complications unique to laparoscopic approach requirements for bilateral herniorrhaphy. In addition, Steep learning curve pre-peritoneal repair (TEP/TAPP) avoids the scarring of Increased cost the anterior groin that follows failed open repair, and it should be expected to be less time-consuming and fraught with fewer complications than open herniorrhaphy for recurrent hernias. LAPAROSCOPIC FEMORAL HERNIA REPAIR

The published literature on femoral hernia repair is inadequate to make firm conclusions regarding the rela- SUMMARY tive safety and efficacy of different surgical approaches. Although a few prospective studies comparing different Recurrence rates following various open hernia repair methods of open femoral hernia repair exist, small study techniques have ranged from less than one per cent to more sizes hinder definitive conclusions regarding differences than ten per cent at long-term follow-up. Laparoscopic in outcomes. Laparoscopic femoral hernia repair is per- techniques that were introduced in the early 1990s show formed in the same fashion as that for inguinal hernior- promise in treating unilateral, bilateral and recurrent her- rhaphy. Reports of laparoscopic femoral hernia repair nias with respect to less postoperative pain, earlier recovery, are, in general, limited to case reports, with no random- and improved cosmesis (Table 11.3). Recurrences that do ized trials comparing open and laparoscopic repair. occur following laparoscopic repair are usually the result of inadequate lateral pre-peritoneal dissection or an inadequate size of the prosthesis. In addition, the skill and expe- REFERENCES rience of the operating surgeon greatly affect the rate of recurrence, such that results during the initial learning 1 Juul P, Christensen K. Randomized clinical trial of laparoscopic curve are worse than later in a surgeon’s operative series. In versus open inguinal hernia repair. Br J Surg 1999; 86: 316–19. addition, the lack of an inguinal incision, avoidance of 2 Fleming WR, Elliott TB, Jones RM, Hardy KJ. Randomized clinical trial comparing totally extraperitoneal inguinal hernia repair with extensive dissection, creation of a tension-free repair, and the Shouldice technique. Br J Surg 2001; 88: 1183–8. low complication rates all contribute to more rapid return 3 Aeberhard P, Klaiber C, Meyenberg A, et al. Prospective audit of to normal activity following laparoscopic inguinal hernia laparoscopic totally extraperitoneal inguinal hernia repair: a repair. multicenter study of the Swiss Association for Laparoscopic and Comparing laparoscopic and open inguinal hernior- Thoracoscopic Surgery (SALTC). Surg Endosc 1999; 13: 1115–20. 4 Katkhouda N, Campos GM, Mavor E, et al. Laparoscopic rhaphy, differences in outcomes regarding postoperative extraperitoneal inguinal hernia repair. A safe approach based on pain, return to work, and analgesia requirements have the understanding of rectus sheath anatomy. Surg Endosc 1999; generally favored the laparoscopic approach. However, 13: 1243–6. potential limitations to the laparoscopic approach include 5 Farinas LP, Griffen FD. Cost containment and totally extra- increased cost, the requirement for general anesthesia, peritoneal laparoscopic herniorrhaphy. Surg Endosc 2000; 14: 37–40. and a steep learning curve. Disadvantages to laparo- 6 Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Endoscopic scopic hernia repair include the widespread use of gen- total extraperitoneal repair of primary and recurrent inguinal eral anesthesia and the potential for visceral and vascular hernias. Surg Endosc 1999; 13: 507–11. complications, unique to the laparoscopic approach 7 Ferzli GS, Frezza EE, Pecoraro AM, Jr, Ahern KD. Prospective (Table 11.4). randomized study of stapled versus unstapled mesh in a laparoscopic preperitoneal inguinal hernia repair. J Am Coll Surg 1999; 188: 461–5. 8 Frankum CE, Ramshaw BJ, White J, et al. Laparoscopic repair of Table 11.3 Potential advantages of laparoscopic inguinal bilateral and recurrent hernias. Am Surg 1999; 65: 839–42, hernia repair 842–3. 9 Halkic N, Ksontini R, Corpataux JM, Bekavac-Beslin M. Less difficulty in repairing a recurrent hernia Laparoscopic inguinal hernia repair with extraperitoneal double- Ability to treat bilateral hernia via same incisions mesh technique. J Laparoendosc Adv Surg Tech A 1999; 9: 491–4. Performance of simultaneous diagnostic laparoscopy (TAPP) 10 Lucas SW, Arregui ME. Minimally invasive surgery for inguinal Less postoperative pain hernia. World J Surg 1999; 23: 350–5. Reduced recovery time 11 O’Riordain DS, Kelly P, Horgan PG, et al. Laparoscopic Improved cosmesis extraperitoneal inguinal hernia repair in the day-care setting. Surg Endosc 1999; 13: 914–17. Results of laparoscopic inguinal/femoral hernia repair 87

12 Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Laparoscopic 25 Champault GG, Rizk N, Catheline J-M, et al. Inguinal hernia repair; repair of recurrent inguinal hernias after endoscopic totally preperitoneal laparoscopic approach versus Stoppa herniorrhaphy. Surg Endosc 1999; 13: 1145–7. operation: randomized trial of 100 cases. Surg Laparosc Endosc 13 Smith AI, Royston CM, Sedman PC. Stapled and nonstapled 1997; 7: 445–50. laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia 26 Khoury N. A randomized prospective controlled trial of laparoscopic repair. A prospective randomized trial. Surg Endosc 1999; 13: extraperitoneal hernia repair and mesh-plug hernioplasty: a study 804–6. of 315 cases. J Laparoendosc Adv Surg Tech A 1998; 8: 367–72. 14 Johansson B, Hallerbäck Glise H, Anesten B, et al. Laparoscopic mesh versus open preperitoneal mesh versus conventional technique for inguinal hernia repair: a randomized multicenter trial (SCUR Hernia Repair Study). Ann Surg 1999; 230: 225–31. FURTHER READING 15 Liem MSL, van der Graaf Y, van Steensel CJ, et al. Comparison of conventional anterior surgery and laparoscopic surgery for inguinal-hernia repair. N Engl J Med 1997; 336: 1541–7. Barkun JS, Wexler MJ, Hinchey EJ, et al. Laparoscopic versus open 16 Paganini AM, Lezoche E, Carle F, et al. A randomized, controlled, inguinal herniorrhaphy: preliminary results of a randomized clinical study of laparoscopic vs open tension-free hernia repair. controlled trial. Surgery 1995; 118: 703–10. Surg Endosc 1998; 12: 979–86. Champault G, Benoit J, Lauroy J, et al. Inguinal hernia in adults. 17 Zieren J, Zieren HU, Jacobi CA, et al. Prospective randomized study Laparoscopic surgery versus the Shouldice method. Controlled comparing laparoscopic and open tension-free inguinal hernia randomized study in 181 patients. Preliminary results. Ann Chir repair with Shouldice’s operation. Am J Surg 1998; 175: 330–3. 1994; 48: 1003–8. 18 Koninger JS, Oster M, Butters M. Management of inguinal hernia: Cheek CM, Black NA, Devlin HB, et al. Groin hernia surgery: a a comparison of current methods. Chirurg 1998; 69: 1340–4. systematic review. Ann R Coll Surg Engl 1998; 80 (suppl 1): S1–80. 19 Payne JH, Jr, Grininger LM, Izawa MT, et al. Laparoscopic or open Collaboration EH. Laparoscopic compared with open methods of groin inguinal herniorrhaphy? A randomized prospective trial. Arch Surg hernia repair: systematic review of randomized controlled trials. 1994; 129: 973–9, 979–81. Br J Surg 2000; 87: 860–67. 20 Heikkinen T, Haukipuro K, Leppala J, Hulkko A. Total costs of EU Hernia Trialists Collaboration. Mesh compared with non-mesh laparoscopic and Lichtenstein inguinal hernia repairs: a methods of open groin hernia repair: systematic review of randomized prospective study. Surg Laparosc Endosc 1997; 7: 1–5. randomized controlled trials. Br J Surg 2000; 87: 854–9. 21 Beets GL, Dirksen CD, Go PM, et al. Open or laparoscopic Kozol R, Lange PM, Kosir M, et al. A prospective, randomized study of preperitoneal mesh repair for recurrent inguinal hernia? A open vs laparoscopic inguinal hernia repair. An assessment of randomized controlled trial. Surg Endosc 1999; 13: 323–7. postoperative pain. Arch Surg 1997; 132: 292–5. 22 Filipi CJ, Gaston-Johansson F, McBride PJ, et al. An assessment of Maddern GJ, Rudkin G, Bessell JR, et al. A comparison of laparoscopic pain and return to normal activity. Laparoscopic herniorrhaphy vs and open hernia repair as a day surgical procedure. Surg Endosc open tension-free Lichtenstein repair. Surg Endosc 1996; 10: 983–6. 1994; 8:1404–8. 23 Aitola P, Airo I, Matikainen M. Laparoscopic versus open Stoker DL, Spiegelhalter DJ, Singh R, Wellwood JM. Laparoscopic versus preperitoneal inguinal hernia repair: a prospective randomised open inguinal hernia repair: randomised prospective trial. Lancet trial. Ann Chir Gynaecol 1998; 87: 22–5. 1994; 343: 1243–5. 24 Wellwood J, Sculpher MJ, Stoker D, et al. Randomised controlled Vogt DM, Curet MJ, Pitcher DE, et al. Preliminary results of a trial of laparoscopic versus open mesh repair for inguinal hernia: prospective randomized trial of laparoscopic onlay versus outcome and cost. Br Med J 1998; 317: 103–10. conventional inguinal herniorrhaphy. Am J Surg 1995; 169: 84–90. This page intentionally left blank 12

Complications and their management

RICARDO V. COHEN, CARLOS A. SCHIAVON, SÉRGIO ROLL AND JOSÉ C.P. FILHO

Anesthesia 89 Neuropathy 91 Events related to laparoscopic access 89 Visceral complications 92 Organ involvement 90 Mesh-related problems 93 Hydrocele 90 Recurrence 93 Seroma 90 Conclusion 94 Vascular injury 91 References 94

The modern era of the treatment of inguinal/femoral than age, to general anesthesia exists, then hernias must be hernias has evolved over the past 155 years. From truss repaired through an anterior approach under local anes- support to elective outpatient procedures, the surgical thesia. No controlled trial has been published that has techniques to treat these patients have progressed, such shown definitely that a local anesthetic is truly superior that now surgeons are able to employ the use of laparoscopy to carefully administered general anesthesia. Consequently, to approach these hernias. Laparoscopic approaches allow this does not represent a strong reason to avoid TAPP the inspection of the inguinal and femoral areas bilaterally, or TEP. thereby avoiding unexpected non-diagnosed contralateral hernias. This method of hernioplasty has been shown to reduce postoperative pain and disability and allows the EVENTS RELATED TO LAPAROSCOPIC treatment of bilateral defects in one sitting. But, as in ACCESS all operative procedures, complications exist. Nothing is more effective in the prevention of the occurrence of Inherent to laparoscopy are the insufflation of carbon complications as one’s awareness and fear of them. dioxide and the possibility of systemic alterations follow- In this chapter, complications and their management ing pneumoperitoneum, documented very well in the will be focused on the two most commonly performed literature. Additionally, trocar access may carry some laparoscopic inguinal hernia repairs, the transabdominal intra-abdominal complications, such as major vascular pre-peritoneal (TAPP) approach and the totally extraperi- or visceral injuries.3 Blind insertion of the Veress needle toneal (TEP) technique. or trocars may cause intra-abdominal and abdominal wall complications. In a retrospective study of 103 852 ANESTHESIA laparoscopic operations (nine per cent inguinal hernias), which involved the insertion of 390 000 trocars, the incidence of serious complications was 3.2/1000 inter- It has been suggested that the general anesthesia needed ventions (0.032 per cent).4 Bleeding from the trocar site for laparoscopic herniorrhaphy is a major drawback, and was the most common complication, accounting for open procedures are preferred because they can be two-thirds of the accidents; this resulted in conversion to performed under local anesthesia. However, numerous an open procedure in 11.3 per cent. Visceral injuries reports have revealed the relative absence of anesthesia- occurred in 0.6/1000 interventions, and the conversion related complications, probably associated with proper rate was 65 per cent. The incidence of vascular injuries patient selection.4,5 If a medical contraindication, other was 0.5/1000, and resulted in six deaths (17 per cent); the 90 Laparoscopic inguinal/femoral hernioplasty conversion rate to laparotomy was 85 per cent. The two with the conventional techniques, ranging from 0.3 to most important risk factors were inexperienced surgeons 5 per cent.12 and the introduction of the first trocar, which was responsible for 83 per cent of vascular injuries, 75 per cent of bowel injuries, and 50 per cent of local hemorrhage. Vas deferens complications Complications are theoretically different depending upon the laparoscopic technique (TAPP or TEP). In TEP, The incidence of vas deferens injuries is about the same because there is no invasion of the abdominal cavity, major (about 0.04 per cent) regardless of whether the hernia intracavity injuries are very rare. However, there have repair is performed open or laparoscopically. Trauma to been reports of enterotomies resulting from the tearing of the vas deferens can be one of immediate transection or adhesions during extraperitoneal balloon dissection.5 ultimate obstruction. Transection is a very rare mishap Another complication related to the laparoscopic following TAPP or TEP repair. If this does occur, then approach is trocar site incisional hernia. Although quite repair must be attempted unless fertility is not a con- uncommon, this is associated particularly with TAPP sideration. Obstruction can result from the vigorous repair. Because the incidence varies from five to 15 per handling of the vas deferens with instruments/graspers, cent, it is recommended that all port sites over 5 mm yielding a fibrosis of variable intensity through the mus- should be closed in order to avoid this postoperative cular wall of the vas deferens. Sometimes, the vas defer- complication. ens may become adherent to the posterior inguinal floor following the operation and form kinks that may represent an outflow obstruction and hence account for ORGAN INVOLVEMENT dysejaculation.

Almost all organ complications that follow the laparo- HYDROCELE scopic treatment of inguinal/femoral hernias are similar to those that follow open techniques. The morbidity rate in open operations is approximately ten per cent.6 Tetik This is an uncommon complication following either and colleagues in 1994,7 Phillips and colleagues in 1995,8 laparoscopic approach. It may be secondary to overzealous and Crawford and Phillips in 19989 reported complica- skeletonization of the spermatic cord or tissue dissection tion rates in the order of 11 per cent. Roll and coworkers, from the sac and at the internal ring. Some authors, in in a large Brazilian multicenter trial of 4000 operated retrospective studies, found a low incidence of hydrocele. patients, found that the rate of complications was seven When a TEP repair was employed, the incidence reported 13,14 per cent.10 Felix and colleagues in 1999 reported an inci- varied from 0.5 to 1.5 per cent. Felix and coworkers, in dence of complications of 6.1 per cent.11 All authors a paper devoted to significant complications following demonstrated that the incidence of the complications laparoscopic hernia repair, pointed out that the incidence were significantly higher in the period of the learning of hydrocele was higher in patients with the use of a mesh curve and could be reduced to less than one per cent with that was modified to place a ‘keyhole’ to accommodate 11 greater experience. the spermatic cord. Earlier, in a large, multicenter trial, Phillips and colleagues reported an incidence of 0.2 per cent, regardless of the method of laparoscopic technique.8 Testicular complications In a study of open repairs by Obney and Chan, the incidence of hydrocele formation was 0.9 per cent.15 The two pertinent complications concerning the testicle are ischemic orchitis and testicular atrophy. Postoperative inflammation of the testicle occurs within 24–72 hours fol- SEROMA lowing the procedure. The associated pain is severe, usually requiring aggressive and effective analgesia. Ischemic orchitis may progress, resulting in testicular atrophy, a Seromas represent an exudate, normally resulting from the process that may be observed over several months. The trauma of electrocautery, balloon dissection of the pre- mechanism of this complication originates from an intense peritoneal space in the TEP approach, scissors dissection, venous congestion within the testicle, secondary to throm- or foreign bodies, such as sutures and mesh. They are bosis of the veins within the spermatic cord. The initiating infrequently clinically evident and usually they can be trauma is seen during dissection of the spermatic cord allowed to reabsorb spontaneously. Size may vary, and from the hernia sac, whether for direct, indirect or femoral ultrasound follow-up may be important to determine hernias, or the TAPP or TEP procedure. The incidence of whether needle aspiration and/or drainage is necessary. testicular complications is lower with laparoscopy than Several publications have discussed whether the incidence Complications and their management 91 of seromas is more common in the TEP or the TAPP The aggressiveness of the dissection and complete parietal- approach. Studies by Felix and colleagues,11 Ramshaw and ization of the cord structures is the probable cause. Injuries colleagues,16 D’Allemagne and colleagues,17 Kald and col- of the aorta were described during TAPP, either secondary leagues,18 and Cohen and colleagues19 revealed different to the first blind trocar or during dissection in the inappro- results regarding the higher incidence of seroma in the priate location and resultant injury to the terminal aorta.20 TEP approach. It seems plausible that the use of balloon The introduction of prosthetic materials originally dissection in TEP repair can be more aggressive to the pre- raised some concerns with regard to their proximity to peritoneal space than the TAPP technique. Consequently, arteries and veins. Flat sheets of prosthetic materials it appears that seromas following TAPP are often smaller have not been associated with vascular erosions and and easier to manage than those that follow TEP. thrombosis.21 Additionally, it is quite rare for a seroma to become encap- sulated with such a strong fibrotic capsule that resection is required. NEUROPATHY

VASCULAR INJURY Residual neuralgia following laparoscopic hernia repair represents the most vexing complication of the inguinal region. The absence of convincing objective tests and the Bleeding from arteries or veins can occur at all anatomic subjective nature of the complaints do not favor an easy levels during an inguinal hernia repair. Superficially, sub- resolution of the problem. cutaneous hematomas or severe ecchymoses can result The femoral branch of the genitofemoral nerve, the from injuries to superficial vessels, such as the epigastric lateral cutaneous nerve of the thigh, and the intermediate artery or vein. The dissection in the space of Bogros dur- cutaneous branch of the femoral nerve are at risk of dam- ing TAPP, if careless, may incur bleeding that is usually age during laparoscopic inguinal hernioplasty because of: insidious and may result in large hematomas that can a failure to appreciate the anatomy from the extend from the anterior abdominal wall to the scrotum. • posterior aspect; During TEP, it is recommended after balloon insertion difficulty in visualizing the nerves pre-peritoneally; and insufflation to keep the balloon full of air for five to • the variable course of the nerves in this region; seven minutes to allow for better hemostasis. • improper staple placement; Injuries below the iliopubic tract to the major vessels, • extensive pre-peritoneal dissection. such as the iliac and femoral artery and vein, can occur • and obviously must be controlled swiftly. All control of The incidence of neurological complications varies bleeding must be done under direct vision. Blind clamp- with the technique (TAPP, 1.2–2.2 per cent; TEP, 0–0.5 ing and the use of deep suture ligatures must be avoided. per cent).22,23 Careful postoperative observation must be instituted, and The main clinical features of genitofemoral nerve early detection of vascular complications is important. injury consist of intermittent or constant pain and burn- Injury to the inferior epigastric vessels is not infre- ing sensations in the inguinal region, with radiation of quent during the learning curve. As this injury is diag- pain to the genitalia and upper medial thigh. As the nosed, the vessels should be clamped; posterior clip mechanism of injury is defined poorly, its diagnosis may ligation is the desirable treatment. No adverse sequelae be imprecise and available treatment options are varied. have been reported when the inferior epigastric vessels The best way to minimize this kind of complication is to have been ligated. avoid any extensive dissection of the posterior pelvis and The presence of an aberrant obturator artery origi- to avoid placement of staples or tacks below the iliopubic nating from the deep inferior epigastric artery can be tract, thereby keeping far away from the triangle of doom the source of bleeding when tacks or staples are anchored and the trapezoid of disaster (Figure 12.1).24 A study in 50 to the ligament of Cooper. Care must be taken, and cadaveric inguinal regions by Rosen and Halevy demon- acknowledgment of its existence underneath the mesh is strated that the mean safe distance to avoid any possible very important. If this bleeding is managed poorly, the contact with the genitofemoral nerve or the lateral result can be a bloody operative field that can be an femorocutaneous nerve during fixation is 3.95 cm lateral obstacle to the completion of the procedure. This dan- to the internal inguinal ring.25 To take all anatomic vari- gerous injury must be avoided. This complication has ations into account, Rosen and Halevy recommended earned the artery the unenviable designation of the placement of staples no further than 1.5 cm lateral to the ‘artery of death’. lateral border of the internal inguinal ring. This location Injuries to the spermatic vessels are more common dur- of fixation, in addition to the non-extensive dissections ing the learning curve for both TAPP and TEP procedures. and the avoidance of manipulation or stapling below the 92 Laparoscopic inguinal/femoral hernioplasty

of the pain. Electromyography may also be helpful. The management is controversial and multimodal. Initial efforts at clinical control with non-steroidal anti- inflammatory drugs, rest, and eventually infiltration with local anesthetics are frequently helpful. If inguinodynia persists, and sensory/motor deficit is present on examination, then immediate exploration and staple removal should be considered. If there is mild pain relief, then local infiltration may be a good step, but if local-ized tenderness persists with positive Tinel’s sign, then removal of the staple/tack or mesh or neurectomy may be required. If re-exploration is undertaken, care must be exer- cised during the removal of the staples/tacks and/or (a) mesh. The removal of the mesh or staples may disrupt the structural integrity of the hernia repair. It should also be realized that removal of the prosthesis could be a very difficult procedure that could pose a threat of injury to contiguous structural injuries, such as the iliac vessels.

VISCERAL COMPLICATIONS

Urinary bladder complications

Laparoscopic hernia repair is associated with urinary complications with an incidence of 1.5–5 per cent, 26 (b) including retention, infection and hematuria. Bladder injury with closed peritoneal access is rare but possible. It may be adherent or it may ‘slide’ into a direct or femoral hernia. The most common offender is the Veress needle, followed by the ﬁrst blind trocar. There is an increased risk in patients with previous dissection in the pre- peritoneal space or space of Retzius, such as a prior laparoscopic hernia repair or prostatectomy.

Intestinal complications

Bowel obstruction is almost unheard of with conventional repair, but it can be associated with the laparoscopic (c) approach, particularly TAPP. However, its incidence in the literature is low, ranging from 0.06 to 0.2 per cent.27 Figure 12.1 (a) TAPP – anatomical view: (1) Cooper’s ligament; The complication was frequent in the developmental (2) vas deferens; (3) spermatic cord; (4) nerve area below the stages secondary to inadequate peritoneal closure over iliopubic tract; (5) iliopubic tract; (6) internal ring. (b) Black the prosthesis, allowing bowel to migrate into the pre- area, triangle of doom; red area, trapezoid of disaster. peritoneal space, which could result in intestinal obstruc- (c) Recurrence Mesh invagination in the defect. tion. The major advantage of the TEP procedure is the theoretical avoidance of this problem, as the peritoneal iliopubic tract, are the most effective tools to avoid sheath is kept untouched. neuralgia paresthetica that may follow the laparoscopic Another situation, related almost solely to TAPP approach to groin hernias. repair, is the lack of appreciation of the need to close The ilio-inguinal nerve and the ilio-hypogastric nerve trocar sites. If one considers any hernia as a part of a are more superficial structures, making them easier to systemic abdominal wall disease, then it is mandatory to injure in open repair than in the laparoscopic method. close all fascial defects, avoiding potential port site her- Diagnosis can be made after careful anatomical localization nias. The incidence of delayed bowel obstruction related Complications and their management 93 to adhesions because of the intra-abdominal nature of required, due to their pore diameter, the inability of TAPP has yet to be determined but would appear to be drainage through them, and impaired macrophage extremely low. migration and activity. Intraoperative laceration of incarcerated or sliding When systemic conditions are unstable and sepsis is (large bowel) hernias must be avoided and currently are present, an aggressive surgical approach is the rule. One reported rarely. Following general principles of gentle should never forget, however, that removal of an infected surgical technique, this kind of problem should seldom mesh could be perilous, as firm adhesions to local struc- be found. tures such as major vessels may be found. Fortunately, the incidence of infections in the laparoscopic era varies 6,28 Bone complications from 0 to 0.6 per cent. Rarely, delayed infections may be seen months or years later. The mechanism in this delay is not understood. Bone-related complications were very rare before the Conservative management is the choice, and mesh laparoscopic era. Today, osteitis pubis after the learning removal is required rarely, subject to the above discussion. curve is an avoidable complication. The usual mechanism of injury is tacking/stapling the mesh while anchoring it over the periosteum. Oral analgesia and eventually Mesh and infertility local infiltration may be a good way to initiate treatment of this complication. If unsuccessful, re-exploration with Although infertility is not usually reported after hernia tack/staple removal is the best alternative to treat such a repair, a few reports from fertility clinics have shown an painful complication. It is a personal observation that association of infertility and previous hernia repair, pubic pain is more frequent when employing tacks rather without accounting for vas deferens injuries or ‘over- than the regular hernia staples, probably due to their manipulation’.The placement of large meshes in the pre- penetration into the bone. peritoneal space in TAPP or TEP repair may lead to fibrosis in the proximity of the vas deferens and may pre- Skin complications dispose to an unknown effect on its function, without any clear vas luminal obstruction. Further studies are needed. It should be noted that it is important to avoid extensive In major series, ecchymoses and subcutaneous emphy- manipulation of the cord structures and vas deferens in sema were reported, but these are self-limiting and with- men of reproductive age to avoid affecting fertility. out major consequences. Skin infections are very rare following laparoscopic repair, and there are no situations that impose a higher risk in either TAPP or TEP. RECURRENCE

MESH-RELATED PROBLEMS As stated by Rutkow in 1995, recurrences are not a param- eter of success in the surgical repair of groin hernias;29 rates higher than three per cent are unacceptable, and The introduction of prosthetic mesh in an inguinal if any technique reports recurrences higher than that hernioplasty is a standard procedure today. Mesh place- number, then it should be abandoned. However, despite ment allows tension-free repair, leading to significantly Rutkow’s reasonable ideas on recurrence, and the increas- lower recurrence rates, but its main complication – infec- ing popularity of the comparison of outcomes by mea- tion – poses a series of special management problems. surement of postoperative pain, return to work, patient The use of monofilament biomaterials carries a theoretic satisfaction, and cost, the standard by which any repair is advantage over the braided biomaterials. Pores in braided measured is its recurrence rate. That rate in laparoscopic yarns and expanded polytetrafluoroethylene (ePTFE) are techniques has fallen gradually as experience and knowl- smaller than macrophages, which implies that an infec- edge of the anatomy and mesh sizes have improved. tion associated with these types of mesh affects its man- Recurrence may be due to a variety of mechanisms, agement. The presence of infection does not necessarily including: mandate removal of a polypropylene or polyester mesh, unless the mesh is sequestered or is bathing in a puru- • incomplete dissection, with missed hernias, lent exudate. The infection is predominantly in the sur- inadequate identification of anatomical landmarks, rounding tissue, and abscess drainage and aggressive and the prosthesis being allowed to roll up instead clinical management with broad-spectrum antibiotics of lying flat; are required. However, when a braided mesh or ePTFE • mesh being too small, therefore not covering all prosthesis is employed, their removal is almost always potential defects; 94 Laparoscopic inguinal/femoral hernioplasty

Table 12.1 Recurrences in large multicenter trials REFERENCES Mean No. Recurrence follow-up 1 Arvidsson D, Smedberg S. Laparoscopic compared with open Reference Repair hernias (%) (months) hernia surgery: complications, recurrences and current trends. Eur J Surg 2000; 585: 40–47. Tetik et al. TAPP 553 0.7 13 2 Moreno-Egea A, Aguayo JL, Canteras M. Intraoperative and 7 (1994) TEP 457 0.4 postoperative complications of totally extraperitoneal laparoscopic inguinal hernioplasty. Surg Laparosc Endosc 2000; Fitzgibbons TAPP 562 5 23 27 10: 30–33. et al. (1995) TEP 87 0 3 Baadsgard SE, Egelblad K. Major vascular injury during Phillips et al. TAPP 1944 1 22 gynecologic laparoscopy: report of a case and review of published (1995)8 TEP 578 0 cases. Acta Obstet Gynecol Scand 1989; 68: 283–5. 4 Champault G, Cazacu F, Taffinder N. Serious trocar accidents in laparoscopic surgery: a French survey of 103,852 operations. Surg Laparosc Endosc 1996; 6: 367–70. 5 Topal B, Hourlay P. Totally preperitoneal endoscopic inguinal • migration of the mesh; hernia repair. Br J Surg 1997; 84: 61–3. • mesh slit (the slit is the site of the recurrence); 6 Bendavid R. Complications of groin hernia surgery. Surg Clin N Am • folding or invagination of the mesh into the defect; 1998; 78: 1089–2000. displacement of the mesh by hematoma. 7 Tetik C, Arregui M, Castro D. Complications and recurrences • associated with laparoscopic repair of groin hernias: a multi- The first reports with the abandoned laparoscopic institutional retrospective analysis. In: Arregui M, Nagan RF, eds. plug or plug-and-patch reported recurrence rates of Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe 30 Medical Press, 1994: 494–500. 25 per cent. As experience and knowledge of the anatomy 8 Phillips EH, Arregui M, Caroll BJ, et al. Incidence of complications and mesh size have grown, so recurrence rates have following laparoscopic hernioplasty. Surg Endosc 1995; 9: 16–21. decreased. Evaluation of large multicenter trial results 9 Crawford DL, Phillips EH. Laparoscopic repair and groin hernia reveals the low recurrence rates for TEP (Table 12.1). surgery. Surg Clin N Am 1998; 78: 1047–62. Tetik and coworkers reported a 0.4 per cent incidence of 10 Roll S, Cohen R, Miguel P, et al. Laparoscopic transabdominal 7 inguinal hernia repair with preperitoneal mesh. Surg Endosc 1994; recurrence in TEP, whereas no recurrences were reported 8: 485. 8 in 578 patients by Phillips and colleagues or in 87 repairs 11 Felix EL, Harbetson N, Vartanian S. Laparoscopic hernioplasty. by Fitzgibbons and colleagues.27 It is important to stress Significant complications. Surg Endosc 1999; 13: 328–31. that the vast majority of surgeons throughout the world 12 Cohen RV. Laparoscopic transabdominal preperitoneal hernia began their experience and learned the TAPP procedure repair. Doctoral thesis presented to the Department of Surgery, University of Sao Paulo, Brazil. Sao Paulo, Brazil: University of Sao first; TEP came later, bringing more comfort with the Paulo Press, 1996: 43–57. anatomy and handling the mesh better. Adoption of the 13 Ferzli G, Massad A, Albert P. Extraperitoneal endoscopic inguinal TEP technique by many of these surgeons occurred later, hernia repair. J Laparoendosc Surg 1992; 2: 281–5. thereby providing a higher level of comfort with the 14 McKernan B, Laws HL. Laparoscopic repair of inguinal hernias anatomy, and better handling and sizing of the mesh using a totally extraperitoneal prosthetic approach. Surg Endosc 1993; 7: 26–8. for the laparoscopic procedure. This may explain the 15 Obney N, Chan CK. Hydrocoeles of the testicle complicating relatively lower recurrence rates with TEP than with inguinal hernias. Can Med Assoc J 1956; 75:733–6. TAPP in these large trials. 16 Ramshaw B, Tucker JG, Conner T, et al. A comparison of the approaches to laparoscopic herniorrhaphy. Surg Endosc 1996; 10:29–32. 17 D’Allemagne B, Markiewicz S, Iehaes C. Extraperitoneal CONCLUSION laparoscopic inguinal hernia repair: technique and results. Surg Endosc 1996; 10: 228–34. 18 Kald A, Anderberg B, Smedh K. Transperitoneal or totally Over the past 15 years, laparoscopic hernioplasty has extraperitoneal approach in laparoscopic hernia repair. Surg made the transition from an experimental to a proven Laparosc Endosc 1997; 7: 86–9. procedure. With increasing laparoscopic skills, many 19 Cohen RV, Alvarez G, Roll S, et al. Transabdominal or totally surgeons are now faced with the question of when to extraperitoneal hernia repair? Surg Laparosc Endosc 1998; 8: 264–8. recommend a laparoscopic approach to their patients. 20 Oshinsky GS, Smith AD. Laparoscopic needles and trocars: an overview of designs and complications. J Laparoendosc Surg 1992; Complication and recurrence rates, although initially 2: 117–25. higher than traditional repairs, have now fallen to equal 21 Kathkouda N. Avoiding complications of laparoscopic hernia or lower levels at centers experienced in laparoscopic repair. In: Arregui M, Fitzgibbons R, Kathkouda N, eds. Principles of techniques. Prospective randomized trials prove that when Laparoscopic Surgery: Basic and Advanced Techniques. New York: patients are selected properly and surgeons are trained, Springer-Verlag, 1995: 435–8. 22 Starling JM. Genitofemoral neuralgia. In: Arregui M, Nagan RF, TAPP or TEP repairs may be performed with reasonable eds. Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe rates of complications and recurrence. Medical Press, 1994: 213–17. Complications and their management 95

23 Eubanks S, Newman L, Goehring L, et al. Meralgia paresthetica: a 28 MacFadyen BV. Laparoscopic inguinal herniorrhaphy: complication of laparoscopic herniorrhaphy. Surg Laparosc Endosc Complications. In: Arregui M, Nagan RF, eds. Inguinal Hernia: 1993; 3: 381–5. Advances or Controversies? Oxford: Radcliffe Medical Press, 1994: 24 Seid AS, Amos E. Entrapment neuropathy in laparoscopic 284–96. herniorrhaphy. Surg Endosc 1994; 8: 1050–53. 29 Rutkow I. The recurrence rate in hernia surgery. How important is 25 Rosen A, Halevy A. Anatomical basis for nerve injury during it? Arch Surg 1995; 130: 575–8. laparoscopic hernia repair. Surg Laparosc Endosc 1997; 7: 469–71. 30 Schultz L, Graber J, Pietraﬁtta J. Laparoscopic laser herniorrhaphy: 26 Payne JH. Complications of laparoscopic herniorrhaphy. Semin a clinical trial preliminary study. J Laparoendosc Surg 1990; 1: Laparosc Surg 1997; 4: 166–81. 41–5. 27 Fitzgibbons RJ, Camps J, Cornet DA, Annibali R. Laparoscopic inguinal herniorrhaphy: results of a multicenter trial. Ann Surg 1995; 221: 3–13. This page intentionally left blank PART 3

Laparoscopic incisional and ventral hernioplasty

13 History 99 19 Parastomal hernia repair 143 14 Anatomy and physiology 103 20 Lumbar hernia and ‘denervation’ hernia repair 151 15 Laparoscopic repair in the emergent setting 111 21 Results of laparoscopic incisional and ventral 16 Herniorrhaphy with the use of transfascial sutures 115 hernia repair 155 17 Pre-peritoneal herniorrhaphy 125 22 Complications and their management 161 18 Hernioplasty with the double-crown technique 133 This page intentionally left blank 13

History

KRISTI L. HAROLD, BRENT D. MATTHEWS AND B. TODD HENIFORD

Laparoscopic ventral herniorrhaphy 99 Conclusion 100 Adoption of procedure 100 References 100

Ventral hernias present a challenging surgical problem. to the armamentarium of biomaterials in the 1970s and Approximately 3–11 per cent of all laparotomy incisions has become a popular prosthetic for ventral/incisional develop a fascial defect, resulting in 90 000 ventral hernias hernia repair.3 repairs each year.1 Due to the high rate of recurrence with The introduction of tension-free repair with bio- simple suture closure, the techniques of hernia repair materials has drastically reduced the recurrence rate of have evolved from primary repair to those employing abdominal wall hernias. In several studies, the addition biomaterials. More recently, surgeons’ options have of prosthetic mesh has reduced hernia repair failure expanded to include repairs using minimally invasive by more than 50 per cent.4 Nevertheless, the techniques approaches. developed by Stoppa and others to employ meshes Primary repairs involve suturing of the aponeurotic for repair involve large areas of tissue-flap dissection layers of the abdominal wall to close defects, along with and create significant patient morbidity, including unique variations such as the ‘vest-over-pants’ technique wound complications, infection, a need for drains, and developed by William J. Mayo in 1895. To repair large pain.5 defects, in the 1920s Gibson introduced the concept of Advances in minimally invasive surgery prompted the relaxing incisions, which allowed closure of the abdomi- first attempts at laparoscopic ventral hernia repair in the nal wall in the midline with reduced tension.2 Despite the early 1990s.6 These techniques eliminated the need for various and inventive techniques for primary repair, the wide soft-tissue dissection and large incisions, and it was recurrence rate after primary repair remained unaccept- hoped that there would be a corresponding decrease ably high, spurring the development of biomaterials in morbidity, such as was seen in the transition from to repair abdominal wall defects in the first half of the conventional to laparoscopic cholecystectomy. twentieth century. The first biomaterials employed for hernia repair were metallic. Silver wire mesh, tantalum mesh, and stainless- LAPAROSCOPIC VENTRAL steel mesh were all used in an attempt to create stronger HERNIORRHAPHY hernia repairs. The metallic prostheses, however, led to problems such as erosion, fragmentation, fistulas, and patient intolerability. Hence, a variety of synthetic poly- Initial laparoscopic ventral hernia repairs were usually meric meshes were developed, leading to a revolution in performed by placing a large intraperitoneal prosthesis hernia repair. Francis Usher introduced monofilament and securing it to the anterior abdominal wall with her- polypropylene mesh in 1958, and today this is the most nia staples or spiral tacks.6–8 Recurrences secondary to commonly used mesh. Polyester mesh, which is very the mesh pulling free from the abdominal wall or migra- popular in Europe, was also introduced in the 1950s. tion with the peritoneum into the hernia prompted most Expanded polytetrafluoroethylene (ePTFE) was added surgeons to adopt a fixation technique that employs 100 Laparoscopic incisional and ventral hernioplasty transfascial non-absorbable sutures in addition to staples Table 13.1 Number of articles published or tacks to secure the mesh.7,9 Surgeons also recognized concerning laparoscopic ventral hernia that the lack of overlap of the defect by the prosthesis repair by year (Medline and Embase search) contributed to recurrent hernia formation.10 This has Publication Number of led to the recommendation that at least a 3-cm overlap year articles published be provided circumferentially. Many surgeons advocate a 4–6-cm circumferential overlap if the mesh can be placed 2001 18 without undue technical difficulty. We and others often 2000 19 underlay the entire previous incision, even if it is not 1999 11 1998 13 involved with the hernia, to prevent the development of 1997 9 another hernia above or below the repaired defect. 1996 12 The choice of prosthetic material for laparoscopic ven- 1995 8 tral hernia repair is varied and often debated. By far, how- 1994 13 ever, the most frequently used mesh has been expanded 1993 3 polytetrafluoroethylene (ePTFE). While some authors 1992 3 have reported the use of polypropylene or polyester materials for laparoscopic ventral herniorrhaphy without complication,8 these biomaterials lead to adhesion formation and have been associated with intestinal erosion CONCLUSION and fistula formation in up to five per cent of patients when placed intraperitoneally.11 Accordingly, the trend The future of laparoscopic ventral and incisional hernia has been toward the use of PTFE in most hospitals. repair is promising. Many studies now document a low recurrence rate with this technique, as well as minimal patient morbidity afforded by the laparoscopic approach. ADOPTION OF PROCEDURE While advances in biomaterials and mesh-fixation devices may lead to future modifications in this technique, the ability to perform tension-free repair by a minimally While laparoscopic inguinal herniorrhaphy enjoyed a invasive approach is a positive milestone in the history of rather quick acceptance after its introduction, the popu- hernia surgery. larity of laparoscopic ventral hernia repair has arrived somewhat more slowly. This can probably be attributed to the inherent difficulty of the adhesiolysis in the previously operated abdomen and the need for surgeons with REFERENCES limited laparoscopic experience to apply large pieces of mesh. A search of Medline and Embase demonstrated 1 Mudge M, Hughes LE. Incisional hernias: a 10-year prospective only three articles concerning the procedure published study of incidence and attitudes. Br J Surg 1985; 72: 70–71. in 1992, the year that laparoscopic ventral herniorrha- 2 Flament JB, Palot J, Burde A, et al. Treatment of major incisional phy was introduced. However, interest in the technique hernias. In: Bendavid R, Abrahamson J, Arregui M, et al., eds. Abdominal Wall Hernias: Principles and Management. New York: increased, and by 1994, 13 publications were posted. Springer-Verlag, 2001: 508–16. There has been a steady or increasing number since that 3 DeBord JR. The historical development of prosthetics in hernia time, and now more than 100 peer-reviewed articles surgery. Surg Clin North Am 1998; 78: 973–1006. concerning laparoscopic ventral hernia have been pub- 4 Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of lished (Table 13.1). Additionally, the number of patients suture repair with mesh repair for incisional hernia. N Engl J Med 2000; 343: 392–8. included in single and multi-institutional studies has 5 White TJ, Santos MC, Thompson JS. Factors affecting wound continued to grow. Currently, well over 1000 patient out- complications associated with prosthetic repair of ventral hernias. comes have been reported in peer-reviewed articles, and Am Surg 1998; 64: 276–80. one manuscript details the outcomes of more than 400 6 LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal patients.9 hernias using expanded polytetrafluoroethylene: preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. Use of the technique for laparoscopic ventral hernior- 7 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic rhaphy has also been reported in cases of unusual defects, incisional and ventral herniorrhaphy: our initial 100 patients. such as lumbar hernias, parastomal hernias, and diaphrag- Hernia 2001; 5: 41–5. matic hernias.12–14 While the number of patients in these 8 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral and series is small, the outcomes have been positive, and the incisional hernioplasty. Surg Endosc 1997; 11: 32–5. 9 Heniford BT, Park A, Ramshaw B, Voeller G. Laparoscopic ventral laparoscopic approach seems uniquely suited for defects and incisional hernia repair in 407 patients. J Am Coll Surg 2000; located in challenging anatomical locations. 190: 645–50. History 101

10 LeBlanc KA. The critical technical aspects of laparoscopic 12 Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of repair of ventral and incisional hernias. Am Surg 2001; 67: lumbar hernias. J Am Coll Surg 1998; 187: 147–52. 809–12. 13 LeBlanc KA, Bellanger DE. Laparoscopic repair of paraostomy 11 Leber GE, Garb JL, Alexander AI, Reed WP. Long-term hernias: early results. J Am Coll Surg 2002; 194: 232–9. complications associated with prosthetic repair of incisional 14 Matthews BD, Bui H, Harold KL, et al. Laparoscopic repair of hernias. Arch Surg 1998; 133: 378–82. traumatic diaphragmatic hernias. Surg Endosc 2003; in press. This page intentionally left blank 14

Anatomy and physiology

KARL A. LEBLANC

Anatomy and function 103 Maturation of the hernia repair 108 Anatomy of a hernia 105 Cosmetic result 109 Anatomical considerations in the repair of Functional result 109 abdominal wall defects 106 Conclusion 110 Effects of biomaterial placement in laparoscopic References 110 herniorrhaphy 107

The abdominal wall is a complex structure with a multi- This hernia, in turn, can result in complications such as tude of components, including skin, muscles, aponeu- incarceration, strangulation, loss of domain, and signifi- roses, fat and mesothelium. This musculo-aponeurotic cant cosmetic deformities. Therefore, the approximation structure is attached to the vertebral column posteriorly, of the abdominal wall as the final act of laparotomy the pelvic bones inferiorly, and the ribs superiorly. The should be considered to be as important as the intra- integrity of the abdominal wall is essential for protecting abdominal procedure that necessitated the incision. This the underlying organs, allowing for movement of the represents the optimum opportunity to avert the devel- trunk of the body, providing assistance in respiration, opment of herniation in the future. and preventing herniation of the intra-abdominal con- Once a hernia has developed and a surgeon is to repair tents. Breaches in this integrity can occur with incisions, the fascial defect, many considerations influence the drainage tubes, and postoperative complications. Further- herniorrhaphy or hernioplasty chosen, whether open or more, the closure of the incisions is affected by the method laparoscopic. The aim of this chapter is to familiarize the of closure, the type of suture used, and the development of laparoscopic hernia surgeon with a working knowledge of wound sepsis. Recent studies have even identified that the anterior abdominal wall. This understanding is the suture technique, the suture length to wound length important because the anatomical basis of the repair of ratio, and the suture tension have an effect on the ultra- incisional and ventral hernias is necessary to assure an structural composition of the regenerating tissue and optimal result, structurally, functionally and cosmetically. collagen composition.1 Despite the importance of this portion of the body, many surgeons have little knowledge of the anatomical ANATOMY AND FUNCTION details as they relate to the function of the structure. All physicians know of the need for the disruption of its structural integrity during the course of an operation The functional anatomy of the abdominal wall centers that requires access to the abdomen and sometimes the upon the flat muscles that provide protection and reten- retroperitoneum. The factors that influence both the tion of the abdominal viscera. These muscles also pro- prevention and development of hernias are frequently vide assistance in respiration and allow movement of the overlooked during the closure of wounds. The result can mid-portion of the body. These components include the be predisposition to a fascial defect that will allow extra- rectus abdominus, external oblique, internal oblique, abdominal migration of the contents of the abdomen. and transversus abdominus muscles. 104 Laparoscopic incisional and ventral hernioplasty

Rectus abdominus muscle anterior iliac spine and the iliac crest. This muscle, in concert with the internal oblique and the transversus This muscle extends from the xiphoid process and abdominus muscles, functions to contain the abdominal the lower rib margins to the pubis. The entire length viscera. Bilateral contraction of the external oblique of this muscle inserts into the linea alba in the midline of lowers the ribs, thereby bringing the thorax closer to the the abdomen. Because the linea alba is the site of the pelvic brim. In this manner, it functions as an accessory most frequent point of entry into the abdomen for open muscle of expiration. Unilateral contraction of this mus- surgical procedures, this is the site that most commonly cle causes the opposite hemithorax to depress and rotate becomes the site of herniation. We have found that toward the side of muscle contraction. approximately 80 per cent of the incisional hernias that The function of this muscle can be compromised by we repair laparoscopically are located in the midline of the development of the hernias that are located away from the abdomen.2 The rectus muscle, when contracted, will the midline of the abdomen. Such hernias include sub- bring the xiphoid and ribs closer to the pubis. It also acts costal incisional, post-appendectomy, post-colostomy and to contain the viscera in concert with the other flat mus- Spigelian hernias. Because of the lack of re-approximation cles of the abdominal wall. The function of the rectus will of the edges of the fascial defect during laparoscopic repair, be compromised after the development of a hernia at the expiratory function will not resume the efficiency that site of the linea alba. The laparoscopic repair of midline was present before the herniation. The extent of this effect hernias does not re-approximate the linea alba. A few will be dependent upon the size of the fascial defect and centers make an effort to close this defect when possible, the tone of the other muscles of the abdomen. but the vast majority of surgeons make no effort to do so. Therefore, in most cases the normal function of the rec- Internal oblique muscle tus is not restored to its native state. The placement of the prosthetic biomaterial will reconstruct the containment These fibers course beneath those of the external oblique function of the muscle, but it will improve its motor muscle in an opposite direction. The muscle runs from functions only minimally, if at all. However, the contrac- the pelvic brim upward and medially to the thoracic cage tion of the scar of the hernia itself will result in a mild to and the linea alba. The function of the internal oblique moderate reduction in the size of the gap of the linea alba muscle is similar to that of the external oblique muscle, in many patients. but its unilateral contraction results in rotation and low- Some laparoscopic surgeons use the posterior rectus ering of the thorax on the ipsilateral side of the contrac- sheath of the rectus within which to perform the operation. Consequently, laparoscopic hernioplasty has an tive procedure and to place the prosthetic material. This effect on the internal oblique muscle that is similar to posterior rectus sheath is entered, the hernia is reduced, that seen in the external oblique muscle. and the repair is performed within that space. This provides for an extraperitoneal operation similar to that of the laparoscopic inguinal herniorrhaphy and the Transversus abdominus muscle Rives–Stoppa repair. The space limitations of this operative field make the approach impractical for very large This innermost muscle layer of the abdominal wall and/or incarcerated hernias that do not reside within inserts posteriorly on to the lower six ribs, the lumbo- the rectus sheath, such as Spigelian or lumbar hernias. It dorsal fascia, the iliac crest, and the iliopsoas fascia. It has also not been proven that this method of repair also inserts on the medial surface of the costal portion of improves the functionality of the muscles to a greater the lower seven or eight ribs and interdigitates with the extent than that provided by intraperitoneal placement insertions of the diaphragm. It is a very important com- of prosthetic biomaterial. The extraperitoneal repair that ponent of respiration as it is the main antagonist of the is described in Chapter 17 does not afford any differences diaphragm. As such, it could be considered a key muscle as to the function of the linea alba because it is not of expiratory function. It acts in this role by displacing re-approximated in this repair. the visceral contents under the diaphragm at the end of the initial stage of diaphragmatic inspiration. Because of its position within the layers of the External oblique muscle abdominal wall, the transversus abdominus muscle is also the major component of the containment function This outermost layer of the flat muscles of the wall of the of these muscles. Because of its structure, it has a power- abdomen arises from the lowest seven or eight ribs and ful action that results in traction on the abdominal wall. courses obliquely downward and towards the midline. It is this action that results in the tendency of the margins There, it interdigitates with the fibers of the contralateral of the laparotomy incision to separate. This act, of rapid external oblique. The fleshy muscle fibers insert on the retraction, explains the dehiscence that can occur acutely Anatomy and physiology 105 with a vertical midline laparotomy incision. It also Most incisional and ventral hernias will be single accounts for the difficulty encountered during attempts defects within the fascia. The layers of muscle and to provide closure of the midline following dehiscence or fascia will be displaced from the normal position into after development of midline incisional hernias. One of all directions from the hernia. This results from the the advantages of laparoscopic hernioplasty and the use traction effects of the flat muscles of the abdomen. of a prosthetic biomaterial is that the forces of traction Approximately 22 per cent will be of the multiple defect by this muscle are diminished. Therefore, the function of (‘Swiss-cheese’) variety.1 In these cases, the muscle will the transversus abdominus that would weaken or destroy be displaced laterally from the defect, but the fascia will a tissue re-approximating type of repair is averted. Con- be intact between the hernias. This will create one or versely, the use of prosthetic material to bridge the gap many ‘fascial bridges’ separating the various hernias. In that is created by the hernia does little to correct the res- either of these hernia anatomic variations, the peritoneal piratory function that is lost after such an occurrence. surface of the hernia will then be covered with pre- Much is known about the function of the muscles of peritoneal fat (if any exists), subcutaneous fat, and the the abdominal wall before the occurrence of a hernia, but skin of the abdominal wall. In some patients, there may few studies have examined the effects of the muscle func- be a lack of any tissue between the hernia sac and the tion after incisions through them or after the develop- skin. If this is encountered, good judgment will dictate ment and subsequent repair of the hernias. These studies that no energy source, such as electrocautery or ultra- are needed to assess the ability of these operations to sonic dissection, should be utilized in that area during restore the function of these muscles other than that of the dissection of adhesions. This will avoid the applica- the retention of the viscera within the abdomen (see tion of heat in the area, which might otherwise cause below). necrosis of the compromised skin surface and exposure of the underlying prosthetic biomaterial. Numerous types of incisions are used to enter the ANATOMY OF A HERNIA abdomen, obviously influenced by the intra-abdominal procedure to be performed. Because of this, some patients may have separate and distinct hernias in more Approximately 90 per cent of non-inguinal hernias of than one location. This is not infrequent in patients who the abdominal wall result from an incision through the have temporary colostomies placed after diverticular aponeurotic layer. The loss of integrity of the transver- perforation of the colon. These are particularly well salis fascia predates its development. Additionally, poor suited for the laparoscopic approach as both hernias can nutritional status, infection, pulmonary disease, steroid be repaired simultaneously without the requirement of usage, and morbid obesity can potentiate the weakening two separate incisions. A similar situation is seen in effects of such an incision. Initially, one may not recog- patients who present with both incisional and inguinal nize that a hernia has developed as it could take several hernias. months for this to become apparent. Sometimes, how- The tissue disruption that can be seen following the ever, a postoperative incisional infection will be of such flank incisions for anterior lumbar interbody fusions and severity so as to delineate the fascial defect before dis- nephrectomies are not usually hernias. This problem is charge of the patient from hospital. There is a five-fold not a true defect in the fascia but is the result of denerva- increase in the occurrence of incisional hernias following tion of the musculature caused by the incision itself. The an infection in the wound. flat layer of muscles becomes paralytic. This loss of tissue The edges of the fascial defect may be difficult to support results in a broad area of weakness that is demarcate preoperatively by the surgeon because of unsightly and frequently symptomatic. While there is no obesity and/or incarceration. The muscle layers will be true fascial defect in the usual case, occasionally one will forced aside from the herniation of the pre-peritoneal note intestinal contents in a fascial defect within the area tissues or intra-abdominal contents. The herniated struc- of muscle paralysis (see Chapter 20). tures can be pre-peritoneal fat, omental fat, or small or Finally, hernias that occur without a premorbid event large intestine. Rarely, other organs can herniate. Fre- are known as primary hernias. These include epigastric quently, these organs will be fixed to one another due to and umbilical hernias. These can represent 10–20 per adhesions that have developed after the initial operation. cent of abdominal-wall hernias in most series (excluding Generally, as the number of the intra-abdominal opera- inguinal hernias). These patients, however, will incur a tions increases, so does the probability of encountering weakness in the transversalis fascia that results in hernia- more numerous and denser adhesions. Each additional tion of pre-peritoneal fat and/or the intra-abdominal operative procedure increases these odds, especially if the contents (Figure 14.1). Predisposing factors include low patient has had a previous hernia repair using a polypropy- birth weight, steroid usage, pulmonary disease, urologi- lene mesh. cal disorders, trauma and obesity. Despite the origin, the 106 Laparoscopic incisional and ventral hernioplasty

cosmetic results for the patient. Unfortunately, this method of repair is fraught with a recurrence rate of 25–51 per cent in most centers.4,5 In many patients, re- approximation of the midline is impossible due to the distraction of the abdominal wall musculature. In such cases, some form of prosthesis is absolutely required if the hernia is to be repaired. The use of a prosthetic biomaterial in the open repair of incisional hernias has reduced the rate of recurrence to 10–25 per cent.2,6 The manner of placement of this biomaterial can vary widely, however.7 The biomaterial can be placed intraperitoneally, extraperitoneally, below the rectus muscle, above the rectus muscle, or above the fascia. Additionally, there are several methods Figure 14.1 Attenuated epigastric fascia (arrows) in a patient by which to handle the fascial defect itself during the with an umbilical hernia. insertion of the prosthesis. Some surgeons will place the mesh at the edge of the fascial defect; others will close the fascial defect before or after the insertion of concepts of the laparoscopic repair of these hernias are the mesh.8 not changed. Additionally, methods of fixation of biomaterial vary There is only limited information regarding the func- greatly across the world. Indeed, it is very common for tion of the abdominal wall once herniation develops. Of the method of fixation to vary between staff of a single course, the development of a hernia mandates a loss of institution. Thus, a comparison of the method of pros- the retention function of the muscles of the abdominal thetic repair of open incisional hernias can be difficult wall. It is felt that there is also a decrease in the respira- and inaccurate. tory function of the flat muscles as they have now been Proponents of the laparoscopic repair of incisional compromised. With chronic incisional herniation, the and ventral hernias share the common belief that an affected muscles are no longer inserted into the midline effective repair of the defect requires the insertion of a and are initially hypertonic. Over time, these muscles prosthetic biomaterial. Only the very smallest of hernias undergo ultrastructural changes that result in hypo- (Ͻ1–1.5 cm) are closed with sutures alone, although tonicity. The resultant musculofascial changes increase most series have not mentioned this.9 The method of the risk of recurrence with the sutured repair. For this fixation and the location of the prosthetic can vary, as with reason, the use of a prosthesis is preferred. open repair. The biomaterial can be placed intraperi- Large hernias can result in a paradoxical motion of the toneally, extraperitoneally, or behind the rectus muscle abdominal wall with respiration. As the diaphragm is but within the rectus sheath. Most commonly, however, moved inferiorly to inspire, this action increases the intra- it is placed in the intraperitoneal position. The method abdominal pressure, which then forces the hernia out- of fixation is usually with tacks alone or with tacks and ward. In this case, the respirations are shallower than transfascial sutures. Other fixation devices are also avail- normal, which can be revealed as exertional dyspnea. This able (see Chapter 4). It appears that in only one pub- will worsen as the hernia enlarges, but compensatory lished series has there been a concerted effort to close the mechanisms will normalize the respiratory exchanges at fascial defect;10 it has not been the practice in other pub- the expense of increased respiratory work.3 lished reports to close this defect. In fact, little attention has been paid to the necessity of the closure of the linea alba in the laparoscopic hernioplasty of incisional and ANATOMICAL CONSIDERATIONS IN THE ventral hernias. It is believed that the repair of the fascial REPAIR OF ABDOMINAL WALL DEFECTS defect will place tension on the repair and offer no improvement in outcome. The anatomical considerations of the closure of the The goal of abdominal-wall hernioplasty is the restora- fascial defect and, in most cases, the linea alba will be the tion of the integrity of the covering of the abdominal reconstitution of the normal anatomy and function of contents. The oldest method by which to do this is the the anterior abdominal wall. It has not been proven that sutured technique of herniorrhaphy. This method will any long-term benefits will be seen if this is done. Many approximate the linea alba and attempt to restore the proponents of open repair will insist on the approx- normal architecture of the abdominal wall. It is felt that imation of the linea alba, as it is felt that this will this will provide the best long-term functional and restore the respiratory function of the abdominal wall. Anatomy and physiology 107

This can be done in many but certainly not all cases of motion of the hernia and its contents in relation to the herniation within the abdominal wall (other than normal movements of the abdominal wall. This may be inguinal and femoral defects). Hernia defects that are enhanced over time as the healing process results in larger than 5 cm2 are unlikely to be repaired, primarily the contraction of the original fascial defect. because re-approximation of the fascial edges is usually The method of fixation could potentially impact the not possible. Should one accomplish this closure, then the function of the abdominal-wall musculature, although repair of most of these hernias will result in a consider- this has never been studied. The use of tacks, coils or able amount of tension. The success of both open and other fixation devices alone in the fixation of biomaterial laparoscopic hernia repair depends on the elimination of may not allow the prosthesis to act in tandem with the tension on the tissues. This can be accomplished, in the muscles, as would the use of transfascial sutures. These majority of patients, only with the use of a prosthetic bio- devices will penetrate only 3–4 mm, thereby attaching material. The question of the anatomical modification of the biomaterial to the posterior layers of the transversus the laparoscopic approach becomes moot if acknowledg- abdominus and possibly the internal oblique muscles. It ment of the concept of tension-free hernioplasty is applied could be postulated that only the movement of the trans- to every hernia repair. versus abdominus muscle will affect the patch attached in this manner. Similarly, one could postulate that the use of transfascial sutures increases the likelihood that the EFFECTS OF BIOMATERIAL PLACEMENT IN flat muscles that are attached to the prosthesis in that LAPAROSCOPIC HERNIORRHAPHY manner will function more normally. Fixation of the biomaterial with transfascial sutures will more likely ensure that the movement of each of the During the repair of incisional and ventral hernias, the three layers of muscle of the abdominal wall will impact prosthesis will usually be placed in the intraperitoneal the prosthesis in some manner. The prosthesis becomes a position. In some areas and in some patients this may not significant portion of the abdominal-wall function once be the case, but in the majority of published series the it has been fixed in this manner. I believe that the patch location is within the abdomen. While there is a theoreti- will respond to movement of these muscles and have a cal risk of patch migration, such as has been seen in open greater impact in the function of the wall of the abdomen. repair, to date none have been reported with laparoscopic However, the sutures will also transfix all of the layers repair. In only one series has the defect within the fascia of the flat muscles together. This could diminish the been closed.10 The usual operation will simply place the independence of each of their functions at those points prosthesis under the defect with a minimum fascial over- of fixation. If the biomaterial is placed in the retro- lap of 3 cm. The biomaterial is then fixed into position rectal position, then the effects of this will also be felt. and the operation terminates without regard to the re- Usually, however, hernias are smaller and only in the mid- approximation of the linea alba. Certainly, in hernias that line if this method is utilized. The same functional result are located in sites not in the midline, the linea alba is not should be seen. More experimental data are needed to involved in the repair of the hernia. These typically are evaluate the impact of these issues. not large and are not considered to be significant in the During adhesiolysis and particularly at the time of overall function of the wall of the abdomen. Laparoscopic fixation of the biomaterial, there is a risk of injury to the repair does not provide for the resection of the peritoneal vessels of the abdominal wall. The significant vessels of sac. Because this sac is not resected, seromas occur very the abdominal wall are the inferior epigastric arteries frequently. Some authors have used electrocauterization and veins. These are usually out of harm’s way during of the peritoneal surface of the sac to diminish the occur- more traditional repairs of hernias of the abdomen. rence of seromas.11 Others have used argon-beam coagu- Generally, any injury to these vessels will be recognized lation for the same purpose.12 When seromas do occur, and controlled on the operating table. The most com- some may require additional procedures to treat them; mon method of control is the transfascial placement of fortunately, this is infrequent. sutures, similar to the manner used to fix the patch. This The prosthesis acts as a barrier to the protrusion of will easily and effectively control the hemorrhage. Late the intra-abdominal contents. It does not assume any hematomas have been described in several series in the functional role in the abdominal wall. The muscles of the literature. One could assume that these represented late abdomen will not have any significant change in their development of hemorrhage from these vessels, due to own function after the operation. Repair of the hernia, either partial tamponade or delayed necrosis of the vessel especially larger ones, will probably improve the function wall secondary to electrocautery or other smaller vessels of the flat muscles of the abdomen. There are no sup- that experience the same process. portive data to prove this, but one would assume that The sutures may also impinge the small nerves of the elimination of the hernia eliminates the paradoxical subcutaneous space. This is unavoidable, but it has 108 Laparoscopic incisional and ventral hernioplasty

MATURATION OF THE HERNIA REPAIR

Once LIVH is completed, the healing processes will begin immediately. Scar contraction, which has the effect of shrinking the biomaterials, will generally be completed within 90 days. Following this time period, the effects of the biomaterial choice will become apparent. PPM products can contract as much as 20–60 per cent, although this process may take place over the ensuing one or two years. In so doing, the original defect will correspond- ingly contract, which results in a closer re-approximation of the abdominal wall muscles. This could improve the function of these muscles, but the dense scar may actu- Figure 14.2 CT appearance of the repaired midline incisional ally be more of a detriment to this fact; no studies are hernia with DualMesh six months postoperatively. available to verify this statement. ePTFE biomaterials will contract 20–50 per cent but with more flexibility than polypropylene biomaterials. not proven to be a significant complaint following the There is rapid infiltration of cellular elements into the operation. Most of the pain is probably related to neu- interstices of the product. This may effect more rapid roma formation, but there are patients who seem to have healing and result in the function of the abdominal wall prolonged pain (one to two per cent) that may be due to being more ‘matured’ at the completion of the LIVH if suture constriction. I have had two patients who were ePTFE rather than other materials is used in the repair. relieved of symptoms after laparoscopic incisional hernia This is especially true with the newest products that have repair by the incision of the offending sutures. Local a ‘corduroy’ surface.13 anesthetic injection can also be used. During the healing phase following the operation, The type of biomaterial that is used in laparoscopic many clinical changes will be seen that may be new to incisional and ventral hernioplasty (LIVH) will also surgeons who have just started using this technique. impact the functionality of the abdomen. The polypropy- Initially, many patients will not have any noticeable prolene meshes (PPM) are usually quite stiff and result in a trusion at the site of the original hernia, particularly if significant amount of cicatrization during the healing a pressure dressing or abdominal binder is used follow- process. The contraction of the scar that occurs will result ing the procedure. Many, if not all, patients, however, in a firm area of the abdomen at the site of the previous will develop a seroma at the site of the hernia sac.14 The hernia sac and defect. This site will not be pliable in the size and significance of this varies greatly. This can be manner of the normal anatomy. It is not an area that acts worrisome and unsightly, but it usually resolves without in unison with the muscles of the abdomen but instead intervention. it is an independent site in which the muscles of the Following its resolution, the patient will generally have abdomen act around rather than with the biomaterial. an abdominal wall that is very similar in appearance to the The thicker, two-layered Composix® mesh has an even premorbid condition before the development of the her- greater effect of solidifying the site of implantation than nia. The cosmetic result in the vast majority of patients does the single layer of PPM. In the few patients I have will be acceptable to both the surgeon and the patient seen who have had this implanted, the abdominal wall because of the resumption of a normal contour as per- was more board-like than flexible. ceived by the patient. Most patients, particularly obese Expanded polytetrafluoroethylene (ePTFE) products individuals, will have a lax abdomen due to lack of tone in result in an organized healing process that resembles the muscles of the abdominal wall. In these individuals, more closely that of the normal progression. As a result, the larger patches will actually result in a flattened appear- the abdominal wall is more likely to act with rather than ance compared with other areas of the abdomen. This is against the patch in the function of the muscles. While probably related to the improved support of the abdomi- this prosthesis is not stretchable, the softness of the prod- nal wall by the prosthetic. In some patients, the lateral uct and the characteristics of the collagen infiltration aspects of the abdomen (outside the prosthetic biomater- into the biomaterial allow it to conform more naturally ial) will seem to protrude disproportionately compared to the abdominal wall. Follow-up computerized tomog- with the mid-portion where the repair was done. These raphy (CT) of the abdomen after this procedure will ver- effects are more pronounced with PPM biomaterials than ify the conformability of the prosthetic biomaterial with ePTFE products. A few patients will need reassurance (Figure 14.2). of this phenomenon. In patients that have a particularly Anatomy and physiology 109 lax abdomen, I prefer to make a note of this to the patient preoperatively so that this can be anticipated.

COSMETIC RESULT

Many surgeons are concerned with the skin that overlies the hernia protrusion. In many cases, this represents a fairly sizable amount of tissue that is much larger than the defect of the fascia itself. Patients with a large amount of redundant skin after the hernia repair may need to wear the binder for a longer period of time. This will help to eliminate the dead space that is created by the repair of the hernia. Despite this effort, however, many patients will have changes that will take a few months to resolve. Initially, this area will be soft owing to the presence of a seroma in many cases. After a few weeks or months, this will become firmer as a result of the healing process. The seroma fluid will be Figure 14.3 Preoperative photograph of a patient with a absorbed, and scar tissue will replace this fluid. The scar post-appendectomy hernia. will then contract within several weeks or months. The timeframe of these events will be dictated by the size of the hernia at the original operation. The larger eventrations will, of course, take a longer period of time to complete the healing process. Generally, however, this will be completed within 90–120 days (Figures 14.3 and 14.4). The redundant skin will contract as these events are taking place. Once this is complete, the skin will almost always resume the appearance that it had before the development of the hernia. The pre-peritoneal fat that was scarce preoperatively overlying the hernia sac will sometimes be replaced by new fat. The patch will not be felt underneath the skin, and a more normal curve of the abdomen will be seen, regardless of the size of the hernia that was repaired. In essence, the cosmetic result will be excellent. In no patient, in either my personal work or any known published series, has any mention been made of the need for reconstruction or revision of the skin and subcutaneous tissues overlying the hernia defect after Figure 14.4 Postoperative photograph of the patient shown in this period of time has transpired. Figure 14.3 after five months. Note the resumption of the However, some surgeons believe that the cosmetic contour of the abdomen. The cosmetic result was symmetrical result is unacceptable to themselves and their patients. bilaterally. For this reason, open repair may be preferred so that a paniculectomy can be performed at the same time. This and ventral hernias. This seems to be dependent on the is particularly apparent with large hernias, such as those type of biomaterial that has been used in the repair of that have loss of domain. One may be advised to proceed the fascial defect. The elasticity (tensile strength) of the with the open repair from the outset. abdominal wall has been evaluated in the laboratory. The mean distention of the abdominal wall at 16 N ranged from 11 to 32 per cent. The textile analysis of FUNCTIONAL RESULT PPM, polyester and other meshes revealed the range of elasticity from four to 16 per cent.15 This would indicate that the flexibility might be affected by the implantation There is a paucity of information regarding the functional of these meshes. These measurements, however, were result following LIVH. The compliance of the abdominal taken in cadavers, which may have affected the results. wall has been noted to change after the repair of incisional Nevertheless, there has been a move to decrease the 110 Laparoscopic incisional and ventral hernioplasty amount of PPM material that is used in the open repair of 2 LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes VK. Laparoscopic incisional hernias when repaired with PPM. The effect of incisional and ventral hernioplasty: lessons learned from 200 patients. Hernia 2003; in press. this can be shown in the laboratory, but the actual clinical 3 Trivellini G, Danelli P. Respiratory pathophysiology and giant significance has not been shown conclusively. There are incisional hernias. In: Bendavid R, ed. Abdominal Wall Hernias. even fewer data relating to ePTFE products, and no data New York: Springer-Verlag, 2001: 166–72. are available regarding the laparoscopic approach to this 4 Hesselink VJ, Luijendijk RW, deWilt JHW, et al. An evaluation of implantation. risk factors in incisional hernia recurrence. Surg Gynecol Obstet 1993; 176: 228–34. It can certainly be said that there is no re-approximation 5 Luijendijk RW, Hop WCJ, Tol van den P, et al. A comparison of of the fascia or the muscles of the abdominal wall with suture repair with mesh repair for incisional hernia. N Engl J Med LIVH. The long-term effects of this remaining defect in 2000; 343: 392–8. the fascia of these muscles have not been studied. The 6 Leber GE, Garb JL, Alexander AI, Reed WP. Long-term follow-up of our patients over a period of time that exceeds complications associated with prosthetic repair of incisional hernias. Arch Surg 1998; 133: 378–82. ten years has not revealed a single problem related to this 7 Flament JB, Avisse C, Palot JP, Delattre JF. Biomaterials. Principles remaining functional defect. I believe that these patients of implantation. In: Schumpelick V, Kingsnorth AN, eds. Incisional have lost the benefit of a normal anatomical functioning Hernia. Berlin: Springer-Verlag, 1999: 217–30. abdominal wall because of lax musculature and/or the 8 Flament JP, Palot JP, et al. Treatment of major incisional hernias. hernia itself. The repair of the single defect does not impact In: Bendavid R, ed. Abdominal Wall Hernias. Berlin: Springer- Verlag, 2000: 508–16. the innate laxity of the normal muscles. Additionally, the 9 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic development of the hernia itself signifies that the patient incisional and ventral herniorrhaphy in 100 patients. Am J Surg has weakened fascia. 2000; 180: 193–7. 10 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and incisional hernia repair. Surg Laparosc Endosc 1998; CONCLUSION 8: 294–9. 11 Tsimoyiannis EC, Siakas P, Glantzounis K, et al. Seroma in laparoscopic ventral hernioplasty. Surg Laparosc Endosc Percutan Laparoscopic repair of incisional and ventral hernias Tech 2001; 11: 317–21. requires the use of a prosthetic biomaterial. In all but the 12 Lehr SC, Schuricht AL. A minimally invasive approach for treating smallest of hernias, no tension is placed on the repair. This postoperative seromas after incisional hernia repair. J Soc may explain the decrease in the length of hospitalization of Laparoendosc Surg 2001; 5: 267–71. 13 LeBlanc KA, Bellanger DE, Rhynes VK, et al. Tissue attachment patients because of diminished levels of pain and ileus. strength of prosthetic meshes used in ventral and incisional hernia This does not provide for the reconstitution of the normal repair. Surg Endosc 2002; 16: 1542–6. anatomy of the abdominal wall. In so doing, expiratory 14 Susmallian S, Gerwurtz G, Ezri T, Charuzi. Seroma after function may be compromised. In no cases, however, has laparoscopic repair of hernia with ePTFE patch: is it really a this been proven to be a clinical problem. More experi- complication? Hernia 2001; 5: 139–41. 15 Junge K, Klinge U, Prescher A, et al. Elasticity of the anterior mental and clinical studies are needed to assess accurately abdominal wall and impact for reparation of incisional hernias the functionality of the wall of the abdomen following using mesh implants. Hernia 2001; 5: 113–18. laparoscopic ventral and incisional hernioplasty.

REFERENCES

1 Höer JJ, Junge K, Schachtrupp A, et al. Inﬂuence of laparotomy closure technique on collagen synthesis in the incisional region. Hernia 2002; 6: 93–8. 15

Laparoscopic repair in the emergent setting

GUY R. VOELLER

References 113

Laparoscopic repair of ventral/incisional hernias is usually an elective surgical procedure. While these hernias may incarcerate, it is usually over a long period of time and they become what should be called chronically incarcerated. The bowel comes to reside in the subcutaneous tissues and can cause cosmetic problems and/or discomfort, but only infrequently does it acutely obstruct. When discussing laparoscopic repair of ventral/incisional hernias in the truly emergent setting, we are talking about the few cases where the bowel is acutely obstructed and/or strangulated. While not common, there is a role for the laparoscopic approach in select cases. Basic preoperative preparation is fairly standard and well known to most surgeons. Fluid and electrolyte correction is most important, along with nasogastric decompression and Foley catheter placement to monitor fluid Figure 15.1 Hasson cannula at left costal margin. replacement. Appropriate antibiotic therapy should be administered before making the first incision. If there costal margin (Figure 15.1). This is carried out through a is evidence of a septic situation, then pulmonary artery 10-mm incision using the S-shaped Hasson retractors. catheters, arterial lines and ventilators must be available. Each layer is incised under direct vision and the muscle A review of our technique is published elsewhere,1 but layers are spread with a tonsil-type clamp. The retractors important points will be described here. The abdominal hold the muscle aside while a number 11 blade is used to wall is shaved and prepped in its entirety. The one well- incise each layer of fascia.Again, in several hundred repairs established advantage of the laparoscopic repair of ventral/ we have never injured any viscera with this method and we incisional hernias when compared with open techniques have never been unable to gain access. An angled laparo- is fewer wound problems. In addition, the mesh becomes scope (30 or 45 degrees) is very beneficial since it allows infected less frequently. We treat the mesh like a vascular viewing of almost any area, depending upon how the angle graft and avoid any contact with the skin, etc. An Ioban® is directed. A good 5-mm laparoscope allows use of 5-mm (3M Healthcare) protective drape is used to cover all the working ports, which keeps 10-mm holes to a minimum. skin. Using this approach, we have never encountered a The amount of bowel distention in the case of an patient who has developed a postoperative infection of acutely obstructed ventral/incisional hernia will dictate the prosthesis when placed laparoscopically. the ease with which adhesiolysis and visualization can be Safe access to the peritoneal cavity is of utmost impor- accomplished. There have been, and continue to be, deaths tance, especially when dealing with distended loops of due to bowel injuries during lysis of adhesions that are bowel. As we first described, our procedure of choice is the not detected at the time of surgery. In almost every case use of a balloon-tipped Hasson-type trocar lateral at the reviewed by the author, harmonic-type scalpels and 112 Laparoscopic incisional and ventral hernioplasty

Figure 15.2 Incarcerated small bowel. Figure 15.3 Dual-sided mesh. electrocautery have been used in these cases. We do not recommend the use of these devices unless the surgeon knows that he or she is far removed from the bowel. It is very important to have special graspers for bowel that are atraumatic in every respect. The best grasper we have found is made by Applied Medical and utilizes a reusable instrument with disposable padded cushions that are placed at the tips of the grasper. If adhesiolysis can be done safely and totally laparoscopically, such that the incarcerated bowel can be seen, then the next decision involves reduction of the bowel from the defect(s) (Figure 15.2). Gentle traction on the bowel will either allow or not allow reduction. One must be very careful with this movement; if the bowel is Figure 15.4 Suture fixation of mesh. reduced easily, then one can proceed with a standard laparoscopic repair. If the surgeon fears the bowel might reduced, the borders of the defect are determined and the be torn, then there are two options. The first option is to correct size of mesh is brought to the field (Figure 15.3). take a well-insulated J-type or L-type hook and use it to We taught the first organized course in the world on enlarge the hernia defect to aid in reduction. It is critical laparoscopic ventral/incisional hernia repair in 1996 and that this is done away from the bowel; if the bowel is at based our technique on an open repair, the Rives–Stoppa risk, it should not be done, since this involves use of repair, which we teach our residents and has been shown energy close to the bowel. We have used this maneuver worldwide to have the lowest recurrence rates for ventral/ several times, with good success. incisional hernia repair.2,3 This open repair relies on If the incarcerated bowel cannot be reduced laparo- retrorectus suture fixation of the mesh (behind the defect) scopically, then there is a second option that involves to the fascia of the abdominal wall for long-term success. a small incision directly over the acutely incarcerated The same holds true for the laparoscopic approach. To bowel. One should maintain the pneumoperitoneum as believe that in-growth of various meshes is important for the skin incision is made and monitor progress with the long-term success fails to recognize that any significant laparoscope until pneumoperitoneum is lost. The inci- in-growth is to peritoneum, not muscular fascia, and if sion does not have to be large, and usually the bowel can the hernia is of any size then the mesh simply migrates be reduced under direct vision. In several cases, we have over time with the peritoneal sac into the fascial defect. even performed a small-bowel resection through this The sutures are placed every 5–7 cm or more frequently, small counter-incision, replaced the bowel back into the based on the size of the defect. The mesh is tacked between abdomen, closed the skin, and finished the procedure the suture fixation points to prevent internal hernia for- laparoscopically. In no instance has this resulted in mation. The tacks add nothing to the long-term strength infected mesh or wound infection. of the repair (Figure 15.4). The details of our repair technique are described The types of mesh available have significantly increased elsewhere. Once the obstructed/incarcerated bowel is surgeons’ options in the face of emergent repair of Laparoscopic repair in the emergent setting 113

incision, where one is now faced with repairing a large defect in the face of contamination and/or gangrenous intestine. This becomes a very complicated and problematic situation, usually with open wounds, nutritional problems, and prolonged hospitalization. The second option, in the face of strangulated bowel, is to place the mesh if contamination is judged to be minimal and the chance of mesh infection is low (see below). None of this addresses the ability of the various meshes to resist infection when placed in a contaminated or potentially contaminated situation, which is what we are faced with in the emergent setting. Mandala and colleagues have shown that PPM can usually be placed safely in clean contaminated situations but they are not as in favor in contaminated cases (Altemeier classification of wound Figure 15.5 Final repair. contamination 3).4 Studies need to be carried out with respect to this. More recently, pig submucosa-based mesh (Surgisis®) has been promoted for use in the contaminated ventral/incisional hernias laparoscopically. A detailed situation. We have used this on several occasions, with- description of meshes is beyond the scope of this chapter, out infection of the mesh. Lastly, W. L. Gore has incor- but a few things need to be mentioned. When we, and porated an antimicrobial coating into its DualMesh Plus others, first developed the technique, expanded polytetra- that lasts for five to seven days. Intuitively, this makes us fluoroethylene (ePTFE) became the prosthetic of choice feel that there is an element of protection. We have used since it could be placed safely in an intraperitoneal posi- this mesh in many cases of minimal contamination dur- tion without the worry of in-growth to the viscera. While ing laparoscopic ventral/incisional hernia repair, and we Franklin has shown that polypropylene mesh (PPM) can have never had to remove it once due to mesh infection. be placed laparoscopically against the bowel, we know that Additionally, in animals, Stone has shown that ePTFE in-growth will occur, and long-term problems are well can be used to patch full-thickness defects in bowel with- 3 described when this has been done in an open fashion. out it becoming infected.5 He believes this is due to the Fistulas and extrusion have been reported with PPM. type of bacteria that reside in the bowel. Various coatings of both PPM (Sepramesh®) and poly- In conclusion, laparoscopic ventral/incisional hernia ester mesh (Parietex Composite®) are being investigated can be done safely in the emergent setting but should to prohibit visceral in-growth. Animal studies show some be limited to surgeons experienced in the technique in effectiveness with these coatings. the elective setting. Much work needs to be done with Strangulated bowel presents a different situation. respect to meshes and their abilities to resist infections in First, it should be said that bowel that appears dead often the emergent setting laparoscopically. returns to normal appearance if given time. The incarcerated hernia shown in Figure 15.2 had 20 cm of dark- black-appearing small bowel incarcerated in the defect REFERENCES once it was reduced. The patient was a physician who presented with signs and symptoms of acute small-bowel 1 Voeller GR, Mangiante EC. Laparoscopic repair of ventral/incisional obstruction. Once the bowel was reduced, the color hernias. In: Fitzgibbons ER, Greenburg A, eds. Nyhus and Condon’s returned to normal after several minutes and the proce- Hernia, 5th edn. Philadelphia: Lippincott Williams & Wilkins, 2001: dure was completed (Figure 15.5). However, if the bowel 373–9. is truly gangrenous, then two options now exist. Another 2 Rives J, Pire JC, Palot JP, Flament JB. Surgery of the abdominal wall. big advantage of the laparoscopic approach is that the Major incisional hernias. In: Chevrel JP, ed. Surgery of the Abdominal Wall. Berlin: Springer-Verlag, 1987. hernia does not have to be fixed at the time of finding 3 Flament JB, Rives J, Palot JP, et al. Major incisional hernia. In: truly necrotic intestine. One can simply resect the bowel Chevrel JP, ed. Hernia and Surgery of the Abdominal Wall, 2nd edn. laparoscopically or laparoscopically assisted as above, New York: Springer-Verlag, 1997: 128–58. wash out the abdomen, and come back later for definitive 4 Mandala V, Bilardo G, Darca F, et al. Some considerations on the use hernia repair. If the large bowel is involved in an unprepped of heterologous prostheses in incisional hernias at risk of infection. Hernia 2000; 4: 268–71. colon, then a colostomy can easily be carried out laparo- 5 Stone H. Abdominal compartment syndrome. Presented at the scopically. This is not the case through a large formal American Hernia Society Meeting, Tucson, AZ, USA, May 2002. This page intentionally left blank 16

Herniorrhaphy with the use of transfascial sutures

KARL A. LEBLANC

Indications 115 Intraoperative considerations 118 Contraindications 116 Postoperative considerations 123 Preoperative evaluation 116 Conclusion 124 Prosthetic biomaterials 117 References 124

Laparoscopic incisional and ventral hernioplasty (LIVH) few different methods that are used to perform this pro- was first described in 1993.1 The concepts of this tech- cedure; these are described in Chapters 17 and 18. nique are equivalent to the tension-free repair of inguinal hernias, which has become popular in the past two INDICATIONS decades. The open tissue repair of incisional hernias has a recurrence rate of 25–52 per cent. The use of a prosthetic biomaterial to repair these fascial defects lowers the recur- Any patient that could undergo an open prosthetic repair rence rate to 11–23 per cent. The rate of recurrence with can be considered for the laparoscopic approach. The the laparoscopic approach has been reported to be from size of the fascial defect will play a significant role in 1 to 9 per cent.2–6 It is important to note that in most of many circumstances. The size of the defect is not a limit- these reports, the results included the early experiences of ing factor, although I frequently restrict my use of the the authors as well as the repairs that occurred with the laparoscopic procedure to hernias that are larger than knowledge gained from that experience (see Chapter 21). 2–3 cm in their greatest dimension. The size of the inci- The repair of incisional and ventral hernias by this sion required for the open repair of a small defect is sim- approach should be considered an advanced laparo- ilar to the combined size of the incisions required for scopic technique. It is best to have the assistance of a insertion of the laparoscopic trocars. Because we use only surgeon experienced in performing this particular pro- 5-mm trocars to perform this operation, these hernias cedure for at least the first ten to 15 patients if possible. will approximate the size of the combined incisions. Of course, to optimize outcome, conversion from the Additionally, such small defects can often be repaired laparoscopic technique to the open method should be without the use of a prosthetic material. This recommen- done at the earliest sign of difficulty. In our experience, dation would be universally applicable only to thin this will be necessary in 3.5 per cent of patients. patients. Obese patients will have an unacceptably high Approximately one-third of these will be due to an injury rate of recurrence without the use of a prosthesis because to the bowel.5 Others have reported that conversion to of the increased intra-abdominal pressure.7 Therefore, I the open procedure was necessary in seven per cent of routinely repair these hernias in obese and morbidly patients, with a bowel injury rate of four per cent.6 Once obese patients with the laparoscopic technique (even pri- past the learning curve, the participation of an assistant mary umbilical hernias). Patients with recurrent hernias surgeon who is knowledgeable in advanced laparoscopic should be repaired with this technique even if the size is techniques is generally considered optimum for the less than 3 cm, because they have demonstrated the need repair of all but the smallest defects. Finally, there are a for prosthetic placement. LIVH is the easiest method by 116 Laparoscopic incisional and ventral hernioplasty which to repair such hernias and also allows the surgeon reconsideration of a laparoscopic approach. The operat- to inspect the entire length of the abdominal wall to ing time required to repair a defect that approximates the identify any unsuspected fascial defects that were not entire surface of the abdominal wall could negate the ben- apparent clinically. This can be seen in 22 per cent of efits of the laparoscopic method. These patients are prone patients who undergo LIVH.5 Some patients will have to having significant postoperative ileus, regardless of the areas of fascial weakness that are apparent with the repair employed. The surgeon may think that the increase laparoscopic approach (Figure 14.1). These areas of in operative time and risk will not justify use of a laparo- potential herniation should be repaired when identified. scopic repair. However, there are currently no hard and fast rules about this issue. In those patients with very large CONTRAINDICATIONS defects, I generally prefer to begin the operation laparoscopically and convert to an open repair if that appears to be the best alternative. More often than not, this proves to As with any operative procedure, the surgeon must eval- be unnecessary. If there is a significant loss of domain, it uate the overall status of the patient before proceeding may be impossible to actually enter the abdomen because with a laparoscopic incisional hernia repair. In general, the entire musculature of the abdominal wall is absent. In if the patient is a medically appropriate candidate for these cases, conversion to the open method is certainly an the open hernioplasty, then they could be considered a option. If the patient requires preoperative pneumoperi- candidate for the laparoscopic approach. Patients with toneum because of the size of the hernia, then it is not severe cardiomyopathy or pulmonary disease may not recommended to attempt the repair laparoscopically. tolerate the insufflation pressures that are necessary for Morbid obesity can occasionally become a limiting any laparoscopic procedure. Therefore, these individuals factor. In such patients, the available trocars may be of must be evaluated carefully preoperatively. Portal hyper- insufficient length to maintain adequate access to the tension is nearly always a contraindication. abdominal cavity. It could become necessary to convert If there is a suspicion of an intra-abdominal infection to the open repair because a working channel through or an acute surgical abdomen, then the use of prosthetic the abdominal wall cannot be maintained. The open biomaterial is generally prohibited. In this situation, the ends of the trocars will be withdrawn continually into laparoscopic approach is contraindicated because of the the excessive fatty tissue, which eliminates the working risk of infecting the prosthesis. One may elect to initiate channel and results in insufflation of the subcutaneous this operation if incarcerated bowel is suspected. Release of tissues. One may actually sew the trocars to the skin to the obstruction will allow the surgeon to inspect the viabil- ensure the position, but the newer, longer trocars that are ity of the intestine. If there is no strangulation or perfora- now available will usually solve this dilemma. tion, then the operation can proceed. A few centers will In our series of patients, 90 per cent of the hernias perform a bowel resection and repair the hernia laparo- that are repaired with this method are incisional. Because scopically and concomitantly (see Chapters 15 and 18). the most common incision of the abdomen is placed in A relative contraindication may be the number of the midline, approximately 90 per cent of those hernias intra-abdominal procedures that the patient may have are located in the midline of the abdomen.5 These her- undergone prior to the anticipated LIVH. This decision nias are generally easier to approach with this method should be made based upon the surgeon’s skill level and than hernias located outside of the midline. However, the type of the procedures that were performed previ- as more experience is achieved, the presence of a non- ously. Frequently, the patient may not have significant midline defect or multiple defects that are not adjacent to adhesions despite many previous intestinal procedures. each other should not preclude the use of laparoscopy. However, one should be very cautious if the patient has Appropriate positioning of the patient and accurate had a previous repair of an incisional hernia that placement of the trocars will permit an approach to the included the placement of a polypropylene biomaterial entire abdominal cavity in most cases. The use of angled in direct contact with the contents of the abdomen. laparoscopes also facilitates these repairs. There is nearly always a significant amount of very dense In addition to the site of the hernia, the number and and extensive adhesions. The risk of intestinal injury is type of previous open abdominal operations will influ- particularly high in these patients. ence the choice of patient position, the method of abdominal entry, trocar placement, and the position of the PREOPERATIVE EVALUATION monitors. Decisions regarding these factors should be made preoperatively and then finalized when the patient is on the operating table and under general anesthesia. There Once the patient has been identified as an acceptable will be a greater likelihood of significant adhesions that surgical risk, the surgeon should evaluate the condition of will require lysis during the initial phases of the operation the patient’s abdomen and the hernia(s) that will be if the patient has had many separate intra-abdominal pro- repaired. A very large fascial defect may sometimes cause cedures. Patients in whom a previous repair included the Herniorrhaphy with the use of transfascial sutures 117 insertion of a polypropylene prosthesis can be expected to dissection required will dictate whether a patient remains have dense scarring in all areas in which the material was in hospital overnight or for longer. Minimal preoperative not covered by omentum; however, this should not deter preparation is required, but appropriate laboratory test- experienced surgeons from attempting a laparoscopic ing should be obtained before the day of surgery. Patients approach. It is important to note that the difficulty of the are routinely given an antibiotic (usually a first-genera- procedure will be magnified greatly because of the dissection cephalosporin) preoperatively. However, if the bio- tion of the tenacious scarring that will have occurred to material that will be implanted contains antimicrobial the bowel and/or omentum. Because the risk of entero- agents (e.g. DualMesh Plus®), antibiotic prophylaxis is tomy is increased significantly in such cases, occasionally it not felt to be mandatory. will be necessary to leave remnants of the mesh attached to the bowel to avoid injury to the intestine (Figure 16.1). PROSTHETIC BIOMATERIALS Laparoscopic incisional hernioplasty should be indi- vidualized in patients with known ascites because it is impossible to close the trocar sites in a consistently Many products are available for the repair of incisional watertight manner that averts ascitic leaks. Moreover, hernias. The most commonly used product for this oper- these patients usually have a metabolic problem (e.g. ation is the 1-mm thick expanded polytetrafluoroethyl- cardiac, renal or hepatic disease), which can cause poor ene (ePTFE) prosthesis, DualMesh® or DualMesh Plus healing and predispose to development of multiple (see Chapter 3). My choice of biomaterial for this opera- hernias at the trocar sites. However, it is these metabolic tion is DualMesh Plus. This contains antimicrobial problems that make the laparoscopic approach particu- agents that impart a brown color to the biomaterial larly appealing in these types of patients. If a medical (Figures 16.2 and 16.3). This color inhibits the glare of comorbidity does not preclude the laparoscopic method from these patients, then one should use 5-mm non- cutting or self-dilating trocars to diminish the risk of prolonged leakage from one of the trocar sites. A Z-path of entry will help in closure of these puncture sites. It is preferable to close the trocar site defects even with the use of these trocars to further decrease the risk of ascitic fluid leakage. Several types of instruments that allow the passage of sutures transfascially are used in this procedure that will also close these defects. LIVH patients are admitted to hospital day-surgery units because they can usually be considered for discharge on the day of surgery. Twenty-six per cent of our patients are discharged on the day of surgery, and Figure 16.2 DualMesh Plus. 85 per cent of our patients remain in hospital for 23 hours or less.5 The type of hernia and the amount of

Figure 16.1 Laparoscopic view of small intestine with remnant Figure 16.3 Laparoscopic view of the ‘visceral’ surface color of of polypropylene mesh. The white arrows outline the mesh. DualMesh Plus. 118 Laparoscopic incisional and ventral hernioplasty the white surface of the standard product and identiﬁes the surface that should lie in contact with the intra- abdominal organs (‘brown is down’). If one chooses to (a) use the standard DualMesh, it is recommended that the parietal surface of the prosthesis is marked with a skin- marking pencil before its insertion to avoid the inadvertent reversal of the orientation of the patch. The corduroy appearance of the parietal surface also helps (b) distinguish the two different surfaces of the biomaterial.

INTRAOPERATIVE CONSIDERATIONS

Patient preparation and positioning (c)

LIVH repair requires the use of general anesthesia to achieve the necessary degree of relaxation and sedation. Figure 16.4 Instrument jaws for organ and prosthetic In most cases, it is not necessary to use a gastric tube or biomaterial manipulation: (a) aggressive, (b) self-retaining, urinary catheter unless the operative sites are in close and (c) smooth. proximity to the stomach or bladder or if the procedure will be prolonged. Typically, when used, both the gastric choice of these instruments will be the shape of the jaws. tube and urinary catheter are removed at completion of For grasping the bowel, omentum and the prosthesis, the procedure. aggressive, thick jaws are preferred (Figure 16.4a). These Most patients will be placed in the supine position. allow for the firm grasp that is usually required during Operations upon lateral defects of the abdominal wall, adhesiolysis and placement of the prosthetic biomaterial. such as those in a subcostal or flank incision, will be facil- To pull in the biomaterial from the trocar site (see below), itated by the use of a semi-decubitus or full decubitus a strong-jawed, self-retaining grasper is necessary (Figure position that is maintained with the use of a beanbag. 16.4b). This will be required to maintain a firm grasp of The additional use of the tilt capabilities of the operating the prosthesis so that it can be pulled into the abdomen table (i.e. Trendelenburg or lateral rotation) will assist through the 5-mm port site. The placement of the trans- in the manipulation of the bowel during dissection by fascial sutures should be done with the aid of fine-toothed moving these into the dependent portion of the abdomen. instruments (Figure 16.4c). These hold the sutures better The patient’s arms should be tucked in close to the body, than instruments with aggressive jaws because the suture unless the size of the patient is prohibitive, to allow suffi- will slip between the large spaces of the teeth of the latter cient room to move around the patient. This is especially (see Chapter 2). important if the hernia is in the lower abdomen. The most difficult and tedious portion of the hernioplasty is the dissection of adhesions within the abdomen Instrumentation and/or the hernia itself. The method of dissection is critically important in order to prevent injury to the intestine. There are several choices of laparoscopes (0-, 30- or 45- If the adhesions encountered are few and rather filmy, then degree) for incisional hernia repair. Because thin patients one may use scissors with or without the additional appli- with good muscle tone do not accommodate as much cation of electrocautery. The use of this and all energy distention as obese patients with poor muscle tone, a sources for hemostasis should be judicious and carried out 30-degree laparoscope may provide a better view in thin only if there is absolute certainty that there is no bowel patients. The 45-degree laparoscope is used rarely, if ever. adjacent to the area that will be affected by the lateral Most surgeons prefer to use the 30-degree laparoscope but extension of the heat of the energy source. The upper I generally use the 0-degree instrument. The angle or size of abdomen and falciform ligament are the most common the laparoscope itself is not important as long as the view is locations for such a situation. In most cases, however, the best available. Smaller laparoscopes permit the use of some dissection of omentum and bowel will be required smaller trocars, which decreases postoperative pain and to allow the identification of the fascial edges and the minimizes the risk of herniation at the site of the trocar. placement of the prosthetic biomaterial. One may choose Because I prefer the exclusive use of 5-mm port sites, to use the Harmonic® scalpel (Ethicon Endosurgery, Inc.). all of the instruments used will be of that size. However, This device has scissor-like jaws that dissect using ultra- the size of the instrument is not important. The critical sonic energy. There is very minimal lateral spread of heat Herniorrhaphy with the use of transfascial sutures 119 with this energy source, which enhances the safety in the dissection near the intestine. It cannot be overstated, however, that improper use of any energy source can result in an injury to the intestine. Sometimes, a burn may occur that will not become apparent until the intestinal wall undergoes necrosis several days postoperatively. If intestine is encountered that is densely adherent to the abdominal wall or to a polypropylene biomaterial from a previous repair, then it is recommended that scissors (without electrocautery) are utilized for the required dissection. Some surgeons never use any energy to dissect the tissues. Occasionally, the hernia contents cannot be reduced with dissection and traction because of incarceration. In such cases, the surgical enlargement of the fascial defect will permit the reduction of the involved organs. This can be done with the use of electrocautery scissors or the Harmonic scalpel. Generally, a 1–3-cm incision into the fascia will suffice. The size of this incision is not critical so long as the intestinal contents can be reduced safely because the resulting defect will be covered by the prosthesis that repairs the hernia. A variety of fixation devices is currently available (see Chapter 4). These devices are used to secure the prosthetic biomaterial to the abdominal wall between the Figure 16.5 Gore-Tex suture-passer holding a suture as it is transfascial sutures and to prevent the migration of any withdrawn from the abdomen. portion of the omentum or intestine between the patch and the abdominal wall. My preference is the Salute™ not interfere with the placement of the prosthetic bio- device (Onux Medical, Inc.). This allows the accurate material, in that the overlap may cover the trocar itself. placement of the constructs while ensuring that the Many surgeons will choose to use either an optical periphery of the biomaterial is flat against the abdominal trocar for abdominal entry or an open entry (Hassan wall. Its function is equivalent to that of the helical coil in technique) if the Veress needle method is not chosen. My other respects, however.8 Additionally, a removal instru- preference is the non-bladed trocar (Ethicon Endo- ment is available if one decides that the placement of a surgery, Inc.) but other devices are available, such as the construct is not ideal. Visiport® (U.S. Surgical/Tyco International, Inc.). These Devices to place the transfascial sutures are an integral trocars are designed to provide visualization of each layer part of this operation. Two such devices are the Endoclose of the abdominal wall as the trocar passes through them. (U.S. Surgical Corp./Tyco International, Inc.) and the The former is available in 5-, 10- and 12-mm sizes, whereas Gore-Tex® suture-passer (W. L. Gore & Associates). This the latter is available only in the 12-mm size.While the exact author prefers the latter because it is reusable and has a method in which this is accomplished differs between these consistently sharp tip (Figure 16.5). two devices, both of them are used with the laparoscope inserted into the trocar to view the musculofascial layers as Trocar selection the trocar is passed through them. The non-bladed variety can also be used for the additional trocars that are necessary. It is understood that the method of access into the abdomen should always be the safest possible approach. Trocar site selection In patients with a primary ventral hernia or a single incisional hernia defect, a Veress needle could be considered The location of the trocars will be influenced by the loca- for insufflation before introduction of the first trocar. In tion of the hernia defect(s). Typical sites for these are the repair of incisional hernias, a safe area for needle shown in Figures 16.6 and 16.7. As can be seen easily, the insertion is usually in the right or left upper quadrants effort is to achieve triangulation of the site of the hernia to because this area is generally free of adhesions of bowel allow for its repair. This is typical of most other laparo- and omentum, particularly for lower-abdominal hernias. scopic procedures. While I prefer to place the laparoscope An entry point in the midline could be used if it can be in the midline and have two surgeons work from opposite placed far enough away from the hernia so that it does sides of the operating table, others place all trocars on 120 Laparoscopic incisional and ventral hernioplasty the same side of the patient. The placement of the monitors will be dictated by the location of the hernia to be repaired. Generally, upper abdominal hernias will need the monitors to be at the head of the table while lower hernias will have them at the foot of the table.

Operative technique

In nearly every patient with an incisional hernia, a complete view of the abdomen is obscured by adhesions. Following the introduction of the initial trocar, the next effort of the surgeon is the placement of additional trocars so that the operation can be performed. Because of these frequent adhesions, the surgeon may be forced to use the laparoscope itself to dissect them before the insertion of any other trocars because there is no working space in which to allow these trocars to be placed Figure 16.6 Typical trocar site locations for a lower midline under direct vision. After each new trocar is introduced, hernia. Blue, trocar locations; green, umbilicus; black, the laparoscope should be placed through it to visualize hernia. the abdomen from that new vantage point to identify the optimal placement of the other trocar sites. Additionally, the collection of views provided by visualization of the abdomen through these multiple trocar sites will help to minimize the risk to the bowel by the necessary surgical maneuvers. In other words, the two-dimensional view that is recorded by the laparoscope may not permit the recognition of any intestinal structures that may be in harm’s way during the dissection of the adhesions. These views will help to avoid an enterotomy. It is frequently necessary to place and manipulate instruments from the side of the patient in direct opposi- tion to the viewing laparoscope. This produces a mirror image of any manipulation that is viewed from that port. In this case, a move of the laparoscopic instrument to the left will be seen as a move to the right, and vice versa. Placement of the laparoscope in the midline, when possible, will prevent this viewing difficulty. Another option Figure 16.7 Typical trocar site locations for an upper midline would be to insert an additional trocar(s) on the opposite hernia. Blue, trocar locations; green, umbilicus; black, side of the patient from where the surgeon is standing so hernia. that the laparoscope is always on the side where the surgeon (or the assistant) is standing. With experience, even Adhesiolysis and identification of fascial this technical problem can be overcome without the use defect(s) of additional trocars. However, additional trocars should be used when this problem cannot be corrected easily to Before insertion of the prosthesis, the entire fascial ensure the accurate assessment of the intra-abdominal defect(s) must be uncovered. This usually requires lysis contents and the proper performance of the operation. of all of the adhesions within the abdomen unless these Those surgeons who prefer to place all trocars only on are far away from the operative field, such as in the pelvis one side of the abdomen will avoid mirror-imaging, but when the hernia is in the upper abdomen (Figure 16.8). such site selection will not allow viewing of the adhesions It is important to dissect away from the abdominal wall from the opposite side of the abdomen. Additionally, this any adhesions that may interfere with the subsequent trocar location on only one side can make fixation placement of the prosthetic material. The prosthesis awkward because the use of the fixation devices can be must contact the fascia without the interposition of any difficult on the ipsilateral side of the patch biomaterial significant amount of adipose tissue so that tissue (Figures 16.6 and 16.7) (see Chapter 4). in-growth into the biomaterial will not be impaired. In the Herniorrhaphy with the use of transfascial sutures 121

Figure 16.9 Skin marks demarcating the edges of the defect of a lower midline incisional hernia.

Figure 16.8 Small intestinal adhesions to the anterior abdominal wall. areas low in the abdomen, such as in the parapubic sites, it will be necessary to create a pre-peritoneal flap similar to that done for the transabdominal pre-peritoneal inguinal hernia repair so that the biomaterial can be fixed to Cooper’s ligament. Only this will ensure strong fixation and adequate overlap of the prosthesis. It is not necessary to excise the hernia sac or close the fascia defect. The defect is measured most accurately with the insufflation pressure reduced from the working amount of 12–14 mmHg to near-zero. Reducing the pressure prevents the inflation artifact because the distention of the abdominal wall can substantially increase the apparent size of the defect. This occurs because the measurement is typically taken on the external surface of the abdominal wall rather than on the interior surface of the fascial Figure 16.10 DualMesh Plus with marks and initial two ePTFE defect. This measurement would be artifactually larger sutures. than the actual measurement. After desufflation, the defect is outlined on the skin over the abdomen with a There are many variations of the technique used to fix- skin-marking pencil (Figure 16.9). The entire circumfer- ate the patch material once it is inserted into the abdomi- ence of the defect should be identified to ascertain its nal cavity. Most surgeons will use transfascial sutures in maximum dimensions. To ensure adequate coverage of addition to a metal fixation device, such as a titanium the hernia defect, many authors have stated that a mini- staple or helical tack, a construct of stainless steel, or a mum of a 3-cm overlap (in all directions) of the pros- nitinol anchor (see Chapters 4 and 17–22). The number thetic biomaterial is mandatory.3–5,9 In general, I strive to of sutures that are applied to the biomaterial before inser- cover the entire length of the original incision even tion into the abdomen will be dictated by the preference though an actual hernia defect may be located only at of the surgeon. One method that I choose places two one site along the incision. This will provide coverage ePTFE sutures (CV-0) at either side of the midpoint of and prevent the future development of a hernia at the the long axis of the patch. Two marks are placed on uncovered portions of the incision and, therefore, avoid a both sides of the midpoint of its short axis with a marking recurrence of the hernia.5 In this situation, the patient pencil before its insertion into the abdominal cavity develops a new hernia that is above or below the original (Figure 16.10). It is important to mark both the visceral one that was repaired. In obese patients and/or patients and parietal surface midpoints because once fixation is with very large defects, an overlap that exceeds this initiated, the view of the patch will be only that of the minimum, such as 5 cm, is recommended. visceral surface. These initial two sutures and the marks 122 Laparoscopic incisional and ventral hernioplasty

Figure 16.11 Folded and twisted DualMesh Plus patch as it is Figure 16.12 Laparoscopic view of the twisted patch as it is pulled into the abdomen at the site of a 5-mm trocar. drawn into the abdomen. will help to ensure the correct axial orientation and Placement of the prosthesis the degree of overlap on all sides of the hernia defect. Other surgeons place four or more sutures into the patch Once the insertion of the prosthetic is complete, the before insertion. I find that this creates a tangle of suture patch must be unfolded. The surgeon and the assistant material that is cumbersome to work with in the limited will assist each other in the manipulation of the bio- space available. The placement of only these two initial material to unfold the patch completely until it is as flat sutures assures that the center of the fascial defect as possible. The two initially placed sutures are now is placed at the middle of the prosthetic biomaterial. This pulled through the entire abdominal wall with the use of is particularly evident if the trocars are placed as in a sharp suture-passing instrument inserted through a Figures 16.6 and 16.7. small skin incision (Figure 16.5). By pulling the initial The DualMesh Plus patch, with its attached sutures two sutures through the abdominal wall and viewing the placed on the inside of the folds, is folded into sequential hernia with the laparoscope, one can confirm that the halves for introduction into the abdomen.10 These bioma- patch is centered over the defect and that there is a mini- terials are 50 per cent air by volume, which allows them to mum of a 3-cm overlap in all directions. It may be neces- be twisted into a tight roll that substantially reduces their sary to move the laparoscope to another port to do this size (Figure 16.11). In those cases in which the larger effectively. If there is insufficient tautness of the prosthe- patches are used, the skin incision at the site of patch intro- sis or if the patch is not properly centered over the hernia duction should be made larger than that necessary for defect, then the suture(s) must be repositioned. Once the placement of the trocar itself (typically 6–8 mm). A strong optimal position is achieved, the sutures are tied. It is grasping instrument (Figure 16.4b) is passed through a important to make sure that these (and all of the sub- trocar and advanced through another trocar. The trocar sequent sutures) are tied sufficiently tightly to pull the through which the instrument is exited is then removed, knots to the fascial level without any laxity. whereupon the instrument will grasp the biomaterial and The next step will be to confirm that the orientation pull it into the abdominal cavity (Figure 16.12). The assis- along the short axis of the patch is correct (e.g. the lateral tant surgeon can assist this maneuver by maintaining the aspects of the midline hernia). The biomaterial is twist of the patch as it is introduced. This method of fold- grasped by both surgeons at the previously marked mid- ing and introduction into the abdomen and the pliability points on either side of the biomaterial to position it over of the abdominal wall musculature will allow even the the desired final location. Either the assistant or the sur- largest DualMesh Plus patch (26 ϫ 34 cm) to be inserted geon then uses a fixation device to deliver the metal con- into the abdomen with the exclusive use of 5-mm trocars. struct to fix the midpoint of one side by placing only one Just before the complete introduction of the patch, the or two devices at that location. The fixation instrument is tight twist must be undone to make the patch as flat as then handed to the other surgeon and the unattached possible, which facilitates its fixation to the abdominal opposite midpoint is secured similarly. The use of only a wall. This is another important step because it is very few constructs at this time will permit the removal of tedious to try to untwist and unfold the patch once it is these devices if it is determined that the prosthesis must introduced into the abdomen. be repositioned. After four-point fixation is achieved, the Herniorrhaphy with the use of transfascial sutures 123

Figure 16.14 Completed repair of the hernia. The proper Figure 16.13 Correct spacing of the constructs along the placement of the sutures and Onux constructs are seen on the periphery of the patch. DualMesh Plus. position of the biomaterial is verified again with the laparoscopically to confirm that this action did not result laparoscope. After this inspection, the devices are placed in a loosening of the suture. If this has occurred, the in a staggered fashion along the periphery of the prosthe- suture must be cut to prevent migration of any intra- sis 1–1.5 cm apart (Figure 16.13). abdominal contents into the loop and another suture This initial fixation not only positions the patch at its must be placed. correct location but also ensures that bowel cannot migrate The repair is now complete. At this point, a reasonable between the prosthesis and the abdominal wall once the precaution may be to scan the intestine to identify any repair is completed. The most important component of possible injury that may have gone undetected. The fixation, however, is the use of transfascial non-absorbable trocar cannulas are removed, but before their removal sutures (e.g. ePTFE size CV-0). These sutures will be placed the suture-passer should be used to pass an absorb- through all layers of the abdominal wall and are tied above able suture to close any port sites larger than 5 mm. The the fascia in a manner similar to that of the initial two skin incisions can then be closed with or without a sutures. A small (2–3-mm) skin incision is made. Through subcutaneous suture and the use of Steri-Strips® (3M this incision the suture-passer, with a suture in its jaws, Healthcare) or Dermabond® (Ethicon, Inc.) adhesive. is passed through all layers of the abdominal wall. The Band-Aid-type dressings or small gauze sponges should assistant surgeon then grasps the suture with a laparoscopic be placed over the wounds. The use of an abdominal instrument (Figure 16.4c). The suture-passer is then binder that will be left in place for at least 72 hours will removed and re-inserted through the same skin incision. aid in the prevention of a postoperative seroma at the site The assistant hands back the suture to the passer, where- of the hernia and eases postoperative pain. The use of upon the suture is retrieved. During the insertion of all this binder for as long as 7–14 days is preferred, especially sutures, it is critical to avoid the application of any instru- for very large hernias. ment or clamp on any portion of the suture material that will remain within the patient because this will permanently weaken the suture at that site. It may later fracture POSTOPERATIVE CONSIDERATIONS at that site, leading to a possible failure of fixation and recurrence of the hernia.5 These additional sutures are placed at intervals that are Patients are sent to the postanesthesia care unit, where no more than 4–5 cm apart. Once fixation is completed, they are usually given a single dose of ketorolac intra- the patch should now obliterate the fascial defect. A final venously. Once recovered from anesthesia, they are examination of the prosthetic is performed to ensure transferred to the day-surgery unit. Most (85 per cent) that all sutures are tight and that all edges of the patch patients are discharged within 24 hours. In our practice, are secured (Figure 16.14). When any of these sutures are the average length of stay is slightly over one day. Patients tied, a dimple of the skin may develop at the site of can consume their diet of choice on the day of surgery the incision where the suture has been passed because the and can resume any regular medications immediately. subcutaneous tissue may have been drawn down when Oral or parenteral sedatives are given as needed. the suture was tied. This dimple can be removed by the Pain may be used as the guide to determine when placement of a fine-pointed hemostat into the incision to patients can resume their normal activities. They are lift the skin, which releases the tissue from the suture allowed to shower the next day. Patients may return to knot. After this is done, one should view the sutures their daily activities, including work, as soon as they can 124 Laparoscopic incisional and ventral hernioplasty do so without marked pain. Most are able to drive within 2 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and a week and resume job-related activities in 7–14 days. incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. 3 Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral We do not restrict their activities but allow their pain to and incisional hernia repair in 407 patients. J Am Coll Surg 2000; be their own guide. 190: 645–50. 4 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg CONCLUSION 2000; 180: 193–7. 5 LeBlanc KA, Whitaker JM, Bellanger DE, Rhynes KV. Laparoscopic incisional ventral hernioplasty: lessons learned from 200 patients. LIVH continues to gain popularity. There are several Hernia 2003; in press. 6 Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications modifications of this technique that can be adopted with laparoscopic intraperitoneal expanded according to one’s preferences. Surgeons who perform polytetrafluoroethylene patch repair of postoperative ventral this advanced operation must have a thorough under- hernia. Surg Endosc 2002; 16: 785–8. standing of the specific factors that ensure that the pro- 7 Arroyo A, Garcia P, Perez F, et al. Randomized clinical trail cedure will be associated with an acceptable outcome. comparing suture and mesh repair of umbilical hernia in adults. Br J Surg 2001; 88: 1321–3. Continued research and experience will result in contin- 8 LeBlanc KA, Stout RW, Kearney MT, Paulsen DB. Comparison of ued modifications to this operation. Technical refine- adhesion formation associated with Pro-Tack (US Surgical) versus ments will undoubtedly occur that will enhance the a new mesh fixation device, Salute (ONUX Medical). Surg Endosc fixation methods that are currently available. 2003; in press. The laparoscopic repair of incisional and ventral her- 9 Koehler RH, Voeller G. Recurrences in laparoscopic incisional hernia repairs: a personal series and review of the literature. nias may become the standard of care in the future. As J Soc Laparoendosc Surg 1999; 3: 293–304. the population of general surgeons adopts this method- 10 LeBlanc KA. A new method to insert the DualMesh prosthesis for ology, the recurrence rates associated with this difficult laparoscopic ventral herniorrhaphy. JSLS 2002; 6: 349–52. malady will, hopefully, decline.

REFERENCES

1 LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetraﬂuoroethylene: preliminary ﬁndings. Surg Laparosc Endosc 1993; 3: 39–41. 17

Pre-peritoneal herniorrhaphy

SÉRGIO ROLL, WAGNER C. MARUJO AND RICARDO V. COHEN

Incisional hernias 125 Comparative studies of open versus laparoscopic repair 129 Principles of treatment 125 Advantages and disadvantages of different Indications for laparoscopic repair 127 laparoscopic techniques 130 Laparoscopic transabdominal pre-peritoneal repair 127 Conclusion 130 Personal series results 129 References 131

INCISIONAL HERNIAS diseases such as obesity, cancer, chronic hepatic and cardiopulmonary failures, severe anemia, and malnu- trition.2,3 The underlying pathological process, such as Incidence prostatism, radiotherapy, steroid therapy, and operative technical issues are also fundamental factors. Although Incisional hernias represent one of the more common clinical experience seems to suggest that vertical celiotomy complications of abdominal surgical procedures. The true and certain types of suture (e.g. continuous suture and incidence of incisional hernias has not been well defined, mass tissue closure) may increase the risk of incisional although a number of reports suggest that 3–13 per cent hernias, randomized studies have failed to show that any of patients undergoing laparotomy will develop a fascial 1 of these factors significantly alters the incidence of post- defect in their abdominal scar. The majority of inci- operative incisional hernia. Wound infection is associ- sional hernias occur within the first postoperative year. ated with a five-fold increase in the risk of developing a However, the limited follow-up of most series may hernia.1,4 underestimate late hernia occurrence.

Diagnosis PRINCIPLES OF TREATMENT

Most patients with small, uncomplicated incisional her- The classical principles of ventral hernia repair are wound nias are asymptomatic or have only minor or intermit- closure without excessive tension, suture placement into tent complaints. However, these postoperative hernias healthy tissue, and the use of strong material to support may be a significant source of morbidity. Patients with the wound through the critical period of healing. In many incisional hernias alter their lifestyles so as not to exacer- cases of incisional hernia with small defects, fascial clo- bate their abdominal wall hernia and often complain of sure can be achieved by apposing the fascial edges, which their esthetic appearance or suffer from discomfort, pain closes the defect. When the fascial defect is large, a num- or, occasionally, intestinal obstruction. ber of techniques have been proposed, including relaxing incisions, internal retention sutures, muscle or fascial Predisposing factors flaps, fascial grafts, and mesh repair.5 However, the results have often been disappointing. Primary repair with Predisposing factors for the development of incisional suture only has been associated with 25–52 per cent fail- hernias include advanced age, male gender, and systemic ure rates.6 The use of a prosthetic material to cover the 126 Laparoscopic incisional and ventral hernioplasty hernia defect has reduced substantially the incidence of these materials should be balanced in some situations recurrence. In a multicenter randomized trial that enrolled (e.g. the feasibility of closing the peritoneum over the 100 patients in each arm, Luijendijk and coworkers com- mesh, and the issues of cost) when selecting all prosthetic pared the results of suture alone with those of open mesh biomaterials. repair for incisional hernias.7 After a follow-up of 36 months, the three-year cumulative rates of recurrence among patients who had suture only and those who had Repair strategies mesh repair of a primary hernia were 43 and 24 per cent, respectively. The recurrence rates were 58 and 20 per cent, Although the modern era of hernia repair began more respectively, for repair of the first recurrence. The risk fac- than a century ago, controversies continue to exist regard- tors for recurrence were suture repair, infection, prosta- ing the optimal surgical technique to repair incisional tism, and previous surgery for abdominal aortic aneurysm. hernias. Open techniques involve a large incision and The size of the hernia did not affect the rate of recurrence. extensive subcutaneous and intra-abdominal dissection, The majority of the recurrences were in the first two years and often necessitate the placement of drains. Complica- following the repair of the hernia. The same factors involved tion rates range from 8 to 19 per cent after open ventral in the genesis of these incisional hernias may contribute repair.14,15 Fistula rates after elective open hernia mesh to these results. repair vary from 2 to 5 per cent.6 Moreover, the infected prosthesis should be excised, demanding another, more complicated repair. Transabdominal approaches carry Prosthesis materials the risk of injury to the viscera adherent to the undersurface of the scar. The basic strategy of the open repair is The use of prosthetic materials to assist in incisional based upon the Stoppa technique: the peritoneal cavity hernioplasty usually demands a more extensive dissec- should not be entered and the mesh is secured to the fas- tion and may increase the risk of wound complications cial edges in the pre-peritoneal space.16 However, the risk slightly.5,8 The synthetic material should be physically of re-entering the site of a previous incision is an inad- unmodified by tissue fluid, chemically inert, and non- vertent enterotomy. The open repair does allow the carcinogenic. It should also induce no inflammatory or concomitant excision of a usually wide, irregular and foreign-body reaction, allergy or hypersensitivity.9,10 unesthetic scar. If this is the case, it is not unusual to Finally, it should resist mechanical stresses, be able to be enter the abdominal cavity. tailored into the form required, and be easily and fully Surgical laparoscopy has become an increasingly pop- sterilizable. The most popular prosthesis materials are ular method of treatment for many diseases because it made of polypropylene, polyester, and expanded poly- potentially offers cost-savings as a result of shorter hos- tetrafluoroethylene (ePTFE). These are all nonabsorbable, pital stays, less postoperative pain, and a more rapid and there is no clear evidence from the literature that return to work.17 Laparoscopic hernioplasty has been supports a preference for the clinical use of any one of reported to be a safe and feasible technique, with low the three main materials.11 Polypropylene shows a rela- morbidity and low rates of early recurrence. LeBlanc and tively small inflammatory response with a far lesser Booth first reported the laparoscopic approach to repair degree of foreign-body reaction than does polyester incisional hernias in 1993,18 and several series have now mesh. ePTFE elicits less chronic inflammatory cell reac- demonstrated the efficacy of minimally invasive surgery tion but greater foreign-body reaction. Mesh infection in incisional hernia repair. Laparoscopic repair involves rates in selected laparoscopic series for repair of ventral no long incision, no wide fascial dissection or flap and incisional hernias vary from 0.5 to 12 per cent.12 creation, and usually no drains. It also minimizes the Despite different characteristics regarding fibroblastic manipulation of a potentially contaminated site because reaction and the time required for incorporation, the trocars are placed far from the original wound.19 polypropylene and polyester prosthetic materials are Additionally, the pneumoperitoneum facilitates the nec- associated with a high incidence of dense adhesions. essary adhesiolysis in order to identify the edges of the Their biological behavior increases the risk of adhesions defect and the hernia sac. Enterotomy rates in selected and fistula formation when the mesh is placed in contact laparoscopic series of ventral hernia repair, including with the peritoneum.13 There is strong evidence that incisional hernias and many with previous open mesh adhesions are more common with polypropylene and repair, vary from 0 to 14 per cent (Table 17.1). Mesh polyester than with ePTFE. It is acceptable to place the infection rates vary from 0.5 to 12 per cent.12 One of the latter in contact with the bowel, as lower complication drawbacks of the laparoscopic approach is that it does rates were reported when using ePTFE. Polypropylene not allow an esthetic reconstruction of the abdominal and polyester require reperitonization to avoid mesh wall since the old scar that covers the hernia defect is contact with intra-abdominal structures. The use of left untouched. The need for an overall esthetic result Pre-peritoneal herniorrhaphy 127

Table 17.1 Results of laparoscopic ventral/incisional hernioplasty Complications Patients Intraoperative Postoperative Hospital Follow-up Recurrence Reference (n)(n)(n) stay (days) (months) (n) Constanza et al. (1998)14 31 0 2 2.0 18 1 Franklin et al. (1998)34 176 0 9 2.2 30 2 Toy et al. (1998)24 193 4 28 2.0 22 9 Sanders et al. (1999)35 12 0 3 3.5 12 1 Scott-Roth et al. (1999)20 73 2 14 2.9 17 7 Heniford et al. (2000)6 415 5 48 1.8 23 14 Roll et al. (2000)25 28 1 3 1.2 36 0 should not be underestimated because the patient fre- LAPAROSCOPIC TRANSABDOMINAL quently demands this outcome. PRE-PERITONEAL REPAIR

Patient preparation and room set-up INDICATIONS FOR LAPAROSCOPIC REPAIR A thorough preoperative evaluation is performed. The The size of the defect and the characteristics of the patient patient is informed fully of the risks of recurrence and should dictate the best technical strategy. Patient selection the chance of conversion into an open procedure. for laparoscopic incisional hernioplasty is usually based Educational handouts are given in order to aid the upon a demonstrable fascial defect under a previous patient during the period of convalescence with a partic- abdominal incision or a highly suspect abdominal wall ular emphasis on pain management. Factors that might defect in a very obese patient, such as in Spigelian hernia. increase the recurrence rate are corrected, if at all possible, The patient must be able to tolerate general anesthesia in the preoperative period. Special attention is given to and abdominal insufflation.20 Patient size is not a pro- respiratory care before admitting the patient to the hos- hibiting factor; nor is a history of previous abdominal pital. In-hospital standard guidelines to prepare patients explorations or previous attempted repairs with or with- for abdominal surgery are followed. Mechanical bowel out placement of prosthetic material. A massive incisional preparation is not usually necessary, and the patient is hernia with the protrusion of a substantial portion of asked to void just before leaving the ward. the abdominal viscera may be a contraindication for a The patient is placed on the operating table in a dorsal laparoscopic approach. Significant loss of the abdominal recumbent position with the arms padded alongside the domain by the intestine might preclude the placement of body. It is important that the patient is strapped securely the functional trocars because of insufficient lateral space. to the operating table in order to permit the extremes A densely scarred abdomen, an inability to establish safely of table positioning, which is occasionally necessary for a pneumoperitoneum, and the presence of infected mate- visceral displacement or retraction. General anesthesia is rial in the abdomen may also contraindicate the laparo- instituted, and an orogastric tube is inserted for gastric scopic approach. It should be noted that the intensity and decompression. Patients are given antibiotic prophylaxis, extent of adhesion formation is unpredictable. Because of usually with a first-generation cephalosporin. this, multiple previous abdominal operations do not pre- For most midline hernias, the surgeon stands on clude laparoscopy, since an entry port for the first trocar either the patient’s left or right side. The video monitor is can be obtained. The so-called ‘Swiss cheese’ hernia is a positioned on the opposite side of the patient so the sur- good indication for the laparoscopic approach since it geon’s view on the screen is parallel and in line with the allows a very clear delineation of the wall defects and a laparoscopic repair of the hernia within the abdomen. more precise repair. Hernias very close to the costal mar- The assistant stands opposite the surgeon, and a second gin may be difficult to treat through an open approach monitor is placed in a suitable position. since they usually lack a good rim of strong tissue to secure the mesh. In this situation, the laparoscopic approach is Operative technique more appropriate, because the mesh can be easily tacked and/or sutured to the internal surface of the abdominal Good laparoscopic skills are mandatory, since each cavity. Moreover, full-thickness stitches around this area anatomical situation may be unique. The surgeon must are usually followed by pain. always keep a low threshold for conversion to an open 128 Laparoscopic incisional and ventral hernioplasty repair. Access to the abdominal cavity is obtained in an area away from the hernia using the Veress needle or, more frequently, by the open technique. Pneumoperitoneum is established by insufflating the abdomen to 12 mmHg with carbon dioxide. A 30-degree laparoscope is introduced through the initial trocar, and the abdomen is explored. The hernia defect and any associated adhesions are identified. Usually two or three additional trocars are inserted under direct vision. The ultimate number and the exact site of the trocars depend on each individual case. For an optimal view and exposure, it is better to place the working ports as far away as possible from the hernia defect. Since the mesh must overlap the defect by about 3 cm, a very lateral or inferior position of the trocar sites maxi- mizes the view and the efficiency of the instruments. The repair technique is based on the Stoppa technique utilized in the open surgical procedure, in which the prosthetic material is placed posteriorly to the anterior fas- Figure 17.1 The hernia sac is opened and the healthy fascia cia.21 Adhesiolysis is performed to free the bowel from the along the defect rim is defined clearly. abdominal wall, and the margins of the hernia defect are defined clearly. External manual pressure on the abdomi- case, some authors recommend interfacing the omentum nal wall helps to delineate the edges of the hernia defect; it between the mesh and the bowel. However, we make a vig- also changes the angles of vision and usually facilitates the orous effort to interface the sac layer between the mesh and dissection. Once the entire abdominal wall is cleared up the abdominal contents (Figure 17.1). It is easier to dissect and any incarcerated omentum or bowel reduced, the out the healthy fascial edges within the pre-peritoneal space hernia defect is measured by introducing a sterile ruler of certain hernias, including incisional hernias secondary into the peritoneal cavity. The surgeon must be very cau- to extraperitoneal surgical incisions, such as lumbar discec- tious when dissecting the bowel wall or omentum off the tomies or Pfannenstiel incisions, and defects away from the hernia sac, which typically encompasses attenuated fascia midline. If the pre-peritoneal technique is deemed impos- and peritoneum. The adhesiolysis is almost always the sible, then the hernia sac is not reduced, resected or opened, most challenging part of this procedure, especially if a and the mesh is positioned intraperitoneally according to previous mesh repair has already been attempted. Any the onlay technique.22 energy source is capable of causing a full-thickness injury Prosthetic materials have been used with increasing to the bowel wall. The harmonic scalpel may obviate the confidence in direct contact with the abdominal con- risk of an inadvertent injury. The standard approach in tents. Complications have been few, but this may reflect the advent of an enterotomy is immediate closure of the selective reporting of good results. We always attempt site with simple suturing. If this injury is complicated by to perform a transabdominal pre-peritoneal repair that a significant spillage of luminal fluids, then an open pri- uses a mesh prosthesis to cover and close the hernia mary repair might be performed or a staged laparoscopic defect. Three trocars are usually employed, and it is ideal mesh placement should be advised. to triangulate them around the hernia defect. As the The hernia sac contents are reduced and the peritoneal abdomen is explored, care must be taken to identify and sac is now opened, followed by the precise delineation of dissect the hernia defect. Gentle grasping and separation the fascial defect, with at least 4 cm of healthy tissue sur- of the peritoneal sac are important steps. At this point, rounding it. When possible, small fascial defects may be tears in the peritoneum must be recognized and man- closed simply by suturing the edges of the defect without aged. Generally, it is not easy to dissect and actually have tension. The suture closure is then covered by a mesh a good peritoneal flap prepared in order to have it closed to reinforce the herniorrhaphy. This procedure may pre- over the anchored prosthesis. If a tear occurs, it should be vent the annoying sensation of the mesh just underlying carefully dissected and more peritoneum preserved. If the skin. this is impossible due to firm adhesions to the abdominal Dissection within the pre-peritoneal plane, in an effort wall, then in order to cover the mesh safely an omental to develop an intact layer of peritoneum to separate the flap may be created and used to cover the tear. The mesh, mesh from the abdominal contents, might be extremely under some tension, should be secured to the abdominal difficult in some patients. If unsuccessful, this might result wall using a hernia stapler or a tacking device, or sutured in a large peritoneal defect, leaving the mesh exposed inter- into position with full-thickness transabdominal stitches nally. This is especially true in patients with only a thin layer buried in the subcutaneous tissues. The stitches along of subcutaneous fat and skin overlying the hernia. In this the outer border of the mesh should leave a 3-cm margin Pre-peritoneal herniorrhaphy 129

One patient required conversion to an open repair because of dense adhesions and inadvertent intestinal injury. The defect sizes ranged from 64 to 230 cm2.The original surgical procedures were hysterectomy (11), appendectomy (12), prostatectomy (10), gastrectomy (two), nephrectomy (eight), laparotomy (three), epigas- Hernia tric herniorrhaphy (four), and umbilical herniorrhaphy Defect sac (three). In all cases except one (two incisional hernias), Healthy the defect was covered with a single large piece of mesh. In Mesh fascia all but three patients (in whom polyester mesh was placed), we used a polypropylene mesh for the repair. The average operating time was 60 minutes (range 30–240 minutes), varying directly with the degree of adhesiolysis that was required. All patients were discharged in the first 24 hours, with the exception of one patient, who had an Figure 17.2 The mesh is positioned into the pre-peritoneal enterotomy recognized during the procedure. The mean space and secured to the abdominal wall. The stitches along the length of hospital stay was 1.2 days (range 1–4 days). outer border of the mesh must overlap the rim of the hernia Patients required minimal post-surgical analgesia. Bowel defect by at least 3 cm. function returned quickly in most patients. There were no deaths. Seven complications were lateral to the edges of the fascial defect (Figure 17.2). recorded (13.4 per cent of patients), most of which were Drains are not used. The trocar sites are then closed in minor (four seromas, two hematomas, one accidental the usual fashion.23 small bowel enterotomy). Patients were followed closely postoperatively for three to 60 months (mean 41 Immediate postoperative care months). Two (3.8 per cent) patients were found to have evidence of hernia recurrence. They were among the very Postoperatively, patients are given narcotics for appro- first cases, and they had large defects. Recurrences were priate analgesia. A liquid diet is started on the same day, diagnosed within the first 12 months after the operation. and patients are encouraged to ambulate as soon as pos- Lack of experience and large defects may be related to the sible. Bowel function usually resumes early in the post- reason for recurrence. Most patients developed an area of 24 operative period. Some patients go home on the day of induration at the hernia site, but this resolved without the operation, but 85 per cent are discharged on the first any treatment within four to six weeks. Apart from this postoperative day. Most patients develop an area of transient induration, we have encountered no complica- induration at the previous hernia site, but this resolves tions as a result of excising the hernia sac. without complications or treatment within four to six weeks. In general, patients are allowed to return to work at their convenience and may resume heavy physical activities two to four weeks later. COMPARATIVE STUDIES OF OPEN VERSUS The most common early complications after laparo- LAPAROSCOPIC REPAIR scopic repair are suture-site pain (when using transabdominal stitches) and seroma. The former is probably Two retrospective studies and one prospective study have related to some muscular ischemia and nerve entrap- compared the results of open surgery techniques versus ment. The development of seroma is secondary to the the laparoscopic approach for the repair of ventral her- creation of a dead space and a secretory reaction to the nias. These studies consisted of a majority of incisional prosthetic material. Only large, symptomatic collections defects (Table 17.2). In 1997, Holzman and colleagues should be aspirated. compared 21 patients with ventral/incisional hernias repaired laparoscopically with a group of 16 patients 26 PERSONAL SERIES RESULTS who had undergone conventional open mesh repair. The mean follow-up period was similar, and two recurrences occurred in each group. The investigators con- From January 1997 to January 2002, 52 (21 female, 31 cluded that the advantages of the laparoscopic approach male) patients underwent attempted laparoscopic inci- seem to be a reduced rate of postoperative complica- sional hernia repair.25 We excluded from this series tions, fewer wound healing problems, and more rapid Spigelian hernias and incisional hernias that required the recovery after surgery. In 1998, Park and coworkers intraperitoneal onlay technique. There was a total of compared 56 laparoscopic prosthetic repairs of large inci- 53 hernia repairs (one patient with two incisional hernias). sional hernias with 49 open surgical procedures.27 The 130 Laparoscopic incisional and ventral hernioplasty

Table 17.2 Comparison studies of laparoscopic versus open repair of ventral/incisional hernia Complications Intra- Post- Reopera- Hospital Cost Repair Patients Size Time operative operative tions stay Follow-up Recurrence Reference (US$) type (n) (cm2) (min) (n)(n)(n) (days) (months) (n) Holzman et al. 7299 Open 16 148 98 0 5 2 4.9 18 2 (1997)26 4395 Lap 21 105 128 1 4 0 1.6 20 2 Park et al. Open 49 105 78 1 17 0 6.5 53 17 (1998)27 Lap 56 99 95 0 10 2 3.4 24 6 Carbajo et al. Open 30 141 111 0 35 1 9 27 2 (1999)28* Lap 30 139 87 0 5 1 2 27 0

*Prospective study. mean follow-ups were 24 months for the laparoscopic or a composite mesh prosthesis in the intraperitoneal group and 53 months for the open procedure. The hernia location.30,31 Biomaterials have become an important recurred in six (11 per cent) patients in the laparoscopic tool because they can permanently replace the defective group and in 17 (34 per cent) patients in the open repair transversalis fascia and permit the creation of a truly group, but the investigators could not make a meaningful tension-free hernioplasty. However, utilization of bioma- comparison of the recurrence rates because of the large terials is associated with four major concerns: rejection, difference in the follow-up periods. They found that the infection, early adhesion formation and host tissue incor- laparoscopic procedure took longer to perform, but it poration. It is well known that a peritoneal defect or the was associated with fewer complications and shorter presence of a foreign body in the abdominal cavity creates postoperative hospital stays. adhesions.13 This in turn may result in major complica- In the only prospective randomized study of laparo- tions, including intestinal obstruction, migration of the scopic repair versus open repair, Carbajo and colleagues foreign body and erosion into the bowel, fistula, and infec- randomized 60 patients over a three-year period into two tion. In general, complications resulting from intraperi- homogeneous groups to be operated on for major ven- toneal adhesions account for a significant number of tral hernias using mesh.28 With an average follow-up of emergency surgical admissions and abdominal opera- 27 months, they noted that two hernias in the open repair tions.7 These concerns have prompted the development of group and none in the laparoscopic group recurred. They a further refinement in the transabdominal laparoscopic concluded that laparoscopic repair offers several advan- approach: the pre-peritoneal laparoscopic mesh repair. tages over the classic surgical repair of abdominal wall Dissecting within the pre-peritoneal plane in order to cre- defects, including a reduction in the rate of complications ate an anatomical room for the mesh may sometimes be and recurrence. extremely difficult. However, our own experience shows that this approach is technically feasible in many circumstances and, indeed, this procedure is an extension of our current laparoscopic techniques for repairing inguinal ADVANTAGES AND DISADVANTAGES OF 32 DIFFERENT LAPAROSCOPIC TECHNIQUES hernias. However, we should also underscore the fact that even pre-peritoneal repairs of inguinal hernias have not been free of adhesions and associated bowel complica- Critical assessment of the reported results is difficult and tions. Only a longer follow-up period of our patients will potentially misleading due to the significant variations in allow us to determine whether the theoretical advantages terminology, patient selection, and operative techniques.29 of positioning the mesh in the pre-peritoneal location will No data are available to support unequivocally an overt overcome the possible disadvantages of a more tedious advantage of any particular technique to repair incisional procedure that usually demands a longer operative time.33 hernias. Clinical judgment, previous experience, and team surgical skills should guide the technical choice that is applied to a particular patient. Despite the pitfalls of the CONCLUSION available data (mainly from retrospective studies of selected patients), recurrence rates are slightly lower and complications less frequent in the laparoscopic group, The laparoscopic route has made possible the introduc- regardless of the technique employed. The most popular tion of new surgical techniques for the repair of major laparoscopic technique of incisional hernia repair pro- abdominal wall defects. The laparoscopic surgeon is able poses a transperitoneal approach using either an ePTFE to minimize the great degree of tissue trauma involved in Pre-peritoneal herniorrhaphy 131 classic open surgery, typically associated with large fas- 10 Amid PK. Classification of biomaterials and their related cial dissection, tense sutures, and postoperative drains. complications in abdominal wall hernia surgery. Hernia 1997; 1: 15. 11 Morris-Stiff H. The outcomes of nonabsorbable mesh. J Am Coll Laparoscopic repair of incisional hernias is a promising Surg 1998; 186: 352. but still new technique that may be seen as a further refine- 12 Koehler RH, Voeller G. Recurrences in laparoscopic incisional ment of the current surgical armamentarium to treat this hernia repairs: A personal series and review of the literature. common problem in general surgery. As with any new JSLS 1999; 3: 293–304. operation, we should initially be more careful about 13 Marchal F, Brunaud L, Sebbag H, et al. Treatment of incisional hernias by placement of an intraperitoneal prosthesis: a series of patient selection before embarking on a broader applica- 128 patients. Hernia 2000; 3: 141. tion of this technique. Adequate training and judicious 14 Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of indication can certainly ensure good surgical outcomes. recurrent ventral hernias. Am Surg 1998; 64: 1126–7. Until now, patients in several series have tolerated the 15 Luijendijk RW, Lemmen MHM, Hop WCJ, et al. Incisional hernia procedure well and had shorter postoperative hospital- recurrence following ‘vest-over-pants’ or vertical Mayo repair of primary hernias of the midline. World J Surg 1997; 21: 62–5. izations in comparison to open procedures. Accordingly, 16 Stoppa R. The treatment of complicated groin and incisional given the potentially lower morbidity due to the smaller hernias. World J Surg 1989; 13: 545–54. abdominal wall incisions, the overall hospital cost may be 17 Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional reduced, making this a more attractive approach to inci- hernias. Surg Laparosc Endosc 1996; 6: 123–8. sional hernias. Moreover, laparoscopy allows compre- 18 LeBlanc KA, Booth WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: hensive exploration of the abdominal cavity, adequate preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. assessment of the adhesions in the hernia process, and a 19 Hashizume M, Migo S, Tsugawa Y, et al. Laparoscopic repair of clear delineation of the anatomy. It may be the procedure paraumbilical ventral hernia with increasing size in an obese of choice in patients who develop a recurrence following patient. Surg Endosc 1996; 10: 933–5. a previous open hernia repair. 20 Scott-Roth J, Park AE, Witzked, et al. Laparoscopic incisional/ ventral herniorrhaphy: a five-year experience. Hernia 1999; 4: 209. Laparoscopic incisional hernia repair can be per- 21 Wants GE. Incisional hernioplasty with Mersilene. Surg Gynecol formed safely with no increased morbidity or mortality, Obstet 1991; 172: 129. but the ultimate outcome in assessing the success of any 22 Barie PS, Mack CA, Thompson WA. A technique for laparoscopic hernia repair must be the rate of recurrence. The litera- repair of herniation of the anterior abdominal wall using a ture suggests that the laparoscopic approach, regardless composite mesh prosthesis. Am J Surg 1995; 170: 62–3. 23 Larson GM: Laparoscopic repair of ventral hernia. In: Scott-Conner of where the mesh is placed, has a midterm recurrence CEH, ed. The SAGES Manual. New York: Springer-Verlag, 1998: 379. rate that is at least as good as that seen after the open 24 Toy FK, Bailey RW, Carey S, et al. Prospective multicenter study of operation. However, long-term assessment from large, laparoscopic ventral hernioplasty. Surg Endosc 1998; 12: 955–9. well-controlled, prospective studies is needed to confirm 25 Roll S, Benatti M, Roncada, P, et al. Laparoscopic incisional the expected advantages of the laparoscopic approach. preperitoneal hernioplasty. Presented at the 7th World Congress of Endoscopic Surgery, Singapore, 1–4 June 2000. 26 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral REFERENCES and incisional hernioplasty. Surg Endosc 1997; 11: 32–5. 27 Park AE, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998; 124: 816. 1 Santora TA, Roslyn JJ. Incisional hernia. Surg Clin North Am 1993; 28 Carbajo MA, Martín del Olmo JC, Blanco JI, et al. Laparoscopic 73: 557–70. treatment vs open surgery in the solution of major incisional and 2 Makela JT, Kiviniemi H, Juvonen T, et al. Factors influencing wound abdominal wall hernias with mesh. Surg Endosc 1999; 13: 250–2. dehiscence after midline laparotomy. Am J Surg 1995; 170: 387–90. 29 Chevrel JP, Rath AM. Classification of incisional hernias of the 3 Niggebrugge AH, Hansen BE, Trimbos JB, et al. Mechanical factors abdominal wall. Hernia 2000; 4: 7. influencing the incidence of burst abdomen. Eur J Surg 1995; 161: 30 Alexandre JH, Aouad K, Bethoux JP, et al. Recent advances in 655–61. incisional hernia treatment. Hernia 2000; 4: 1. 4 Meissner K, Jirikowski B, Szecsi T. Repair of parietal hernia by 31 Balique JC, Alexandre JH, Arnaud JP, et al. Intraperitoneal overlapping onlay reinforcement or ‘gap-bridging’ replacement treatment of incisional and umbilical hernias: intermediate results polypropylene mesh: preliminary results. Hernia 2000; 4: 29. of a multicenter prospective clinical trial using an innovative 5 Larson GM. Ventral hernia repair by the laparoscopic approach. composite mesh. Hernia 2000; 4: 10. Surg Clin North Am 2000; 80: 1329–40. 32 Roll S, DePaula AL, Miguel P, et al. Laparoscopic transabdominal 6 Heniford BT, Park A, Ramshaw BJ, et al. Laparoscopic ventral and inguinal hernia repair with a preperitoneal mesh. Surg Endosc incisional repair in 407 patients. J Am Coll Surg 2000; 190: 645–50. 1994; 8: 484. 7 Luijendijk RW, Hop WC, van den Tol P, et al. A comparison of suture 33 Saiz AA, Willis IH, Paul DK, et al. Laparoscopic ventral hernia repair: repair with mesh repair for incisional hernia. N Engl J Med 2000; a community hospital experience. Am Surg 1996; 62: 336–8. 343: 392–8. 34 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and 8 Leber GE, Garb JL, Alexander AI, et al. Long-term complications incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. associated with prosthetic repair of incisional hernias. Arch Surg 35 Sanders LM, Flint LM. Initial experience with laparoscopic repair of 1998; 133: 378–82. incisional hernias. Am J Surg 1999; 177: 227–31. 9 Amid PK, Shulman AG, Lichtenstein I, et al. Preliminary evaluation of composite materials for the repair of incisional hernias. Ann Chir 1995; 49: 539. This page intentionally left blank 18

Hernioplasty with the double-crown technique

SALVADOR MORALES-CONDE AND SALVADOR MORALES-MÉNDEZ

Principles 133 Conclusion 142 Double-crown surgical technique 135 References 142 Results of our series 141

Laparoscopic surgery continues to advance in achieving Hernia further benefits over the conventional approach for certain pathologies. In 1991, LeBlanc and coworkers carried out the first laparoscopic repairs of ventral hernias.1 Although ventral hernia was not originally considered to be a pathology that could benefit from this approach, laparoscopic repair of ventral hernias has attained wide acceptance in recent years because of the significant advantages afforded by improvements in prosthetic materials and in attachment methods, as well as in the surgical technique used. The laparoscopic procedure offers greater comfort during the postoperative period, reduces hospitalization time, and lowers complication rates. Even though many Figure 18.1 Double-crown technique for laparoscopic ventral series still have a limited follow-up, the technique has hernia repair. External sutures are avoided, and the mesh is fixed shown lower rates of recurrence than the open methods, with a double crown of tacks alone. making it a procedure that solves a long-standing challenge to the surgeon. Nevertheless, there are certain points of controversy postoperative pain at this level, and with the same recur- that should be clarified, starting with the simple fact of rence rate as described by groups using transfascial establishing more precise indications. In addition, a mul- sutures. titude of more specific technical details should be discussed, including how to perform adhesiolysis, how to manage the hernia sac, the postoperative seroma, the PRINCIPLES type and size of the mesh, and how to insert and secure the mesh. One of the most interesting points currently being debated is whether it is necessary to use sutures or Indications and contraindications tacks. We have developed a laparoscopic procedure without sutures for the repair of ventral hernias, a technique Indications for the double-crown technique are the we have come to call the ‘double-crown’ technique. same as indications for laparoscopic hernia repair with This system avoids the use of external (transfascial) transfascial sutures. Basically, all ventral hernias can sutures by fixing the mesh with a double crown of be repaired by laparoscopy as the standard procedure. tacks alone (Figure 18.1). This ensures proper anchorage Emergency operations performed in cases of strangu- of the mesh, decreasing surgery time and diminishing lated hernias must be analyzed on an individual basis to 134 Laparoscopic incisional and ventral hernioplasty assess whether laparoscopy should be used. However, transfascial sutures.4,7,8 In fact, they demonstrated that various factors place limits on the indications for laparo- one of the essential factors to avoid recurrence is the use scopic repair, such as the size of the defect and the site of these sutures.9 Analysis of the data derived from these where the defect has occurred. Subxiphoid, suprapubic, early series – data that were later the basis for recom- lumbar and parastomal hernias require special consider- mendations on the use of sutures – shows that other fac- ations for laparoscopic repair, and several technical tors could have been involved in the development of details must still be considered. At the lower end of recurrence in these patients besides the use (or not) of the size spectrum, hernias that can be repaired with transfascial sutures: local anesthesia, encompassing those under 3–4 cm, are • Prostheses initially recommended were small, usually excluded. However, in patients requiring laparo- overlapping the defect by only 2–2.5 cm10–12 in all scopic surgery for other concomitant conditions and in directions, and not the minimum of 3 cm currently obese patients, laparoscopic repair would be indicated recommended. Recently, we have demonstrated in an despite the small size of the hernia. At the upper end of experimental study that expanded polytetrafluoro- the hernia size spectrum, our group has performed many ethylene (ePTFE) prostheses decrease in size once successful repairs of massive abdominal wall defects. We they have been implanted (by 1.63–4 cm after five conclude, therefore, that until the limits are established weeks), probably because of the scar tissue reaction clearly, the degree of difficulty in managing the instru- and the encapsulation process experienced by the ments within the abdominal cavity is the only actual mesh,13 so recurrence in these initial experiences limit to the technique as far as large hernias are con- could have happened mainly because of the smaller cerned. On the other hand, the characteristics of the sac size of the mesh. of the hernia are important to determine the contraindi- • The method of fixation was also inadequate, since cations of this technique, since the evolution and compli- tacks were not yet available and mesh patches were cation of the seroma and the cosmetic results would be anchored with the old endo-staplers that did not different depending on the type of sac. Definitive guide- ensure secure attachment of the material. This problem lines will have to be elaborated on the basis of results was particularly important with the ePTFE mesh from prospective studies. because of its thickness. Thus, the use of transfascial sutures was necessary in these cases, and the real Sutures versus no sutures with purpose of the endo-staplers was to prevent the double-crown technique bowel from slipping between the sutures rather than to fix the mesh.10,11,14 Why are transfascial sutures recommended? • The learning curve of these initial series could be related more directly to the appearance of Laparoscopic surgery for ventral hernias offers enormous recurrences than to the placement (or not) of advantages over open surgery during the immediate post- transfascial sutures. operative period, with clearly lower morbidity2–4 and lower general costs of surgery.5,6 Another important issue is that patients who were operated on by laparoscopy appear Disadvantages of using transfascial sutures to have lower recurrence rates.2–4 Based on the reasons noted above, we do not believe that Despite the lower recurrence rate, various authors these sutures are needed to reduce the recurrence rates, have made efforts to analyze the causes for recurrence in as reported by several authors. Nevertheless, they are order to define adequately the laparoscopic technique associated with a number of disadvantages (Table 18.1): and thereby achieve an even lower recurrence rate. Initial laparoscopic ventral hernia repair series established a • Longer surgery time: surgery times associated with direct correlation between recurrence and the absence of transfascial suture placement are longer because

Table 18.1 Comparison of factors related to the use of transfascial sutures Mean operating Mesh infection Long-term Recurrence Technique time (min) rate (%) pain (%) rate (%) Double-crown (S. Morales-Conde) 79 0 0 2.86 Other technique without 62 0 0 2 transfascial sutures3 Series with transfascial sutures 120 4.87 1.97 3.98 Hernioplasty with the double-crown technique 135

sutures are recommended every 5 cm,14 4–5 cm,12 or Recurrence rate: a reason to use the double-crown even 3–4 cm,9 in addition to at the four corners. The technique operating time in our series is around 79 minutes. Irrespective of the disadvantages associated with sutures The time in the other published series that use only listed above, if the recurrence rate in our series were higher tacks and no sutures is between 62 and 87 minutes.2,3 than in the series using transfascial sutures, then their use The operating times for groups using sutures were would be warranted. In series that advocate the use of between 82 minutes4 and 210 minutes,15 with a mean sutures, the recurrence rate ranges anywhere from zero11 of 120 minutes,4,12,15–17 showing a significant to 8.3 per cent,15 with a mean of 3.98 per cent.4,5,9–11,14–18 increase in surgery time due to the maneuvers The recurrence rate of our series is 2.86 per cent, with a needed to place these sutures. mean follow-up of 24 months. As we noted earlier, recur- More incisions in the skin: transfascial suture • rence after laparoscopic repair of ventral hernias tends to placement involves incisions of 2–3 mm at a pre- appear more frequently during the first few months of the established distance of 3–5 cm, as mentioned earlier. postoperative period. Analysis of our recurrences shows Poorer cosmetic results: small incisions are needed to • that they were not related directly to the use of sutures: one place the sutures. The incisions require only a Steri- case was due to use of a short mesh at the beginning of our Strip and typically leave a small scar; however, they series and the other two cases were two suprapubic hernias do contribute to a higher number of scars. with recurrence at the inferior margin. Recurrence in these Greater infection rate: in our series, the mesh • two cases resulted from inadequate exposure of the pubis infection rate was zero, in keeping with results and Cooper’s ligament in order to anchor the mesh more reported by other authors who do not use these securely at this level. This is a complicated area, which sutures.6 The infection rate reported by groups using presents particular difficulty when placing transfascial transfascial sutures was as high as 11.1 per cent,5 sutures. Even authors who advocate the use of sutures do with a mean infection rate of 4.87 per cent.4,5,18 In not recommend them at this level. addition to mesh infection, the subcutaneous sutures can become infected, or a superficial infection can develop in the small incisions in the skin. In the only DOUBLE-CROWN SURGICAL TECHNIQUE case in our series in which sutures were used, the patient presented with a superficial skin infection at the site of the incisions made to place two of the Preoperative management sutures. • Pain during the early postoperative period: the use of A clinical preoperative evaluation is performed, and the transfascial sutures involves taking 1–2 cm of tissue, indication for laparoscopic approach is set based on pre- trapping it, and compressing it by tying at the vious considerations. Patients are informed fully about subcutaneous tissue level. This is associated with the risk of the surgery, the possibilities of conversion into greater pain during the early postoperative period an open procedure, and the high frequency of the devel- and in the longer term. In the short term, some opment of postoperative seroma (so that they do not authors defending the use of these sutures recognize confuse this seroma with an early recurrence). that there is more pain during the immediate We administer antibiotic prophylaxis in all cases with a postoperative period than after laparoscopic preoperative dose of a second-generation cephalosporin. cholecystectomy and that this pain could extend If the patient has any risk factor, such as diabetes, the pro- hospitalization.9 There may also be discomfort at the phylaxis is continued with two additional doses in the suture level during the first two weeks of the postoperative period. Mechanical bowel preparation is postoperative period.17 not usually necessary; only patients who have undergone • Long-term postoperative pain: the more significant several previous surgeries and who are thought to have problem is long-term pain, whether continuous or densely adherent or incarcerated viscera will undergo this associated with movement, and the pulling sensation preparation. at the site of the sutures. In some cases, oral narcotics, non-steroidal anti-inflammatory drugs, or Instrumentation even injections of local anesthetics at the suture site have been required, perhaps due to nerve Laparoscope entrapment.17,18 Postoperative diagnostic laparoscopy has been recommended to assess the A 30-degree-angled laparoscope is essential to perform condition of the mesh and the sutures. This will the laparoscopic approach of ventral hernias, since this allow the section of the offending sutures, if offers an excellent view of the entire anterior abdominal necessary.19 wall and of the defect that will be repaired. 136 Laparoscopic incisional and ventral hernioplasty

Trocars Different hemostatic systems, such as clips, must be available should their use become necessary. A needle-holder A variety of trocar sizes are available commercially, should be available in case of an enterotomy, so that one including 2-, 3-, 5-, 10-, 11- and 12-mm trocars. In gen- may repair the injury, thereby allowing the procedure to eral, we perform the technique using one 10-mm trocar continue laparoscopically. If we find a full-thickness injury and two 5-mm trocars. A series of factors should be to the small intestinal wall that penetrates into the lumen, considered when choosing the trocars: we usually repair it, either by laparoscopy or by an assisted • A trocar of at least 10 mm is required for introducing mini-laparotomy, and then continue the technique by a mesh. Contamination of the mesh due to placing the mesh intraperitoneally. However, if a colonic microorganisms on the skin of the abdominal injury occurs, we prefer to repair the bowel and, in the case wall can potentially occur when the mesh is of a large defect, repair the hernia defect by placing the introduced through the opening left by the trocar patch a few days later or, in the case of a small defect, once it is removed. Because of this, we prefer to convert to an open repair without the use of a patch. introduce the mesh through the trocar. As a result, we select the trocar based upon the size of the ePTFE Energy sources patch. We most frequently use the sizes 10 ϫ 15 cm, Monopolar cautery is acceptable as long as it is not used in 15 ϫ 19 cm and 18 ϫ 24 cm (as well as others of close proximity to any viscera. Adhesiolysis must be per- larger size). We use a 10-mm trocar when we expect formed with extreme care since missed bowel perforation to use a 10 ϫ 15-cm mesh, an 11-mm trocar for a could be life-threatening for the patient. For this reason, 15 ϫ 19-cm mesh, and a 12-mm trocar for an 18 ϫ electrocautery should be used in a bleeding area after the 24-cm prosthesis. For larger mesh sizes, we use a 10- adhesions are freed. During dissection, there is frequent mm trocar and insert the mesh through the opening hemorrhage, but this is usually minimal and insignificant left in the skin by the trocar after it is removed, since if the proper plane of dissection is maintained. larger meshes cannot be passed through any of the The harmonic scalpel has been advocated for lysis of trocars. In such cases, the mesh to be inserted is adhesions, but the blunt tip of this instrument does not wrapped in a sterile plastic material that covers the allow the easy localization of the proper plane to free the mesh in order to prevent contamination from adhesions of the bowel. For this reason, we use this source microorganisms on the abdominal wall; this plastic is of energy only for the lysis of omental adhesion and only subsequently removed from the abdominal cavity. when we are convinced that there is no bowel attached to We prefer to use a 10-mm, 30-degree laparoscope • the anterior abdominal wall behind the fatty tissue. This is because the visualization and illumination provided particularly useful in cases in which the round ligament by the 5-mm, 30-degree laparoscope are not optimal or the urachus must be dissected to guarantee a proper in our institution. This, of course, requires a trocar of fixation of the mesh, since dissection of these structures is at least 10 mm. a time-consuming maneuver due to frequent bleeding. • A 5-mm trocar is used for introduction of the Pro- Tack device (U.S. Surgical Corp./Tyco International). Prostheses Before this fixation system appeared on the market, this step was performed using an endo-stapler, which Improvements are being made to attain the ideal pros- required the use of 12-mm trocars. thetic material, i.e. one that is biologically inert, that produces little or no foreign-body reaction, that is strong Under these premises, we believe that a 10-, 11- or 12- yet pliable, that maintains its shape after implantation, mm trocar (depending on mesh size) should be used for and that resists the formation of adhesions while support- laparoscopic repair of ventral hernias, as these accom- ing fibrous in-growth of connective tissue.20 Polypropylene modate a 10-mm, 30-degree laparoscope and can be used mesh has been the most widely used prosthetic material in to introduce the mesh. A 5-mm trocar should be used to hernia repair since it was introduced in 1963.21 Numerous introduce the tacks (or other fixation device) that attach materials are currently available, such as ePTFE, with the mesh. Another 3- or 5-mm trocar should be used as a excellent properties closely resembling the ideal prosthesis, working trocar. i.e. being biologically inert, producing fewer adhesions,22 and causing little or no inflammatory reaction, with its Graspers, scissors, and other laparoscopic porous microstructure providing a lattice for the incorpo- instrumentation ration of connective tissue.23,24 Atraumatic bowel graspers are needed to manipulate the Clinical and experimental experience indicates a vari- bowel and to provide gentle traction to reduce the con- ety of complications that may be related to the physical tents of the hernia sac. Sharp scissors are required for properties of polypropylene, such as the risk of bowel proper dissection and prevention of bowel injury. obstruction and/or fistula formation.25–27 Additionally, a Hernioplasty with the double-crown technique 137 recent experimental study conducted in our laboratory hernias, midline hernias located in the lower of the revealed that polypropylene does not attach to the abdomen, or if operation is likely to be prolonged. We use peritoneum as well as it does to the other layers of the a nasogastric tube to decompress the stomach in patients abdominal wall previously dissected. ePTFE appeared to with subxiphoid hernias or hernias in the upper third of attach more firmly to these layers. The new ePTFE mate- the midline of the abdomen. rial is designed specifically to be placed intraperitoneally, since one (visceral) surface has very small pores, which inhibits tissue in-growth, while the opposite (parietal) Operative technique surface that is placed on to the peritoneum has large pores to permit significant tissue in-growth. Creation of pneumoperitoneum and placement We usually use the DualMesh Plus with Holes of trocars (W. L. Gore & Associates), which is impregnated with In all cases, we start by creating the pneumoperitoneum chlorhexidine and silver. These antimicrobial agents using a Veress needle in the left hypochondrium. We do decrease the possibility of contamination of the mesh. not use the Hasson trocar, regardless of the number of Chlorhexidine and silver also change the color of the previous laparotomies that the patient has undergone. ePTFE to brown; this minimizes the bright glare of the Our group has performed more than 4000 laparoscopic ePTFE, which can otherwise hamper the management of procedures for a variety of pathologies, and there has the mesh within the abdominal cavity because of the never been an injury to any structure because of the use brightness of the light of the laparoscope. We also advo- of the Veress needle. Hence, we feel confident when cate the use of the mesh with holes since it will facilitate creating the pneumoperitoneum with this technique, the drainage of the fluid retained between the mesh and even in patients with a history of multiple operations. the sac during the first hours of the postoperative period. Once the pneumoperitoneum is created, we generally The use of an external compressive bandage is also rec- approach the hernia from the patient’s left side, placing ommended, as this will aid in decreasing the size of the three trocars in line, introducing the 10–12-mm trocar seroma that we have seen in some of our patients. first and then placing the other 5-mm trocars under direct vision; the larger trocar is placed in the middle of the other Fixation devices two trocars. An important thing to remember when plac- We fix the mesh in all cases with helical tacks, which pro- ing these trocars is to stay as far away as possible from the vide proper fixation of the mesh to the anterior abdomi- margin of the defect closest to the surgeon. This will pro- nal wall, thereby avoiding the need of transfascial sutures. vide proper visualization of the margin, making it easier to A new fixation device is now available, the SaluteTM achieve a wide overlap of the mesh and perform any (Onux Medical, Inc.), which delivers a cylindrical con- maneuvers needed to secure the prosthesis (Figure 18.2). struct of stainless steel. When it is not possible to maintain a suitable distance We do use sutures in hernias that require a mesh larger than 18 ϫ 2 4 cm to facilitate orientation and initial fixation of the mesh. These sutures may be of any type of material since they will be removed. They are placed at the four cardinal points of the patch and are passed through the abdominal wall with the aid of a suture-passer (W. L. Gore & Associates). These sutures are not tied once the mesh is fixed with the tacks. Instead, they are removed completely when the outer crown of tacks is placed and the mesh is properly extended.

Operative room set-up

The description below is based upon the repair of small to medium-sized (3–10 cm) primary or incisional hernias located in the midline but about 3 cm from the xiphoid and suprapubic areas. We usually place the patient in the supine position, Figure 18.2 Pneumoperitoneum is created using a Veress with the surgeon and the assistant to the patient’s left and needle in the left upper quadrant of the abdominal wall. The first the monitor in front of them to the patient’s right. A uri- trocar is introduced far enough from the defect so we do not nary drainage catheter is used in patients with suprapubic have difficulty in fixing the proximal part of the mesh. 138 Laparoscopic incisional and ventral hernioplasty from this margin, we introduce another 5-mm trocar in entire defect on the skin of the patient. In obese patients, the patient’s opposite flank in order to adequately fix the it is difficult or impossible to feel the grasper on the out- mesh on the margin closest to the trocar through which side. In these cases, we insert an intramuscular needle the laparoscope is placed. If necessary, a contralateral through the skin and abdominal wall. The tip of the 10-mm trocar can be inserted to help anchor the mesh. needle is visualized inside the abdominal cavity under laparoscopic vision and, with multiple passes, is used to Adhesiolysis detect and trace the hernia defect on the patient’s skin (Figures 18.4 and 18.5). Once the trocars are introduced, the adhesions are An exact measurement of the defect is determined evaluated. We consider adhesiolysis to be a key point of when the abdomen is fully desufflated. The patch is then this procedure, since incorrect performance of the adhesio- chosen to provide an overlap of at least 3 cm. We system- lytic process can have extremely serious consequences for atically use a DualMesh Corduroy Plus with Holes. the patient. Nevertheless, if there are any doubts regarding Once the mesh is selected, several marks are traced on the possibility of bowel perforation, the operation should the patient’s abdomen and on the mesh surface that be converted to the open technique or, alternatively, one of the trocar holes may be enlarged to evaluate the bowel. This is critical because a missed enterotomy is associated with high morbidity and mortality.

Identification of the defect and selection of the mesh Once the adhesiolysis process is completed, we proceed to identify the defect and the sac (Figure 18.3). We use the electrocautery to coagulate the entire area where the adhesiolysis was performed. This is done to avoid any bleeding in these areas, which could then create a hematoma at this level. If this were to occur, tension could be produced that could result in the detachment of the tacks following implantation of the prosthetic biomaterial. Once the hernia is identified, the actual hernia defect must be delineated by marking the margins of the hernia Figure 18.4 Once adhesiolysis has been performed, the defect (not the sac) on the skin of the patient. To facilitate the is identified since it will be where the inner crown of tacks will accurate identification of the fascial edges, a laparoscopic be placed. In obese patients, the best way to localize the defect grasper is used (under direct vision) to exert pressure at is by using needles from the outside under direct vision. the margins of the defect. The pressure exerted by this instrument is palpated on the outside of the abdominal wall. This is used to accurately outline and mark the

Figure 18.5 The defect identified previously is drawn on the patient’s skin and the needles are removed. The three trocars Figure 18.3 Defect of the hernia that needs to be covered once placed in line can be observed; one 10-mm trocar and two 5-mm the adhesiolysis process is completed. trocars are usually used. Hernioplasty with the double-crown technique 139 will be placed in contact with the viscera, in order to to perform the maneuvers needed to expand the mesh facilitate orientation of the prosthesis within the cavity once attachment has begun. We prefer to introduce the (Figure 18.6). A circular mark is traced at the cranial end mesh through one of the trocars to prevent potential con- of the mesh. An identical mark is placed on the patient’s tamination, which may occur if it is inserted through the abdomen to denote the location where the mesh will be skin, a strategy that is preferred by some authors (Figure anchored. A triangle is then drawn at the caudad end of 18.7b). If a large prosthesis is needed (Ͼ18 ϫ 24 cm), we the mesh and the abdominal wall, followed by a line that prefer to remove the trocar and insert the mesh wrapped passes through the triangle, starting at the lower limit of in sterile plastic through the trocar hole, and then remove the hernia defect. This is the line where the caudad tack the plastic from inside the cavity. will be positioned, since the outside measurements are different from the internal measurements. Once the cra- Placement and fixation of the mesh nial tack is placed internally, the distance will not correspond exactly to the triangle drawn on the patient’s Once the mesh is inside the cavity and unrolled properly, abdomen when the mesh is tightened. The second (cau- it must be oriented by using the circle drawn on the dad) tack will be placed at the level of the line that passes mesh. The corresponding area of the abdominal wall through the middle of the triangle. A cross is then drawn where the mesh is to be fixed is located by pushing on the on the left side of the patient’s abdomen and on the abdominal wall at that site. If the patient is extremely mesh, and two crosses are drawn on the right in order to obese, we insert a needle at the level of the circle on the extend the mesh properly in both directions. abdomen in order to locate the area where the first tack Afterwards, we roll the mesh along its long axis, leaving should be placed. When this tack is placed (Figure 18.8), the mesh side that will be in contact with the bowel rolled towards the inside (Figure 18.7a). This will make it easier

(a)

(b) Figure 18.7 (a) The mesh is rolled along its long axis, with the (b) area prepared to be placed in contact with the bowel in the Figure 18.6 (a) Different signs are drawn on the mesh to orient inside. (b) Once it has been rolled, the mesh is grasped with a it once it has been introduced in the cavity. (b) The same signs strong grasper to be introduced in the abdominal cavity through are drawn on the patient’s skin on the cardinal points. the 10–12-mm trocar. 140 Laparoscopic incisional and ventral hernioplasty

(a)

Figure 18.8 The first tack is placed where the circle is drawn on the mesh, one of the cardinal points. The exact point to be placed is localized by pressing from the outside on the circle drawn on the skin. we stretch the mesh in the caudad direction and perform the same maneuver, placing the second tack in the line that intersects the triangle traced earlier (Figure 18.9). Subsequently, the lateral tacks are placed following the same system with the crosses, avoiding the tendency of the mesh to move in the opposite direction from the point where the laparoscope is introduced. (b) Once the mesh is fixed in the four cardinal points, we Figure 18.9 (a) The second tack is placed on the opposite extend it adequately, adding an outer crown of tacks that cardinal point (caudal) where the triangle was drawn. (b) If we are placed right on the margin of the mesh (Figure 18.10). have difficulty in localizing the place where we want the tack, These tacks are separated from each other by a distance of we introduce a needle from the outside. 1 cm, which is adequate to ensure that the intestinal loops do not slip between the tacks resulting in an acute incarceration. While the crown is being placed, the surgeon must exert strong pressure against the tacker from the outside to ensure that the mesh is attached to the surfaces closest to the wall surface, thereby reaching the muscle fascia. Once the mesh is extended adequately with the tacks of the outer crown, we check for any mesh areas that may not be extended adequately and that are adherent to the anterior wall of the abdomen, because adhesions would occur at the ‘hanging’ sections of the mesh (we have observed this phenomenon in an experimental study conducted by our group).13 We add the necessary tacks at this level to extend the mesh adequately so that these potential areas of adhesions are prevented. Once the outer crown is finished, we add the inner Figure 18.10 Once the tacks are placed in the four cardinal crown of tacks. Since this level contains a smaller amount points, the outer crown of tacks is placed right at the margin of of pre-peritoneal fat, the inner crown is placed at the mar- the mesh. gin of the hernia sac to ensure better attachment of the mesh (Figure 18.11). Similarly, to identify the sac margin, this level in obese patients, so that we can identify the area we draw the defect on the abdomen of the patient before where the inner crown of tacks should be placed. These inserting the mesh inside the cavity. Pressure can then be are also executed while exerting pressure from the outside exerted from the outside, or a needle can be introduced at to ensure good anchorage at this level. As in the case of the Hernioplasty with the double-crown technique 141

effort to prevent seroma development. This bandage is kept in place for one week and is removed at the seven-day follow-up visit. Skin sutures are also removed at this time. Once the procedure is completed, we start the patient on ﬂuid intake about six to eight hours after surgery, progressing to solid foods as tolerated. The patient is normally discharged within 24 hours of surgery. In terms of physical activity, we do not impose any limitations on the patient, but recommend only gradual resumption of regular daily activities based on the patient’s progress during postoperative recovery. Patient follow-up is carried out at one month, three months, six months, one year, and with yearly visits thereafter.

Figure 18.11 The inner crown of tacks is placed at the margin RESULTS OF OUR SERIES of the hernia sac to ensure better attachment.

Between November 1998 and April 2002, we operated upon 105 ventral hernias on 102 patients using the double- crown technique. Our series included 63 women and 42 men, with a mean age of 57.59 years (range 26–80 years). The ventral hernias included eight primary hernias (four umbilical hernias, four epigastric hernias) and 97 incisional hernias. The hernia site varied considerably, with 87 midline hernias and 18 lateral hernias. The mean size of the defect repaired was 115.87 cm2. Only three cases were converted to open surgery: one patient with extremely strong adhesions who had been operated upon previously for acute peritonitis of tuber- culous origin; one patient who was converted due to technical difficulties; and one patient who was converted due to a strong adhesion from the colon to the hernia sac. Intraoperative complications included three intestinal perforations; one of these was sutured by laparoscopy Figure 18.12 The double crown of tacks is completed. and the other two required enlarging one of the trocar holes to perform resection and anastomosis, continuing later by laparoscopy. The following complications were tacks used for the outer crown, the inner crown tacks are encountered during the postoperative period: three clin- placed about 1 cm apart. ical seromas that required drains, two abdominal wall Once all the tacks are placed (Figure 18.12), we pro- hematomas, two prolonged paralytic ileus, and three ceed to identify and remove any that are left hanging reoperations. One of the reoperations was for missed from the wall or that are placed improperly, since they intestinal perforation and peritonitis requiring emer- should be inserted through the entire thickness of the gency laparotomy. We sutured the bowel perforation and mesh. Poorly positioned tacks will lead to adhesions, as removed the mesh. The second reoperation was in a we have shown in our experimental study, and could patient who had fever of 45 days’ duration. The seroma cause major complications in the future, such as fistulas fluid was drained repeatedly, but cultures were negative. or obstruction.13 It was assumed that the patient had a foreign-body reaction and the mesh was removed. The third reoperation Postoperative management was performed due to small bowel ischemia, the etiology of which is undetermined. Once the procedure is completed, the abdomen is desuf- The mean hospital stay was 1.75 days, with a mean of flated and trocar sites larger than 10 mm are closed. A 2.48 days in our first 45 cases and dropping to 1.12 days in compressive bandage is placed at the level of the hernia sac the last 60 cases of our series. There were three recur- to reduce the space between the mesh and the sac in an rences, accounting for 2.86 per cent of all our cases, with 142 Laparoscopic incisional and ventral hernioplasty a mean follow-up of 24 months. These recurrences 9 Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of occurred in one patient in our initial series in whom a recurrent ventral hernias. Am Surg 1998; 64: 1121–7. 10 Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional small mesh was implanted and in two cases of suprapubic hernias. Surg Laparosc Endosc 1996; 6: 123–8. hernias in which the pubis and Cooper’s ligament were 11 LeBlanc KA, Booth W, Whitaker JM. Laparoscopic repair of ventral not exposed adequately for suitable fixation of the mesh. hernias using an intraperitoneal onlay patch: report of current results. Contemp Surg 1994; 45. 12 Park A, Birch DW, Lovrics P. Laparoscopic and open incisional hernia repair: a comparison study. Surgery 1998; 124: 816–22. CONCLUSION 13 Morales-Conde S, Cadet I, Tutosaus JD, et al. Macroscopic evaluation of mesh incorporation placed intraperitoneally for laparoscopic ventral hernia repair. Experimental model. In: Lomanto Our results indicate that the use of transfascial sutures is D, Kum CK, So CK, Goh PMY, eds. Proceedings of the 7th World not necessary and that the double-crown technique, Congress of Endoscopic Surgery (Singapore June 1–4, 2000). which uses only tacks, offers a number of clear advan- Bologna, Italy: Monduzzi Editore, 2000: 455–60. tages over the combined suture-and-tack method. When 14 Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of using the technique described, we obtained a similar laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc 1998; 12: 955–9. recurrence rate as series that use sutures, while also reduc- 15 Sanders LM, Flint LM, Ferrara JJ. Initial experience with ing the hospital stay and short-, medium- and long-term laparoscopic repair of incisional hernias. Am J Surg 1999; 177: postoperative pain. Hence, we consider the double-crown 227–31. technique to be a valid alternative to ventral hernia repair 16 Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience with sutures. with the ‘four-before’ laparoscopic ventral hernia repair. Am Surg 2000; 66: 465–9. 17 Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair: a report of 100 consecutive cases. Surg Endosc 2000; 14: 419–23. REFERENCES 18 Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral and incisional hernia repair in 407 patients. J Am Coll Surg 2000; 190: 645–50. 1 LeBlanc KA, Booth WV. Laparoscopic repair of incisional 19 LeBlanc KA. Current considerations in laparoscopic incisional and abdominal hernias using expanded polytetrafluoroethylene: ventral herniorrhaphy. JSLS 2000; 4: 131–9. preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. 20 Condon RE, DeBord JR. Expanded polytetrafluoroethylene 2 Carbajo MA, Martín del Olmo JC, Blanco JI, et al. Laparoscopic prosthetic patches in repair of large ventral hernia. In: Nyhus LM, treatment vs open surgery in the solution of major incisional and Condon RE, eds. Hernia, 4th edn. Philadelphia: Lippincott Williams abdominal wall hernias with mesh. Surg Endosc 1999; 13: 250–2. and Wilkins, 1995: 328–36. 3 Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment 21 Usher FC. Hernia repair with knitted polypropylene mesh. Surg of ventral abdominal wall hernias: preliminary results in 100 Gynecol Obstet 1963; 117: 239. patients. JSLS 2000; 4: 141–5. 22 Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and 4 Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of Gore-Tex to repair abdominal wall defects in the rat. Can J Surg laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65: 1989; 32: 244. 827–32. 23 Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal 5 DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal wall defects with expanded polytetrafluoroethylene (PTFE). Ann polytetrafluoroethylene (PTFE) prosthesis patch repair of ventral Surg 1987; 206: 765. hernia. Surg Endosc 2000; 14: 326–9. 24 Law NW, Ellis H. Adhesion formation and peritoneal healing on 6 Morales-Conde S, López F, Tutosaus JD, et al. Cost-effectiveness prosthetic materials. Clin Mater 1988; 3: 95. of ‘Double Crown’ technique for laparoscopic ventral hernia vs 25 Kaufman Z, Engelberg M, Zager M. Fecal fístula: a late open repair. Presented at the 9th International Congress of he complication of Marlex mesh repair. Dis Colon Rectum 1981; 24: European Association for Endoscopic Surgeons, Maastricht, 543. 13–16 June 2001. 26 Voyles CR, Richardson JD, Bland KI. Emergency abdominal wall 7 Koehler RH, Voeller G. Recurrences in laparoscopic incisional reconstruction with polypropylene mesh: short-term benefits hernia repairs: a personal series and review of the literature. JSLS versus long-term complications. Ann Surg 1981; 194: 219. 1999; 3: 293–304. 27 Ponce González JF, Barriga Beltrán R, Martín Zurita I, et al. 8 Chari R, Chari V, Eisenstat M. A case controlled study of laparoscopic Prosthetic materials in incisional hernia. Experimental study. Cir ventral hernia repair. Surg Endosc 1998; 12 (suppl): S09. Esp 1998; 63: 189–94. 19

Parastomal hernia repair

KARL A. LEBLANC

Types of hernia 143 Postoperative management 147 Principles of management 144 Results 148 Indications and contraindications to surgery 144 Conclusion 149 Preoperative preparation 145 References 149 Operative techniques 145

Hernias that develop at the site of the various intestinal TYPES OF HERNIA stomas are quite common and often lead to many problems. Parastomal hernias may present as problems of stoma care, difficulty with the fit of the appliances or irri- The anatomy of the herniation is variable. Four principal gation, leakage of the fluids produced, a significant cos- types can be identified: metic deformity, or as complications of the hernia, such • Subcutaneous: there is herniation alongside the as intestinal obstruction or strangulation. The presence stoma, with a subcutaneous hernia sac containing of a large protrusion may make repair a necessity irre- omentum or small or large intestine. This is the spective of its other side effects because of a significant most common form of paracolostomy hernia cosmetic deformity. Herniation is less frequent with and, not infrequently, the colon is found in the ileostomy than colostomy, but the overall incidence of sac situated just proximal to the stoma. This parastomal herniation is difficult to quantify. positioning of the intestine alters the path of the Burns, in 1970, found 16 paracolic hernias among colon such that the ostomy can be very difficult 307 colostomates, an incidence of five per cent.1 Other to irrigate. authors have quoted figures that range from five to 48 per • Interstitial: there is a hernia sac lying within the cent.2–6 It is apparent that few (approximately 20 per muscle/aponeurotic layers of the abdominal wall, cent) of these hernias are repaired surgically. This may be which may contain omentum or small or large due to the lack of significant symptoms in the majority of intestine. In these cases, the stoma is asymmetrical, these patients and/or the age or infirmity of these indi- and is edematous and cyanotic if its vascular supply viduals, which may prohibit surgical intervention.7,8 The is compromised. The interstitial and subcutaneous incidence of para-ileostomy hernia is between five and hernias are considered to be variants of a sliding ten per cent, while that of para-urostomy stomas in hernia. Because the ring of tissue that surrounds the urological practice is between two and ten per cent.9,10 contents of the hernia can be quite narrow, these However, one radiological study of 28 ileostomies using hernias are particularly at risk of incarceration and clinical and computerized tomography (CT) evaluation strangulation. found that the rate of herniation was 35 per cent; this was • Prolapse: all stomas can prolapse, but transverse the same whether the ileum exited through or lateral to colostomies prolapse three times more frequently the rectus muscle.11 than any other stoma. A prolapsed stoma contains a 144 Laparoscopic incisional and ventral hernioplasty

hernial sac within itself; other viscera, especially the There are four surgical options for treating a para- small intestine, can enter this sac and even become stomal hernia: strangulated. Large hernial sacs that can be 1 Local repair of the stoma, in which case it is associated with prolapse are often seen in neonates mobilized locally, the peritoneal sac is identified and with a transverse colostomy for anorectal agenesis. the sac’s contents are reduced. The peritoneum and Intrastomal: this type of hernia is seen only with end • the musculo-aponeurotic defect are then closed. This ileostomies. A loop of intestine may herniate is associated with an unacceptable recurrence rate. alongside the stoma and lie between the emergent 2 Prosthetic repair by either an extraperitoneal or and the everted layer of the stoma. Intestinal extraparietal route. There have been reports of erosion obstruction has been described in such hernias. and perforation of the colon by the mesh used in this repair.13 3 Stoma relocation either with formal laparotomy or PRINCIPLES OF MANAGEMENT with limited transperitoneal transfer of the stoma. This can be a very effective procedure.14 However, many patients are quite comfortable with the The exact classification of the hernia is not critical to the location of the stoma and would rather maintain the laparoscopic surgeon. The approach to these different current site if feasible. hernia types will not vary significantly, except in the situ- 4 Laparoscopy offers several advantages that ation in which the intestine may be strangulated. In this encompass many of the attributes noted above. The case, the use of the laparoscopic technique may be laparoscopic approach offers the surgeon the ability contraindicated. In the elective operation, the condition to visualize the entire abdominal wall so that any of the patient and any predisposing factors, such as incisional hernias may also be repaired at the same cachexia, malignancy, obesity, and steroid usage, should time. Additionally, the anatomical detail of the influence the decision to proceed with surgical interven- hernia is nearly always identified easily with the view tion, as it would for any operation. that is provided with this technique. This repair However, an accurate diagnosis and assessment of the requires that the prosthetic biomaterial be placed anatomy of the hernia are essential. Therefore, the patient in the intraperitoneal position. The use of must be examined (1) supine and relaxed, (2) supine polypropylene has been described, but I believe with the muscles tensed, and (3) in the erect position. that the preferred biomaterial is expanded Investigation of the detailed anatomy with CT scanning polytetrafluoroethylene (ePTFE).15–18 The experience is useful to delineate large parastomal defects in the with this technique, however, is not vast; nor is there abdominal wall. CT scanning can also detect small any significant long-term follow-up of the few impalpable defects around ileostomies that present with patients that have undergone this hernioplasty. dysfunction.12 This information will assist the surgeon in Currently, the initial reports are promising but the the planning and execution of the operation. I have seen optimal method of repair has not been finalized. a herniation through the ileal conduit mesentery during the repair of a para-urostomy hernia. This was suspected When attempted, it is very unusual that one cannot by the findings on the preoperative CT scan and was repair these hernias laparoscopically. However, it may confirmed at surgery. That procedure was modified sometimes be advisable to identify a potential site for intraoperatively due to this fact (see below). relocation of the stoma if this proves necessary during the Patients who have had cancer surgery must be screened operation due to an inability to complete the procedure for recurrence before surgery is advised. Similarly, it is either laparoscopically or open. prudent to exclude recrudescent inflammatory bowel disease before undertaking operations in patients with ileostomies, although it should be noted that the risk of INDICATIONS AND CONTRAINDICATIONS para-ileostomy herniation is similar in patients with TO SURGERY ulcerative colitis and Crohn’s disease. An additional consideration that has become more commonplace is the life expectancy of the patient. An increasing number of Surgery is imperative in all cases of intestinal obstruction patients of advanced age are seen with multiple medical or strangulation related to any parastomal hernia. Urgent problems that add to the risk of general anesthesia. If emergency surgery is also absolutely indicated in all cases these illnesses will significantly shorten the life of the of paracolostomy hernia where perforation has occurred patient (i.e. by two to three years or more), or if they pro- during irrigation. Operative intervention is also the hibit anesthesia, then one may not wish to proceed if treatment of choice when a parastomal hernia causes there is no immediate need for surgical intervention. abdominal wall distortion and the resultant difficulties Parastomal hernia repair 145 with the fitting of an appliance or irrigating a stoma. Surgery should also be considered if the stoma has become out of the patient’s range of vision, or if its site on a hernia bulge makes it unmanageable in elderly patients, especially those with arthritis. The disfigure- ment caused by a bulging parastomal hernia may warrant surgery for cosmetic reasons. In special circumstances, the repair may need to be accompanied by an abdomino- plasty to permit a good fit of the appliance. Contraindications to surgery include such general problems such as cardiorespiratory failure, inability to have general anesthesia, recurrent Crohn’s disease, extreme obesity, disseminated malignancy, and a short life expectancy from any disease process. However, even these may not be obstacles to surgery, depending upon the presentation of the patient. If the patient exhibits significant skin Figure 19.1 Patient position on a roll to elevate the ipsilateral excoriation in the areas where the transfascial sutures are side of the patient. Note the circle that is marked on the skin to likely to be placed, then the open procedure may be pre- identify the outermost site of the appliance. ferred, unless these lesions can be eliminated by preoperative care. stand on the contralateral side and position the trocars to triangulate the defect (see Chapter 16). The assistant sur- PREOPERATIVE PREPARATION geon will place a fourth trocar in the upper quadrant in the side of the abdomen with the hernia. We use 5-mm trocars exclusively for this procedure. These patients are usually elderly and should be cleared A 2 ϫ 2-cm gauze is placed over the paracolostomy or for surgery in the manner that is common to all opera- para-ileostomy stoma to prevent leakage during the tions. If the patient has a colostomy secondary to a procedure. If the ostomy is an ileal conduit, a urinary malignant resection, it may be advisable to carry out pre- catheter is inserted to provide continuous drainage. operative colonoscopy to assure that there is no recurrent The balloon is inflated with approximately 3 cc’s rather disease. However, this will be dependent upon the num- than 5 cc’s of saline due to the size of the bowel lumen. ber of disease-free years. As noted earlier, a preoperative The entire abdomen is then covered by a sterile, iodine- CT scan is frequently helpful to identify the anatomy and impregnated plastic drape. Before the placement of this the contents of the hernia. This is especially true for the drape, the outer aspect of the position of the stomal para-ileal conduit hernia. appliance is marked on the skin with a marking pencil. I prefer to use gentle cleansing enemas on the day This identifies the outermost boundaries of the potential before the operation for patients that have a para- sites of transfascial suture placement (Figure 19.1). colostomy hernia. This does not assist in the operative The non-bladed trocar (with the laparoscope within procedure, but it may diminish the risk of infection if it) is used for the initial entry into the abdomen. there is a colonic injury during laparoscopy. Preoperative Occasionally, a Veress needle or the open approach may antibiotics are not necessary if an antimicrobial is be preferred, but in our experience this is seldom neces- impregnated into the biomaterial that will be used to sary. As with other intra-abdominal hernia repairs, repair the hernia (e.g. DualMesh Plus). dissection of the adhesions is the most tedious and time- consuming portion of the procedure. This should be OPERATIVE TECHNIQUES done either sharply without electrocautery or with the cautious use of the Harmonic scalpel (see Chapter 16). The instruments that are used for this are shown in The patient is placed in the supine position on the oper- Figure 16.4. Although the use of a large catheter placed ating table. It is best to place a roll underneath the ipsi- within the ostomy to palpate the stoma intraoperatively lateral side of the hernia. This elevates the patient and is appealing, it frequently provides little benefit. enables easier access to the area where the sutures will be As with the usual incisional hernias, the entire fascial placed (Figure 19.1). Typically, a gastric tube is placed for defect and the adjacent abdominal wall must be cleared of decompression, and a urinary catheter is used. The video all adhesions (Figure 19.2). It is at this point that the mea- monitors are usually located at the foot of the table and surement of the defect can be performed. This is somewhat on the ipsilateral side of the hernia. The surgeon will difficult because of the presence of the stoma and the 146 Laparoscopic incisional and ventral hernioplasty

Figure 19.3 Central cut-out and slit in the prosthesis of the initial DualMesh Plus prosthesis.

Figure 19.2 Fascial edges of the paracolostomy hernia. The arrows demarcate the borders of the hernia. gauze that was placed at the outset of the operative procedure. It is usually necessary to use an oversized patch to provide a wide margin of coverage. The most frequently used biomaterial is the 15 ϫ 19-cm DualMesh® Plus patch (W. L. Gore & Associates). This will invariably result in at least a 5-cm margin around the fascial defect. There are variations in the use of these prosthetic products to repair these hernias. To date, no one technique has proven to be superior to the others. We have used three different methods to repair these hernias, which are presented below. Continued follow-up of these patients will allow us to decide upon the best approach to the repair of parastomal hernias. One method involves the placement of two ePTFE Figure 19.4 Position of the initial prosthesis with the slit products. In one version, we used two DualMesh Plus placed opposite the hernia defect. In the photograph, the slit is products; in another version, we used one MycroMesh on the left and the hernia defect is covered with the prosthesis Plus product and one DualMesh Plus product. In both, a on the right. central circle is cut to allow for the exit of the intestine, and a slit is made to allow the patch to be placed around the stoma (Figure 19.3). Usually, this central circle is latter product may provide better fixation for the second 3–3.5 cm, which is adequate for the colon exit, but with patch that will be placed in this method because no the ileostomy 2.5–3 cm is preferred. This first patch is in-growth of collagen will occur through this first patch inserted and secured to the anterior wall in a manner that into the second one. is similar to that of the incisional hernia repair. The slit is A second biomaterial is then used, usually 18 ϫ 24-cm placed adjacent to the colon and directly opposite the DualMesh Plus, so as to completely cover the initial fascial defect so that good fixation can be made at that 15 ϫ 19-cm patch. In this way, there will also be in- point, and the defect is covered completely with the ini- growth of tissue to the periphery of the second patch. tial patch (Figure 19.4). Sutures are used adjacent to the Additionally, this larger product will provide greater sup- bowel to re-approximate this slit. These sutures are port than the smaller one to the anterior abdominal wall. pulled transfascially with a suture-passing instrument Many of these patients will have a significant deformity (see Chapter 16). Additional fixation of the patch is of the anterior abdominal wall because of the size of the then applied using the Onux Salute® constructs (Onux hernia itself. It is believed that the use of this second and Medical, Inc.). This initial step has been done using larger prosthesis will result in a better cosmetic result and either the DualMesh Plus or the MycroMesh® Plus bio- fit of the appliance. This second patch is cut similarly to material, as noted above (see Chapter 3). The holes in the the first one, inserted into the abdomen, and fixed with Parastomal hernia repair 147

Figure 19.7 Typical suture placement in the prosthesis for the onlay type of parastomal hernia repair. Figure 19.5 The potential space that can exist between the intestine and the opening in the prosthesis is shown by the arrows. Another method by which to repair these hernias One may elect to suture the colon at this site. The ePTFE sutures to is based upon the onlay technique described by the second patch are also seen on the left side of the colon. Sugarbaker.20 A critical step in this operation is the lateralization of the intestine against the sidewall of the abdomen. This is done by suturing the herniated intestine at several locations at the antimesenteric border to secure it to the abdominal wall with permanent suture. The laparoscopic approach duplicates this repair but, in most patients, the use of the DualMesh Plus prosthesis has been chosen rather than polypropylene, which was used by Sugarbaker. The important points to this procedure include complete dissection of the adhesions that are present and identification of the fascial edges. A margin of at least 5 cm is also preferred with this repair. I prefer to place one suture at the midpoint of one axis of the prosthesis and two sutures at the other side of the patch (Figure 19.7). These latter sutures will be pulled on either side of the viscera that leads to the stoma. The exact location of these on the biomaterial will be dependent upon Figure 19.6 Final appearance of the completed repair. One the size of the intestine and the location and size of the suture that has sutured the colon to the opening is seen in the hernia itself. One must be careful that these two sutures middle of the photograph. are not pulled so tightly that a relative obstruction could result. Based upon our prior experiences with incisional hernia repairs, additional sutures are placed a minimum the initial sutures similar to the initial patch. However, of 5 cm apart, and Salute constructs are placed 1 cm the slit that is made in this patch is placed opposite the apart, along the periphery of the patch, as with all of location of the slit in the initial patch. This placement these parastomal hernia repairs (see Chapters 16 and 20). is chosen to prevent herniation through the slit in the This results in the placement of several sutures. Others, initial patch because the second patch protects that slit however, do not place as many sutures.6,21 (Figure 19.5). The intent is to cover the first slit with the second patch so that the ring cannot enlarge and result in POSTOPERATIVE MANAGEMENT re-herniation.19 Fixation is then completed with the constructs and multiple transfascial sutures that are placed to include both the first and second patches, as described Patients are usually maintained in the surgical unit, which in Chapter 16. Occasionally, one may choose to suture allows for a one-night postoperative stay. The gastric and the colon to the edge of the hole in the patch if it appears urinary tubes are discontinued in the recovery room. that there is a risk of passage of bowel into that space Patients are allowed a liquid diet immediately, although (Figure 19.6). The final appearance reveals good coverage most have a short-term ileus. The diet is advanced as tol- of the defect (Figure 19.6). erated. Abdominal binders, which are used routinely for 148 Laparoscopic incisional and ventral hernioplasty

Table 19.1 Laparoscopic parastomal hernia repair publications Patients Location of Length of hospital Length of follow-up Reference (n) Prosthesis prosthesis stay (days) (months) Porcheron et al. (1998)15 1 ePTFE Pre-peritoneal 4 12 Bickel et al. (1999)16 1 Polypropylene Intraperitoneal 6 12 Voitk (2000)17 4 Polypropylene Intraperitoneal 2 (3 patients), 9 (1 patient) N/A Kozlowski et al. (2001)21 4 ePTFE Intraperitoneal 3.8 2–33 LeBlanc et al. (2002)18 3 ePTFE Intraperitoneal 1 (all patients) 3–11 Berger (2002)6 15 ePTFE Intraperitoneal N/A 3–12

the incisional hernias, are placed selectively for this repair. postulate that the method of fixation may be inadequate The decision to use these is based upon the patient’s because of the relatively few transfascial sutures that were request, as they do aid in the management of postopera- used in this repair. I believe that it is critical that these tive pain and in the prevention of seromas. The level of sutures are used at not more than 5 cm apart along the activity of the patient is based upon the pain tolerance of entire periphery of the patch unless there is a structure, the individual, and no restrictions are given. such as the iliac bone, that prohibits its placement.22 In this case, the patch should be secured with many more RESULTS metal fixation devices than would be the usual recommendation. Some surgeons have trephined the bone to place sutures to ensure fixation. The laparoscopic repair of parastomal hernias has been My surgical group has now performed one of the utilized as a method to repair these defects only recently. operations described above on a total of nine patients At the time of writing, I am aware of only six reports in (Table 19.2). The average length of stay is somewhat the literature of this methodology.6,14–17 Each of these longer than our experience for incisional hernias, which articles detailed a slightly different technique, involving is 1.25 days. This is not surprising, however, given the fact few patients (Table 19.1). that all of these patients had multiple operations pre- Pocheron and coworkers closed the hernial orifice and viously and several had recurrent parastomal hernias. used the patch only as a reinforcing layer with no slit used The enterotomy occurred in the patient with the para- to allow egress of the colon.15 Bickel and colleagues cre- urostomy hernia. He had undergone two previous ated two strips of mesh, securing one to the abdominal repairs, the latter of which included the repair of an inci- wall and the other to the intraperitoneal colon.16 Voitk sional hernia with PPM intraperitoneally. I repaired this used a technique that mimicked that of Sugarbaker’s injury laparoscopically but did not repair the hernia at intraperitoneal repair.17 All of these authors used tacks that time. His length of stay was increased because he alone to provide fixation to the abdominal wall. Although remained in hospital until the hernia repair was carried Bickel used polypropylene mesh (PPM) for the repair of out four days later. Interestingly, a counter-incision for that patient, he commented that the use of intraperi- open access was required during the second procedure toneal PPM may lead to adhesion formation and that the because of the inability to accurately assess and reduce use of a ‘dual mesh nonadherent surface on one side’ may the incarceration of the hernia. In addition to the incar- be preferable. Kozlowski and coworkers used an onlay cerated small bowel in the hernia, the patient also had a technique with four sutures; the exact technique is not herniation through the mesentery of the urostomy described specifically in their paper, however.21 (Figure 19.8). This was reduced, and the repair was Berger uses an onlay technique that involves fixation completed laparoscopically. with transfascial sutures and tacks.6 Unless the patch is The recurrence that was seen in the para-ileostomy greater than 20 cm, he does not use any more than four hernia occurred after nearly one year. Small bowel had sutures. He also prefers an overlap of 5 cm for this proce- herniated through the slit of both of the patches used in dure. As noted in Table 19.1,Berger has reported upon 15 the repair. This was reduced laparoscopically, and the patients. In the immediate postoperative period, one small bowel was sutured to the abdominal sidewall to patient developed a hematoma and one patient required prevent migration into the slit again. The latter was also reoperation because of incarceration of the small bowel tightened. This failed after one year, and the patient has between the patch and the abdominal wall. This latter now undergone an open repair, which relocated the complication was due to a ‘dislocated tack’. Three of stoma to the left side of his abdomen. the patients (20 per cent) developed a recurrent hernia The other patients have done very well over the between two and four months. One could certainly follow-up period, with the exception of the one fatality. Parastomal hernia repair 149

Table 19.2 Parastomal hernioplasty experience Average length Average follow-up Type of repair Hernia type (n) of stay (days) Complications (months) Two DMϩ Paracolostomy (2) 2.33 Seroma (1) 21 Para-ileostomy (1) 1 Recurrence of para-ileostomy hernia 20 Onlay of DMϩ Paracolostomy (3) 1.67 Ileus (1) 8 Para-urostomy (1) 7 Enterotomy (1) 2 MM and DMϩ Paracolostomy (2) 2 Death (1) 2 Total Paracolostomy (7) 1.86 Ileus (1) 11 (range 2–25) Para-ileostomy (1) 1 Seroma (1) Para-urostomy (1) 7 Enterotomy (1) Recurrence (1) Death (1)

DMϩ, DualMesh Plus; MM, MycroMesh.

laparoscopic recurrence rate of 20 per cent reported by Berger.6 The critical considerations are the use of a large biomaterial and adequate fixation. This fixation must include the use of metal fixation devices at 1–1.5 cm apart, preferably in a staggered fashion, and transfascial sutures placed circumferentially along the entire periphery of the patch (not more than 5 cm apart). Undoubtedly, there are other techniques that are being used today that have not been reported. I know of surgeons who are using a single prosthetic biomaterial with the keyhole and slit that was described above. Additionally, some surgeons are using other prosthetic biomaterials to complete this repair. Long-term follow-up is critical to identify the best procedure and biomaterial that should be chosen for this hernioplasty.

Figure 19.8 Mesenteric herniation of a para-ileal conduit hernia that was reduced with the incision lateral to the defect. CONCLUSION The forceps are placed through the hernia defect. The repair of incisional hernias laparoscopically has pro- This patient aspirated in the immediate postoperative vided us with the technology to repair parastomal her- period, suffered a cardiorespiratory arrest, and did not sur- nias. The ideal method has not been identiﬁed, but the vive the latter event. Seromas and ileus are well-recognized initial experience shows promise. occurrences following laparoscopic hernia repair, such that I do not consider them a true complication unless they are persistent or require intervention. The ideal method REFERENCES of repair for these hernias that should be used routinely has yet to be identiﬁed. However, with the experience of the recurrence of the ileostomy hernia, I would suggest 1 Burns FJ. Complication of colostomy. Dis Colon Rectum 1970; 13: 448–50. that the preferred repair of the parastomal hernia that 2 Phillips P, Pringle W, Evans C, Keighley M. Analysis of hospital involves the small intestine should be the onlay tech- based stomatherapy service. Ann R Coll Surg Engl 1985; nique. The peristalsis of the small bowel may predispose 67: 37–40. the other segments of that organ to invaginate into the 3 Sjodahl R, Anderberg B, Bolin T. Parastomal hernia in relation slits of the two-patch repair. to the site of the abdominal wall stoma. Br J Surg 1988; 75: 339–41. Currently, however, the recurrence rate of eight 4 Londono-Schimmer EE, Leong APK, Phillips RKS. Life table analysis per cent is quite admirable. This is an improvement in of complications following colostomy. Dis Colon Rectum 1994; the open repair of these defects and is better than the 37: 916–20. 150 Laparoscopic incisional and ventral hernioplasty

5 Ortiz H, Sara MJ, Armendariz M, et al. Does the frequency of 14 Rubin M, Schoetz DJ, Matthews JB. Para-stomal hernia: is the para-colostomy hernias depend on the position of the colostomy stoma relocation superior to fascial repair. Arch Surg 1994; in the abdominal wall? Int J Colorectal Dis 1994; 9: 65–7. 129: 413–19. 6 Berger D. Laparoscopic parastomal hernia repair: indications, 15 Porcheron J, Payan B, Balique JG. Mesh repair of paracolostomal technique, and results. In: Morales-Conde S, ed. Laparoscopic hernia by laparoscopy. Surg Endosc 1998; 12: 1281. Ventral Hernia Repair. Paris, Springer-Verlag, 2002: 383–7. 16 Bickel A, Shinkarevsky E, Eitan A. Laparoscopic repair of 7 Burgess P, Matthew VV, Devlin HB. A review of terminal paracolostomy hernia. J Laparoendosc Adv Surg Tech 1999; 9: colostomy complications following abdominoperineal resection for 353–5. carcinoma. Br J Surg Engl 1984; 71: 1004. 17 Voitk A. Simple technique for laparoscopic paracolostomy hernia 8 Martin L, Foster G. Parastomal hernia. Ann R Coll Surg 1996; repair. Dis Colon Rectum 2000; 43: 1451–3. 78: 81–4. 18 LeBlanc KA, Bellanger DE. Laparoscopic repair of para-ostomy 9 Marshall FF, Leadbetter WF, Dretler SP. Ileal conduit parastomal hernias: early results. J Am Coll Surg 2002; 194: 232–9. hernias. J Urol 1975; 113: 4–42. 19 De Ruiter P, Bijnen AB. Successful local repair of paracolostomy 10 McDougal WS. Use of intestinal segments and urinary hernia with a newly developed prosthetic device. Int J Colorectal diversion. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Dis 1992; 7: 132–4. Campbell’s Urology. Philadelphia: W. B. Saunders Co., 1998: 20 Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of 3121–61. paraostomy hernias. Ann Surg 1985; 201: 344–6. 11 Williams JG, Etherington R, Hayward MWJ, Hughes LE. 21 Kozlowski PM, Wang PC, Winﬁeld HN. Laparoscopic repair of Para-ileostomy hernia: a clinical and radiological study. Br J Surg incisional and parastomal hernias after major genitourinary or 1990; 77: 1355–7. abdominal surgery. J Endourol 2001; 15: 175–9. 12 Toms AP, Dixon AK, Murphy MP, Jamieson NV. Illustrated review 22 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic of new imaging techniques in the diagnosis of abdominal wall incisional and ventral herniorrhaphy in 100 patients. Am J Surg hernias. Br J Surg 1999; 86: 1243–50. 2000; 180: 193–7. 13 Aldridge AJ, Simson JN. Erosion and perforation of colon by synthetic mesh in a recurrent paracolostomy hernia. Hernia 2001; 5: 110–12. 20

Lumbar hernia and ‘denervation’ hernia repair

KARL A. LEBLANC

Anatomy 151 Results 153 Indications and contraindications for surgery 152 Conclusion 153 Operative technique 152 References 154

Primary and acquired lumbar hernias are quite uncom- inferiorly. The base of the inferior lumbar triangle is the mon. There have been about 300 cases of primary her- iliac crest, its anterior border is the posterior margin of nias reported in the literature.1 Acquired lumbar hernias the external oblique muscle, its posterior border is the are the result of flank incisions for renal or other retro- anterior edge of the latissimus dorsi muscle, and its apex peritoneal operations, notably anterior lumbar interbody is superior (Figure 20.1). fusion. These acquired hernias can also be the result of Lumbar hernias may contain a variety of intra- division of the anterior branches of nerves that originate abdominal organs. Hernias of the colon are the most fre- from T6 to T12. In these latter circumstances, there is no quent, but small intestine, stomach and spleen are also fascial defect with these denervation injuries, so they are likely candidates for herniation. A particular curiosity is not true hernias. These ‘pseudo-hernias’ are difficult to the sliding hernia of the colon, which causes intermittent treat surgically. Rarely, they can also be seen with diabetic obstructive symptoms. radiculopathy. Differential diagnoses include tumors of the muscles, Approximately 55 per cent of these hernias are pri- lipoma, hematoma associated with blunt trauma, abscess, mary, 25 per cent are acquired, and the remainder are and renal tumors. Small fatty protrusions of retroperi- congenital in origin.2 The latter can sometimes be bilat- toneal fat through the lumbodorsal fascia have been eral. Primary lumbar hernias are found most frequently implicated as a cause of lower back pain. Computerized on the left side; two-thirds of these are seen in men.3,4 tomography (CT) is the best test for delineating the etiology and defining the anatomy of the hernia. ANATOMY Patients that have the ‘denervation’ injury that leads to the protrusion of the flank will frequently complain of back pain related to the defect. It is difficult to explain the The lumbar area is bounded above by the twelfth rib, source of this, as many of these patients will have had a below by the iliac crest, behind by the erector spinae long, pre-existing complaint of back pain requiring disk muscles (sacrospinalis), and in front by the posterior surgery. The most common presentation is the acknowl- border of the external oblique (a line passing from the tip edgment of the significant cosmetic deformity that is of the twelfth rib to the iliac crest). Within this area, two caused by the musculature paralysis. This will cause a triangles are described: the superior lumbar triangle (of broad laxity of the affected abdominal wall (Figure 20.2). Grynfelt) and the inferior lumbar triangle (of Petit). The This appearance will become most pronounced if the superior lumbar triangle is an inverted triangle: its base process is long-standing, if the patient experiences signi- is the twelfth rib, its posterior border is the erector spinae ficant weight gain, or if the patient is morbidly obese. CT muscles, its anterior border is the posterior margin of scanning is not so helpful for delineating this problem, the external oblique, and its apex is at the iliac crest but it can eliminate other pathological entities. 152 Laparoscopic incisional and ventral hernioplasty

Serratus posterior External oblique muscle 12th rib

Superior (Grynfelt's) triangle Latissimus dorsi Internal oblique

Inferior (Petit's) triangle External oblique

Figure 20.1 Anatomy of the ‘true’ lumbar hernias.

Iliac crest Umbilicus

Trocar sites

Arm on pillow

Figure 20.3 Typical patient position for repair of lumbar hernias. Easy access to the posterior aspect of the patient must be preserved.

of these hernias is associated with a high failure rate Figure 20.2 Appearance of the abdominal wall following a because of the tension that occurs with the repair. The use right nephrectomy that resulted in a ‘denervation hernia’. of a prosthetic biomaterial placed in the pre-peritoneal position has been shown to be the most effective method of repair for true hernias.5 The open procedure often INDICATIONS AND CONTRAINDICATIONS requires a very extensive incision to repair these defects. FOR SURGERY Pseudo-hernias are sometimes repaired with abdominal wall plication followed by placement of a prosthetic biomaterial over the plicated muscle, but this also requires These defects will increase in size over time. The cos- a large incision if the mesh is to cover the entire area of metic appearance will deteriorate because of this, but paralysis. there is a risk of incarceration and strangulation with The laparoscopic approach has been applied to this primary hernias. All primary hernias should be repaired, type of herniation. Its concept is similar to the repair of but it is not clear whether surgery can offer a permanent incisional hernias (see Chapter 16). A tube to decom- solution to the pseudo-hernia. Careful follow-up is press the stomach is used routinely, but a urinary needed to evaluate the effectiveness of the laparoscopic catheter is placed only selectively. One significant differ- approach to this entity. ence is that the patient must be turned in the semi- or full lateral decubitus position (Figure 20.3). A beanbag OPERATIVE TECHNIQUE greatly assists in this position. Trocar site positions are critical for this operation. As with incisional hernia repair, the initial efforts focus upon the dissection of the The open approach to a primary, acquired or denervation adhesions and the identification of the fascial edges. hernia is generally a formidable operation. Suture closure With the superior hernias, this must extend posterior to Lumbar hernia and ‘denervation’ hernia repair 153 the kidney. The colon will usually be reflected for either hernia. The use of DualMesh® Plus is recommended because this procedure is intraperitoneal. The prosthesis should be at least 4–5 cm larger than the defect itself. This is slightly larger than that considered necessary for traditional incisional hernia repair. It appears that fixation in these areas is rather difficult, and this larger overlap will help prevent a recurrence. When undertaking the repair of a denervation hernia, I prefer to use a minimum of 5–6 cm of overlap, but I would recommend the use of as large a patch as possible. Fixation on to the diaphragm will frequently be necessary. One must not enter the chest with the use of these fixation methods. It is usually necessary to sew the upper portion of the biomaterial to the diaphragm itself to provide fixation of that portion of the biomaterial. Suture placement that encircles the ribs will frequently result in long-term pain that is diffi- Figure 20.4 Postoperative (six months) appearance of a repair cult to treat. Therefore, this is not recommended unless of a ‘denervation hernia’ subsequent to an anterior lumbar absolutely necessary. The use of transfascial sutures and interbody fusion. metal fixation devices is identical to the incisional hernia, except as noted above. Repair of a pseudo-hernia necessitates the use of a cosmetic result. With these patients, the intent is that the very large prosthesis. This must cover the entire para- shrinkage of the tissues caused by scar contraction will lyzed muscle from the lumbar area to a point across the result in an acceptable cosmetic result. midline of the patient. Because of the positioning of the One patient had prolonged postoperative pain patient, fixation may be very difficult near the midline. thought to be related to the use of suture around a rib. It is sometimes necessary to place two trocars laterally One patient developed a symptomatic seroma. Both of through the biomaterial to allow the visualization and these problems resolved without intervention. Follow-up fixation at that site. These holes are then closed with ranged from nine months to three years. The cosmetic sutures placed with a suture-passing device. result with this method has been acceptable to all the patients and has been excellent in some (Figure 20.4).

RESULTS CONCLUSION

There have been only ten laparoscopic lumbar hernioplasties reported in the literature.6–8 All were case reports, The incidence of lumbar hernias is low. The problem of except for one report that included seven patients.9 This denervation hernias may become more prevalent in the latter report included five hernias that were acquired; two future due to the increasing use of the anterior approach were congenital and two were recurrent. Two patients had for disk disease by spine surgeons. Repair of these defor- two or three separate hernia defects. The hernias ranged mities can be difficult and fraught with failure if it is not in size from 1.5 ϫ 1.5 cm to 8 ϫ 11 cm, averaging 77.8 cm2. approached in a reasoned manner. The use of prosthetic As noted above, a large overlap of the expanded poly- reinforcement is thought to be best, and the laparoscopic tetrafluoroethylene (ePTFE) patches was used; the average approach may be of benefit, although more studies and patch size was 336.4 cm2. One of these patients developed follow-up are needed. an abscess over the repair, which required removal of the prosthesis. The remaining six patients were free of REFERENCES recurrence after 1–15 months of follow-up. This author has repaired six denervation hernias. All were performed using the technique described above. One 1 Gentileschi P, Kini S, Gagner M. Laparoscopic repair of unusual of these patients had an implantation of DualMesh Plus hernias: lumbar, spigelian and other special hernias. In: Morales- Conde S, ed. Laparoscopic Ventral Hernia Repair. Paris: Springer- with Holes. This product is 1.5 mm thick, compared with Verlag, 2002: 363–74. the 1-mm thickness of DualMesh without Holes. It was 2 Swartz WT. Lumbar hernias. J Ky Med Assoc 1954; 2: 673–8. hoped that the thicker material would result in a better 3 Thorek M. Lumbar hernia. J Int Coll Surg 1950; 14: 367–93. 154 Laparoscopic incisional and ventral hernioplasty

4 Watson LE. Hernia, 3rd edn. St Louis, MO: Mosby, 1948: 443–5. 7 Bickel A, Haj, Eitan A. Laparoscopic management of lumbar hernia. 5 Knol JA, Eckhauser FE. Inguinal anatomy and abdominal wall Surg Endosc 1997; 11: 1129–30. hernias. In: Greenﬁeld LJ, ed. Surgery: Scientiﬁc Principles and 8 Woodward AM, Flint LM, Ferrera JJ. Laparoscopic retroperitoneal Practice. Philadelphia: JB Lippincott, 1993: 1081–107. repair of recurrent postoperative lumbar hernia. J Laparoendosc Adv 6 Burick AJ, Parascandola SA. Laparoscopic repair of a traumatic Surg Tech A 1999; 2: 181–6. lumbar hernia: a case report. J Laparoendosc Surg 1996; 6: 9 Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of 259–62. lumbar hernias. J Am Coll Surg 1998; 2: 147–52. 21

Results of laparoscopic incisional and ventral hernia repair

RODRIGO GONZALEZ AND BRUCE J. RAMSHAW

Results of series 155 Conclusion 159 Results of comparative studies 157 References 160

Although the principles of abdominal wall repair are fixation of a large mesh without subcutaneous tissue dis- well established and the complication rate has decreased section in patients with large hernia defects.10–12 significantly over the past decade, the complication and Laparoscopic ventral hernia repair is based on the recurrence rates for open incisional hernia repair are far method described by Stoppa for open incisional hernia from ideal. A prospective, randomized, multicenter study repair,4 reported to have the lowest recurrence rate. recently reported a 46 per cent recurrence rate after pri- It involves posterior reinforcement of the abdominal mary open repair of ventral hernias when a prosthetic wall with a large piece of prosthetic material based on material was not employed.1 Others have reported recur- Laplace’s law. The large surface area of the mesh allows rence rates of 25 per cent and 52 per cent for fascial defects substantial ingrowth of tissue for permanent mesh fixa- smaller and larger than 4 cm, respectively.2–4 Recurrences tion, and the intra-abdominal pressure tends to hold the are also associated with the number of repairs performed, mesh in apposition to the posterior abdominal wall over with 18–43 per cent after initial repair and over 50 per cent a wide surface area.13,14 after recurrent repair.1,3 It is common to perform a primary repair for ventral hernias smaller than 4 cm in diameter. For larger defects, RESULTS OF SERIES the use of a prosthetic material is recommended to allow for a tension-free repair. The use of a variety of mesh materials for open hernia repairs has resulted in a lower Patient demographics recurrence rate compared with primary repairs,1,5 but they have been associated with other types of complica- Since the first report of laparoscopic ventral hernia tions, including wound infection, seromas, mesh extru- repair,15 numerous series have been published supporting sion, fistula formation, and adhesions.5–7 Infections can the use of this technique. Table 21.1 summarizes the occur in up to 15 to 45 per cent of open mesh repairs and results of 2002 laparoscopic ventral hernia repairs pub- may also correlate with recurrence rates.1,8 This high lished in the literature. We have tabulated these data infection rate is thought to be secondary to the large inci- and will discuss the averages from this information. sion with which the mesh is in contact and the wide dis- Demographic data show a slightly higher predominance section necessary for adequate mesh placement. The of females (56 per cent), with a mean age of 55 years. laparoscopic technique involves access to the abdominal Fifty-six per cent of the patients were obese, with a mean cavity away from the defect, avoiding placement of the body mass index (BMI) of 34 kg/m2. Consistent with pre- mesh through a large incision, thereby reducing the prob- vious literature, the prevalence of incisional hernias (89 ability of contamination and infection.9 It also allows per cent) is higher than for primary hernias (11 per cent). Table 21.1 Results of laparoscopic ventral hernia repair Prior Hernia Operating Conversion Hospital Seroma Infection Mesh Recurrence Patients repairs size room time rate stay rate rate removed Follow-up rate Reference (n) (%) (cm2) (min) (%) (days) (%) (%) (%) (months) (%) LeBlanc et al. (1994)16 28 7 – – 0 – 4 4 4 10 0 Saiz et al. (1996)17 10 20 – 68 0 2 10 10 0 – 0 Park et al. (1996)18 28 – 104 108 0 4.1 0 4 – 8 4 Tsimoyiannis et al. (1998)19 11 – – 49 0 3 9 9 0 15 0 Franklin et al. (1998)20 176 39 – – 3 – 0a 2 1 30 1 Toy et al. (1998)21 144 26 98 120 – 2.3 16 3 4 7 4 Constanza et al. (1998)22 16 100 130 – 6 2 ––– 18 6 Sanders et al. (1999)23 12 58 – 210 8 3.5 36 8 0 13 8 Kyzer et al. (1999)24 53 55 – 89 4 3.3 – 2 2 12 2 Roth et al. (1999)25 75 – 101 105 3 2.9 4 4 – – 9 Koehler and Voeller (1999)26 32 41 – 101 – 1.9 – 6 6 20 9 Balique et al. (2000)27 29 – – – – – 14 3 – – – Farrakha (2000)28 18 33 – 85 0 3.2 33 0 0 22 6 Carbajo et al. (2000)29 100 – 93 62 1 1.2 10 0 0 30 2 Reitter et al. (2000)30 49 37 – 152 4 4.3 0 2 2 27 6 Heniford et al. (2000)31 100 49 87 88 0 1.6 3b 2 2 23 3 Heniford et al. (2000)32 415 33 100 97 2 1.8 5a 2 1 23 3 Szymanski et al. (2000)33 44 20 20 – 9 – 2 5 – – 5 Chowbey et al. (2000)34 202 – – 50 0.5 1.8 18 2 – 35 1 Kozlowski et al. (2001)35 17 – – 240 0 – ––– – 12 LeBlanc et al. (2001)36 100 18 155 – 4 1.2 7 2 1 51 9 Birgisson et al. (2001)37 64 42 34 130 0 1.7 5 4 0 10 2 Moreno-Egea et al. (2001)38 20 75 7 – 0 – 15 0 0 12 0 Bageacu et al. (2002)39 159 23 – 89 14 3.5 16 3 – 49 16 Ben Haim et al. (2002)40 100 25 6 119 7 5 11 1 1 19 2 Total 2002 32 89 114 3 1.9 7.5 2.2 1.5 26 3.3 aSeromas persisting Ͻ 6 weeks. bSeromas persisting Ͼ 4 weeks. Results of laparoscopic incisional and ventral hernia repair 157

This includes 11 per cent umbilical and 0.6 per cent is estimated that about 80 per cent of hernias are repaired Spigelian hernias. Sixteen per cent of the hernias were utilizing ePTFE mesh, 15 per cent with polypropylene multiple and 32 per cent were recurrent. mesh, and ﬁve per cent with polyester mesh.

Intraoperative complications Operative and postoperative results

Laparoscopic repair was shown to be safe, even in large The mean operative time was 114 minutes, with an esti- ventral defects, with an intraoperative complication rate of mated blood loss of 80 cc. The return of bowel function one per cent. The most frequent major intraoperative was 1.7 days after surgery. The average hospital stay was complication was bowel injury, occurring in 0.8 per cent of 1.9 days, and the average return to normal activities was cases. Conversions to open repair were reported in three two weeks after the operation. Postoperative wound com- per cent of cases and were more frequent during the early plications were minimal after laparoscopic ventral hernia 9 phase of the learning curve. The most common reasons repair. They included infection (2.2 per cent), seroma for conversion were bowel injuries, failure to reduce incar- persisting for more than six weeks (7.5 per cent), and cerated hernias, and extensive adhesions. Enterotomies are hematoma formation (six per cent). In 1.5 per cent of most likely to occur during adhesiolysis and reduction of patients, mesh removal was required due to mesh infec- hernia sac contents. The occurrence of an enterotomy is tion or reoperation for missed or delayed bowel injury. considered a reason for conversion by some surgeons; it Other complications included ileus (2.4 per cent), urinary may also be a contraindication for mesh placement due to retention (1 per cent), bowel obstruction (0.5 per cent), potential contamination. The incidence of unrecognized and trocar site bleeding (0.3 per cent). Chronic pain can or delayed bowel injury is reported to be between zero and develop at sites where full-thickness abdominal wall five per cent. These can be the result of missed injury sutures are used for mesh fixation; this has been reported or thermal or partial-thickness injury that progresses to in 0.2–2 per cent of patients. Most instances of pain full-thickness injury over time, and can result in serious resolve without intervention. Some authors have reported 10,11,30 complications such as sepsis and even death. the use of injection of local analgesics for the relief of pain. Occasionally, repeat injections are necessary to achieve Choice of prosthetic pain relief. Reoperation for suture removal is required rarely. These sutures are considered an essential step by Laparoscopic surgery allows placement of a large overlay most surgeons to help reduce hernia recurrences by of mesh without soft-tissue dissection. The mean size of preventing mesh migration. all hernia defects was 89 cm2 and the mean mesh size was 201 cm2. Most surgeons used expanded polytetrafluoroethylene (ePTFE) DualMesh® as the prosthetic material Recurrence of choice. The 3-␮m-size pores on the side of the mesh in contact with the abdominal contents result in a low inci- The mean recurrence rate from the series in Table 21.1 dence of adhesion formation between the biomaterial was 3.3 per cent, at a mean follow-up of 26 months. Few and the viscera. More importantly, even if bowel is adher- additional recurrences are expected in these series, since ent to the mesh, the ePTFE DualMesh inhibits ingrowth, up to 90 per cent of recurrences occur within the first two 1,31 preventing fistula formation and bowel obstruction. A years after ventral hernia repair. In fact, future recur- variety of composite mesh products are available and are rence rates for laparoscopic ventral hernia repair may being evaluated (see Chapter 4). One side of the compos- actually be lower, because most of these reports included ite mesh is made of polypropylene or polyester to pro- surgeons’ experience during their learning curve. A com- mote ingrowth into the abdominal wall (although the mon cause for recurrence noted in some series is a lack of 26,32,36 mesh is actually placed in direct contact with the peri- suture fixation. toneum in most cases). The other side of the mesh is made of either permanent ePTFE or an absorbable anti- RESULTS OF COMPARATIVE STUDIES adhesion barrier. This side is placed toward the abdominal cavity with the intention of preventing ingrowth to the polypropylene (ePTFE permanent material) or Comparative studies between laparoscopic and open ven- preventing adhesions (absorbable material). The great tral hernia repairs have consistently reported advantages majority of authors who have published series of laparo- for the laparoscopic approach, especially in the evaluation scopic ventral hernia repair refrained from using of wound complications and recurrence rates. Results of polypropylene or polyester mesh that would allow poten- eight of these series are summarized in Table 21.2.In most tial direct contact with intra-abdominal organs, especially comparative series, the technique is selected based on large and/or small intestine. Based on published series, it each surgeon’s experience, and most are retrospective Table 21.2 Results of comparative studies between laparoscopic and open ventral hernia repair Previous Hernia Operating Length Postoperative Patients repairs size room time of stay complication Infection Seroma Follow-up Recurrence Reference Technique (n)(n) (cm2) (min) (days) rate (%) rate (%) rate (%) (months) rate (%) Holzman et al. (1997)41 Open 16 4 148 98 5 31 6 0 19 13 Laparoscopic 20 8 105 128 1.6 23 5 5 10 10 Park et al. (1998)42 Open 49 9 105 78 6.5 37 2 2 54 35 Laparoscopic 56 16 99 95 3.4 18 0 4 24 11 Carbajo et al. (1999)43* Open 30 22 141 112 9.1 50 18 67 27 7 Laparoscopic 30 23 140 87 2.2 20 0 13 27 0 Ramshaw et al. (1999)10 Open 174 51 34 82 2.8 26 3 – 21 21 Laparoscopic 79 36 73 58 1.7 15 0 – 21 3 DeMaria et al. (2000)44 Open 18 3 – – 4.4 72 33 50 24 0 Laparoscopic 21 11 – – 0.8 57 10 19 24 6 Chari et al. (2000)45 Open 14 – – 78 5.5 14 0 – – – Laparoscopic 14 – – 124 5 14 7 – – – Robbins et al. (2001)13 Open 23 – – – –– 30 – – – Laparoscopic 31 – – – –– 16 – – – Wright et al. (2002)12 Open with mesh 90 28 79 102 2.5 28 13 12 32 6 Open without mesh 119 6 12 70 1.5 22 10 4 24 9 Laparoscopic 86 15 112 131 1.5 24 9 9 24 1

*Prospective randomized study. Results of laparoscopic incisional and ventral hernia repair 159 studies. Surprisingly, in many reports, the patients in the Finally, the favorable cosmetic results for primary ventral laparoscopic group had a tendency to have larger hernia hernia repair with the laparoscopic technique may be an defects10,13,44 and a higher incidence of previous hernia important consideration for some patients. repairs10,41,42,44 than in the open group. This suggests that Wright and colleagues compared the laparoscopic the results are even more favorable for the laparoscopic approach with two techniques of open repair, with and repair, since recurrences occur more frequently in large without use of mesh.12 The group that underwent open defects and after previous repairs.3,42 repair with mesh had a higher incidence of previous Some series have reported increased operative times repairs. The laparoscopic group had larger hernia defects with the laparoscopic technique.13,42 This is important and larger mesh sizes. The laparoscopic technique resulted when considering anesthesia times and operating room in a longer mean operative time and lower wound compli- expenses. However, once beyond the learning curve, the cation rates. The laparoscopic approach also resulted in laparoscopic repair can frequently be completed in a lower recurrence rates, but the difference was signiﬁcant shorter time than a comparable open repair, even in the only when compared to open repair without mesh. presence of large hernia defects.10,34 Laparoscopic repair In the only prospective randomized study so far, is also associated with reduced estimated blood loss.10 Carbajo and coworkers reported a shorter operative time Most comparative series have reported lower overall and hospital stay, as well as lower recurrence and compli- postoperative complication rates with the laparoscopic cation rates (including infections and seromas) with the technique than with the open technique (20 v. 31 per cent, laparoscopic approach.43 The patients in each group had respectively) (Table 21.2). The laparoscopic approach a similar incidence of previous repairs and hernia size. results in lower wound complication rates,10,11,13,42 includ- Two recurrences occurred in the open group with a 27- ing fewer seromas,42,43 fewer infections,10,11,13,44 and fewer month follow-up. Two mesh explantations were required dehiscences.13 Since wound complications that may be in the open group for postoperative infections. There present after laparoscopic hernia repairs occur in small were no recurrences or late complications in the laparo- trocar incisions, they tend to be less severe, to be treated scopic group. more easily, and to require mesh removal less frequently A primary goal for ventral hernia repair is to mini- than in open repairs.10,43 Seromas are frequently obser- mize recurrence rates. Factors associated with recurrences ved following a ventral hernia repair whether performed include larger hernias,3,42 previous hernia repairs, lateral through an open or laparoscopic approach. Ultrasound defects, and postoperative complications (mainly infec- examinations revealed seroma formation in 100 per cent tions). The laparoscopic technique has resulted in lower of patients, with a peak occurrence seven days after the recurrence rates, even in the presence of larger defects,10,13 operation, and almost complete resolution after 90 days.46 and higher rates of previous repairs.10,42 Indeed, as Seromas may be a source of concern to patients not demonstrated in Table 21.2, the recurrence rate was 15 informed of the likelihood of their occurrence. Most sur- per cent for the open repair, with a 33-month follow-up, geons agree that they should not be considered a com- and 4.5 per cent for the laparoscopic technique, with a plication unless they persist, increase steadily in size, or 22-month follow-up. cause symptoms. Aspiration of seroma contents should be approached with caution, since even under sterile conditions there is a potential for contamination. Infection CONCLUSION requiring mesh removal has been reported following aspiration of a seroma.44 After repair of large hernias, the use of binders can be considered in an attempt to reduce Laparoscopic repair of ventral and incisional hernias is an seroma formation. attractive approach for a difﬁcult problem. The achieve- Another advantage consistently reported with the ment of a low recurrence rate while minimizing wound laparoscopic technique is the shorter length of hospitaliza- complications is a combination of goals that has eluded tion.10,42–44 This may be due partially to decreased pain,44 open approaches for ventral hernia repair. While the fewer complications,10,11,13,42,43 earlier oral intake,45 infre- laparoscopic approach makes sense and is being adopted by quent use of drains,10 and reduced postoperative ileus.10,42 many surgeons, it remains an advanced laparoscopic proce- In general, these patients ambulate earlier than patients dure with inherent potential complications, especially dur- undergoing open repair. Laparoscopic ventral hernia repair ing the learning curve. Results of the studies presented in can be performed on an outpatient basis in some cases.41,44 this chapter point out the importance of good patient selec- The shorter operative time and length of stay after laparo- tion and recognition of the potential for intraoperative and scopic repair may offset the increased operative costs for delayed visceral injury. Improvements in training and edu- surgical equipment compared with open techniques.41 One cation of minimally invasive surgical procedures will help study shows lower costs for the laparoscopic approach, even to maximize the safe adoption of advanced laparoscopic when accounting for the costs of treating complications.44 techniques, such as laparoscopic ventral hernia repair. 160 Laparoscopic incisional and ventral hernioplasty

REFERENCES 25 Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic incisional/ventral herniorrhaphy: a five-year experience. Hernia 1999; 4: 209–14. 1 Luijendijk RW, Hop WCJ, van der Tol MP, et al. A comparison of 26 Koehler RH, Voeller G. Recurrences in laparoscopic incisional suture repair with mesh repair for incisional hernia. N Engl J Med hernia repairs: a personal series and review of the literature. 2000; 343: 392–8. JSLS 1999; 3: 293–304. 2 Larson GM. Ventral hernia repair by the laparoscopic approach. 27 Balique JG, Alexandre JH, Arnaud JP, et al. Intraperitoneal Surg Clin North Am 2000; 80: 1329–40. treatment of incisional and umbilical hernias: Intermediate results 3 Hesselink VJ, Luijendijk RW, de Wilt JHW, et al. An evaluation of of a multicenter prospective clinical trial using an innovative risk factors in incisional hernia recurrence. Surg Gynecol Obstet composite mesh. Hernia 2000; 4 (suppl): S10–16. 1993; 176: 228–34. 28 Farrakha M. Laparoscopic treatment of ventral hernias. Surg 4 Stoppa RE. The treatment of complicated groin and incisional Endosc 2000; 14: 1156–8. hernias. World J Surg 1989; 13: 545–54. 29 Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment 5 Korenkov M, Sauerland S, Arndt M, et al. Randomized clinical trial of ventral abdominal wall hernias: preliminary results in 100 of suture repair, polypropylene mesh or autodermal hernioplasty patients. JSLS 2000; 4: 141–5. for incisional hernia. Br J Surg 2002; 89: 50–56. 30 Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience 6 Cassar K, Munro A. Surgical treatment of incisional hernia. with the ‘four-before’ laparoscopic ventral hernia repair. Am Surg Br J Surg 2002; 89: 534–45. 2000; 66: 465–9. 7 Leber GE, Barb JL, Albert AI, Reed WD. Long-term complications 31 Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair. associated with prosthetic repair of incisional hernias. Arch Surg A report of 100 consecutive cases. Surg Endosc 2000; 14: 419–23. 1998; 133: 378–82. 32 Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral 8 George CD, Ellis H. The results of incisional hernia repair in a and incisional hernia repair in 407 patients. J Am Coll Surg 2000; 12-year review. Ann R Coll Surg 1986; 68: 185–7. 190: 645–50. 9 White TJ, Santos MC, Thompson JS. Factors affecting wound 33 Szymanski J, Voitk A, Joffe J, et al. Technique and early results of complications in repair of ventral hernias. Am Surg 1998; 64: outpatient laparoscopic mesh onlay repair of ventral hernias. Surg 276–80. Endosc 2000; 14: 582–4. 10 Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of 34 Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic ventral laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65: hernia repair. J Laparoendosc Adv Surg Tech A 2000; 10: 79–84. 827–32. 35 Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of 11 Morris-Stiff GJ, Hughes LE. The outcomes of nonabsorbable mesh incisional and parastomal hernias after major genitourinary or placed within the abdominal cavity. Literature review and clinical abdominal surgery. J Endourol 2001; 15: 175–9. experience. J Am Coll Surg 1998; 186: 352–67. 36 LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic 12 Wright BE, Niskanen BD, Peterson DJ, et al. Laparoscopic ventral incisional and ventral herniorrhaphy. Our initial 100 patients. hernia repair: are there comparative advantages over traditional Hernia 2001; 5: 41–5. methods of repair? Am Surg, 2002; 68: 291–6. 37 Birgisson G, Park AE, Mastrangelo MJ, et al. Obesity and 13 Robbins SB, Pofahl WE, Gonzalez RP. Laparoscopic ventral hernia laparoscopic repair of ventral hernias. Surg Endosc 2001; 15: repair reduces wound complications. Am Surg 2001; 67: 896–900. 1419–22. 14 Temudom T, Siadati M, Sarr MG. Repair of complex giant or 38 Moreno-Egea A, Lirón R, Girela E, Aguayo JL. Laparoscopic recurrent ventral hernias by using tension-free intraperitoneal repair of ventral and incisonal hernias using a new composite prosthetic mesh (Stoppa technique): lessons learned from our mesh (Parietex). Surg Laparosc Endosc Percutan Tech 2001; initial experience (fifty patients). Surgery 1996; 120: 738–44. 11:103–6. 15 LeBlanc KA, Booth WV. Laparoscopic repair of incisional 39 Bageacu S, Blanc P, Breton C, et al. Laparoscopic repair of abdominal hernias using expanded polytetrafluoroethylene: incisional hernia. A retrospective study of 159 patients. Surg preliminary findings. Surg Laparosc Endosc 1993; 3: 39–41. Endosc 2002; 16: 345–8. 16 LeBlanc KA, Booth WV, Whitaker JM. Laparoscopic repair of 40 Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications ventral hernias using an intraperitoneal onlay patch: report of with laparoscopic intraperitoneal expanded current results. Contemp Surg 1994; 45: 211–14. polytetrafluoroethylene patch repair of postoperative ventral 17 Saiz AA, Willis IH, Paul DK, Sivina M. Laparoscopic ventral hernia hernia. Surg Endosc 2002; 16: 785–8. repair: a community hospital experience. Am Surg 1996; 62: 336–8. 41 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral 18 Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional and incisional hernioplasty. Surg Endosc 1997; 11: 32–5. hernias. Surg Laparosc Endosc 1996; 6: 123–8. 42 Park A, Birck DW, Lovrics P, et al. Laparoscopic and open incisional 19 Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic hernia repair: a comparison study. Surgery 1998; 124: 816–22. intraperitoneal onlay mesh repair of incisional hernia. Surg 43 Carbajo MA, Martín del Olmo JC, Blanco JI, et al. Laparoscopic Laparosc Endosc 1998; 8: 360–2. treatment vs open surgery in the solution of major incisional and 20 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and abdominal wall hernias with mesh. Surg Endosc 1999; 13: incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. 250–52. 21 Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of 44 DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral 1998; 12: 955–9. hernia. Prospective comparison to open prefascial polypropylene 22 Constanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of mesh repair. Surg Endosc 2000; 14: 326–9. recurrent ventral hernias. Am Surg 1998; 64: 1121–7. 45 Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of 23 Sanders L, Flint LM, Ferrara JJ. Initial experience with laparoscopic laparoscopic incisional hernia repair. Surg Endosc 2000; 14: repair of incisional hernias. Am J Surg 1999; 177: 228–31. 117–19. 24 Kyzer S, Alis M, Aloni Y, Charuzi I. Laparoscopic repair of 46 Susmallian S, Gewurtz G, Ezri T, Charuzi I. Seroma after postoperation ventral hernia. Early postoperation results. Surg laparoscopic repair of hernia with PTFE patch: is it really a Endosc 1999; 13: 928–31. complication? Hernia 2001; 5: 139–41. 22

Complications and their management

SAMUEL K. MILLER, STEPHEN D. CAREY, FRANCISCO J. RODRIGUEZ AND ROY T. SMOOT, JR

Bowel injury 161 Prolonged ileus/persistent nausea and vomiting 166 Laparoscopic assisted hernia repair 163 Recurrence of hernia 166 Mesh infection 164 Conclusion 168 Seroma 165 References 168 Postoperative/suture pain 166

A ventral hernia is any protrusion through the anterior Review of laparoscopic hernia repairs demonstrates an abdominal wall with the exception of the inguinal area. overall complication rate ranging from five to thirty per Ventral defects include those found in the umbilical, epi- cent,3–16,18,19 with a mean of 15.2 per cent. The major gastric, Spigelian, incisional, and parastomal locations. advantage of laparoscopic ventral hernia repair is a Five to fifteen per cent of laparotomies will result in ventral decreased rate of major wound complications19 and incisional hernias, with the incidence of incisional hernia lower recurrence rates.3–18,20 rising to nearly 40 per cent following wound infection.1,2 Approximately 100 000 ventral hernias are repaired in the USA each year, comprising about 13 per cent of all BOWEL INJURY hernia repairs annually. Over the past decade, techniques for the laparoscopic approach to ventral hernia repair have been developed. The most feared complication associated with the laparo- Potential advantages include avoidance of large incisions scopic approach to ventral hernia is enterotomy. Bowel with associated flaps and drains, tension-free repairs injury has resulted in serious morbidity and mortality. stabilized by intra-abdominal pressures (Laplace’s law), Several authors report bowel injuries,3,4,9,11–13,18 with an reduced length of stay with reduced convalescence and overall average incidence of 1.1 per cent. Table 22.2 pres- more rapid return to full activity, and lower complication ents the series reporting bowel injuries. Holzman and col- and recurrence rates. leagues describe a single enterotomy during laparoscopy A review of the literature on laparoscopic ventral and that required conversion to an open procedure to avoid incisional hernia repair as well as our clinical experience placement of prosthetic material.3 Toy and coworkers over ten years was undertaken. A Medline search demon- mention two enterotomies in their prospective multicen- strated 18 articles suitable for analysis. These articles ter study but do not give any further details.4 Ramshaw contained data on complications and recurrences. This and colleagues had two serious bowel injuries: one was chapter will give an overview of the complications asso- recognized and repaired at the time of injury but subse- ciated with laparoscopic ventral and incisional hernia quently it dehisced and required reoperation; the second repairs, and will suggest strategies to address these com- went unrecognized and required reoperation with mesh plications. Table 22.1 lists the articles chosen for review. removal.9 Ramshaw and colleagues also had one minor In comparison to open hernia repairs, overall compli- serosal bowel injury with no sequelae.9 cation rates for laparoscopic hernia repairs are much Koehler and Voeller mention two unrecognized bowel lower. Complication rates reported for recent series of injuries, with one patient ultimately dying of hepatic fail- open repairs may be high as 27–34 per cent.16,19,21,22 ure on the twenty-ninth postoperative day.11 This death 162 Laparoscopic incisional and ventral hernioplasty

Table 22.1 Reported series analyzed, with recurrence rates and total complication rates Mean follow-up Recurrence Complications Reference Cases (n) (months) (%) (%) Holzman et al. (1997)3 20 10.2 1.0 25 Toy et al. (1998)4 144 7.4 4.2 25 Franklin et al. (1998)5 176 33.6 1.1 5 Costanza et al. (1998)6 15 18 0 13 Tsimoyiannis et al. (1998)7 10 15 0 30 Park et al. (1998)8 56 24 11.0 18 Ramshaw et al. (1999)9 79 21 2.5 19 Kyzer et al. (1999)10 53 12 0 11 Koehler et al. (1999)11 34 20 8.8 21 Roth et al. (1999)12 75 17 9.3 19 Chari et al. (2000)13 14 – 7.0 14 LeBlanc et al. (2000)14 96 51 9.3 15 Carbajo et al. (2000)15 100 30 2.0 16 DeMaria et al. (2000)16 21 – 4.8 10 Reitter et al. (2000)17 42 27 7.1 – Heniford et al. (2000)18 407 23 3.4 13 Robbins et al. (2001)19 31 – – 16 Kozlowski et al. (2001)20 17 – 11.8 24 Personal series (2002) 182 31 2.7 17 Total 1572 65/1541 233/1530 Mean 22.7 4.2 15.2

Table 22.2 Series reporting bowel injuries Cases Enterotomies Complications Reference (n)(n) (%) Holzman et al. (1997)3 20 1 5.0 Toy et al. (1998)4 144 2 1.4 Ramshaw et al. (1999)9 79 3 3.8 Koehler and Voeller (1999)11 34 2 5.9 Roth et al. (1999)12 75 2 2.7 Chari et al. (2000)13 14 2 14.3 Heniford et al. (2000)18 407 6 1.5 Reporting no injuries 799 0 0 Total 1572 17 1.1 occurred in a patient requiring lysis of densely adherent mesh due to infection. The second enterotomy resulted small-intestinal loops to the polypropylene mesh. The in a prolonged postoperative course, with respiratory other patient presented on the fifth postoperative day with failure and sepsis; the patient survived. an enterocutaneous fistula, and required removal of the Finally, Heniford and colleagues, with the largest patch and segmental resection of the small bowel. Kyzer retrospective study involving 407 patients, describe and coworkers had two recognized small-bowel injuries, six patients with small bowel enterotomies.18 Minimal which were both converted to open laparotomy: one spillage was noted in four cases. These four patients had required a bowel resection and the other required simple their enterotomies repaired laparoscopically and the her- suture closure.10 Roth and colleagues had two cases of nia repairs completed. The fifth patient was converted to intraoperative enterotomies recognized at the time of an open repair. None of the five patients had infectious operation: in one case, the operation was converted to complications or recurrence of the hernia. The sixth an open procedure; the second enterotomy was closed patient had an unrecognized enterotomy and subse- laparoscopically, but no prosthetic patch was placed.12 quently underwent a laparotomy with resection of a Chari and coworkers, in a small case–control study, short segment of small bowel and removal of the mesh. describe two patients with enterotomies in the laparo- Bowel injury can occur during initial entry into the scopic group.13 One patient required removal of the peritoneal cavity, although no such injury has been Complications and their management 163 reported in the literature describing laparoscopic ventral ‘beware of mesh’,although a previous mesh repair is not a incisional hernia repairs. Most surgeons, including contraindication to the laparoscopic approach. Voeller and Heniford,18,23 prefer the Hasson technique in Management of enterotomies requires sound clinical a site well away from the hernia defect and in a quadrant judgment. In most cases, we recommend conversion to free of previous surgery. We agree with this technique and open laparotomy to repair bowel injuries. Koehler and use the Hasson technique for nearly all cases. LeBlanc, Voeller advise the same, especially for surgeons that are however, favors the use of the Optiview trocar (Ethicon still early in their laparoscopic ventral hernia repair expe- Endosurgery, Inc.).23 rience.11 The decision to place any prosthetic material in Nearly all reported bowel injuries have occurred dur- the setting of bowel perforation depends on the degree of ing lysis of adhesion. Ramshaw and coworkers9 and Park contamination and whether the injury involves the and coworkers23 considered this to be the most dangerous colon. If a colonic injury is suspected, then prosthetic part of laparoscopic ventral hernia repair, and Koehler hernia repair must be aborted.11,26 The injury must be and Voeller described it as the most challenging part of addressed, and the incisional hernia can be repaired at a laparoscopic incisional ventral hernia repair.11 Robbins later time. In the setting of a small bowel injury, we rec- and colleagues, however, believe that the most difficult ommend conversion to a laparotomy and repair of the part of the procedure is adhesiolysis and reduction of the bowel injury in most cases. A decision to place prosthetic hernia contents.19 The mechanisms of injury include material in a contaminated field must be taken with great direct injury during sharp dissection and thermal injury caution. We would err on the side of conservatism and from various energy sources.24,25 We recommend that all avoid the use of any prosthetic material because of the adhesiolysis is done with cold scissors under direct vision, risk of infection. Many others agree with this.10,11,13 The with absolute minimal use of energy. Ramshaw and col- only exception to this would be in a setting where there is leagues,9 Park and colleagues,23 Robbins and colleagues,19 a skilled laparoscopic surgeon who can routinely repair and others support this position. Cautery and harmonic bowel perforation in a proficient manner and there is dissection can produce immediate perforations as well as minimal contamination. Heniford and colleagues delayed perforation. Delayed perforations are more com- describe six bowel injuries.18 In four patients, the entero- mon with harmonic dissection because the edges are tomy was repaired laparoscopically, one was converted to sealed immediately and the mucosa is not seen readily. open repair, and the hernia repair was completed in each. Kyzer and coworkers note several special situations in In spite of their good outcomes with no mesh infections, which the risk of bowel injury is particularly high.10 they caution strongly against placement of mesh in the These include patients with previous episodes of peri- setting of bowel perforation and contamination. If there tonitis, patients in whom a previous repair utilized is any doubt about the situation, then we recommend intraperitoneal Marlex mesh, and cases of giant hernias conversion to laparotomy. Once the enterotomy is that contain multiple irreducible bowel loops. Koehler repaired and a decision is made not to proceed with the and Voeller also warn of the dangers during adhesiolysis mesh repair, then the patient can be closed, placed on in the setting of previous synthetic mesh repair.11 intravenous antibiotics, and returned to the operating Adhesions to the prosthetic material can be fairly dense, room in three to seven days for completion of the laparo- and lysis of adhesions may be almost impossible. An scopic hernia repair.23 Koehler and Voeller describe a excellent strategy in this situation is conversion to open similar second-stage patch placement if an enterotomy is enterolysis, closure of the abdominal wall, and comple- made and repaired.11 tion of the hernia repair laparoscopically. Many others Lastly, sage advice given by Koehler and Voeller is that are advocates of this technique.9,10,13,23 Heniford and one should always consider the possibility of the conver- coworkers describe conversion to open surgery in eight of sion of an occult partial-thickness injury into a full- 415 patients:18 two patients were opened because of an thickness bowel injury when a patient is clinically inability to reduce incarcerated intestine, one was deteriorating after an uneventful laparoscopic ventral opened for loss of abdominal domain, one for resection hernia repair.11 We second this opinion and do not hesi- of strangulated bowel, and one for enterotomy. tate to relaparoscope a patient who is not doing well As noted above, a special circumstance in which clinically and who is deteriorating. enterotomy may occur is in the setting of previous hernia repair with the use of synthetic mesh. Adhesions to polypropylene and polyester mesh tend to be dense and LAPAROSCOPIC ASSISTED HERNIA REPAIR vascular, with clear planes of dissection that are difficult to define. Our one enterotomy occurred in the face of a previous repair with Prolene mesh. This prompted us to be The techniques of laparoscopic assisted ventral hernia especially wary of the risk of enterotomy when working repair should be part of the armamentarium of all sur- adjacent to a previous mesh repair. A good rule to follow is geons who perform hernia repairs using the laparoscopic 164 Laparoscopic incisional and ventral hernioplasty approach. Indications for this approach include inability draped. Many surgeons recommend the use of an adhe- to gain access to the peritoneal cavity, inability to com- sive barrier drape, as is commonly done in vascular plete safe lysis of adhesions laparoscopically, any question surgery. The mesh itself should be treated in the same of visceral injury, and incarcerated hernias for which fashion as any vascular graft, in that contact with the skin reduction using laparoscopic techniques is impossible. should be avoided. Even the largest expanded polytetra- When these indications are encountered, the abdomen is fluoroethylene (ePTFE) patches can easily be drawn into opened through a limited incision. The bowel is inspected the abdomen through a standard Hasson trocar. Use of if visceral injuries are suspected, and any injuries are antibiotic-impregnated prosthetics may offer some meas- repaired in the appropriate fashion. The remainder of the ure of protection against infection. The lower infection adhesiolysis is then completed with the abdomen open. rates in laparoscopic repairs may be due to the avoidance The defect is then measured, and an appropriately sized of long incisions, wide dissection or flap creation, open- patch is prepared, including placement of pre-tied ing of the hernia sac, and placement of drains.4,8,18,28 sutures. The patch is then introduced into the abdomen, With rare exception, all infected biomaterials placed unrolled, and oriented. The abdomen is closed in an air- laparoscopically to repair incisional hernias must be tight fashion. The pneumoperitoneum is re-established removed to control infection and sepsis. Toy and col- and the procedure completed in the standard laparo- leagues describe five wound infections, four of which scopic fashion. Other authors have employed this started at a trocar site.4 Three responded to intravenous technique.9,10,13,23 antibiotic therapy without mesh removal, and two cases The laparoscopic assisted technique provides the sur- required removal of the mesh. Franklin and coworkers geon with an alternative to complete abandonment of the document only a single mesh infection with staphylococ- laparoscopic approach should the problems described cus in series of 176 patients.5 The mesh infection occurred above be encountered. It also provides the surgeon with a 14 months postoperatively and the mesh was removed. safe alternative if visceral injury is suspected. Until a sur- Kyzer and coworkers had a single mesh infection that geon gains experience with laparoscopic ventral hernia required removal and subsequently led to a recurrent her- repair, this may initially be the procedure of choice. nia.10 Koehler and Voeller11 and Roth and colleagues12 mention two mesh infections in each of their respective series, but they fail to give any further clinical details. MESH INFECTION DeMaria and coworkers had a single mesh infection requiring mesh removal because of an abscess.16 The author felt that seroma aspiration led to contamination Mesh infections (Table 22.3) are a very serious complica- and subsequent abscess formation. Heniford and col- tion reported in multiple series, with an average reported leagues had four mesh infections in 407 patients, and all incidence of 1.4 per cent.4–6,8,10–12,16,18,19 Infection rates required removal of the mesh.18 Two had prior mesh for open incisional hernia repairs are 16 per cent.27 infections with open hernia repair. One developed skin Avoidance of infection includes strict attention to sterile necrosis over the mesh, which eventually became exposed. technique. The patient should be carefully prepped and The last patient developed a mesh infection several weeks

Table 22.3 Series reporting mesh infections Cases Mesh infection Complications Reference (n)(n) (%) Toy et al. (1998)4 144 2 1.4 Franklin et al. (1998)5 176 1 0.6 Costanza et al. (1998)6 15 1 6.7 Park et al. (1998)8 56 2 3.6 Kyzer et al. (1999)10 53 1 1.9 Koehler et al. (1999)11 34 2 5.9 Roth et al. (1999)12 75 2 2.7 DeMaria et al. (2000)16 21 1 4.8 Heniford et al. (2000)18 407 4 1.0 Robbins et al. (2001)19 31 1 3.2 Personal series (2002) 182 5 2.7 Reporting no mesh infections 378 0 0 Total 1572 22 1.4 Complications and their management 165 postoperatively. Robbins and coworkers reported 31 reported average incidence of 4.4 per cent, with a range laparoscopic hernia repairs with a single abdominal wall of 0–16 per cent (Table 22.4). Toy and colleagues describe abscess in the hernia site.19 Ultimately, the mesh had to be the largest number of seromas in their prospective, mul- removed. In our series, we had one infection that required ticenter study.4 Seromas occurred in 23 (16%) patients. patch removal; the hernia recurred and was later repaired Fifteen of these seromas resolved within 30 days, two laparoscopically. resolved after 30 days, and six required aspiration. These Once the infected mesh is removed, options for closure six patients required aspiration because of the size of the of the abdominal defect include primary closure of the seroma, per patient request, or because there was suspi- fascia or closure of the fascial defect with biological grafts. cion of infection. None of the seromas became infected The wound is generally left open to close secondarily. After after aspiration. Tsimoyiannis and coworkers describe a the open wound has closed completely, and at least three single seroma that was aspirated, but they give no details to four months have passed since the infection developed of the indication for drainage.7 Park and colleagues and the mesh was explanted, the patient can return to the aspirated two seromas because of symptoms or their operating room for laparoscopic hernioplasty. presence for more than six weeks.8 Ramshaw and coworkers described two seromas, one of which was drained under computerized tomography 9 SEROMA (CT) guidance. The patient subsequently developed a subcutaneous abscess that required open drainage, but the underlying mesh did not have to be removed. The standard laparoscopic techniques for ventral hernia Koehler and Voeller had two obvious seromas, but nei- repair involve reduction of the hernia contents followed ther required drainage and both resolved over a period of by coverage of the defect with an appropriately sized three to six weeks.11 LeBlanc and colleagues had seven piece of mesh. The hernia sac is left in situ. Fluid accu- seromas, none of which required aspiration.14 They have mulation in the hernia sac is very common in our expe- instituted bulky dressings for 72 hours to help minimize rience and confirmed by many others.3–5,7–9,11,12,14,15,18,23 seroma fluid accumulation. Heniford and coworkers des- LeBlanc and colleagues considered postoperative sero- cribed eight seromas that were defined as fluid collec- mas to be the most common ‘minor complication’.14 tions over the mesh that lasted for six to ten weeks.18 Heniford and coworkers state that many patients develop They stated that no long-term complications occurred, ‘small, self-limited collections’ of fluid over the mesh.18 regardless of whether the seromas were aspirated. The definition of ‘significant’ collection varies among Most fluid collections can simply be observed, because reported series. Some authors define a significant fluid they will resolve spontaneously over four to ten weeks. collection as one that requires aspiration because of Therefore, we recommend observation for the vast major- steady growth or clinical symptoms. Others define a ity of postoperative seromas.14,23 Not all authors agree, significant fluid collection as one that lasts for more than however. Carbajo and colleagues described ten seromas, all six weeks.8,18 Review of the literature demonstrates a of which were managed with aspiration.15 No comments

Table 22.4 Series reporting seromas Cases Seromas Complications Reference (n)(n) (%) Holzman et al. (1997)3 20 1 5.0 Toy et al. (1998)4 144 23 16.0 Franklin et al. (1998)5 176 2 1.1 Tsimoyiannis et al. (1998)7 10 1 10.0 Park et al. (1998)8 56 2 3.6 Ramshaw et al. (1999)9 79 2 2.5 Koehler and Voeller (1999)11 34 2 5.9 Roth et al. (1999)12 75 3 4.0 LeBlanc et al. (2000)14 96 7 7.3 Carbajo et al. (2000)15 100 10 10.0 Heniford et al. (2000)18 407 8 2.0 Personal series (2002) 182 8 4.4 Reporting no seromas 193 0 0 Total 1572 69 4.4 166 Laparoscopic incisional and ventral hernioplasty were made as to when and why these seromas required defined prolonged suture site pain as pain lasting for aspiration. DeMaria and coworkers also aspirated all more than eight weeks.18 They describe eight cases in seromas; they stated that most resolved with one or two their report, most of which resolved with time (in six aspirations, with three attempts at most.16 DeMaria and patients) or injection (in two patients) of bupivacaine. coworkers also described an abdominal wall abscess developing in a patient who had a seroma aspirated in the early postoperative period. The mesh ultimately had to be PROLONGED ILEUS/PERSISTENT NAUSEA removed, and they concluded that the infection occurred AND VOMITING because of inadequate sterile technique during seroma aspiration. Park and colleagues feel that routine aspiration Several authors report prolonged ileus or persistent nau- of seromas has resulted in mesh infection, and they advise sea and vomiting following these procedures. The cumu- against this practice.23 lative reported incidence is two per cent.3,4,8,9,12,14,18,20 Although not well described in the literature, our Other authors have also reported prolonged ileus and experience shows that many postoperative seromas will persistent nausea and vomiting, but they did not comment display subtle signs of inflammation, such as localized further. warmth, erythema, and minimal tenderness to palpation, We generally do not use nasogastric tubes in the post- but do not represent true infections. Subtle signs of operative period. If patients develop nausea, this is treated inflammation do not require any specific treatment other with anti-emetics, such as ondansetron hydrochloride than observation. There is also no associated leukocytosis 4 mg every four hours, as necessary. If patients develop or fever. These findings generally resolve spontaneously as protracted emesis along with their ileus, a nasogastric the fluid is reabsorbed. The level of comfort in observing tube will be placed, but this will be removed as soon as these subtle signs will depend upon one’s clinical experi- possible. Early ambulation and activity are encouraged to ence. Close clinical follow-up is critical in this setting. prevent ileus. Development of worsening pain, fever, and increasing erythema would all be indications to start oral antibiotics. There are very few indications for the aspiration of RECURRENCE OF HERNIA seromas. Toy and colleagues stated that they try to avoid aspiration because it may contaminate the seroma and cause an abscess.4 Aspiration may be required for sero- Overall recurrence rates for open ventral incisional her- mas that are painful and enlarging. Park and coworkers nia repairs have been high and range from 30 to 60 per and other experts feel that aspiration of seromas tends to cent.4,29–37 A review of the literature demonstrates that increase the rate of mesh infections.23 Removing fluid laparoscopic hernia repair has lowered this dramatically may be both therapeutic and diagnostic in this setting. to approximately four per cent (with a mean follow-up Clear, straw-colored fluid is normal; however, turbid and period of 22.5 months) (Table 22.1). purulent fluid is highly suggestive of infection, requiring Several factors are reported to increase the risk of removal of the prosthetic material. recurrence after ventral hernia repairs. These include infection at the original operation38 and size of the original hernia.31 Other authors have noted wound infec- POSTOPERATIVE/SUTURE PAIN tions, obesity, advanced age, pulmonary complications, hepatic insufficiency, and male gender as risk factors for recurrence.6 Park and colleagues report higher recur- We have found that laparoscopic ventral and incisional rences with larger hernias, hernias in a central or midline hernia repairs tend to be exceedingly painful compared location compared with lateral hernias, and wound com- with other minimally invasive surgeries. Ramshaw and plications after hernia repair.8 Roth and coworkers, on colleagues report similar findings.9 They believe that the the other hand, found no association between the size pain is related to the number of full-thickness sutures and the number of previous repairs, age, postoperative and posterior fascial tacks used. Length of hospital stay complications, or location of recurrence.12 Koehler and will be proportional to the degree of pain. We generally Voeller warn us to consider occult liver disease in any keep patients in the hospital for three to four days for hernia recurrence that cannot be explained by infection postoperative pain management. This is several days or collagen-vascular disease, and they give supporting longer than the average length of stay reported in the lit- references.11,39,40 LeBlanc and colleagues state that their erature. Our preferred method of analgesia is patient- recurrences are generally associated with large and mul- controlled analgesia (PCA) with morphine. tiple defects, the use of only one method of fixation for The reported incidence of suture and/or protracted the prosthetic patch, and an inadequate patch size.14 pain is around 1.3 per cent. Heniford and colleagues Hesselink and coworkers noted a 41 per cent cumulative Complications and their management 167 recurrence rate at five years, with second, third and We believe that sutures and spiral tacks are needed in all fourth incisional hernia repairs having recurrence rates repairs. of 56, 48 and 47 per cent, respectively.31 To place transabdominal nonabsorbable sutures, we Several factors are crucial for the maintenance of low employ a suture-passer to place them 4–5 cm apart. recurrence rates. The defect must be defined completely, Heniford and coworkers also place full-thickness abdom- the adhesions must be separated, and the repair must not inal-wall sutures every 4–5 cm.18 The sutures should be have any tension. The prosthetic patch should be below placed no more than 5 cm apart. Koehler and Voeller state the plane of the fascial defect, and the size of the patch that tacks should be placed every 1.5 cm on the periphery, must be larger than the hernia defect.41,42 with sutures every 6 cm.11 They also suggest using three to The use of prosthetic materials is by far the most four tacks around the edges of the hernia defect to mini- important step in the evolution of recurrent hernia mize the dead space. LeBlanc and colleagues believe that repairs.37,39,43,44 In the early reports of laparoscopic ventral both sutures and tacks are important for securing the and incisional hernia repairs, many authors reported that mesh.14 their early recurrences were due to the use of only one type Overlapping the hernia defect with the prosthetic patch of fixation method, such as staples or tacks alone, without of an adequate size is also critically important. Several properly fixing the mesh with sutures. Conversely, pure studies have demonstrated that side-to-side suturing of suture repair of hernias without using mesh is also the patch to the edge of the hernia defect leads to recur- not advisable. This advice is confirmed by Franklin and rence rates of 11–42 per cent.55–57 Tsimoyiannis and col- colleagues, who report that one recurrence (out of two) leauges7 and Park and colleagues8 state that the overlap was due to the lack of use of a prosthetic patch.5 must be at least 2.5 cm. Ramshaw and coworkers,9 LeBlanc Tension-free placement of a prosthetic patch on the and coworkers,14 and Robbins and coworkers19 prefer a posterior surface of the abdominal wall is important, and 3–4-cm overlap beyond the edge of the defect. Kyzer and this alone has led to lower recurrence rates.26,29,31,35,41,45–47 colleagues10 and Koehler and Voeller11 suggest that the The intra-abdominal pressure tends to hold the mesh in overlap should be 5 cm or greater. Koehler and Voeller place by Laplace’s law. describe a recurrence due to patch disruption with a 9-cm We believe, like others, that tissue in-growth into the overlap but with no suture fixation.11 Gillion and col- mesh material is important for long-term fixation.4,48–50 leagues have shown clearly that overlapping the mesh with However, in the immediate postoperative period, sutures the hernia defect lowers the recurrence rate significantly.58 and spiral tacks play a critical role in fixation. Franklin We feel that complete coverage of the entire incision is and colleagues5 and Reitter and colleauges17 all place important whenever possible, even though the actual strong emphasis on full-thickness transabdominal wall recurrent hernia defect may encompass only a small por- sutures to prevent recurrent hernias. However, they felt tion of the entire incision. Koehler and Voeller also state that tacks and staples were necessary only to hold the that coverage of the entire incision is crucial to minimize mesh in place initially and to fill in the gaps between the recurrence risk.11 For example, if a patient has a midline sutures. Ramshaw and coworkers describe one recurrence incision with a recurrence at one end, we would cover in a laparoscopic repair where only a hernia stapler was the entire midline incision with the prosthetic material used for fixation (i.e. without sutures or tacks).9 They to minimize recurrence. In our personal series, several of subsequently modified their technique using sutures and the recurrent hernias were noted above or below the pre- tacks in all but the smallest (Ͻ2 cm) hernia defects. viously placed prosthesis. We have not seen a recurrence Heniford and colleagues state that 43 per cent (6/14) of in which the prosthetic material failed intrinsically. their recurrences developed in patients in whom sutures Most laparoscopic recurrences tend to occur within were not used at all or not placed in difficult areas, such as the first two years, and this has also been our experience. the costal margins.18 We feel, as do Heniford and cowork- Toy and colleagues had six patients (other than those ers,6 Ramshaw and coworkers,9 and LeBlanc and cowork- recurrences from removal of infected mesh) with recur- ers,14 that suture fixation is extremely important to the rences of their ventral hernias.4 All six recurrences success of the laparoscopic hernia repair. Without suture presented by nine months postoperatively, with none fixation, the prosthetic patch can pull away from the thereafter. Franklin and coworkers report two recur- abdominal wall, eventually leading to recurrence. This has rences, one at four months and the other at 13 months been documented clearly.3,11,14,18,26,51–54 However, we and following the operation.5 The first recurrence occurred Park and colleagues8 feel that spiral tacks are just as after a non-prosthetic umbilical hernia repair. The sec- important. The mesh should be secured to the abdominal ond recurrence followed the removal of an infected pros- wall with spiral tacks placed 1 cm apart. Not all authors thetic biomaterial. LeBlanc and colleagues report nine agree: Carbajo and colleagues felt that sutures led to hernia recurrences at a mean of 24 months, with a range more complications (hematomas, increased postopera- of four to 47 months.14 Recurrence in one patient was tive pain) and abandoned them for helical tacks only.15 recorded at 47 months. If this patient is excluded, then 168 Laparoscopic incisional and ventral hernioplasty the mean time of recurrence was 22 months. LeBlanc and 4 Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of coworkers also report four of nine recurrences occurring laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc 14 1998; 12: 955–9. after 30 months. 5 Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and We have had five recurrences in 182 laparoscopic her- incisional hernia repair. Surg Laparosc Endosc 1998; 8: 294–9. nia repairs. They all occurred within the first 24 months 6 Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of after repair. Other series report nearly all of the recur- recurrent ventral hernia. Am Surg 1998; 12: 1121–7. rences by two years.8,11,12,16 7 Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic intraperitoneal onlay mesh repair of incisional hernia. Surg Laparosc Endosc 1998; 8: 360–2. 8 Park A, Birch DW, Lovrics P. Laparoscopic and open incisional CONCLUSION hernia repair: a comparison study. Surgery 1998; 124: 816–22. 9 Ramshaw BJ, Esartia P, Schwab J, et al. 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Am Surg 1998; 64: initial results of the procedure are encouraging, and 276–80. long-term follow up is essential to verify the long-term 23 Park A, Heniford BT, LeBlanc KA, Voeller GR. Laparoscopic repair of benefit of the procedure. incisional hernias. Part 2: surgical technique. Contemp Surg 2001; 57: 225–38. 24 Brill AI, Feste MD, Hamilton TL. Patient safety during laparoscopic monopolar electrosurgery – principles and guidelines. J Soc REFERENCES Laparoendosc Surg 1998; 2: 221–5. 25 Vancille TG. Active electrode monitoring; how to prevent unintentional thermal injury associated with monopolar 1 Mudge M, Hughes LE. Incisional hernia: a 10 year prospective electrosurgery at laparoscopy. Surg Endosc 1998; 12: 1009–12. study of incidence and attitudes. Br J Surg 1985; 72: 70–1. 26 Temudom T, Siadati M, Sarr MG. Repair of complex giant or 2 Munson JL. Problems in General Surgery 1985; 2: 589–614. recurrent ventral hernias by using tension-free intraperitoneal 3 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral prosthetic mesh (Stoppa technique): lessons learned from our and incisional hernioplasty. Surg Endosc 1997; 11: 32–5. initial experience (fifty patients). Surgery 1996; 120: 738–44. Complications and their management 169

27 Houck JP, Rypins EB, Sarfeh IJ, et al. Repair of incisional hernia. 44 Condon RE. Incisional hernia. In: Nyhus LM, Condon RE, eds. Surg Gynecol Obstet 1989; 169: 397–9. Hernia, 4th edn. Philadelphia: JB Lippincott, 1995: 319–39. 28 Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic 45 Mclanahan D, King LT, Weems C, et al. Retrorectus prosthetic mesh treatment vs open surgery in the solution of major incisional repair of midline abdominal hernia. Am J Surg 1997; 173: 445–9. and abdominal wall hernias with mesh. Surg Endosc 1999; 46 Amid PK, Shulman AG, Lichtenstein L. A simple stapling technique 13: 250–2. for prosthetic repair of massive incisional hernias. Am Surg 1995; 29 Langer S, Christiansen J. Long-term results after incisional hernia 60: 934–7. repair. Acta Chir Scand 1985; 151: 217–19. 47 Ramshaw BJ, Schwab J, Mason EM, et al. Comparison of 30 Van der Linden FT, van Vroonhoven TJ. Long-term results after laparoscopic and open ventral herniorrhaphy. Am Surg 1999; 65: correction of incisional hernia. Neth J Surg 1988; 40: 127–9. 827–31; 831–2. 31 Hesselink VJ, Luijendijk RW, de Wilt JWH, et al. An evaluation of 48 Cristoforoni PM, Kim YB, Preys Z, et al. Adhesion formation after risk factors in incisional hernia recurrence. Gynecol Obstet 1993; incisional hernia repair: a randomized porcine trial. Am Surg 1996; 176: 228–34. 62: 935–8. 32 Santora TA, Roslyn JJ. Incisional hernia. Surg Clin N Am 1993; 49 Law NW, Ellis H. Adhesion formation and peritoneal healing on 73: 557–70. prosthetic materials. Clin Mater 1988; 3: 95–101. 33 Paul A, Korenkov M, Peters S, et al. Unacceptable results of the 50 Murphy JL, Freeman JB, Dionne PG. Comparison of Marlex and Mayo procedure for repair of abdominal incisional hernia. Gore-Tex to repair abdominal wall defects in the rat. Can J Surg Eur J Surg 1998; 164: 361–7. 1989; 32: 244–7. 34 Luijendijk RW, Lemmen MH, Hop WC, Wereldsma JC. Incisional 51 Molloy RG, Moran KT, Walaron RP, et al. Massive incisional hernia: hernia recurrence following ‘vest over pants’ or vertical Mayo abdominal wall replacement with Marlex mesh. Br J Surg 1991; repair of primary hernia of the midline. World J Surg 1997; 78: 242–4. 21: 62–6. 52 McCarthy JD, Twiest MW. Intraperitoneal polypropylene 35 Koller R, Miholic J, Jakl RJ. Repair of incisional hernias with mesh support incisional herniorrhaphy. Am J Surg 1981; expanded polytetrafluoroethylene. Eur J Surg 1997: 163: 261–6. 142: 707–11. 36 Gecim II E, Kocak S, Ersoz S, et al. Recurrence after incisional 53 Bellon JM, Contreras LA, Sabeter C, Bujan J. Pathologic and clinical hernia repair: results and risk factors. Surg Today 1996; 26: 607–9. aspects of repair of large incisional hernias after implant of PTFE 37 George CD, Ellis H. The results of incisional hernia repair: a twelve prosthesis. World J Surg 1997; 21: 402–7. year review. Ann R Coll Surg Engl 1986; 68: 185–7. 54 Monaghan RA, Meban S. ePTFE patch in the hernia repair: a 38 Bucknall TE, Cox PJ, Ellis H. Burst abdomen and incisional hernia: a review of clinical experience. Can J Surg 1991; 34: 50–55. prospective study of 1129 major laparotomies. Br Med J 1982; 55 Ambrosiani N, Harb J, Gavelli A, Huguet C. Echec de la cure des 284: 931–3. eventrations et des hernies par plaque de PTFE (111 cas). Ann Chir 39 Bauer JJ, Salky BA, Gelernt IM, Kreel I. Repair of large abdominal 1994; 48: 917–20. wall defects with ePTFE. Ann Surg 1987; 206: 765–9. 56 Saiz AB, Willis IH, Paul DK, Sivina M. Laparoscopic ventral 40 Lamont PM, Ellis H. Incisional hernia in re-operated abdominal hernia repair: a community hospital experience. Am Surg 1996; incisions: an overlooked risk factor. Br J Surg 1988; 75: 374–6. 5: 336–8. 41 Stoppa RE. The treatment of complicated groin and incisional 57 Ven der Lei B, Bleichrodt RP, Simmermacher RKJ, van Schilgaarde hernias. World J Surg 1989; 13: 545–54. R. Expanded polytetrafluoroethylene patch for the repair of large 42 Condon RE. Prosthetic repair of abdominal hernias. In: Nyhus LM, abdominal wall defects. Br J Surg 1989; 76: 803–5. Condon RE, eds. Hernia, 4th edn. Philadelphia: JB Lippincott, 1995: 58 Gillion JF, Begin GF, Marecos C, Fourtanir G. Expanded 188–210. polytetrafluoroethylene patches used in the intraperitoneal or 43 Wantz G. Incisional hernioplasty with Mersilene. Surg Gynecol extraperitoneal position for repair of incisional hernias of the Obstet 1991; 172: 129. anterolateral abdominal wall. Am J Surg 1997; 174: 16–17. This page intentionally left blank PART 4

Laparoscopic treatment of diaphragmatic herniation

23 History 173 29 Etiology of recurrent gastroesophageal 24 Anatomy and physiology 179 reflux disease 217 25 Preoperative evaluation 187 30 Reoperation for recurrent gastroesophageal 26 Gastroesophageal reflux disease 193 reflux disease 227 27 Para-esophageal hernias 201 31 Results of laparoscopic treatment of hiatal hernias 235 28 Traumatic and unusual herniation 209 32 Complications and their management 239 This page intentionally left blank 23

History

RAYMOND C. READ

Initial experience 173 Laparoscopic approach 175 Short esophagus 173 Conclusion 176 Phillip Allison’s contribution 174 References 176 Rudolph Nissen’s contribution 175

Even though Barrett did not introduce the term ‘reflux though diaphragmatic hernias were considered rare, oesophagitis’ until 1950,1 this entity is now considered Hedblom reviewed almost 400 cases (19 at the Mayo to be the most common chronic disease afflicting the Clinic) operated upon worldwide by 1925. The following Western world. Forty per cent of the population complain year, Akerlund published his radiological studies;8 these of occasional heartburn, and a third of these require long- were performed with barium, the patient being placed in term medical treatment. A significant minority progress the Trendelenburg position, as recommended by Soresi.9 to Barrett’s metaplasia. Other complications include Most surgeons operated only on large protrusions esophagitis, ulceration, stricture, herniation and neopla- (mainly para-esophageal) because of their known risk of sia, many of which require surgery. The purpose of this incarceration, volvulus and strangulation. Based on experi- chapter is to trace the evolution of such therapy. ence with external hernias, pain and dysphagia were attributed to ‘pinching’ of the stomach by the hernial ring. Harrington considered diaphragmatic herniation to be the INITIAL EXPERIENCE ‘great masquerader’ because it was frequently confused (and associated) with the more commonly recognized peptic ulcer disease or cholecystitis.10 Therefore, in con- Herniation of abdominal contents through the diaphragm trast to most surgeons of his time, he preferred the has been recognized for centuries. According to Reid, the abdominal approach. Thoracotomy allowed phrenic nerve lesion was first documented by Sennertus in 1541 at post- crush, which was still being recommended in the 1950s mortem examination.2 Boyle described the clinical find- to facilitate return of the stomach to the abdomen.11 ings in 1812.3 Successful repair was accomplished by Gastropexy was used to limit recurrence and prevent Potemski in 1889.4 Congenital diaphragmatic herniation postoperative volvulus.12 was reported in 1701 by Holt.5 Operative correction was effected in 1902 by Heidenhain.6 Ambroise Pare in 1610, quoted by Hedblom,7 described cases of hiatus herniation SHORT ESOPHAGUS and post-traumatic protrusion at autopsy, but it was not until 1908 that the former, discovered fortuitously Harrington10 and other surgeons in the period between at laparotomy, was dealt with in a living person. Even the two world wars encountered some patients, young and old, whose stomachs could not be reduced below the diaphragm because of shortening and narrowing of the Part of this review was presented at the third Annual Scientific Meeting of the American Hernia Society, Toronto, 15 June 2000, and has been esophagus. Forceful taxis resulted in disruption. These published previously as ‘Contribution of Allison and Nissen to laparo- individuals were therefore not operated upon, being scopic hiatal herniorrhaphy’ in Hernia 2002; 5: 200–203. managed instead by bougienage. Harrington, as pointed 174 Laparoscopic treatment of diaphragmatic herniation out by Hayward,13 also deserves credit for being the first Barrett in 1950 distinguished between peptic ulcera- to distinguish between ‘really’ short esophagus and one tion of the esophagus lined with squamous epithelium that is ‘apparently’ so.14 He also separated para-esophageal and gastric ulceration distally in what he called thoracic hiatus herniation from the sliding type, the latter, the more stomach, even though it had no serosal covering to go common, having a higher incidence of stricture. along with its adenomatous mucosa.1 (Barrett’s rejoinder A seminal but ultimately malign contribution to our to such quibblers was ‘Neither does the cardia!’) Three understanding of these cases was made by Findlay and years later, Allison and Johnstone, in a paper entitled ‘The Kelly in 1931.15 Their paper was entitled ‘Congenital esophagus lined with gastric mucous membrane’,argued shortening of the esophagus and the thoracic stomach that Barrett’s thoracic stomach was actually esophagus resulting therefrom’. In this, they described nine infants with an abnormal mucosa.18 They conferred his name on and children who presented with dysphagia from high both the epithelium and ulcers arising therein. They also strictures of the esophagus. Distally, the remaining foregut noted the presence of sliding hiatus herniation with or in the chest was shown by endoscopic biopsy to be lined by without a para-esophageal component in their patients, ‘gastric’ mucosa. This structure was therefore considered all of whom demonstrated ‘peptic esophagitis’ (Allison’s to be the stomach. Since their youngest patient was only term) or Barrett’s ‘reflux esophagitis’.In over 100 patients five days old, its intrathoracic position was presumed to with peptic stricture of the esophagus, less than ten per cent have been present before birth; thus it was not a hernia were in the ‘gastric’ lining. Most occurred at the junction but a congenital misplacement. To support this concept, of squamous and adenomatous epithelium. Their con- Findlay and Kelly cited seven necropsies, mostly of elderly clusion was that the ‘gastric’ epithelium in the esophagus, men whose intrathoracic stomach had been thought pre- rather than being congenital in origin, might develop by viously to be herniation. Kelly later reported further healing of reflux esophagitis with metaplasia. Lortat- examples of congenital intrathoracic stomach, but he Jacob19 and Hayward13 concluded that all such cases were did accept that in some patients herniation could occur acquired. Interestingly, the former, a Frenchman, intro- postnatally.16 The associated strictures were considered to duced the term ‘endo-brachy-oesophage’,analogous to the arise from esophagitis, spasm, and ascending fibrosis. English ‘short esophagus’.Lortat-Jacob agreed with Allison During barium studies on normal children, these authors that reflux esophagitis could shorten the squamous-lined incidentally observed longitudinal muscular spasm pro- esophagus when its inferior portion became lined with ducing hiatal herniation during deglutition. This was the gastric-type mucosa. first evidence for the modern concept that hernia may fol- One of Allison and Johnstone’s patients developed a low rather than cause gastroesophageal reflux disease cancer in the adenomatous lining of the esophagus.18 At (GERD). 72 years of age, he had complained of hiccup, epigastric pain, flatulence, and nocturnal regurgitation on and off for his entire life. Increasing dysphagia had started eight PHILLIP ALLISON’S CONTRIBUTION weeks before admission. Olsen and Harrington had previously reported on four such examples of malignancy associated with short esophagus and hiatus herniation.20 This thoracic surgeon (1908–74) was born and educated In discussion, Sweet commented that 13 per cent of his and, for most of his career, practiced in Yorkshire, resections for cancer of the cardia at the Massachusetts England. In the late 1930s, while at the University of Leeds, General Hospital had been in patients with the short he pioneered intrapericardial pneumonectomy. In 1954, esophagus–hiatus hernia syndrome. Cases of the latter he was appointed Nuffield Professor of Surgery at Oxford presenting with perforation or massive hemorrhage had University. Unfortunately, because of petty parochialism ulcers arising in the adenomatous epithelium of the practiced by the Harley Street surgeons of London, his esophagus (Barrett’s), not in the squamous lining above. achievements were appreciated more overseas than in To prevent reflux esophagitis, Allison focused on his native land. In 1943, he and his colleagues described hiatus herniorrhaphy.21 Since there was, at the time, no ten middle-aged or elderly men and women with short anatomical or physiological evidence for a sphincter at esophagus and peptic ulceration. They had complained the esophagogastric junction, he set out to re-establish for months or years of substernal pain, dysphagia and, both the angle of His and the diaphragmatic ‘pinchcock’ in half, occasional bleeding. Symptoms responded to dila- formed by the right crus of the diaphragm and the tion and antacids, and endoscopy demonstrated fibrotic phreno-esophageal ligaments. The situation being consid- narrowing. Some patients also had gastric or duodenal ered analogous to that of the puborectalis sling around the ulceration. Allison and colleagues’ conclusion was that ‘the anorectal junction, Allison felt that a posterior rather than deformity referred to as congenitally short esophagus may the popular anterior repair was indicated. His hernior- be acquired and result from herniation of the stomach rhaphy was conducted through the chest, the diaphragm with ulceration and scarring’.17 being incised to expose the abdomen. History 175

Unfortunately, Allison’s repair, which was adopted and stitched the fundoplication to the esophageal wall widely, proved unsatisfactory because a significant num- to obviate slippage. He mobilized the lesser curvature of ber of patients suffered symptomatic relapse. Collis cited the stomach, being careful to preserve the vagi and their these results in recommending a return to anterior clo- branches. The left gastric vasculature rather than the short sure of the defect in the dome of the diaphragm.22 This gastric vessels was divided. A nasogastric tube was left surgeon, who also worked in the UK (Birmingham), had postoperatively to prevent vomiting. described in 1957 an operation for patients with hiatus Initially, Nissen performed a partial wrap since he did hernia and short esophagus that has stood the test of not mobilize the fundus by dividing its blood supply. time.23 This involved constructing a neo-esophagus from Later, he recommended 360-degree rotation, since he the ‘Magenstrasse’ of the stomach. Hiebert and Belsey pro- ligated the short gastric vessels rather than branches of vided an explanation for the failure of Allison’s procedure the left gastric on the lesser curvature. Today, both partial when they documented incompetence of the gastric cardia and complete fundoplications are performed, depending in the absence of hiatal herniation.24 The problem was on the emptying characteristics of the esophagus and primary incompetence of the intrinsic gastroesophageal stomach. Whereas Nissen was not concerned about an sphincter of Code and colleagues.25 intrathoracic location of the fundoplication, either intraoperatively with short esophagus or, later, secondary to herniation, surgeons have adopted Belsey’s recommenda- RUDOLPH NISSEN’S CONTRIBUTION tion that the intra-abdominal portion of the esophagus should be restored and maintained by repair of any hiatal herniation.24 Any shortening of the esophagus from This distinguished thoracic surgeon (1896–1981), the scarring, secondary to GERD, is eliminated by the use of son of a surgeon, was an assistant between 1921 and 1933 Collis’ procedure.23 To avoid gas bloat and dysphagia, the to Professor Sauerbruch of Munich and Berlin. Being length of the wrap, which is floppy, has been halved. Jewish, Nissen was forced to emigrate to Turkey, from his Nissen retired from surgical practice in 1967 and died in Fatherland despite being wounded in the lung during 1981. Despite modifications, his operation continues to World War I. In 1931, he performed the world’s first suc- be the basis for the surgical relief of complications arising cessful pneumonectomy on a 12-year-old girl with a torn from reflux esophagitis with or without hiatus herniation. left mainstem bronchus. While in Istanbul, he undertook a transthoracic gastroesophagectomy for benign ulcera- 26 tion of the cardia. He later learned that this was the sec- LAPAROSCOPIC APPROACH ond such resection to be accomplished successfully, the first being performed by the Japanese in 1933. It is interesting that Sauerbruch pioneered the procedure experi- This mini-invasive surgical technique evolved from mentally in the dog in 1906. Since almost all previous endoscopy,29 which began on the island of Kos with the attempts had failed in humans because of anastomotic school of Hippocrates (460–375 BC), who described the leakage, Nissen buried the anastomosis of the transected rectal speculum. A three-bladed vaginal speculum was esophagus in the fundus of the stomach. He brought up recovered from the ruins of Pompeii. The earliest light two folds in the manner of a Witzel gastrostomy. sources were mirrors, introduced by the Arabs before Amazingly, while he was Chief of Surgery at Basel, 1000 AD. In 1587, Aranzi described the use of the camera Switzerland, 17 years after this operation he obtained obscura, popularized by Leonardo da Vinci in 1519. A follow-up information from a relative of the patient. spherical glass flask filled with water was used to focus a The patient was well and had no symptoms of reflux beam of sunlight into the nasal cavity. In the seventeenth esophagitis. Two years later, Nissen decided to perform century, Borell employed a lantern. fundoplication alone for esophageal reflux disease. He Bozzini in 1806 initiated modern endoscopy by devel- undertook this procedure in a man and a woman who oping a complex tubular system to convey light from each had the signs and symptoms of reflux esophagitis a candle allowing observation of the bladder or cervix without evidence of hiatal herniation. Nissen reported through a second channel. Segal in 1826 used a similar success in 1956.27 In agreement with modern thought,28 arrangement to fabricate a cystoscope without lenses. he believed that hiatus herniation was the result rather Desormeaux in 1865 and Nitze in 1879 developed tele- than the cause of reflux esophagitis. Therefore, in cases of scopic instruments. Originally, their light source was symptomatic hiatus herniation, he paid no attention to an overheated, water-cooled platinum wire (described the hernial sac, considered closure of the defect unneces- by Bruck in 1867), but after the electric light bulb was sary, and with short esophagus performed transthoracic invented in 1880 by Edison, this was incorporated into fundoplication. He always conducted the procedure over a gastroscope by Mickulicz in 1881 and into a cystoscope a large-bore bougie to prevent postoperative dysphagia, by Newman in 1883. Later, the bulb was mounted distally, 176 Laparoscopic treatment of diaphragmatic herniation an operating channel was added, and the lens was sepa- Whereas a 360-degree fundoplication is the most com- rated therefrom. mon procedure, partial wraps are favored by some sur- Laparoscopy began in 1901 when Ott reported on geons, especially if emptying of the esophagus or stomach culdoscopy and later (1909) on ‘ventroscopy’ using a is inadequate. The mini-invasive nature of laparoscopy speculum. Kelling in 1902 suggested that a better view has made surgery more acceptable, and it has become of the compressed viscera could be obtained by inducing competitive with long-term medical treatment. Improved pneumoperitoneum, this having been performed earlier outpatient pH monitoring and other diagnostic measures in the treatment of tuberculosis. His first observations, have expanded the population known to be suffering Koelioskopie, were made on animals but in 1910 Jacobeus from GERD. reported 17 ‘lapothorakoskopies’ on patients with ascites The success of laparoscopic fundoplication, complete employing a Nitze cystoscope. Further developments or partial, in both children and adults has extended this included the use of the Trendelenburg position and a technique to prosthetic repair of hiatal defects, the Collis trocar endoscope by Nordentoeft in 1912. The automatic operation for short esophagus, and the management of spring insufflating needle was invented by Goetz in 1918. incarcerated para-esophageal herniation. Other dia- Carbon dioxide, which is absorbed more rapidly than phragmatic hernias protruding through the foramina of air, was substituted for air by Zollikofer in 1924. Kalk in Bochdalek and Morgagni have been dealt with similarly, 1929 devised a new lens system that permitted oblique along with blunt or penetrating injuries seen early or (135-degree) viewing, along with a dual-trocar technique. late. Heller cardiomyotomies have also been performed In the 1930s, laparoscopy was performed largely by for achalasia. Smaller ports, narrower instruments, and general surgeons and internists (e.g. Ruddock) for the joystick controls have facilitated these procedures.30 diagnosis and biopsy of visceral disease. The stomach, Robotics are now on emerging technology. bladder and rectosigmoid were sometimes transillumi- nated for better evaluation. The first operation using laparoscopy, adhesiolysis, was carried out by Fervers in CONCLUSION 1933. Boesch in 1936 used the procedure for sterilization, coagulating the fallopian tubes. Palmer expanded its use Our understanding of the common ailment, reflux in gynecology. Advances in instrumentation enhanced its esophagitis, has been shown to be based largely on the pio- popularity: cold light illumination (Foursestiere in 1943), neering efforts of European thoracic surgeons. By unrav- fiber-optics (Hopkins in 1952), and new instruments eling congenital misplacement, hiatus herniation, short (Frangenheim in 1954, Semm in 1963). Semm also intro- esophagus, stricture, ulceration, adenomatous hyper- duced the automatic insufflator. Later, bipolar coagulation plasia, and its malignant transformation, they made (Frangenheim in 1972) and laser technology (Bruhat in modern surgical therapy possible. 1979) were added. Nevertheless, the major breakthrough European surgeons again played a leading role in the was the invention of the computer-chip video camera in evolution of laparoscopy from endoscopy. The success- 1986. This enabled assistants and students to view the ful application of this technique to appendectomy and progress of the operation. cholecystectomy stimulated its use, a decade ago, in the In 1981, Semm performed laparoscopic appendec- management of GERD. This approach has now sup- tomy; cholecystectomy followed (Muhe in 1986, Mouret planted open fundoplication. It has been adopted for in 1987). Despite initial censure, laparoscopic herniorrha- prosthetic repair of various diaphragmatic hernias, phy, hysterectomy, bowel resection, gastrectomy, nephrec- Heller myotomy, Collis gastroplasty and, combined with tomy, cystectomy, splenectomy, adrenalectomy, vagotomy thoracoscopy, esophagectomy. Technical advances and and esophagectomy followed rapidly. Thoracoscopy was new instrumentation continue to improve patient out- rejuvenated. come while reducing costs and hospitalization. Laparoscopic fundoplication was introduced independently by Geagea and Dallemagne in 1991. Since then, it has been adopted worldwide and has supplanted the REFERENCES open Nissen procedure. Hospital stay is reduced along with postoperative morbidity. Treatment costs are thereby 1 Barrett NR. Chronic peptic ulcer of the oesophagus and ‘oesophagitis’. reduced. An increase in operating time can be eliminated Br J Surg 1950; 38: 175–82. by experience. Follow-up studies, many of which are pro- 2 Reid J. Case of diaphragmatic hernia produced by a penetrating longed and randomized, show that results are as good as wound. Edinburgh Med J 1840; 53: 104–12. those obtained by classical open procedures, except per- 3 Boyle A. Case of wounded diaphragm. Edinburgh Med J 1812; 8: 42–4. haps with esophageal shortening or giant para-esophageal 4 Potemski M. Nouvo processo operativo per la reduzione cruenta herniation. Here, restoration of the abdominal esophagus della cruie diaframmatiche da trauma e per la sutura della ferite or recurrence pose problems. del diaframma. Bull Reale Acad Med Roma 1889; 15: 191. History 177

5 Holt C. Child that lived two months with congenital diaphragmatic 18 Allison PR, Johnstone AS. The esophagus lined with gastric hernia. Philos Trans 1701; 22: 922. mucous membrane. Thorax 1953; 8: 87–101. 6 Heidenhain L. Geschichte eines Fallas von chronischer 19 Lortat-Jacob JL. Les malpositions cardia-tuberositaires. Incarceration des Magens in einer angeborenen Zwerch fellhernie Arch Mal App Dig 1953; 42: 750–74. welcher durch Laparotomie geheilt wurde, mit anschliessen – 20 Olsen AM, Harrington SW. Esophageal hiatal hernias of the den Bemerkungen ueber die Moglichkeit. Das Kardiocarcinom der short esophagus type: etiologic and therapeutic considerations. Speiserohre zu reseciren. Deutsch Ztschr Chir 1905; 76: 394–403. J Thorac Surg 1948; 17: 189–209. 7 Hedblom CA. Diaphragmatic hernia: a study of three hundred and 21 Allison PR. Reﬂux esophagitis, sliding hiatal hernia and the seventy eight cases in which operation was performed. anatomy of repair. Surg Gynecol Obstet 1951; 92: 419–31. JAMA 1925; 85: 947–53. 22 Collis JL. Review of surgical results of hiatus hernia. Thorax 1961; 8 Akerlund A. Hernia diaphragmatic Hiatusoesophagei vom 16: 114–23. anatomischen und rontgenologischen Gesicfhtspunkt. Acta Radiol 23 Collis JL. An operation for hiatus hernia with short esophagus. 1926; 6: 3–22. J Thoracic Surg 1957; 34: 768–78. 9 Soresi AL. Diaphragmatic hernia, its unsuspected frequency: its 24 Hiebert CA, Belsey RHR. Incompetency of the gastric cardia diagnosis, technique for radical cure. Ann Surg 1919; 69: 254–70. without radiologic evidence of hiatal hernia, the diagnosis and 10 Harrington SW. Diagnosis and treatment of various types of management of 71 cases. J Thorac Cardiovasc Surg 1961; 42: diaphragmatic hernia. Am J Surg 1940; 50: 377–446. 352–71. 11 Adams HD, Lobb AW. Esophagoaortal hiatus hernia. N Engl J Med 25 Fyke FE, Code CF, Schlegel JF. The gastroesophageal 1954; 250: 143–8. sphincter in healthy human beings. Gastroenterologia 1956; 12 Boeremia I, Germs R. Anterior geniculate gastropexy for hiatal 86: 135–47. hernia of the diaphragm. Zentralbl Chir 1955; 80: 1585–93. 26 Nissen R. Die Transpleurale Resektion der Kardia. Deutsche Ztschr 13 Hayward J. The treatment of ﬁbrous stricture of the esophagus Chir 1937; 249: 311–16. associated with hiatal hernia. Thorax 1961; 16: 45–64. 27 Nissen R. Gastropexy as the lone procedure in the surgical repair 14 Harrington SW. The surgical treatment of the more common types of hiatus hernia. Am J Surg 1956; 92: 389–92. of diaphragmatic hernia. Ann Surg 1945; 122: 546–68. 28 Dunne DP, Paterson WG. Acid-induced esophageal shortening 15 Findlay L, Kelly B. Congenital shortening of the esophagus and in humans: a cause of hiatus hernia? Can J Gastroenterol 2000; the thoracic stomach resulting therefrom. J Laryngol Otol 1931; 10: 847–50. 46: 797–816. 29 Lau WY, Leow CK, Li AKC. History of endoscopic and laparoscopic 16 Kelly AB. Some oesophageal affections in young children. surgery. World J Surg 1997; 21: 444–53. J Laryngol Otol 1936; 51: 78–99. 30 Awad ZT, Filipi CJ. Commentary: the short esophagus, pathogenesis, 17 Allison PR, Johnstone AS, Royce GB. Short esophagus with simple diagnosis and current surgical options. Arch Surg 2001; 136: peptic ulceration. J Thorac Surg 1943; 12: 432–57. 113–14. This page intentionally left blank 24

Anatomy and physiology

MARK A. REINER

Anatomy 179 Conclusion 185 Physiology 183 References 185 Surgical considerations for diaphragmatic repair in patients with gastroesophageal reﬂux disease 184

In an attempt to elucidate the etiological factors that the first three lumbar vertebrae.1 These segments have contribute to gastroesophageal reflux disease (GERD), it four components: the medial and lateral lumbosacral is necessary to have a full understanding of normal dia- arches or internal and lateral arcuate ligaments, and the phragmatic anatomy and physiology. Pathological reflux right and left crura.1,3 The medial lumbosacral arch (inter- occurs when there are anatomical and physiological nal arcuate ligament) drapes over the psoas muscle; it is abnormalities at the gastroesophageal junction and crura. fixed to the transverse processes of the first and second These abnormalities are influenced by postural changes lumbar vertebra, and fuses into the lateral portion of the and gradients between intra-abdominal and intrathoracic contiguous crus. The lateral lumbosacral arch (external pressures. Corrective surgery must include a proper arcuate ligament) covers the quadratus lumborum and diaphragmatic repair in order to minimize the potential becomes fixed to the first lumbar vertebrae and twelfth for recurrence. Postoperative management must be rib.1,3 The crura originate as tendons that are a direct tailored to the patient’s age, the size of the hiatal defect, extension of the longitudinal ligament of the vertebral col- and the patient’s lifestyle. umn and as such are attached to the lumbar vertebrae. The tendon of the left crus is shorter and thinner than the right crus. It originates from the ventral surface of the bodies ANATOMY and intervertebral disks of L1 and L2. The right crus, the stronger and longer of the two, originates from the ventral surfaces and intervertebral cartilages of L1, L2 and L3. The The diaphragm separates the abdominal and thoracic cav- crura muscular fibers, originating from their respective ities. It is composed of a non-contractile central tendon tendons, then merge and surround the esophageal hiatus and three peripheral or skeletal muscular components, the at the level of T10.1,3,4 Before doing this, the medial mar- sternal, costal, and lumbar or crural.1 The central tendon gins of the crura pass ventrally and then merge medially connects all of the muscular components by acting as a near the midline to surround the anterior surface of the central focal point from which these three muscle groups aorta. The muscular fibers coming off the crural tendons radiate. The sternal portion of the muscular component then integrate and connect into the central tendon. The originates from the undersurface of the sternum and may right crus muscular fibers split into two segments. The be considered as an independent structure or as the medial medial segment completely surrounds the esophageal hia- aspect of the costal segment.1,2 The costal portion origi- tus, while the lateral segment merges directly into the cen- nates from the undersurface of the lower six costochon- tral tendon. The muscular fibers of the left crus enter dral junctions, extending on to these ribs, and then ending directly into the central tendon. Occasionally, muscle bun- by interdigitating with the transversus abdominis muscles dles will overlap and may be derived from both tendons bilaterally. The lumbar or crural segment originates from (Figure 24.1).1,3,5,6 180 Laparoscopic treatment of diaphragmatic herniation

Costal origin Esophageal hiatus

Vena cava foramen Median arcuate ligament

Lumbar crural Aortic hiatus

Right crus Left crus

Medial arcuate ligament

Lateral arcuate ligament

Quadratus lumborum Lumbar vertebrae Figure 24.1 Normal diaphragmatic anatomy.

Central component

Right component Left component

Figure 24.2 Central tendon.

The muscular components of the diaphragm merge the inferior vena cava and along the right side of its hia- centrally into the central tendon. This structure is a tus. The vessel divides into a medial and lateral branch. strong aponeurosis broken down into three components. The medial branch angles further anteriorly and anasto- The largest is the right component, followed by the cen- moses with the same branch of the opposite side, as well tral and left components. The entire structure is slightly as the musculophrenic and pericardiophrenic vessels. off-center, being biased slightly anteriorly and to the The lateral branch courses laterally to anastomose with right.1 The tendon gets its considerable strength because the posterior intercostal arteries.1 The left vessel is signi- the fibers merge at different angles (Figure 24.2). ficantly more medial and runs anterior to the esophagus Anatomical rents in the diaphragm exist so that pas- and ventrally along the left side of the esophageal hia- sage of structures can occur between the thoracic and tus.1,4 It must be noted carefully at this site to prevent abdominal cavities. There are three main and five minor inadvertent injury during anti-reflux procedures, espe- defects or apertures in the diaphragm. The minor defects cially when closing the diaphragmatic rent. Branches of serve for passage of small vessels, such as the superior the inferior phrenic vessels and occasionally an arterial epigastric artery and vein anteriorly, and the hemiazygos branch off the left gastric artery will pass just anterior vein and splanchnic and sympathetic nerves posteriorly. to the ventral margin of the esophageal hiatus.5 These The three major apertures are for the vena cava, the vessels can be injured when mobilizing the left lateral aorta, and the esophagus. segment of the liver or when a probe is placed in the The innervation of the diaphragm is from the phrenic hiatus for anterior displacement aiding visualization nerves, which arise mainly from the fourth and to a lesser during an anti-reflux procedure. If this vessel is near the degree the third and fifth cervical nerves. The blood apex, I prefer to use a more flat or fan retractor to help supply is from the inferior phrenic arteries. The right prevent injury. phrenic artery is more lateral, while the left phrenic The next integral anatomical component in prevent- artery is more medial. The right vessel passes anterior to ing reflux disease is the phreno-esophageal ligament. This Anotomy/physiology 181

Lower esophageal attachment

Gastrophrenic ligament attachment

Pars condesa attachment Anterior cardial attachment

Figure 24.3 Phreno-esophageal ligament.

Elliptical hiatus

Figure 24.4 Normal esophageal hiatus. is a misnomer, being not a true ligament but rather a con- of GERD. The etiology of this laxity remains obscure, tinuation of the subperitoneal fascia. Its attachments are but it has been attributed to a variety of factors, including the anterior portion of the cardia of the stomach, the atrophic changes as seen with age, chronic stretching lower 4 cm of the esophagus, and the left and right sides secondary to each peristaltic contraction,10 obesity, preg- of the crura around the esophageal hiatus. It terminates nancy, surgical destruction, and trauma. Since the physio- on the left by merging into the gastrophrenic ligament logical benefits of the phreno-esophageal ligament are and on the right into the pars condensa of the lesser diminished in the presence of a hiatus hernia, wide omentum (Figure 24.3).4,7 The phreno-esophageal liga- dissection of the ligament in anti-reflux surgery has ment is the only structure that establishes a direct con- no detrimental effect. Adequate dissection of the crura, nection between the lower esophageal sphincter and the proximal stomach, and lower esophagus are mandatory crural diaphragm. This structure has been considered an in order to perform an adequate repair. This condition important factor in preventing reflux. It tends to be is not present in patients having upper-esophageal sur- stretched and distracted in hiatal hernias.7–10 When this gery for conditions other then reflux disease, such as a occurs, it minimizes or eliminates any positive effect Heller myotony for achalasia. Minimal dissection of the that a normal ligament will have on reflux prevention. phreno-esophageal ligament in these cases may help This stretching, when seen in conjunction with a hiatus minimize postoperative GERD. hernia, allows a segment of gastric cardia to herniate The structural anatomy of the normal esophageal through the hiatus into the mediastinum, shortening the hiatus has a significant impact in preventing reflux disease. length of the abdominal esophagus. When this occurs in In its normal form, it is elliptical in shape and present the presence of a hypotensive or atonic lower-esophageal in the muscular portion of the diaphragm (Figure 24.4). sphincter (LES), the patient will experience the symptoms The hiatus is located at the level of the tenth thoracic 182 Laparoscopic treatment of diaphragmatic herniation

Oval-shaped

Figure 24.5 Esophageal hiatal hernia.

Central tendon

Interlocking anterior muscle fibers

Figure 24.6 Muscle and tendon borders of the esophageal hiatus.

vertebra,1 and its lateral borders are formed by a split in lateral muscular fibers of the hiatal borders stretch, espe- the muscular fibers of the right crus with only minor rein- cially as the phreno-esophageal ligaments elongate. This forcement on the left side by the left crus. The anterior sur- causes a circular deformity of the esophageal hiatus with- face of the hiatus is supported by a sling of muscle fibers out significantly enlarging its cross-sectional diameter. and tendinous attachments merging into the junction The weakest portion of the hiatus is formed at the triangu- between the medial and lateral leaflets of the central ten- lar shaped merging of the right crus fibers posteriorly don. The posterior segment of the esophageal hiatus is (Figure 24.7).7,9 This is an inherent site of anatomical supported only by a sling of muscular tissue that is com- weakness that cannot be overcome by the extra support prised almost exclusively of fibers originating from the provided by the prevertebral fascia. Forces that influence right crus. The presence of a hiatus hernia reflects a break- the development of a hiatal hernia cause the rounding or down in the anatomical structures of the hiatus. As the separation of these V-shaped muscular fibers, with the hernia enlarges, the defect becomes more oval in shape subsequent effect of increasing the size of the esophageal (Figure 24.5).9 Stress on the hiatus causes an enlarging hiatus. Since the majority of the defect seen in hiatal her- defect in the muscular boundaries. The anterior border is nias occurs dorsally, repair should be performed posterior more resilient, being supported by interlocking muscle to the esophagus in order to re-establish normal anatomy. fibers reinforced by tendinous fibers of the central and left I prefer to do the repair in the presence of a 56–60 French leaflets of the central tendon (Figure 24.6). This area tends dilator so that I do not inadvertently make the new hiatal to resist forces that would cause the hiatus to enlarge. The size too narrow. Care must be taken to avoid injury to the Anotomy/physiology 183

Triangular shaped merging of the right crus fibers posteriorly

Figure 24.7 Posterior border of the esophageal hiatus.

Intrathoracic esophagus

Lower esophageal sphincter

Intra-abdominal stomach Figure 24.8 Anatomy of the lower esophageal sphincter.

aorta at this stage because of its proximity to the posterior play. The first two are the normal average pressure and aspect of the defect. the length of the sphincter.11 The third component of this anti-reflux triad is the lower esophageal position. The adequate presence of all three components will prevent PHYSIOLOGY GERD under the conditions of rest, changing body positions, ingestion of moderate amounts of food and drink, and physical activity that results in significant increases in The physiology of diaphragmatic function has a direct intra-abdominal pressures. A functional change in any effect on the presence or absence of symptomatic reflux. one of these components, without a corresponding com- A brief review of the etiological factors causing GERD pensatory adjustment in another of the other compo- is warranted before we consider how to integrate the dia- nents, will result in GERD. An example of this adjustment phragmatic repair into the surgical treatment of reflux can be demonstrated in a patient with a shortened LES disease. Reflux occurs when gastric contents are regurgi- segment. Reflux would occur unless there was a compen- tated into the esophagus. The normal stomach resides in satory rise in the LES pressure. There is, however, one an area of higher pressure than the thoracic esophagus. In situation in which there is an alteration in the balance order for reflux not to occur, a pressure barrier must exist between these three factors that is physiologically normal between these areas of low and high pressure. A segment and the most common cause of non-pathological reflux: of esophagus approximately 2 cm long, of which at least transient lower esophageal sphincter relaxation (tLESR). 1 cm usually resides intra-abdominally, called the LES, is This occurs when there is gastric distention secondary to the junction between the two different pressure zones ingestion of excess food, air, or gas, such as is seen with (Figure 24.8). The presence of pathological reflux is carbonated beverages. This is unrelated to swallowing or dependent on failure of the LES. Three factors come into esophageal peristalsis, and it may have a neuromuscular 184 Laparoscopic treatment of diaphragmatic herniation component, a purely mechanical component, or combi- pressures are also affected by the contraction of the nations of both.10–12 diaphragm. The presence of a large hiatal hernia, with the The presence of the LES is not defined by any specific subsequent stretching of the phreno-esophageal ligament, anatomical landmarks, but it is well demonstrated by will disrupt the angle of His and diminish the length of placing an intragastric pressure monitor and withdraw- intra-abdominal esophagus. This, in conjunction with ing it into the distal esophagus. A high-pressure zone will intrinsic LES factors, will affect the development of GERD. exist in the lower esophagus as compared with the gastric The size of a hiatal hernia has been shown to affect the baseline.11 In normal individuals, this will fall only severity of GERD.10,14,16 A larger defect will have a shorter during swallowing or when the gastric fundus overfills sphincter length and lower LES pressures. Not surpris- with gas or food. This segment of elevated pressure is ingly, the amount of reflux will be greater, with decreased partially dependent on the length of the distal esophagus efficiency of acid clearance and a higher degree of exposed to intra-abdominal pressure. This length can be esophagitis. altered by gastric distention, resulting in tLESR, the shortening of the intra-abdominal component in the presence of a hiatal hernia, or a shortened esophagus as SURGICAL CONSIDERATIONS FOR seen in chronic reflux. Once the pressure of the high- DIAPHRAGMATIC REPAIR IN PATIENTS pressure zone falls below an average of 6 mmHg, an aver- WITH GASTROESOPHAGEAL REFLUX age intra-abdominal length of 2 cm or less and/or an DISEASE average length exposed to the positive intra-abdominal pressure of 1 cm or less than the LES is permanently destroyed.11 These patients require surgical intervention Patients with hiatal hernias and GERD have a large poste- when they cannot be controlled adequately by medical rior diaphragmatic defect. In these patients, the phreno- management. esophageal ligament has lost its anatomical importance A number of explanations have been postulated in an due to stretching or laxity developed as a result of the effort to explain the relationship between the diaphragm, increasing size of the hiatus. In this condition, the lower the lower esophageal pressure, and the intra-abdominal or esophagus and stomach can herniate into the chest. This distal few centimeters of esophagus. Allison believed that will then alter the angle of His and diminish or eliminate when the right crus of the diaphragm contracts during the incursion of the lower esophagus into the abdomen. inspiration, it compresses the esophagus together at the These anatomical changes reduce the LES pressure, same time increasing its angulation.6 This action com- shorten the abdominal esophagus, and diminish the total bined with a normal phreno-esophageal ligament pro- length of the LES. Reflux can occur and, if treated inade- duces adequate intra-abdominal esophageal length, thus quately, can result in chronic esophagitis with extensive allowing an acceptable LES pressure to be generated fibrosis and total irreversible atony of the LES. Surgical to prevent reflux. Delattre and colleagues believe that repair is directed at increasing the efficacy of the malfunc- diaphragmatic contraction causes the changes in LES tioning LES and re-establishing the presence of the pressures and should not be attributed solely to changes in abdominal esophagus. The laparoscopic gold standard is intra-abdominal pressure.5 Most authors, however, believe the Nissen fundoplication coupled with an adequate that there is both an intrinsic and an extrinsic mechanism crural repair. In their reviews of fundoplication failures, to prevent esophageal relux.4,11,13–15 The intrinsic com- Soper and Dunnegan17 and Hunter and coworkers18 ponent is made up of the smooth muscle of the distal showed that the most frequent anatomical cause for fail- esophagus under a variety of neuro-hormonal controls. ure was transdiaphragmatic herniation. The correct sur- This component is referred to as the LES. A variety of gical approach for diaphragmatic repair is mandatory in pathophysiological conditions affect this non-anatomical order to minimize operative failures in the treatment of sphincter. These effects can be mostly asymptomatic and reflux disease. The repair should be done posterior to the normal, as found with physiological reflux associated with esophagus, using a mattress suture of adequate strength tLESR. They can also be pathological, causing symptoms nonabsorbable suture material (Figure 24.9). Pledgets are of GERD, as demonstrated by patients with a hypotensive not usually needed, but in elderly patients or in excep- or atonic LES. The extrinsic component is comprised of tionally large defects their use may be warranted. The size the diaphragm, with its reaction to respiration, position, of the defect should be just large enough to easily fit a varying intra-abdominal pressures, and the phreno- 56–60 French dilator. To prevent crural disruption in the esophageal ligament. GERD is most often expressed as a immediate postoperative period, extubation should be result of a combination of intrinsic and extrinsic compo- smooth to prevent bucking against the endotracheal tube. nents. The tLESRs are affected by diaphragmatic contrac- Anti-emetics should be used generously to prevent vio- tions and relaxations mediated partially by their mutual lent postanesthesia retching. Delayed disruption can be attachments to the phreno-esophageal ligament.15 LES avoided if the patient refrains from strenuous competitive Anotomy/physiology 185

Esophagus

Pledget Crural closure

Figure 24.9 Posterior crural repair. sports, where sudden abdominal impact could cause a 5 Delattre JF, Palot JP, Ducasse A. The crura of the diaphragmatic significant and rapid rise in intra-abdominal pressure. passage. Anat Clin 1985; 7: 271. 6 Allison PR. Reflux esophagitis, sliding hiatal hernia, and the Caution must also be given to weight-lifters, who possess anatomy of repair. Surg Gynecol Obstet 1951; 92: 419–31. thicker and stronger muscular diaphragms, about lifting 7 Postlethwait RW. Surgery of the Esophagus, 2nd edn. Norwalk, CT: practices that could disrupt the repair. Appleton-Century-Crofts, 1986. 8 Eliska O. Phrenoesophageal membrane and its role in the development of hiatal hernia. Acta Anat (Basel) 1973; 86: CONCLUSION 137–50. 9 Marchand P. A study of the forces productive of gastroesophageal regurgitation and herniation through the diaphragmatic hiatus. The surgical treatment of GERD can be addressed suc- Thorax 1957; 12, 189–202. 10 Kahrilas PJ. Suoraesophageal complications of reflux disease and cessfully and safely only after fully understanding the hiatal hernia. Am J Med 2001; 111: 51S–5S. normal anatomy and physiology of the diaphragm, the 11 DeMeester TR, Peters JH, Bremner CG, Chandrasoma P. Biology lower esophageal forces that prevent and cause reflux, and of gastroesophageal reflux disease: pathology relating to the abnormal anatomical defects found in patients with medical and surgical management. Annu Rev Med 1999; 50: hiatus hernias. Failures can be kept to a minimum by the 469–506. 12 Richter J. Do we know the cause of reflux disease? Eur J diligent performance of a meticulous posterior repair of Gastroenterol Hepatol 1999; suppl 1: 83–9. the diaphragm before completing the fundoplication. 13 Cuomo R, Grasso R, Sarnelli G, et al. Role of diaphragmatic crura and lower esophageal sphincter in gastroesophageal reflux disease. Dig Dis Sci 2001; 45: 2687–94. REFERENCES 14 Kahrilas P. The role of hiatus hernia in GERD. Yale J Biol Med 1999; 72: 101–11. 15 Orlando RC. Overview of the mechanisms of gastroesophageal 1 Goss CM, ed. Gray’s Anatomy, 28th edn. Philadelphia: Lea & reflux. Am J Med 2001; suppl 8A: 174S–7S. Febiger, 1966. 16 Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size 2 Poole DC, Sexton WL, Farkas GA, et al. Diaphragm structure and affects lower esophageal sphincter function, esophageal acid function in health and disease. Med Sci Sports Exerc 1997; 29: exposure, and the degree of mucosal injury. Am J Surg 1995; 738–54. 171: 182–6. 3 Agur AMR, Lee MJ, eds. Grant’s Atlas of Anatomy, 10th edn. 17 Soper NJ, Dunnegan D. Anatomic fundoplication failure Philadelphia: Lippincott Williams & Wilkins, 1999. after laparoscopic antireflux surgery. Ann Surg 1999; 229: 4 Delattre JF, Aviss C, Marcus C, Flament JB. Functional anatomy of 669–77. the gastroesophageal junction. Surg Clin North Am 2000; 80: 18 Hunter JG, Smith CD, Branum GD, et al. Laparoscopic 241–60. fundoplication failures. Ann Surg 1999; 230: 595–606. This page intentionally left blank 25

Preoperative evaluation

MARCO G. PATTI AND PIERO M. FISICHELLA

Preoperative evaluation for anti-reﬂux surgery 187 Evaluation for failed anti-reﬂux surgery 190 Esophageal manometry 188 References 191 Ambulatory pH monitoring 189

Laparoscopic Nissen fundoplication is one of the opera- PREOPERATIVE EVALUATION FOR tions performed most frequently by general surgeons ANTI-REFLUX SURGERY today. The past decade has seen a progressive increase in the number of laparoscopic Nissen fundoplications performed throughout the USA due to the recognition that All patients who are candidates for laparoscopic fundopli- although the laparoscopic approach gives results similar cation should undergo the following preoperative evalua- to those obtained with the open approach (excellent con- tion in order to determine whether abnormal reflux is trol of symptoms in about 90 per cent of patients), it is present, whether the symptoms are caused by the reflux, also associated with shorter hospital stay, less postopera- and whether complications of GERD, such as Barrett’s tive discomfort, and faster recovery time.1–5 The increased esophagus, are present, and to define the anatomy and number of patients referred for surgical treatment has pathophysiology of the disease in the individual patient. allowed us to improve the understanding of the pathophysiology of the disease and to define the technical ele- Symptomatic evaluation ments that play a role in the performance of an effective and durable fundoplication.2 Patients are questioned regarding the presence of typical Traditionally, gastroenterologists have referred patients and atypical symptoms (Table 25.1). The severity of the for surgery based on clinical evaluation and findings of symptoms is scored from 0 (asymptomatic) to four endoscopy, particularly if they had a poor response to acid- (severely affecting quality of life). Symptoms alone, how- reducing medication. Today, however, this approach is ever, are not diagnostic of GERD. Unfortunately, many unacceptable for the following reasons: (1) many patients clinicians are overly confident that a diagnosis of GERD undergo surgery for control of symptoms in the absence of can be based firmly on the clinical findings, even though esophagitis; (2) more patients are referred for treatment it has been shown that symptoms are unreliable in diag- of atypical symptoms of gastroesophageal reflux disease nosing GERD.8–10 For instance, our group found that (GERD) such as cough or chest pain;6,7 and (3) because of among 822 consecutive patients referred for esophageal the efficacy of proton-pump inhibitors, in patients who do function tests with a clinical diagnosis of GERD (based on not respond to these medications a diagnosis other than symptoms and endoscopic findings), 30 per cent had no GERD should be sought.8,9 Therefore, a careful and com- abnormal reflux by pH monitoring (GERDϪ patients).8 plete preoperative evaluation is of key importance for the Heartburn and regurgitation were as frequent in success of the operation. GERDϩ and GERDϪ patients, so symptoms alone could 188 Laparoscopic treatment of diaphragmatic herniation

Table 25.1 Symptoms of gastroesophageal reflux disease 247 patients with negative pH studies, 60 (25 per cent) had been found to have grade I or II Typical symptoms Atypical symptoms esophagitis.8 Heartburn Cough • Major interobserver variation exists for esophageal Regurgitation Wheezing endoscopy, particularly for the low grades of Dysphagia Chest pain esophagitis.14 Hoarseness Otitis media Therefore, we feel that the major value of endoscopy Enamel problems is to exclude other pathology and to detect the presence of Barrett’s esophagus, which occurs in about 12 per cent of patients with GERD.15 not distinguish between those with and those without genuine reflux. Other studies have shown that heartburn and regurgitation have a low sensitivity and specificity, with positive predictive values of 59 and 66 per cent, ESOPHAGEAL MANOMETRY respectively.9 The response to proton-pump inhibitors is a better This test provides information about the length and rest- predictor of the presence of abnormal reflux. For example, ing pressure of the LES and the quality of esophageal ϩ in our study 75 per cent of GERD patients but only peristalsis (amplitude, duration and velocity of the peri- Ϫ 26 per cent of GERD patients reported a good or excellent staltic waves). In most patients with GERD referred for 8 response to these medications. Similarly, in a multivariate surgery, the LES is hypotensive. However, in some analysis of factors predicting outcome of laparoscopic patients, the resting pressure of the LES is normal, and it fundoplication, Campos and colleagues found that a clin- is assumed that transient LES relaxations account for the ical response to acid-suppression therapy was one of three majority of reflux episodes.16 Regardless of the mecha- factors predictive of a successful outcome, along with an nism underlying the abnormal reflux, a fundoplication abnormal 24-hour pH score and the presence of a typical restores the function of the LES by increasing the pres- 11 primary symptom, such as heartburn or regurgitation. sure and length of the sphincter1–3 or by decreasing the frequency of episodes of transient LES relaxation.17 In Barium swallow addition, esophageal manometry provides information about esophageal peristalsis, which is the most impor- 18 This test provides information about the presence and tant factor in acid clearance. Among 1006 consecutive size of a hiatal hernia, the presence and length of a stric- patients with GERD confirmed by pH monitoring, we ture, and the length of the esophagus. The test is not diag- found that peristalsis was normal in 56 per cent of nostic of GERD, as a hiatal hernia or reflux of barium can patients, severely abnormal in 21 per cent of patients be present in patients who do not have GERD. However, it (ineffective esophageal motility, IEM), and mildly abnor- has been shown that among patients with proven GERD, mal in 23 per cent of patients (non-specific esophageal a large hiatal hernia impairs the function of the lower- motility disorder, NSEMD) (Figure 25.1). Patients with esophageal sphincter (LES) and prolongs esophageal acid clearance, producing more severe mucosal injury and increasing the risk of pulmonary symptoms.12

Endoscopy

23% Endoscopy is usually the first test performed to confirm a symptom-based diagnosis of GERD. However, the 56% approach has the following pitfalls: Even though the goal of endoscopy is to assess the • 21% mucosal damage due to reflux, mucosal changes are absent in about half of patients who have GERD.13 For instance, in our study esophagitis was absent in 54 per cent of the patients who had positive 8 pH-monitoring studies. Normal NSEMD IEM • The sensitivity of endoscopy is low, particularly for low grades of esophagitis.9 In our study, among Figure 25.1 Esophageal peristalsis in 1006 patients with GERD. Preoperative evaluation 189

IEM had more severe reflux, slower acid clearance, worse • It establishes a correlation between symptoms and mucosal injury, and more frequent respiratory symp- episodes of reflux. This is particularly important toms.18 Thus, manometry (and pH monitoring) can help when atypical symptoms such as cough or wheezing in staging the severity of the disease, identifying patients are present, as 50 per cent of these patients do not who might benefit most from surgical treatment. experience heartburn and 50 per cent do not have Finally, esophageal manometry allows proper place- esophagitis on endoscopy.13 In these patients, we use ment of the pH probe for ambulatory pH monitoring a pH probe with two antimony sensors spaced 15 cm (5 cm above the upper border of the LES), avoiding the apart (5 and 20 cm above the upper border of the false positive and negative results that occur in about 75 manometrically determined LES) in order to per cent of patients when the probe is placed with the determine the proximal extent of the reflux.21 The ‘step technique’.19 pH monitoring tracings need to be analyzed for a temporal relationship between an episode of cough and an episode of reflux (signified by a drop of the AMBULATORY pH MONITORING pH to Ͻ4.0). An episode of coughing is induced by reflux if it occurs within three minutes of an episode of reflux in the distal or the distal/proximal Ambulatory pH monitoring is the most reliable test in the esophagus (Figure 25.2). In a study of the effect of diagnosis of GERD, with a sensitivity and specificity of laparoscopic fundoplication on GERD-induced about 92 per cent.20 The results of the test are reproducible, respiratory symptoms, we found that pH monitoring and false positive or negative results are rare. Acid- helped to identify the patients most likely to benefit suppressing medications are discontinued three days from anti-reflux surgery. Following surgery, (H -blocking agents) or 14 days (proton-pump inhibitors) 2 respiratory symptoms resolved in 83 per cent of before the study. Diet and activity are unrestricted during patients when a temporal correlation between cough the study in order to mimic a typical day in the patient’s and reflux was found on pH monitoring, but in only life. This test is of key importance for the following reasons: 57 per cent when this correlation was absent.6 • It determines whether abnormal reflux is present. Ambulatory pH monitoring with symptom In our study, 30 per cent of patients with a clinical correlation is also the single best test for evaluating diagnosis of GERD had a normal pH-monitoring non-cardiac chest pain.22 In our experience, the test test.8 Therefore, in these patients, the test avoided the helps in predicting the outcome of a fundoplication. continuation of inappropriate and expensive drugs, Following laparoscopic fundoplication, chest pain such as proton-pump inhibitors, or the performance improved in 85 per cent of patients when a temporal of a fundoplication. In addition, it prompted further correlation between chest pain and reflux was found investigation that pointed to other diseases, such as on pH monitoring (Figure 25.3), and specifically in cholelithiasis, irritable bowel syndrome, or primary 96 per cent of patients when a strong correlation esophageal motility disorders. (Ͼ40 per cent) was present.7

Figure 25.2 GERD and respiratory symptoms. Dual-sensor pH monitoring: red line, acid reflux 5 cm above LES; green line: acid reflux 20 cm above lower esophageal sphincter. The image shows the correlation between cough and reflux in the distal esophagus; and a correlation between cough and reflux in the distal and proximal esophagus; (c) ϭcough. 190 Laparoscopic treatment of diaphragmatic herniation

Figure 25.3 GERD and chest pain: correlation between chest pain and reﬂux.

Horgan and colleagues from the University of Washington, • It stages the disease according to severity. 23 Ambulatory pH monitoring and esophageal three types of configuration are usually present: manometry allow us to stratify patients according to • Type I hernia: the gastroesophageal junction is above the severity of the disease, identifying a subgroup the diaphragm (type IA, both the gastroesophageal characterized by worse esophageal motor function junction and the wrap are above the diaphragm; type (defective LES, abnormal esophageal peristalsis), IB, only the gastroesophageal junction is above the more acid reflux in the distal and proximal diaphragm). esophagus, and slower acid clearance. As a • Type II hernia: para-esophageal configuration. consequence, these patients experience more • Type III hernia: the gastroesophageal junction is stricture formation and Barrett’s metaplasia.18 It is below the diaphragm, there is no evidence of hernia, very important to identify these patients, as they but the body rather than the fundus of stomach has should benefit from early anti-reflux surgery. been used to perform the wrap.

EVALUATION FOR FAILED Endoscopy ANTI-REFLUX SURGERY This determines whether esophagitis is present and whether there is distortion of the gastroesophageal During the past five years, we have seen an increased junction. number of patients referred to our Swallowing Center for evaluation and treatment of foregut symptoms after Esophageal manometry laparoscopic anti-reflux surgery. In these patients, it is essential to repeat the entire preoperative work-up while This determines the length and pressure of the LES and trying to answer the following questions: its ability to relax in response to swallowing. In addition, • Are the symptoms due to persistent gastroesophageal it assesses eventual changes in peristalsis. reflux? • Are the symptoms due to the fundoplication per se? Ambulatory pH monitoring • Can a cause of the failure be identified and corrected by a second operation? It is often assumed that if a patient has heartburn after a fundoplication, then this is due to a failed operation, so Barium swallow acid-reducing medications are restarted. However, this approach is wrong in the majority of patients, as postop- A barium swallow is essential in order to define the erative pH monitoring is abnormal in only about 20 per anatomy of the gastroesophageal junction. As shown by cent of patients.24 In addition, this test determines whether Preoperative evaluation 191 a correlation exists between symptoms experienced by 11 Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis the patient and episodes of reflux. If abnormal reflux is of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 1999; 3: 292–300. present, then the choice is between medical therapy and 12 Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size affects a second operation. lower esophageal sphincter function, esophageal acid exposure, and the degree of mucosal injury. Am J Surg 1996; 171: 182–6. 13 Richter JE. Typical and atypical presentations of gastroesophageal REFERENCES reflux disease. The role of esophageal testing in diagnosis and management. Gastroenterol Clin North Am 1996; 25: 75–102. 14 Bytzer P, Havelund T, Hansen JM. Inter-observer variation in the 1 DeMeester TR, Bonavina L, Albertucci M. Nissen fundoplication for endoscopic diagnosis of reflux esophagitis. Scand J Gatroenterol gastroesophageal reflux disease: evaluation of primary repair in 1993; 28: 119–25. 100 consecutive patients. Ann Surg 1986: 204; 9–29. 15 Patti MG, Arcerito M, Feo CV, et al. Barrett’s esophagus: a surgical 2 Patti MG, Arcerito M, Feo CV, et al. An analysis of operations for disease. J Gastrointest Surg 1999; 3: 397–403. gastroesophageal reflux disease: identifying the important 16 Doods WJ, Dent J, Hogan WJ, et al. Mechanisms of technical elements. Arch Surg 1998; 133: 600–6. gastroesophageal reflux in patients with reflux esophagitis. 3 Peters JH, DeMeester TR, Crookes P, et al. The treatment of N Engl J Med 1982; 307: 1547–1552. gastroesophageal reflux disease with laparoscopic Nissen 17 Ireland AC, Holloway RH, Toouli J, Dent J. Mechanisms underlying fundoplication: prospective evaluation for 100 patients with the antireflux action of fundoplication. Gut 1993; 34: 303–8. ‘typical’ symptoms. Ann Surg 1998; 228: 40–50. 18 Diener U, Patti MG, Molena D, et al. Esophageal dysmotility and 4 Hunter JG, Smith DC, Branum GD, et al. Laparoscopic gastroesophageal reflux disease. J Gastrointest Surg 2001; 5: 260–5. fundoplication failures: patterns of failure and response to 19 Molena D, Patti MG, Diener U, Way LW. Esophageal manometry is fundoplication revision. Ann Surg 1999; 230: 595–604. a prerequisite for pH monitoring. Gastroenterology 2000; 5 Eubanks TR, Omelanczuk P, Richards C, et al. Outcomes of 118: 715. laparoscopic antireflux procedures. Am J Surg 2000; 179: 391–5. 20 Fuchs KH, DeMeester TR, Albertucci M. Specificity and sensitivity 6 Patti MG, Arcerito M, Tamburini A, et al. Effect of laparoscopic of objective diagnosis of gastroesophageal reflux disease. Surgery fundoplication on gastroesophageal reflux disease-induced 1987; 102: 575–80. respiratory symptoms. J Gastrointest Surg 2000; 4: 143–9. 21 Patti MG, Debas HT, Pellegrini CA. Clinical and functional 7 Patti MG, Molena D, Fisichella PM, et al. GERD and chest pain. characterization of high gastroesophageal reflux. Am J Surg 1993; Results of laparoscopic antireflux surgery. Surg Endosc 2002; 165: 163–8. 16: 563–6. 22 Hewson GE, Sinclair JW, Dalton CB, et al. Twenty-four hour pH 8 Patti MG, Diener U, Tamburini A, et al. Role of esophageal function monitoring: the most useful test for evaluating non-cardiac chest tests in diagnosis of gastroesophageal reflux disease. Dig Dis Sci pain. Am J Med 1991; 90: 576–83. 2001; 46: 597–602. 23 Horgan S, Pohl D, Bogetti D, et al. Failed antireflux surgery. What 9 Johnsson F, Joelsson B, Gudmundsson K, Greiff L. Symptoms and have we learned from reoperations? Arch Surg 1999; endoscopic findings in the diagnosis of gastroesophageal reflux 134; 809–15. disease. Scand J Gastroenterol 1987; 22: 714–18. 24 Lord RVN, Kaminski A, Oberg S, et al. Absence of gastroesophageal 10 Costantini M, Crookes PF, Bremner RM, et al. Value of physiologic reflux disease in a majority of patients taking acid suppression assessment of foregut symptoms in a surgical practice. Surgery medications after Nissen fundoplication. J Gastrointest Surg 1993; 114: 780–7. 2002; 6: 3–10. This page intentionally left blank 26

Gastroesophageal reﬂux disease

J. BARRY McKERNAN AND CHARLES R. FINLEY

Treatment 193 References 200 Discussion 200

Over the past decade, there has been a significant shift in reflux and prevent the development of complications asso- the role of surgery for the treatment of gastroesopha- ciated with GERD. The laparoscopic approach, as in chole- geal reflux disease (GERD). Anti-reflux surgery, once reser- cystectomy, adrenalectomy and splenectomy, has replaced ved for severe disease refractory to medical therapy, is the open technique as a method of choice. Patients consid- now considered appropriate for many patients without ered candidates for laparoscopic anti-reflux surgery are mucosal complications. Several factors have contributed those who have failed medical therapy, those who cannot to the growing acceptance of surgery for reflux disease. afford medical therapy, those who have recurrence of One such factor is the appreciation that abnormal reflux symptoms, those with extra-esophageal manifestations or can result in serious esophageal complications, such as strictures, and those with para-esophageal hernias. Previous ulcerations, strictures, and the development of Barrett’s open abdominal surgery, either for reflux disease or for metaplasia. It is well recognized that many of the extra- other reasons, does not prevent the patient from having esophageal symptoms observed in patients with GERD, a successful laparoscopic anti-reflux procedure. including laryngitis, erosion of dental enamel, and pulmonary disorders (asthma, chronic cough, bronchitis), are due to refluxed gastric material entering the oropha- TREATMENT ryngeal cavity and lungs. Although medical therapy with proton-pump inhibitors is fairly effective in controlling heartburn and esophagitis, it is less effective in control- Non-surgical therapy ling these extra-esophageal symptoms. Current evidence suggests that treatments directed at Although this chapter focuses primarily on the laparo- restoring normal competence to the lower esophageal scopic treatment of GERD, several other non-surgical sphincter (LES) will be more effective than those aimed treatment modalities for GERD and related disorders at controlling acid secretion.1,2 The introduction of safe deserve mention. Patients are becoming more knowl- and effective minimally invasive anti-reflux procedures edgeable and inquisitive about their disease, in particular has contributed greatly to the shift in the role of sur- through the use of the Internet. Two recent procedures gery for treating GERD. Medical therapy is directed at have caught the attention of patients with reflux disease alleviating uncomfortable symptoms, whereas surgery is who are seeking non-surgical alternatives to the treat- directed towards repairing the functional defect. Laparo- ment of GERD. The first is the Stretta Procedure™ scopic anti-reflux procedures are comparable to their (Curon Medical), which involves endoscopic delivery of open counterparts in terms of high rates of symptom radiofrequency energy to the gastroesophageal junction. relief coupled with low rates of complications, but they Indicated in patients with minimally active esophagitis offer advantages in terms of shorter hospital stay, quicker and a hiatal hernia of less than 2 cm in size, one study recovery, and cost-savings.3–5 revealed a significantly improved quality of life and For many patients, operative therapy has become an esophageal acid exposure while eliminating the need for alternative rather than a last resort to treat their abnormal antisecretory medication in the majority of patients 194 Laparoscopic treatment of diaphragmatic herniation studied.6 Another recently studied modality for patients primary surgeon and the assisting surgeon utilize a two- with minimal esophagitis and hiatal hernia less than handed technique. This enhances exposure and speeds up 2 cm in size is the use of an endoscopic suturing device the operation. The patient is placed in the Trendelenburg to perform endoscopic gastroplasty. The authors noted position, with the back elevated to approximately 30 an improvement in heartburn severity score and an degrees. The 10-mm, zero-degree laparoscope is then improvement in postoperative 24-hour pH monitoring.7 replaced with a 45-degree laparoscope. An angled laparoscope is used on every case as it provides optimum Surgical therapy exposure to the areas of the gastroesophageal junction, the splenic hilum, the posterior esophageal area, and the We employ a selective approach to treating GERD, tailor- posterior mediastinum. Initially, peritoneal attachments ing the anti-reflux procedure to each patient’s underlying between the fundus of the stomach and the diaphragm anatomical and functional defect. The most commonly are divided with the surgeon’s energy system of choice. performed procedures for GERD are Nissen fundoplication, modified Toupet fundoplication, and Collis gastroplasty combined with a fundoplication. Additionally, we have chosen a team approach for the treatment of GERD, Liver retraction utilizing an ambulatory surgical center focused on endoscopic surgery as well as a team of nursing staff and anes- thesiologists intimately familiar with the perioperative Surgeon left hand 15 cm Assistant right hand care of patients undergoing laparoscopic foregut surgery. Surgeon right hand Patients are admitted to the outpatient surgery center Assistant left hand one hour before the induction of anesthesia. Liberal use of metoclopramide and ondansetron perioperatively has greatly reduced the incidence of postoperative nausea and vomiting (PONV). Patients are given a single dose of prophylactic antibiotics and pneumatic sequential compression hose to prevent deep venous thrombosis.8

Operative techniques 10 mm Mobilization optical trocar Patients are placed on the operating table in the supine 5 mm trocar position. Six trocars are utilized routinely, as shown in Figure 26.1. Some surgeons prefer the semi-lithotomy Figure 26.1 Typical trocar placement for laparoscopic position. A 10-mm incision is made just to the left of the fundoplication, with patient in supine position. midline (paramedian), approximately 15 cm below the xiphoid process. A zero-degree laparoscope with a 10-mm optically dilating trocar is used to gain entrance into the peritoneal cavity. The use of the optically dilating trocar cannot be overstated, as it has allowed access to the peritoneal cavity in many patients who have had previous open and closed abdominal procedures. The trocar is used in the following manner: after the skin incision is made, the trocar is advanced slowly through sequential layers of the abdominal wall, allowing each layer to be identified. Upon arriving visually at the posterior sheath/ peritoneal layer, the scope is manipulated, which reveals any adherent bowel, thereby preventing inadvertent injury (see Chapter 3).9 The abdomen is then insufflated with carbon dioxide. The remaining 5-mm trocars are placed under direct vision. A locking Allis clamp is attached to the diaphragm just above the apex of the esophageal hiatus to allow for liver Figure 26.2 Locking Allis clamp through the epigastric port on retraction (Figure 26.2). It is very important that both the the diaphragm for liver retraction. Gastroesophageal reflux disease 195

Attention is now turned to the lesser omentum, which at the level of the LES. Intraoperative esophagogastro- is opened over the caudate lobe of the liver. There is one duodenoscopy (EGD) is performed in all ‘redo’ fundopli- vascular anomaly that deserves mention. In approximately cations, in patients with para-esophageal hernias, and in ten per cent of cases, a large branch of the left hepatic any cases in which there is uncertainty as to the location artery traverses the lesser omentum in this area. This ves- of the LES at the time of surgery. EGD is also carried out sel should be preserved if it is felt to be larger than 5 mm in after the performance of a Collis gastroplasty to verify diameter. If there is any doubt about this vessel’s con- that there are no leaks at the site of the staple lines. tribution to hepatic blood flow, then it may be occluded Furthermore, intraoperative EGD is performed follow- temporarily with a grasper and any color change noted in ing all cases of esophageal myotomy. the liver. Next, the right crus of the diaphragm is identi- Once the esophagus has been mobilized, the short fied, along with its peritoneal attachment, or ‘the white line gastric vessels are divided. Various methods of division of the right crus of the diaphragm’. This dissection of the and ligation have been utilized, including clips, the har- right crus of the diaphragm is carried down to the point monic scalpel, vascular staplers, and bipolar cautery for- at which the median arcuate ligament is identified. Now, ceps. The use of bipolar cautery forceps with monopolar dissection proceeds along the left crus of the diaphragm division seems to be the most efficient method, with both until a retro-esophageal window is created. A grasper is surgeons using the two-handed technique. Routine divi- passed behind the esophagus, and a blue silastic vessel loop sion of the short gastric vessels ensures a loose, floppy is grasped, encircling the esophagus and secured in place fundus. A recent prospective, double-blind, randomized with a chromic endo-loop. Occasionally, a branch of the trial with five-year follow-up showed no improvement in inferior phrenic artery is encountered, requiring cauteri- any measured clinical outcome by division of the short zation. Also, a few cases of thoracic duct injury have been gastric vessels at the time of laparoscopic Nissen fundo- reported, which presumably resulted from its location in plication.10 If the surgeon chooses not to divide the proximity to this portion of the dissection. The assistant short gastric vessels, then adequate mobilization of the gently grasps the vessel loop providing traction and excel- posterior surface of the fundus should include division lent exposure for the surgeon. Dissection is begun along of congenital adhesions, adhesions encountered in the right crus, dividing the phreno-esophageal ligament patients with prior pancreatitis, and the occasional vas- circumferentially, until the esophagus is completely mobi- cular anomaly in which there is a direct branch from the lized. Both anterior and posterior vagus nerves are identi- splenic artery to the posterior fundus of the stomach. fied at this point of the dissection. It should also be noted that in nearly all cases, the esophageal dissection is per- Crural closure formed bluntly without the use of cautery for fear of esophageal, vagal or pleural injury (Figure 26.3). We routinely measure the size of the crural opening with an Care must be taken to adequately mobilize the esoph- endoscopic ruler. This has significance with respect to agus in such a way that the fundoplication will be placed recurrence rate, as those with openings greater than 5 cm have a higher rate of recurrence. Simple crural closure is accomplished with interrupted 0-Ethibond (Ethicon, Inc.) sutures tied extracorporally. Several options are available for the difficult hiatal closure. Materials such as expanded polytetrafluoroethylene (ePTFE) and bovine pericardium have been used successfully. These are secured in place with either a hernia stapler or sutures. Recently, we have utilized Surgisis Gold™ (Cook Surgical), a biodegradable mesh, secured with sutures or the hernia stapler. Regardless of the material used, it is important to remember that the area of the gastroesophageal junction is mobile. Care should be taken to avoid direct contact between the materials and the esophagus itself, the obvious concern being erosion of the prosthetic material into the esophagus. In some cases, a relaxing incision is made in the diaphragm, just medial to the right crus of the diaphragm (Figures 26.4 and 26.5). The angled laparoscope provides visualization into the chest, just above and Figure 26.3 Complete mobilization of the distal esophagus, to the right of the right crus of the diaphragm. The inci- with blue silastic vessel loop for gentle anterior retraction. The sion is then made with the harmonic scalpel over the right and left crus and the vagus nerve are visualized. liver. The crura of the diaphragm are then approximated 196 Laparoscopic treatment of diaphragmatic herniation

Figure 26.4 Location of relaxing incision in the diaphragm for Figure 26.6 Buttressed closure of the relaxing incision in the a very large hiatal hernia. diaphragm. Sutures or staples (surgeon’s preference) for mesh ﬁxation.

passes the fundus through the retro-esophageal window. An appropriate area of the fundus, usually near the recently divided short gastric vessels, is then grasped. The anesthesiologist then passes a number 50 French bougie dilator as he or she watches its progression into the stomach on the monitor. The planned fundoplication is then calibrated over the dilator in order to perform a loose fundoplication. The fundus is sutured to the esophagus at the upper border of the LES. Three sutures of 0-Ethibond are used most frequently, the middle suture incorporating only fundus to fundus. Care is taken to avoid the anterior vagus nerve while suturing, as it passes from the esophagus towards the lesser curvature of the stomach.

Modified Toupet fundoplication Esophageal motility is performed in all patients preoperatively. A careful history of any difficulty in swallowing is also elicited.A modified Toupet fundoplication is utilized Figure 26.5 Relaxing incision in the diaphragm performed with in patients with poor esophageal motility, as demonstrated harmonic scalpel and closure of the hiatus. Crural sutures are by esophageal manometrics or in patients with significant rarely placed anteriorly. difficulty in swallowing. The classic Toupet fundoplication did not involve crural closure. Furthermore, the fundus was sutured to the crura laterally and posteriorly and to the with Ethibond sutures and the relaxing incision can be esophagus anteriorly, creating a 180-degree fundoplication. buttressed with one of the above-mentioned prosthetic Theoretically, this caused an unusual degree of tension materials (Figure 26.6).11 and mobility between the esophageal and fundic suture lines, which resulted in a high incidence of recurrence. The Nissen fundoplication modified Toupet fundoplication requires only crural Up to this point in the operation, no bougie dilator has closure, and the two most cephalad sutures anchor the been placed during the procedure. The assistant gently esophagus to the fundus and the crura. In the event that a Gastroesophageal reflux disease 197

Fundus

Right crus

Esophagus

Left crus

Figure 26.9 The 1 o’clock anchoring suture, incorporating the left crus, fundus and esophagus (mirroring the previously placed 11 o’clock suture). Figure 26.7 Posterior suture in modiﬁed Toupet fundoplication, incorporating the fundus to the left crus. This anchors the fundus to the left crus posteriorly. E, esophagus; F, fundus; LC, left crus; RC, right crus.

Figure 26.8 The 11 o’clock suture. The needle is shown after passing through the esophagus. The esophagus will then be sutured to the fundus (directly inferior to the needle in the Figure 26.10 Completion of the modified Toupet photograph) and then to the right crus (just to the left of the fundoplication. fundus in the photograph). to this suture between the esophagus and the fundus. modified Toupet fundoplication is indicated, a grasper is Attention is then turned laterally, and a number 38 French placed behind the esophagus and the fundus is grasped and bougie dilator is advanced into the stomach. At the retracted medially behind the esophagus, such that a 270- 1 o’clock position, approximately 2–3 cm from the esopha- degree wrap can be performed. The first suture in the mod- gus, a suture is passed through the fundus, through the ified Toupet fundoplication is placed through the fundus left crus of the diaphragm, and finally though the esopha- posteriorly and through the left crus using a 0-Ethibond gus, thus anchoring the wrap laterally (Figure 26.9).12 suture (Figure 26.7). A second suture is placed through the Additional sutures are then placed between the fundus and wrap posteriorly and through the right crus. Next, the the esophagus, thus completing the left side of the fundo- esophagus is anchored to the right crus of the diaphragm plication (Figure 26.10). Usually, three sutures incorporate by passing the suture through the esophagus at 11 o’clock, fundus to crura, two sutures anchor esophagus to fundus to then through the fundus, and finally through the crus crura at 11 and 1 o’clock, and there are two sutures on each (Figure 26.8). Additional sutures are then placed caudad side between fundus and esophagus. 198 Laparoscopic treatment of diaphragmatic herniation

Collis gastroplasty Esophagomytomy The true occurrence of shortened esophagus is debatable. Achalasia is secondary to a loss of ganglion cells in In our experience, it occurs in one to two per cent of cases. the lower esophagus, resulting in failure of relaxation Adequate esophageal mobilization well into the chest will of the LES with subsequent hypertrophy of the muscle usually allow the creation of an intra-abdominal fundopli- and aperistalsis of the esophageal body. The diagnosis of cation without the need for a Collis gastroplasty. If there is achalasia is made primarily utilizing esophageal manome- any doubt as to the location of the gastroesophageal junc- try along with the typical radiographic findings on barium tion, then intraoperative esophagoscopy is performed. If esophagogram of the bird-beak appearance of the esopha- the LES, after maximal retroperitoneal mobilization, can- gus. The surgeon generally sees these patients after the fail- not be brought below the planned crural closure, then a ure of standard medical therapy, esophageal dilation, and Collis gastroplasty may be indicated. The Collis gastro- possibly botulinum toxin injection. Surgical treatment plasty is performed prior to closure of the hiatal hernia. A number 50 French bougie dilator is placed along the lesser curve of the stomach to be used as a stent in the formation of the neo-esophagus. An additional 10-mm trocar is then placed just below the subcostal margin in the left midclavicular line. The fundus is splayed out laterally, and the angled linear cutter is introduced into the recently placed 10-mm trocar. The linear cutter is then angled medially to transect the stomach from a point along the greater curvature to a point approximately 3–4 cm below the crural opening (Figure 26.11). This usually requires more than one firing of the stapler. The goal is to have at least 4–5 cm of neo-esophagus below the crural opening. Then the angled linear cutter is placed parallel to the bougie and fired cephalad (this may require more than one firing), thus creating the neo-esophagus and in the process removing a small triangular portion of the fundus of the stomach (Figure 26.12). The remaining stapled lateral fundus is invaginated into a Nissen repair or, if the patient had significant preoperative dysphagia, into a modified Toupet repair (Figure 26.13). We usually perform a highly selec- Figure 26.12 Creation of the neo-esophagus. tive vagotomy in the neo-esophagus to prevent gastritis.

5 cm

Figure 26.13 Remaining fundus utilized for either modified Figure 26.11 Initial application of linear cutting device. Toupet or Nissen fundoplication. Gastroesophageal reflux disease 199 involves esophagomyotomy and an anti-reflux procedure, keep the field clear for dissection. Once the circular fibers typically a modified Toupet fundoplication or Dor ante- are divided down to the mucosa, the mucosa can be rior fundoplication. pushed bluntly inferiorly, and the dissection can proceed Spastic disorders of the esophagus include nutcracker in a cephalad direction. The total length of the myotomy esophagus, diffuse esophageal spasm (DES), and hyper- will depend on the indication for the procedure. For a tensive LES. DES and nutcracker esophagus primarily primary motility disorder such as achalasia, nutcracker involve the lower third of the esophagus. Nutcracker esophagus, or diffuse esophageal spasm, a length of esophagus is typified by significant chest pain and, to a 6–8 cm is usually sufficient. For a hypertensive LES, typi- lesser extent, dysphagia. Esophageal manometry gener- cally only a 4-cm myotomy is needed (length of the LES) ally shows slightly elevated resting LES pressures and to relieve the obstruction. normal relaxation, combined with average esophageal Once the proximal portion of the myotomy is com- pressures of greater than 180 mmHg. Nutcracker esoph- pleted, the more distal segment, which involves the gastro- agus is usually identified easily on standard manometry, esophageal junction, is approached. Dissection is carried as it is a fairly continuous disorder. Diffuse esophageal inferiorly until it impinges upon the decussating fibers of spasm, on the other hand, may not be identified on stan- the stomach wall and the presumed location of the gastro- dard or ambulatory esophageal manometry, due to its esophageal junction. It is our practice, in patients under- episodic nature. DES is characterized by simultaneous, going esophageal myotomy, to perform an intraoperative mostly high-amplitude esophageal contractions. Each EGD to determine accurately the location of the gastro- case should be treated on an individual basis, and esophageal junction. The intraoperative EGD serves two patients should be selected carefully for surgical therapy. purposes: it ensures that the myotomy extends beyond We usually perform a laparoscopic esophagomyotomy the gastroesophageal junction to totally relieve any distal combined with an anti-reflux procedure (either a Nissen obstruction, and it ensures that there is no iatrogenic per- or a modified Toupet fundoplication). foration of the mucosa prior to closure. Once the myotomy Hypertensive LES, less common than the other spastic is complete, the muscular layer is swept laterally to expose disorders of the esophagus, is characterized by high rest- approximately 1.5 cm of mucosa. The site is inspected for ing LES pressures (Ͼ40 mmHg or more than two stan- bleeding and the fundoplication is performed. When per- dard deviations above normal) and normal relaxation of forming a myotomy with a modified Toupet fundoplica- the LES, combined with relatively normal esophageal tion, the fundus is sutured to the divided muscular edges body motility. Reflux does occur in this population, of the esophageal myotomy, taking care not to injure the presumably as a result of transient relaxation of the LES bulging mucosa. with subsequent delayed esophageal clearing of the refluxed acid. Considerable controversy surrounds the Pyloroplasty appropriate management of this condition. The various treatment options include pharmacological agents to Approximately 10–50 per cent of patients with GERD decrease LES pressure, esophageal dilation, and surgery. have delayed gastric emptying. This frequently manifests Only a small number of these patients require surgery. itself in the form of recurrent reflux symptoms after a suc- We most commonly perform an esophageal myotomy cessful anti-reflux procedure. The patient’s history, EGD, and modified Toupet fundoplication when treating this upper gastrointestinal radiological studies, and a nuclear group of patients surgically. medicine gastric-emptying scan are all helpful in making the diagnosis of delayed gastric emptying. Once the diag- Technique nosis is made, the patient is treated initially with endoscopic pneumatic dilation of the pylorus. If the patient Once esophageal and fundic mobilization has been com- responds favorably to this treatment, then the definitive pleted, and before closure of the esophageal hiatus, the treatment by laparoscopic pyloroplasty can be offered. anterior esophagus is exposed between 11 and 12 o’clock. Trocars are placed similarly as for laparoscopic fundo- This area avoids the anterior vagus nerve. Beginning plication, although usually in a more caudad position on approximately 2 cm above the gastroesophageal junc- the abdominal wall. The duodenum is then mobilized tion, the longitudinal fibers in the first muscular layer of (Kocher maneuver) utilizing the harmonic scalpel and the esophagus are sharply dissected and separated with blunt dissection. The pylorus is identified, and a longi- scissors. We use disposable endoscopic scissors with no tudinal incision is made on the anterior surface of the cautery, since we find that cautery is needed only rarely duodenum, through the pylorus and then on to the stom- on the small vessels in the esophagus. Once the longi- ach. This longitudinal incision is now closed transversely tudinal fibers have been bluntly separated, the circular in one layer utilizing 0-Ethibond sutures. Following the fibers become exposed. These are divided under direct completion of the pyloroplasty, intraoperative EGD is visualization. The assistant uses a suction irrigator to performed to check for air leaks, and additional sutures 200 Laparoscopic treatment of diaphragmatic herniation are placed as necessary. The EGD is also valuable in deter- roles. Additionally, good-quality and well-maintained mining the adequacy and patency of the pyloroplasty. equipment makes for a better experience for the physician. The patient ultimately reaps the benefit from the smaller, more patient- and physician-friendly setting. DISCUSSION

The technical steps presented in this chapter represent REFERENCES the authors’ preferred methods of performing anti-reflux procedure. It should be emphasized that each patient 1 Orlando RC. The pathogenesis of gastroesophageal reflux should be treated individually. As surgeons, we love to disease: the relationship between epithelial defense, dysmotility, adhere to rules, but we often forget the true intent of and acid exposure. Am J Gastroenterol 1997; 92 (suppl 4): such rules. For example, the intent of dividing the short 3S–5S, 5S–7S. 2 Stein HJ, Barlow AP, DeMeester TR, Hinder RA. Complications of gastric vessels was to allow adequate mobilization of the gastroesophageal reflux disease: role of the lower esophageal fundus of the stomach. We now know that the fundus sphincter, esophageal acid and acid/alkaline exposure, and can be mobilized adequately and the patient can obtain a duodenogastric reflux. Ann Surg 1992; 216: 35–43. good result without division of the short gastric vessels, 3 Bowry, DJ, Peters JH. Current state, techniques, and results of as discussed earlier. Certainly, one can mobilize the fun- laparoscopic antireflux surgery. Semin Laparosc Surg 1996; 6: 194–212. dus posteriorly by dividing the posterior gastric attach- 4 Dallemagne B, Weerts JM, Jeahes C, Markiewics S. Results of ments. What is important is that minimal tension be laparoscopic Nissen fundoplication. Hepatogastroenterology 1998; placed on the fundoplication. 45: 1338–43. Much has been said about the results of preoperative 5 Spechler SJ. Veterans Affairs Gastroesophageal Reflux Disease esophageal motility. Again, by individualizing each Study Group. Comparison of medical and surgical therapy for complicated gastroesophageal reflux disease in veterans. patient, the history of possible dysphagia is much more N Engl J Med 1992; 326: 786–92. important to us than the fact that they can generate a 6 Triadafilopoulos G, Dibaise JK, Nostrant TT, et al. Radiofrequency pressure of 30 mmHg in the body of the esophagus, as it energy delivery to the gastroesophageal junction for the treatment relates to the decision to perform a complete or partial of GERD. Gastrointest Endosc 2001; 53: 407–15. fundoplication. 7 Filipi CJ, Lehman GA, Rothstein RI, et al. Transoral, flexible endoscopic suturing for treatment of GERD: a multicenter trial. Lastly, our tendency as surgeons often to adhere Gastrointest Endosc 2001; 53: 416–22. rigidly to tradition has made the question of performing 8 Finley CR, McKernan JB. Laparoscopic antireflux surgery at an the above procedures in an ambulatory surgical center a outpatient surgery center. Surg Endosc 2001; 15: 823–6. controversial issue. However, the outpatient setting is our 9 McKernan JB, Finley CR. Experience with optical trocar in preference in performing anti-reflux procedures (includ- performing laparoscopic procedures. Surg Laparosc Endosc Percutan Tech 2002; 12: 96–9. ing ‘redos’, para-esophageal hernias and Collis gastro- 10 O’Boyle CJ, Watson KI, Jamieson GG, et al. Division of short plasties). Available data support the fact that this can be gastric vessels at laparoscopic Nissen fundoplication. A prospective done with similar morbidity and mortality, as compared double-blind randomized trial with 5-year follow-up. Ann Surg with the inpatient setting. We feel strongly that a dedi- 2002; 235: 165–70. cated team approach is the single most important factor 11 Huntington TR. Laparoscopic mesh repair of the esophageal hiatus. J Am Coll Surg 1997; 184: 399–400. to the success of any advanced laparoscopic procedure. 12 Thor KB, Silander T. A long-term randomized prospective trial of The team must be composed of individuals who are both the Nissen procedure versus a modified Toupet technique. expertly trained and self-motivated in their respective Ann Surg 1989; 210: 719–24. 27

Para-esophageal hernias

HUGO BONATTI, BEATE NEUHAUSER AND RONALD A. HINDER

Treatment of para-esophageal hernias 201 Postoperative management 207 Preoperative management 202 Conclusion 208 Surgical procedure 203 References 208

Hiatal hernias are common disorders in the western pop- Indications for surgical repair ulation.1 The overall incidence of hiatal hernias has been reported to lie between ten and over 20 per cent.2 Hiatal PEH may occur with or without symptoms. PEH can hernias are categorized into four groups, as determined remain asymptomatic for long periods, but these patients by Hill and Tobias in 1968.3 Type I hiatal hernias, also require close observation.4 On closer examination, the known as sliding hiatal hernias, account for the most patient may eventually report distinct symptoms, such as common group (Ͼ80 per cent) and are characterized by coughing, chest pain or epigastric pain, which the patient a sliding herniation of the gastroesophageal junction may relate to other causes.5 The more common com- through the hiatus into the chest. Para-esophageal her- plaints associated with symptomatic PEH are dysphagia, nias (PEHs) account for the remaining three groups: gastroesophageal reflux (GER), epigastric pain, chest pain, type II represent a herniation of the fundus of the regurgitation and vomiting, shortness of breath, and stomach through the hiatus with a fixed gastroeso- coughing; there is also chronic anemia in up to 38 per cent phageal junction in the normal position; type III are the of patients with PEH.6,7 Symptomatic PEH is always an most common PEHs, and represent a combination of indication for elective surgical repair in order to avoid the type I and type II with a displaced gastroesophageal junc- potentially serious complications, such as acute strangulation as well as herniation of parts of the stomach into the tion, volvulus, massive hemorrhage, and perforation.8,9 chest; type IV are composed of a large PEH combined with a large hiatal defect containing not only the stomach Contraindications to surgical repair but also other intra-abdominal organs, such as colon or spleen. PEHs are observed more commonly in the elderly Patients with PEH are usually of an older age than population. In our series of 117 patients undergoing patients with type I hiatal hernias. A meticulous cardio- laparoscopic PEH repair, the median age was 68 years pulmonary investigation is necessary in most cases. One (range 39–95); 12 patients were over the age of 80 years. must bear in mind that symptoms consistent with PEH Sixty per cent of patients were female. in this population could also originate from cardiac or pulmonary disease.10 If these latter etiologies are TREATMENT OF PARA-ESOPHAGEAL excluded and the patient is fit for laparoscopy, then we do HERNIAS not see any major contraindications for the procedure, regardless of age. It has been shown that laparoscopic anti-reflux procedures can be performed safely in elderly The only curative treatment available for PEH is surgery. patients.11 We recently published a series of 30 octo- and The principles are complete reduction of the hernia from nonagenarian patients undergoing laparoscopic fundo- the chest, repair of the hiatal defect, and fundoplication. plication, with zero mortality.12 Although considered by 202 Laparoscopic treatment of diaphragmatic herniation some to be a contraindication to the procedure, we do PREOPERATIVE MANAGEMENT not hesitate to use a laparoscopic approach for recurrent PEH or in patients with a history of previous abdominal surgery.13 Anatomy/pathology Whereas GER symptoms are present in most patients Laparoscopic versus open approach with type I hiatal hernias, the presence of reflux in type II PEH is variable and dependent on the esophageal length A variety of studies have shown that the laparoscopic and function. Type III hernias are usually accompanied approach is as effective as the open approach in terms of by GER. The presence of dysphagia can be explained by recurrence rate and perioperative complications, if an the fact that the PEH tends to rotate along the long axis experienced laparoscopic surgeon carries out the pro- of the stomach, resulting in gastric volvulus, which can cedure.14–16 However, hospitalization was shorter after cause obstruction at the esophagogastric or gastroduode- laparoscopy and patients experienced less pain.17 Recent nal junction. In patients with a large type IV PEH, the studies based on symptomatic outcomes analyses have likelihood of pulmonary symptoms is greatest. Coughing, shown that the laparoscopic repair of large PEHs is safe, shortness of breath, asthma-like symptoms, and lower- successful, and equivalent to open repair.18 A disturbingly respiratory-tract infections result not only from recurrent high (42 per cent) prevalence of recurrent herniation fol- aspiration but also from compression of the lung by the lowing laparoscopic repair of type III hiatal hernias has intrathoracic mass. been reported recently in a single study.19 However, more than half of such recurrences had few, if any, symptoms, Preoperative testing and recurrence rates in other series were considerably lower.20 In our own series, we observed a recurrence rate A substantial number of PEHs are diagnosed incidentally of 15 per cent; there was no mortality.2 Other authors on thoracic radiography (Figure 27.1a). Usually, a gas have also concluded that the laparoscopic approach is bubble within the mediastinum – in most cases on superior to a transthoracic approach due to less pain the left side – can be observed. Preoperative evaluation and shorter hospitalization.2,17 Gastrostomy or gastropexy, includes a barium esophagogram (Figure 27.1b), upper- although suggested for high-risk patients, cannot provide intestinal endoscopy, esophageal manometry, and some- results comparable to surgical PEH repair.21 times 24-hour ambulatory pH monitoring. The lower

(a) (b) Figure 27.1 (a) Thoracic radiograph showing gas bubble within the chest as a result of a giant PEH. (b) Barium esophagogram showing large PEH (type III). The fundus of the stomach and the gastroesophageal junction are positioned above the diaphragm. Para-esophageal hernias 203

Figure 27.2 On CT scan, the PEH is seen in the posterior mediastinum anterior to the spine and to the right of the aorta. esophageal sphincter (LES) is considered incompetent if any of the following criteria are met: Figure 27.3 Trocar placement for laparoscopic PEH repair. • resting pressure less than 6 mmHg; • overall sphincter length less than 2 cm; • intra-abdominal sphincter length less than 1 cm. A computerized tomography (CT) scan can be of value in some cases in order to obtain optimal imaging of the hernia (Figure 27.2).

SURGICAL PROCEDURE

Operating room set-up

The patient is placed supine in the lithotomy position in the steep reversed Trendelenburg position. Full muscle relaxation is of major importance in order to create a Figure 27.4 After the ports are placed, the stomach is retracted good intra-abdominal working space. The laparoscopic to the left, exposing the large hiatal defect. procedure is performed using 5–11-mm ports in similar positions to those used for Nissen fundoplication (Figure 27.3). Instrumentation includes a zero-degree laparo- repair is to completely reduce the hernia contents (Figure scope, atraumatic graspers, a liver retractor, a small hook 27.4). Dissection is commenced by dividing the gastro- attached to the electrocautery, the harmonic scalpel, and hepatic ligament at its ﬂaccid part. The right crus is visual- two needle-holders. A nasogastric tube is inserted only if ized, and the hernia sac is divided along the free edge of the there is excessive gas within the stomach. hiatus. This is extended on to the left crus, ensuring that the sac is freed far posteriorly on the left (Figure 27.5). Operative technique Thereafter, the peritoneum is completely mobilized within the mediastinum and the sac is pulled caudally (Figures A transverse 1-cm incision is made above the umbilicus in 27.6 and 27.7). This can usually be achieved easily without the midline, the Veress needle is introduced, and a pneu- the need to divide any adhesions within the mediastinum. moperitoneum is created. After placement of the other Once the sac is reduced from the chest, it remains adherent ports, the abdomen is inspected. The ﬁrst step of PEH to the anterior surface of the stomach. Dissection in this 204 Laparoscopic treatment of diaphragmatic herniation

Figure 27.5 The peritoneum along the edge of the right crus is Figure 27.8 This dissection is continued from the right side divided. behind the esophagus but inferior to the left crus of the diaphragm.

Figure 27.6 The incision of the peritoneum along the crural edge allows access to adipose tissue in the posterior mediastinum, and the sac can be dissected easily out of the Figure 27.9 A window is created behind the esophagus, ﬁrstly mediastinum. inferior to the left crus and then superior to the left crus. This allows the esophagus to be separated completely from all of its crural attachments.

region should be carried out cautiously in order to avoid injury to the gastric or esophageal wall, blood vessels, or the left vagus nerve. The peritoneal sac may, however, be trimmed if it is very bulky. The esophagus can now be observed and elevated on a closed instrument (Figures 27.8 and 27.9). This allows for the creation of a window posterior to the esophagus, which can be freed further from its attachments in the mediastinum to achieve adequate length. Once there is sufficient esophageal length, the hiatus is reconstructed using two to ten interrupted nonabsorbable stitches, such as 0-Ethibond or Prolene (Ethicon, Inc.), depending on the size of the Figure 27.7 The peritoneal incision is continued far posterior defect (Figure 27.10). The first stitch should be placed on the left crus. This allows access to the connective tissue immediately above the point where the two crura join. behind the lower esophagus. Sufficient tissue should be included in the stitches to avoid Para-esophageal hernias 205

Figure 27.10 The hiatal defect is closed using interrupted nonabsorbable sutures. Figure 27.12 Fundic wrap being created using Prolene ‘U’- stitch with Teﬂon pledgets.

Figure 27.11 The hiatal closure is continued posterior to the esophagus until an adequate defect remains to easily accommodate the esophagus and its contents. Figure 27.13 The completed fundoplication with an additional tearing the muscle.A tension-free reconstruction should be silk suture placed inferior to the ‘U’-stitch to secure it in position. achieved. Stenosis of the hiatus around the esophagus must be avoided (Figure 27.11). The hiatal defect can be rein- (Figures 27.12 and 27.13). The decision as to which proce- forced with mesh, such as polypropylene, Marlex® dure to perform is based on preoperative esophageal motil- (BARD), Gore-Tex® DualMesh (W.L. Gore & Associates), ity. If a severe motility disorder was diagnosed, then a or denatured animal tissue (Surgisis ES®, Cook Surgical Toupet fundoplication is indicated. With the Nissen repair, Inc.) fixed to the diaphragm using metallic staples or the fundoplication should be tacked to the diaphragm stitches. The mesh measures about 4 ϫ 5 cm; it is cut with on either side to prevent recurrence of a sliding hernia. a keyhole to enclose the esophagus and is overlapped pos- Gastrophrenic anchorage can be added by suturing the teriorly. The mesh is placed on the hiatal musculature. We peritoneum of the hernia sac to the diaphragm. prefer to use Surgisis, which is absorbable and soft. It is less desirable to use a nonabsorbable material adjacent to the Operative pitfalls esophagus, which has the potential for erosion into the lumen or stricture formation. Following repair of the hiatal Para-esophageal hernia repair in patients with defect, the short gastric vessels are divided using the har- previous abdominal surgery monic scalpel (Ethicon Endosurgery, Inc.). The procedure is completed by a fundoplication, which can be performed An increasing number of PEHs are seen in patients as a 360-degree Nissen or a 270-degree Toupet procedure who have undergone previous surgery. As in other 206 Laparoscopic treatment of diaphragmatic herniation laparoscopic procedures, insertion of ports can be diffi- Large defects at the hiatus cult, and placement at non-standard sites might be neces- In some patients, the defect at the hiatus is too large to be sary. If a previous midline incision is present, then the closed primarily. This occurs most frequently in type IV Veress needle can usually be placed safely in the left sub- hernias. In other cases, the fibrous tissue at the hiatus in costal area. After division of adhesions between the pari- this elderly patient population is not compliant and cannot etal peritoneum and intra-abdominal organs, placement be approximated adequately. This can result in large dis- of the other trocars can be achieved. Occasionally, patients secting tears in the crura, which must be managed by the must undergo PEH repair following an unsuccessful anti- use of mesh (Figures 27.14–27.16). These patches should reflux operation. Dissection of the left liver lobe from the be cut with a keyhole defect and positioned to lie circum- stomach and diaphragm can be particularly difficult in ferentially around the esophagus. The keyhole technique these cases. Nevertheless, in ‘redo’ operations, conversion allows for overlapping of the mesh posteriorly. There is to laparotomy is required rarely.22,23 the risk of erosion of the mesh into the esophagus if nonabsorbable materials are used. They must be attached to Left accessory or replaced hepatic artery the diaphragm using staples or interrupted sutures. Some These arteries originate from the left gastric artery and authors suggest the universal use of such patches to allow 25 are found in up to 25 per cent of patients. Some accessory for tension-free repair. Diaphragmatic stitches placed arteries are small and can be divided without conse- anterior to the esophagus have been suggested to close quence; however, large vessels suggest that there is com- large defects; however, tension is usually even greater in plete replacement of the arterial blood supply to the left this area. Others have used a relaxing incision made lateral lateral liver segments. If this is suspected, the vessel should be preserved intact in order to avoid ischemic damage of the biliary tree.24

Tearing and perforation of stomach and esophagus This is best avoided by gentle handling of tissues in these elderly patients. However, surrounding tissues can be rather ﬁbrotic and sharp dissection might be necessary. Small serosal tears can be oversewn and should be included in the fundoplication site whenever possible. Transmural injuries of the esophagus and stomach can be repaired laparoscopically using a stapling device. Intraoperative endoscopy can be helpful to make sure that the defect is closed completely.

Type IV hernias Figure 27.14 Giant hiatal defect with a tear in the right crus These hernias can contain colon or the spleen. Injuries to after failed primary closure. the spleen may result in major hemorrhage. Closure of the defect can be particularly difﬁcult in these patients. Postoperative use of incentive spirometry is of importance to avoid atelectasis and pneumonia.

Pneumothorax This occurs more frequently on the left side and can result in a symptomatic pneumothorax. When this occurs, the intra-abdominal gas pressure should be decreased to avoid a tension pneumothorax. Should the latter occur, conversion to an open procedure may be necessary. A chest tube can be used to alleviate the tension in the pneumothorax if necessary. Generally, however, most cases do not require a chest tube, as the gas in the pleural space may be expelled by forceful lung inflation at the time of release of the pneumoperitoneum. Figure 27.15 Closure of the large defect using a Gore-Tex patch. Para-esophageal hernias 207 to the esophageal hiatus with primary closure of the hiatus mobilization.6 In most cases, dissection of the esophagus and mesh repair of the relieving incision. far up into the mediastinum allows for adequate mobilization. Dissection can be performed as high as the Hernia sac bronchial bifurcation. If adequate intra-abdominal length of the esophagus without tension cannot be Some controversy exists as to whether to excise the sac or obtained, then an esophageal-lengthening procedure, 26 mobilize it fully with complete excision. We feel that a such as Collis gastroplasty, followed by a fundoplication remnant of the sac in the mediastinum might cause an should be performed. This can be achieved laparoscop- effusion or lead to recurrent herniation. We always mobi- ically, but in our opinion the best approach for this pro- lize the sac completely from the mediastinum. On dissec- cedure is through the chest. Hashemi and colleagues have tion, care must be taken not to injure the esophagus, reported the need for thoracotomy in over 33 per cent of stomach, vagus nerve, or blood vessels. The sac is left cases.27 A novel approach for esophagus lengthening has anterior and to the left of the cardia and can be used as a been suggested by Champion and coworkers (personal plug to help avoid recurrent herniation of the stomach. communication, 2002): they laparoscopically flap the fundus of the stomach to the right and then carry out a Division of short gastric vessels stapled fundectomy to a point 3 cm inferior to the angle It is our preference that the short gastric vessels are of His. This is then stapled off along the left side of the divided along the upper 10 cm of the greater curvature of esophagus, achieving a Collis gastroplasty (see Chapter 26). the stomach to allow for a tension-free wrap. In most cases, these vessels have been stretched by the gastric Para-esophageal hernia repair in obese patients herniation, allowing the fundus to be brought behind In obese patients there may be excessive fat in the opera- the esophagus easily and without tension. tive field, and/or the left lateral liver segments may be very large. This might hinder retraction of the liver. Such Possible kinking of the esophagus fatty livers are rigid and the capsule can be injured easily, Following the posterior approximation of the crura, the resulting in hemorrhage. Local appliance of argon-beam esophagus might be forced anteriorly, causing kinking coagulation or electrocautery may be used, followed by and obstruction as it rides up and into the hiatus. This insertion of a collagen plug to control such hemorrhage. has been observed occasionally as a kink on a barium esophagogram, but there are seldom any observed symp- POSTOPERATIVE MANAGEMENT toms related to such a kink in the follow-up of our patients. In general, we do not place a nasogastric tube. For the Short esophagus majority of patients, this represents an unnecessary incon- venience and is tolerated poorly. Patients are encouraged In type III hernias, insufficient intra-abdominal length of to ambulate early and to use incentive spirometry. A gas- the esophagus has been reported following attempted trografin esophagogram is performed only if the dissection was difficult and in the presence of symptoms such as excessive pain, vomiting or fever. During the first 24 hours after surgery, pain control is achieved satisfacto- rily using oral analgesics. We prefer to use paracetamol (acetaminophen) elixir; however, any synthetic opioid, tramadol or non-steroidal anti-inflammatory drug can be used. Metoclopramide or ondansetron are our preferred antiemetic drugs. Retching and vomiting must be suppressed in order to avoid stress on the repaired hiatus and the fundoplication. Patients are started on a liquid diet on the night following surgery and advanced to a pureed diet, as tolerated. Fresh bread and meat should be avoided for about three weeks. A normal diet is usually achieved within six weeks following surgery. We have now completed 120 laparoscopic repairs of large PEH with zero mortality and a 15 per cent recurrence rate. These recur- Figure 27.16 Closure of a large defect using a polypropylene rences are usually asymptomatic type I hernias. Others mesh. reported higher rates of mortality (three per cent28) and 208 Laparoscopic treatment of diaphragmatic herniation morbidity (30 per cent29). Dahlberg and colleagues28 and 7 Moskovitz M, Fadden R, Min T, et al. Large hiatal hernias, anemia, Trus and colleagues29 also report the need for conversion and linear gastric erosion: studies of etiology and medical therapy. Am J Gastroenterol 1992; 87: 622–6. to an open procedure in 1.3–5.4 per cent of cases. We feel, 8 Maruyama T, Fukue M, Imamura F, Nozue M. Incarcerated however, that with adequate experience, these rates of paraesophageal hernia associated with perforation of the morbidity and mortality should be reduced. fundus of the stomach: report of a case. Surg Today 2001; 31: 454–7. 9 Nattakom T, Schuerer D, Batra S, et al. Emergency laparoscopic repair of a paraesophageal hernia. Surg Endosc 1999; CONCLUSION 13: 75–6. 10 Richter JE. Noncardiac (unexplained) chest pain. Curr Treat Options Gastroenterol 2000; 3: 329–34. Currently, the only effective treatment available for PEH 11 Kamolz T, Bammer T, Granderath FA, et al. Quality of life and is surgery. This is successful in most cases if appropriate surgical outcome after laparoscopic antireflux surgery in the principles of operative therapy are followed. Surgical elderly gastroesophageal reflux disease patient. Scand J reduction of the hernia results in the relief of dysphagia Gastroenterol 2001; 36: 116–20. in 91 per cent of patients. The principles of PEH repair 12 Bammer T, Hinder RA, Klaus A, et al. Safety and long term outcome of laparoscopic antireflux surgery in patients in their include reducing the stomach, mobilizing the hernia eighties and older. Surg Endosc 2002; 16: 40–42. sac from the mediastinum, effectively closing the hiatus, 13 Neuhauser B, Hinder RA. Laparoscopic reoperation after failed and achieving a sufficient gastropexy. Open repair using antireflux surgery. Semin Laparosc Surg 2001; 8: 281–6. laparotomy or thoracotomy was the standard procedure a 14 Freeman ME, Hinder RA. Laparoscopic paraesophageal hernia decade ago. The development of laparoscopic anti-reflux repair. Semin Laparosc Surg 2001; 8: 240–5. 15 Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000; surgery has stimulated interest in laparoscopic para- 80: 1243–52. esophageal hiatal hernia repair. Minimally invasive tech- 16 Buenaventura PO, Schauer PR, Keenan RJ, Luketich JD. niques today offer a better treatment option with lower Laparoscopic repair of giant paraesophageal hernia. Semin Thorac risk. Laparoscopic repair of PEH is safe, technically feasi- Cardiovasc Surg 2000; 12: 179–85. ble, and well tolerated, with rapid relief of symptoms. The 17 Oelschlager BK, Pellegrini CA. Paraesophageal hernias: open, laparoscopic, or thoracic repair? Chest Surg Clin North Am 2001; laparoscopic approach allows for excellent visualization 11: 589–603. of the hiatus and superior esophageal mobilization, with 18 Basso N, Rosato P, De Leo A, et al. ‘Tension-free’ hiatoplasty, significantly less surgical insult to this often aged and gastrophrenic anchorage, and 360 degrees fundoplication in the debilitated patient population. PEH repair remains a laparoscopic treatment of paraesophageal hernia. Surg Laparosc challenging surgical procedure. We feel that an anti-reflux Endosc Percutan Tech 1999; 9: 257–62. 19 Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of procedure is necessary because the LES is mobilized large type III hiatal hernia: objective followup reveals high extensively during the dissection and is likely to be recurrence rate. J Am Coll Surg 2000; 190: 553–60, 560–1. incompetent as a result. This does not add significantly to 20 Edye MB, Canin-Endres J, Gattorno F, Salky BA. Durability of the time required for this operation, and it provides an laparoscopic repair of paraesophageal hernia. Ann Surg 1998; excellent anchoring mechanism for the stomach on to the 228: 528–35. 21 Kercher KW, Matthews BD, Ponsky JL, et al. Minimally invasive diaphragm. We consider laparoscopic PEH repair with management of paraesophageal herniation in the high-risk Nissen fundoplication to be the procedure of choice in surgical patient. Am J Surg 2001; 182: 510–14. appropriately selected patients with PEH. 22 Seelig MH, Hinder RA, Klingler PJ, et al. Paraesophageal herniation as a complication following laparoscopic antireflux surgery. J Gastrointest Surg 1999; 3: 95–9. 23 Floch NR, Hinder RA, Klingler PJ, et al. Is laparoscopic reoperation REFERENCES for failed antireflux surgery feasible? Arch Surg 1999; 134: 733–7. 1 Ilves R. Hiatus hernia. The condition. Chest Surg Clin N Am 1998; 24 Edoga JK, Willekes CL. Laparoscopic fundoplication and the 8: 401–9. aberrant left hepatic artery. Arch Surg 1997; 132: 448–9. 2 Perdikis G, Hinder RA, Filipi CJ, et al. Laparoscopic paraesophageal 25 Hui TT, David T, Spyrou M, Phillips EH. Mesh crural repair of large hernia repair. Arch Surg 1997; 132: 586–9, 590–1. paraesophageal hiatal hernias. Am Surg 2001; 67: 1170–4. 3 Hill LD, Tobias JA. Paraesophageal hernia. Arch Surg 1968; 96: 26 Athanasakis H, Tzortzinis A, Tsiaoussis J, et al. Laparoscopic repair 735–44. of paraesophageal hernia. Endoscopy 2001; 33: 590–4. 4 Allen MS, Trastek VF, Deschamps C, Pairolero PC. Intrathoracic 27 Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of stomach. Presentation and results of operation. J Thorac large type III hiatal hernia: objective follow-up reveals high Cardiovasc Surg 1993; 105: 253–8, 258–9. recurrence rate. J Am Coll Surg 2000; 190: 553–60. 5 Akdemir I, Davutoglu V, Aktaran S. Giant hiatal hernia presenting 28 Dahlberg PS, Deschamps C, Miller DL, et al. Laparoscopic repair of with stable angina pectoris and syncope – a case report. Angiology large paraesophageal hiatal hernia. Ann Thorac Surg 2001; 72: 2001; 52: 863–5. 1125–9. 6 Hashemi M, Sillin LF, Peters JH. Current concepts in the 29 Trus TL, Bax T, Richardson WS, et al. Complications of management of paraesophageal hiatal hernia. J Clin Gastroenterol laparoscopic paraesophageal hernia repair. J Gastrointest Surg 1999; 29: 8–13. 1997; 1: 221–8. 28

Traumatic and unusual herniation

SERGIO G. SUSMALLIAN AND ILAN CHARUZI

Diaphragmatic injuries 209 Surgical treatment of chronic diaphragmatic injuries 213 Acute diaphragmatic herniation 210 Conclusion 214 Surgical treatment of acute diaphragmatic injuries 211 References 215 Chronic diaphragmatic hernia 212

The diaphragm is a thin muscle with a full-time job. It colon through a small defect in the diaphragm. In 1853, is innervated by the ipsilateral phrenic nerve and has Bowditch became the first physician to diagnose a post- an abundant blood supply.1 The anatomical role of the traumatic diaphragmatic hernia in vivo.11 In 1886, Riolfi diaphragm consists of dividing the two large cavities of performed the first repair of a diaphragmatic herniation the human body and maintaining its different pressures.2 after a stab wound,12 while Walker in 1900 was the first sur- Its presence separates and contains the viscera of the geon to repair a diaphragmatic hernia after blunt trauma.13 abdominal and thoracic cavities. The symptoms related The aim of this chapter is to provide a clear concept of to diaphragmatic injuries are caused by the incapacity to the various diaphragmatic lesions and the approaches for contain the abdominal viscera in the cavity favored by successful diagnosis and treatment. the pressure gradient.1 During inspiration, the diaphragm contracts physiologically, acquiring a flat shape. During expiration, it DIAPHRAGMATIC INJURIES relaxes passively and acquires a dome shape. This concept is important for understanding and diagnosing diaphragmatic injury in the various chest and abdominal Injuries of the diaphragm can be classified into two levels of penetrating trauma. groups: acute and chronic. Acute injuries (from blunt or Diaphragmatic injury is not common, but its inci- penetrating trauma) detected in the first 24 hours are dence has increased over the past few years, probably called ‘early diagnosed’; after the first 24 hours, they are because of the increased frequency of high-speed motor- called ‘delayed diagnosed’. If the diaphragmatic lesion vehicle accidents.3–5 Additionally, early recognition has was missed in the acute phase, then the second latent become more feasible with the diagnostic procedures that phase occurs. In this variable time (months to years), the are now available. It is also conceivable that early recogni- injury may be asymptomatic. The chronic phase begins tion of signs and symptoms of a possible diaphragmatic with the appearance of symptoms related to the hernia- injury can result in the correct treatment being given, so tion of the abdominal viscera into the thoracic cavity. avoiding chronic injuries. The diagnosis of diaphragmatic This, in turn, will affect respiratory patterns or cardio- injury is influenced strongly by the severity of the associ- vascular performance or cause digestive symptoms, ated lesions.6–8 such as gastric distention, gastric or colonic obstruction, Sennertus in 1541 was the first to report a diaphrag- volvulus, and perforation.14–17 Each of the three phases matic injury, in a postmortem examination.9 He described of diaphragmatic injury has a relevant importance in the a strangulated stomach herniated through a left diaphrag- operative strategy decision. matic defect seven months after a stab wound. In 1579, Paré The early-diagnosed acute phase accounts for about described the consequences of diaphragmatic herniation in 90 per cent of diaphragmatic injuries. These patients will blunt and penetrating injuries.10 He found a strangulated typically have associated injuries and are treated by the 210 Laparoscopic treatment of diaphragmatic herniation open approach.18 Delayed-diagnosed acute injuries differ Abdominal contents were found to invade the thorax from early-diagnosed injuries in that patients with the in 58 per cent of patients with a left-sided diaphragmatic former are generally more stable and have fewer severely tear and in 19 per cent with a right-sided defect. These associated injuries. In this subgroup of acute patients, findings can be explained by the presence of the liver in laparoscopic approach and repair can be achieved.19–21 the upper right abdominal cavity, thereby protecting the Laparoscopic treatment for chronic diaphragmatic herni- passage of the viscera. Because of this anatomical differ- ation is quickly becoming widely accepted and performed. ence, patients with a right-sided tear are generally injured more severely than those with a tear on the left side.18 ACUTE DIAPHRAGMATIC HERNIATION Boulanger and colleagues showed that the mean Glasgow Coma Scale was 8 for patients with right diaphragmatic tear compared with 11 for those with left diaphragmatic The etiology of diaphragmatic injuries can be classified tear.18 Patients with a right diaphragmatic injury had as penetrating or blunt trauma. Diaphragmatic injury more significant amounts of blood loss than patients with in trauma patients is not uncommon: its incidence injuries elsewhere in the diaphragm. is 0.8 per cent of all trauma patients admitted, 5 per cent The injuries associated with blunt diaphragmatic of all blunt abdominal traumatic admissions, and 9.5 trauma are shown in Table 28.1.29–31 The figures shown in per cent of all thoracoabdominal penetrating trauma this table indicate that hemothorax occurs in 78.5 per cent admissions.8,22,23 of patients with blunt trauma. Table 28.2 outlines the over- Penetrating diaphragmatic hernia during thoraco- all rate of abdominal injuries associated with blunt trauma. abdominal trauma, such as in shotgun wounds, has a The overall mortality rate in the blunt diaphragmatic different incidence of severity. This massive destructive injuries group of patients is 16–20 per cent, depending on effect requires laparotomy or thoracotomy and laparotomy the associated injuries. Bilateral rupture of the diaphragm to repair visceral or vascular damage. Stab wounds and is associated with the highest rate of mortality, followed iatrogenic diaphragmatic injuries are usually less severe, by traumatic rupture of the right hemidiaphragm. and if vascular penetration is ruled out laparoscopic repair Intrapericardial diaphragmatic rupture is a rare condition is feasible. Blunt trauma is more common in motor-vehicle that can mimic cardiac tamponade during the acute diag- accidents, especially during high-speed impact.7,24 nosed phase of herniation; most commonly, it is the stom- The physiological pressure of the abdominal cavity ach that protrudes into the pericardium.32–34 varies from 4 to 20 cm of water, and it can climb to Posterior rupture of the diaphragm is an infrequent 100 cm of water during a forced inspiration. Elevation of lesion that can compromise the crura and the hiatus.35 the abdominal pressure up to 400 cm of water occurring Recently, we had the opportunity to treat a patient with a during motor-vehicle accidents can explain the rupture known hiatal hernia after a motor-vehicle accident. He of the diaphragm and the herniation of the viscera into presented with a posterior transverse rupture of the the thorax, which has a negative pressure (Ϫ2 to Ϫ10 cm of water). Blunt diaphragmatic injury is seen more fre- Table 28.1 Injuries associated with blunt trauma quently after motor-vehicle accidents than after pedes- trian or motorcycle accidents or falls from great heights. Injury Percentage During blunt trauma, the rupture of the diaphragm can Hemothorax 78.5 occur in the right, left or both sides, the central tendinous Rib fracture 51 area (opening into the pericardium), or into the posterior Pelvic fracture 46 area, thereby compromising the hiatus. Diaphragmatic Extremity fracture 40 injury is an indicator of an impact with high-energy Pneumothorax 28 transmission. Spinal fracture 16.5 Each of the affected areas demonstrates differing charac- Thoracic aortic tear 7 teristic features. In 80 per cent of cases the trauma results in herniation through the left side of the diaphragm, 15 per cent affect the right side, and in five per cent both sides are Table 28.2 Overall rate of abdominal injuries in blunt trauma affected.18 Rupture of the diaphragm is effected, generally, Abdominal injury Percentage by an impact that occurs on the ipsilateral side of the injury.25 An associated injury has been reported in 90 per Liver 63.5 cent of patients with diaphragmatic tear. Mortality varies Spleen 51 between three and 30 per cent, and depends upon the sever- Hollow viscus 25.5 ity of the trauma and associated injuries. The differences Kidney 11 Bladder 9 between right and left side on admission were well defined Pancreas 6.5 in the literature.26–28 Traumatic and unusual herniation 211 diaphragm, which included a total avulsion of the right diaphragm and discontinuity of the diaphragmatic edge. crura. A primary repair by open approach was per- On the right side, ultrasonography can be sensitive to formed, and the crura was sutured with non-absorbable detection of diaphragmatic rupture with liver herniation. sutures. In these cases, esophageal perforation must be Spiral computerized tomography (CT) and magnetic res- ruled out either before (with preoperative testing) or onance imaging (MRI) are the most accurate diagnostic during operation by irrigation with saline solution or methods for finding diaphragmatic ruptures.38,39 Diag- methylene blue solution through a nasogastric tube. nostic peritoneal lavage (DPL) is a controversial tool for Manifestations of diaphragmatic injury during the diagnosing diaphragmatic injury.1 DPL in the presence of acute phase depend upon the severity of pulmonary isolated diaphragmatic injury may be falsely negative, and compromise and the associated clinical manifestations. the positive results depend upon the status of the abdom- The symptoms of thoracic pain referred to the scapula, inal viscera. dyspnea, and decreased breath sounds are present in Laparoscopy and thoracoscopy are the best invasive more than 70 per cent of these patients. Specific symp- techniques for diagnosing diaphragmatic lesions and toms of diaphragmatic rupture may be absent in 25–37 eventual treatment of the rupture.40–42 However, the diag- per cent of the patients.36 Abdominal tenderness, disten- nosis and treatment of this problem can also be accom- sion and rebound can also be present. Almost half of plished with the use of a thoracotomy and/or laparotomy the victims are admitted to the emergency room with when necessary. symptoms of shock. Following historical and physical examination, the initial assessment of a trauma patient with suspected SURGICAL TREATMENT OF ACUTE diaphragmatic injury should be a chest radiograph. DIAPHRAGMATIC INJURIES However, the ability of the chest X-ray to demonstrate a diaphragmatic injury varies from 37 to 50 per cent.37 Direct signs of diaphragmatic rupture on chest X-ray are When diaphragmatic injuries are diagnosed, repair is visceral herniation, indistinct diaphragmatic lines, eleva- mandatory. If, during the acute phase, early diagnosis is tion of the diaphragm, and position of a nasogastric tube confirmed, then the approach to the repair must be dic- within the thorax (Figure 28.1). Indirect signs of dia- tated by any associated injuries. Generally in this case, phragmatic injury on chest X-ray are rib fractures, sternal laparotomy will be the preferred method to treat addi- fracture, pneumothorax, hemothorax, lung contusion, tional visceral injuries. The repair of the diaphragm will atelectasis, gastric dilation, and subcutaneous air. usually be accomplished with simple suturing of the 43 Ultrasonography can demonstrate diaphragmatic defect with nonabsorbable sutures in one or two layers. rupture by the presence of fluids above and below the If the diaphragmatic injury is isolated or the associated damages allow a laparoscopic approach, then the repair can be performed easily with the advantage of good visualization, even in the posterior areas.

Operative technique

The patient is placed in lithotomy and Fowler’s position. Some surgeons prefer to stand on the right side of the patient, with the patient supine. In the former approach, the surgeon stands between the legs of the patient. The first assistant is positioned on the left side of the patient and the second assistant is on the right of the patient. A pneumoperitoneum using carbon dioxide is obtained by introducing a Veress needle in the left subcostal midclavicular line at low pressure, such as 12 mmHg. The use of high-pressure insufflation (15 mmHg or higher) must be avoided in trauma patients. High abdominal pressure can reduce the venous return by 30 per cent, and the patient could became hemodynamically unstable. One 10-mm trocar is introduced supraumbilically where a 30-degree laparoscope is placed. It is important to Figure 28.1 Chest X-ray, showing nasogastric tube in the left remember that in obese patients, this first trocar must be thorax after trauma. introduced in a slightly higher position between the 212 Laparoscopic treatment of diaphragmatic herniation

(ePTFE) prosthetic biomaterial. Polypropylene mesh can also be used to close these defects, but severe adhesions to the adjacent viscera can develop, especially to the splenic flexure of the colon. Additionally, polypropylene mesh should be used carefully when it is fixed in the proximity of the esophagus due to the possibility of erosion. If contaminated fluids are found in the abdominal cavity, then the use of nonabsorbable material is not advised. In these cases, an absorbable material such as Dexon or Vicryl mesh is preferred. Another unusual type of diaphragmatic injury is that of posterior rupture, which can compromise the hiatus. We recommend that this injury is repaired with a procedure that restores the normal anatomy, such as restoration of the crura by nonabsorbable sutures. The area of repair is then reinforced by placing an ePTFE mesh around the 10 mm trocar esophagus in either a ‘U’- or ‘O’-shape, depending on the 5 mm trocar size of the defect. The ePTFE patch is then attached to the diaphragm with titanium spiral tacks posterior to the Figure 28.2 Schematic position of trocars for laparoscopic esophagus and to the crura (using special care not to treatment of diaphragmatic herniation. injure the aorta). Lateral and anterior to the esophagus, the fixation of biomaterial should be performed with umbilicus and the xiphoid process. Another 11- or 12-mm sutures or an endo-stapler. Regardless of the method of trocar is introduced in the left upper quadrant, higher than choice, one must be careful in the tendinous area to avoid the first one, in the midclavicular line, with direct visuali- penetration of the myocardium. In our experience, we zation with the laparoscope. A third trocar (5 mm) is have demonstrated by echocardiogram one case of peri- placed in the left upper quadrant subcostally. The place- cardial effusion after laparoscopic repair of a diaphrag- ment of two more trocars is optional, one for liver retrac- matic hernia induced by a stapler in the pericardial area. tion in the subxiphoid area and one in the left flank for Intrapericardial rupture of the diaphragm is rare, retraction (Figure 28.2). The herniated abdominal viscera with fewer than 60 cases having been reported in the are returned gently into the abdominal cavity using atrau- literature.32–34 Generally, these were long, transverse matic graspers. Any devitalized tissue that is found along wounds that occurred during blunt abdominal trauma. the edge of the laceration should be debrided. The defect CT and echocardiography were used for diagnosis.44 is then sutured with endo-stitches. These can be made Primary suture is recommended in these cases. The free-hand or placed with a device designed to suture myocardium must be protected from injury, which could laparoscopically. occur at the time of repair. If the defect is greater than 4 cm in diameter, then a reinforcement of the suture line can be done with an onlay CHRONIC DIAPHRAGMATIC HERNIA of absorbable mesh, such as braided Dexon® (U.S. Surgical Corp.) or Vicryl® knitted mesh (Ethicon, Inc.), fixing it to the diaphragm with endo-staplers. We believe that the Diaphragmatic injury represents one of the most com- placement of such prostheses can help to relieve any exces- monly missed pathologies in trauma patients.1 Undetected sive tension on the suture line if the patient develops high acute diaphragmatic injuries begin as small lacerations abdominal pressure or abdominal compartment syndrome without associated serious damage. During the post- in the immediate postoperative period. traumatic phase, the positive abdominal pressure causes Treatment of diaphragmatic rupture when diagnosis the viscera to herniate into the pleural space, resulting in an is delayed (more than 24 hours) differs from treatment increase in the size of the diaphragmatic defect.6,45,46 during the early diagnosis phase because of the greater Because of a delay in diagnosis, only ten per cent possibility of failure of primary repair due to tension of diaphragmatic hernias are diagnosed in the acute on the suture line. In this condition, the fibers of the phase. Consequently, 90 per cent of these injuries become diaphragm are contracted. Primary suture of the defect chronic.47 The time interval to diagnosis varies from will be performed under tension, thereby increasing the months to years and depends upon the appearance of possibility of recurrence. symptoms after the latent phase. The size of the original We prefer to treat these defects with nonabsorbable disruption, localization (left, right, central or posterior), material, such as an expanded polytetrafluoroethylene and content can influence the development of pulmonary Traumatic and unusual herniation 213

Figure 28.3 Left chronic diaphragmatic hernia after stab wound three years previously. Figure 28.4 Right chronic hernia: the entire liver, stomach and hepatic ﬂexure of the colon were reduced from the right thorax. or abdominal symptoms. An acute presentation with signs and symptoms of incarceration or obstruction can be the initiating event for the patient (Figure 28.3).17,48 Perforation or necrosis are serious complications that make the emergency repair of these diaphragmatic hernias a life-saving procedure. In such cases, two-stage repairs should be considered. Work-up should include a simple chest X-ray, which can make a diagnosis in 73 per cent of cases with chronic herniation on the left side. Spiral CT is most useful for diagnosis of right-sided herniation in which an indirect sign of herniation can be identiﬁed by an abnormal position of the liver. CT can also help to identify the content of the herniation. MRI is the preferred and the most sensitive diagnostic method for identifying missed diaphragmatic injuries.49

SURGICAL TREATMENT OF CHRONIC Figure 28.5 Diaphragmatic hernia repair with ePTFE mesh by DIAPHRAGMATIC INJURIES laparoscopy. pressure of 15 mmHg. Some surgeons prefer a lateral posi- The diaphragm is a muscle, and its insertions are around tion of the surgeon and the use of one of the optical view- the inferior chest wall. Physiologically, the injured muscle ing trocars. experiences eccentric retraction, with a tendency to A supraumbilical trocar is inserted for the introduc- increase the diameter of the edges. The muscle can also tion of a 30-degree scope (5- or 10-mm). One 11-mm undergo atrophy. Therefore, primary repair in chronic trocar is then inserted in the left upper quadrant at the defects has a high index of failure, with subsequent lateral border of the rectus abdominis muscle under recurrence of the hernia. Additionally, the diaphragmatic vision to avoid injury to the epigastric vessels. Two more hernia does not have a sac, unlike the classical concept of 5-mm trocars are used, one on the right abdominal side the more commonly seen hernias (Figures 28.4 and 28.5). subcostally, and one in the left flank for the assistant. One The choice between the two methods of repair, thora- more 5-mm trocar can be inserted in the epigastrium for coscopic or laparoscopic, is the object of debate.50–53 We liver retraction if this is necessary. strongly recommend an abdominal approach, which pro- Meticulous adhesiolysis is the first step in the repair, vides for better management of the adhesions and abdom- avoiding injury to any viscus. Careful reduction of the inal viscera. The technique includes placing the patient in hernia contents from the pleural space to the abdominal the lithotomy position and carrying out abdominal insuf- cavity is performed during this dissection. A complica- flation through a Veress needle with carbon dioxide at a tion, such as a perforation, during these procedures can 214 Laparoscopic treatment of diaphragmatic herniation

can be performed using ePTFE mesh fixed by nonabsorbable sutures alone to avoid injury to the myocardium. The complicated diaphragmatic hernia is an emergency and is associated with high mortality and morbidity rates. The herniorrhaphy can be a life-saving procedure. Complicated cases, such as those associated with bowel injury or severe bleeding in an unstable patient, can be treated in relation with the affected viscous, such as primary suture or exteriorization of the injured bowel, and the definitive repair delayed. Contamination is a contraindication for definitive repair. Treatment during an acute presentation consists of the management of the compromised viscera (reduction, resection, colostomy, etc.). The defect in the diaphragm is closed by primary suture if possible or (in our experience) with absorbable mesh if there is a devitalized area of the diaphragm. In the latter case, definitive treatment is delayed for three months and then performed laparoscopically.

Figure 28.6 Chronic diaphragmatic hernia, showing part of the CONCLUSION stomach in the left chest. The presentation of this patient was incarceration of the stomach. Traumatic diaphragmatic hernia is an indicator of the severity of injury in blunt trauma patients, who have high contaminate the operative field. The retracted edges of rates of mortality and morbidity. Penetrating trauma of the laceration must be identified and cleared from the the diaphragm is generally a smaller injury of the adhesions. The definitive repair is then performed with diaphragm but is usually associated with injury of vital nonabsorbable mesh materials. organs of the chest and abdomen. During blunt trauma of We use either ePTFE mesh as the sole prosthesis or the diaphragm, the injury is a long tear caused by the high polypropylene mesh placed on to the diaphragm, which pressure of the forces originated. Preoperative diagnosis is then covered by an ePTFE mesh to avoid contact of diaphragmatic injuries in trauma patients is low between the polypropylene and the viscera (Figure 28.6). (39 per cent) and missed injuries are seen in ten per cent. We recommend an overlap of the mesh size of at least Acute repair can be performed by laparoscopy in stable 3 cm. The mesh is folded into a cylindrical shape and patients without severe associated injuries. The technique introduced into the abdominal cavity through the lumen includes primary repair with separate stitches using a of the 11-mm trocar. nonabsorbable material. After unfolding the mesh in the abdominal cavity, fix- Delayed diagnosis (more than 24 hours) and chronic ation commences in the posterior muscular diaphragm diaphragmatic hernias require prosthetic repair with non- with titanium spiral tacks. In the lateral, central and absorbable mesh, fixed to the diaphragm with titanium anterior portions, we use several interrupted nonab- spiral tacks, sutures and/or EMS staples. If incarceration is sorbable sutures and EMS staples. For a posterior lacera- present without contamination and the reduction can be tion mimicking a para-esophageal hernia, the repair performed without complication, then the repair will be consists of a total reduction of the stomach and dissec- similar to that seen in chronic diaphragmatic hernia. tion of the crura. In these cases, a sac may be present if During strangulation, life-saving procedures must be the patient had a hiatal hernia before the injury; removal performed, such as resection, colostomy, or feeding tubes. of the sac, if present, is recommended. The hiatus is In this situation, absorbable materials are recommended repaired by closure of the crura posterior to the esopha- as a means to effect a temporary repair until definitive gus with endoscopic sutures. repair is possible. After completion of the sutured repair, we reinforce the site with mesh. In the proximity of the esophagus, the use of ePTFE mesh is recommended. Because a repair in REFERENCES this area of the diaphragm must include the esophagus, the ePTFE mesh must be cut into either an ‘O’- or a 1 Schumpelick V, Steinau G, Schluper I, Prescher A. Surgical ‘U’-shape. If an intrapericardial hernia is present in the embryology and anatomy of the diaphragm with surgical tendinous area of the diaphragm, then a meticulous repair applications. Surg Clin North Am 2000; 80: 213–39. Traumatic and unusual herniation 215

2 Feliciano DV, Moore EE, Mattox KL. Trauma, 3rd edn. Stamford: 29 Lee WC, Chen RJ, Fang JF, et al. Rupture of the diaphragm after Appleton & Lange, 1996: 461–85. blunt trauma. Eur J Surg 1994; 160: 479–83. 3 Rubikas R. Diaphragmatic injuries. Eur J Cardiothorac Surg 2001; 30 Jackimczyk K. Blunt chest trauma. Emerg Med Clin North Am 1993; 20: 53–7. 11: 81–96. 4 Simpson J, Lobo DN, Shah AB, Rowlands BJ. Traumatic 31 Meyers BC, McCabe CJ. Traumatic diaphragmatic hernia. Occult diaphragmatic rupture: associated injuries and outcome. Ann R marker of serious injury. Ann Surg 1993; 218: 783–90. Coll Surg Engl 2000; 82: 97–100. 32 Colliver C, Oller DW, Rose G, Brewer D. Traumatic intrapericardial 5 Schneider C, Tamme C, Scheidbach H, et al. Laparoscopic diaphragmatic hernia diagnosed by echocardiography. J Trauma management of traumatic ruptures of the diaphragm. 1997; 42: 115–17. Langenbecks Arch Surg 2000; 385: 118–23. 33 Muysoms F, Verhelst H, Schroe H, De Jongh R. Traumatic 6 Lin YK, Huang BS, Shih CS, et al. Traumatic diaphragmatic hernia intrapericardial diaphragmatic hernia. J Accid Emerg Med 1997; with delayed presentation. Chung Hua Hsiao Hua Tsa Chih 1999; 14: 156. 62: 223–9. 34 Aldhoheyan A, Jain SK, Hamdy M, Alsebayel MJ. Traumatic 7 Athanassiadi K, Kalavrouziotis G, Athanassiou M, et al. Blunt intrapericardial diaphragmatic hernia. Injury 1992; 23: 331–2. diaphragmatic rupture. Eur J Cardiothorac Surg 1999; 15: 469–74. 35 Naunheim FS. Adult presentation of unusual diaphragmatic 8 Mansour KA. Trauma to the diaphragm. Chest Surg Clin North Am hernias. Chest Surg Clin North Am 1998; 8: 359–69. 1997; 7: 373–83. 36 Sukul DM, Kats E, Johannes EJ. Sixty-three cases of traumatic 9 Reed J. Diaphragmatic hernia produced by a penetrating wound. injury of the diaphragm. Injury 1991; 22: 303–6. Edinburgh Med Surg J 1840; 53: 104. 37 Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic 10 Hamby WB. The Case Reports and Autopsy Records of Ambroise injuries: spectrum of radiographic findings. Radiographics 1998; Pare. Springfield, IL: Charles Tomas, 1960: 50–51. 18: 49–59. 11 Bowditch HI. Diaphragmatic hernia. Buffalo Med J 1853; 9: 165. 38 Israel RS, McDaniel PA, Primack SL, et al. Diagnosis of 12 Hedblom CA. Diaphragmatic hernia. A study of three hundred and diaphragmatic trauma with helical CT in a swine model. Am J seventy eight cases in which operation was performed. JAMA Roentgenol 1996; 167: 637–41. 1925; 85: 947. 39 Worthy SA, Kang EY, Hartman TE, et al. Diaphragmatic rupture: 13 Walker EW. Strangulated hernia through a traumatic rupture CT findings in 11 patients. Radiology 1995; 194: 885–8. of the diaphragm. Laparotomy: recovery. Trans Am Surg Assoc 40 Kamelgard JI, Harris L, Reardon MJ, Reardon PR. Thoracoscopic 1900; 18: 246. repair of a recurrent diaphragmatic hernia four years after initial 14 Somers L, Szeki I, Hulbert D. Late presentation of diaphragmatic trauma, laparotomy and repair. J Laparoendoscop Adv Surg Tech hernia and gastric volvulus. J Accid Emerg Med 2000; 17: 230. 1999; 9: 171–5. 15 Andrade Alegre R. Chronic diaphragmatic hernia. Chest 1999; 41 Domene CE, Volpe P, Santo MA, et al. Laparoscopic treatment of 116: 1838–9. diaphragmatic hernia. J Laparoendosc Adv Surg Tech 1998; 8: 16 Montresor E, Procacci C, Guarise A, et al. Strangulated traumatic 225–9. hernia of the diaphragm. A report of two cases. Chir Ital 1999; 42 Yoshida J, Iwai T, Koike E, et al. Thoracoscopic repair of 51: 471–6. diaphragmatic eventration sustained at knife injury: a case report. 17 Mehanna D, Young CJ, Solomon MJ. Large bowel obstruction due Kyobu Geka 1998; 51: 197–200. to diaphragmatic hernia. Aus N Z J Surg 1998; 68: 544–5. 43 Mouroux J, Padovani B, Poirier NC, et al. Technique for the repair 18 Boulanger BR, Milzman DP, Rosati C, Rodrigues A. A comparison of of diaphragmatic eventration. Ann Thorac Surg 1996; 62: 905–7. right and left blunt traumatic diaphragmatic rupture. J Trauma 44 Wenzel DJ, Hamilton JD. Cross sectional CT of strangulating 1993; 35: 255–60. intrapericardial diaphragmatic hernia. Am J Roentgenol 2001; 19 Degiannis E, Levy RD, Sofianos C, et al. Diaphragmatic herniation 177: 686–8. after penetrating trauma. Br J Surg 1996; 83: 88–91. 45 Zieren J, Enzweiler C, Muller JM. Tube thoracostomy complicates 20 Frantzides CT, Carlson MA. Laparoscopic repair of a penetrating unrecognized diaphragmatic rupture. Thorac Cardiovasc Surg injury to the diaphragm: a case report. J Laparoendosc Surg 1994; 1999; 47: 199–202. 4: 153–6. 46 Faul JL. Diaphragmatic rupture presenting forty years after injury. 21 McNamee CJ, Meyns BP, Pagliero KM. Laparotomy vs thoracotomy Injury 1998; 29: 479–80. for acute diaphragmatic injuries. Br J Hosp Med 1990; 43: 411. 47 Smithers BM, O’Loughlin B, Strong RW. Diagnosis of ruptured 22 Van Vugt AB, Schoots FJ. Acute diaphragmatic rupture due to diaphragm following blunt trauma: results from 85 cases. Aus N Z blunt trauma: a retrospective analysis. J Trauma 1989; 29: 683–6. J Surg 1991; 61: 737–41. 23 Mathews JA, Somberg LB, Barker DE. Diaphragmatic rupture. 48 Warren MJ. Delayed presentation of traumatic diaphragmatic J Tenn Med Assoc 1996; 89: 117–19. hernia. Clin Radiol 1991; 44: 436. 24 Nursal TZ, Ugurlu M, Kologlu M, Hamaloglu E. Traumatic 49 Wataya H, Tsuruta N, Takayama K, et al. Delayed traumatic hernia diaphragmatic hernia a report of 26 cases. Hernia 2001: 5: 25–9. diagnosed with magnetic resonance imaging. Nihon Kyobu 25 Thakore S, Henry J, Todd AW. Diaphragmatic rupture and the Shikkan Gakkai Zasshi 1997; 35: 124–8. association with occupant position in right-hand drive vehicles. 50 Matz A, Alis M, Charuzi I, Kyser S. The role of laparoscopy in the Injury 2001; 32: 441–4. diagnosis and treatment of missed diaphragmatic rupture. Surg 26 Sadeghi N, Nacaise N, De Backer D, et al. Right diaphragmatic Endosc 2000; 14: 537–9. rupture and hepatic hernia: an indirect sign on computed 51 Slim K, Bousquet J, Chipponi J. Laparoscopic repair of missed blunt tomography. Eur Radiol 1999; 9: 972–4. diaphragmatic rupture using prosthesis. Surg Endosc 2000; 12: 27 Wuirbel RJ, Mutschler W. Blunt rupture of the right hemi- 1358–60. diaphragm with complete dislocation of the right hepatic lobe: 52 Zantut LF, Machado MA, Volpe, et al. Bilateral diaphragmatic report of a case. Surg Today 1998; 28: 850–52. injury diagnosed by laparoscopy. Rev Paul Med 1993; 111: 430–32. 28 Aoki AA, Mock CN, Talner LB. Traumatic rupture of the right 53 Meyer G, Huttl TP, Hatz RA, Schildberg FW. Laparoscopic repair hemidiaphragm in an automobile accident. Am J Roentgenol 1998; of traumatic diaphragmatic hernias. Surg Endosc 2000; 171: 386. 14: 1010–14. This page intentionally left blank 29

Etiology of recurrent gastroesophageal reﬂux disease

ZIAD T. AWAD AND CHARLES J. FILIPI

Clinical presentation 217 Wrong diagnosis 221 Mechanisms of failure 219 Discussion 222 Wrong operation 221 References 224

Gastroesophageal reflux disease (GERD) is a common reflect the fact that laparoscopic fundoplication is a rela- disease that accounts for approximately 75 per cent of the tively new technique rather than it being intrinsically bet- pathology of the esophagus. Forty per cent of the adults in ter. However, the early adopters of the laparoscopic the USA have occasional heartburn, and ten per cent expe- approach were usually more skillful individuals who were rience heartburn daily.1,2 It is estimated that 20 per cent of likely to be quite compulsive in the indications and tech- patients with GERD develop serious complications, such niques of these operations. Therefore, it is hoped that with as ulceration, stricture, and Barrett’s metaplasia. Although longer follow-up this procedure will reveal its superiority. medical therapy may be effective, it is often required for a Reoperations for failed or recurrent GERD are techni- protracted period of time. In addition, prolonged therapy cally more demanding due to adhesions from previous sur- often requires escalated dosages, and discontinuation of gery and obscured anatomy. The relatively fragile walls of medications may result in an early recurrence of symp- the esophagus, gastric cardia, and fundus are easily dam- toms. Surgery has improved because of a better under- aged or breached, leading to postoperative leak with poten- standing of the underlying pathophysiology of GERD and tially lethal complications. In addition, the recognized and technical refinements of operative techniques.3,4 A con- repaired injury may impair the precise reconstruction trolled, randomized trial showed superiority of surgical required to obtain a good functional result. Reoperative therapy for the treatment of severe GERD, with less fre- anti-reflux surgery has a morbidity and mortality of 4–40 quent side effects than with non-surgical management.5 per cent and 0–4.9 per cent, respectively.17 The overall clin- Other investigators have provided evidence to favor anti- ical results after reoperation – even those obtained by expe- reflux surgery over medical treatment.6,7 rienced surgeons – are significantly less favorable than The advent of minimally invasive surgery has revolu- outcomes for first-time repairs. The incidence of unsat- tionized the surgical treatment of GERD, leading to a sig- isfactory results is at least doubled after reoperation. nificant increase in the number of cases performed. Studies Furthermore, the greater the number of previous failed have shown that the functional results of laparoscopic repairs, the greater the incidence of poor results. anti-reflux procedures are equal to those of open surgery, but with significantly less postoperative morbidity and CLINICAL PRESENTATION a shorter hospital stay.8–10 The surgical management of GERD sometimes fails, whether performed open or laparoscopically, and may require reoperation for optimal Dysphagia results. Failure of open fundoplication occurs in 9–30 per cent of patients,3,11,12 whereas published failure rates of Approximately 30–40 per cent of patients suffer from laparoscopic Nissen fundoplication are 2–17 per cent.6,13–16 some form of dysphagia in the early postoperative The lower published rates for laparoscopic surgery probably period. This, however, decreases to approximately five 218 Laparoscopic treatment of diaphragmatic herniation per cent at long-term follow-up. It is believed that early after the anti-reflux surgery, resulting in the so-called short-term dysphagia is due to distal esophageal edema ‘gas-bloat syndrome’. The symptoms can be treated with and transient esophageal dysmotility. We generally rec- gas-binding agents or prokinetics. Very rarely, it is neces- ommend that the patient stays on a liquid diet for two sary to take down the fundoplication or convert it to a days after surgery and then maintains a soft diet for three partial fundoplication. weeks following surgery. If the patient has difficulty in swallowing liquids and/or there is significant weight loss, then intervention may be necessary. This includes Pain esophageal dilation and, in extreme cases, placement of a gastrointestinal feeding tube. Postoperative gastrografin Some patients complain of pain, mainly in the lower tho- or barium esophagogram helps to define acute postoper- racic region, the epigastrium or the left shoulder, follow- ative events, such as para-esophageal herniation of the ing fundoplication. This is believed to be due to suture stomach producing obstruction at the lower esophagus. placement in the diaphragmatic hiatus, producing referred This finding warrants emergency surgical intervention. pain; it may also be the result of esophageal muscle Patients with dysphagia that persists past three months spasm. These symptoms can be treated expectantly, and represent a complex problem that warrants careful analysis occasionally they respond to a calcium-channel blocker and interpretation. Common causes include slipped such as nifedipine or diltiazem. fundoplication, para-esophageal hernia formation, tight or fibrotic fundoplication, hiatal stenosis, twisted fundoplica- Diarrhea tion, missed tumors at the gastroesophageal junction, low- amplitude esophageal waves, incomplete propagation of After fundoplication, approximately eight per cent of contractile waves, and undiagnosed achalasia. A barium patients have diarrhea. The reason for this may be esophagram with a 12.5-mm barium pill will differentiate increased gastric emptying, excessive liquid intake, or a anatomical abnormalities at the gastroesophageal junction post-vagotomy effect. In those cases in which the cause is (slipped or para-esophageal hernia) from other causes not clear, gastric-emptying studies or, for completeness of dysphagia, such as esophageal dysmotility. The latter of vagotomy, a sham feeding pancreatic polypeptide test diagnosis is confirmed by an esophageal motility study. may help to resolve the question.19 A pyloroplasty is Patients who are still confined to liquids at three months appropriate when the gastric-emptying study has a half- postoperatively, and patients who are losing weight because time of more than 150 minutes. Most patients can be of dysphagia, should be offered reoperation. If the solid treated effectively with anti-diarrhea medication; only dysphagia is mild or moderate with few dietary restrictions, rarely is surgical intervention, such as the reversal of a and there is little or no weight loss, then conservative 10-cm jejunal loop, necessary. management is a viable option.

Recurrent reflux Alkaline reflux gastritis Some patients complain of epigastric discomfort in con- This occurs in up to eight to ten per cent of patients fol- junction with their preoperative complaints of heart- lowed for ten years after the open procedure.3 Common burn and acid regurgitation. Careful evaluation of these causes of recurrent reflux are slipped fundoplication, patients may identify excessive bile in the stomach at intrathoracic fundoplication with partial disruption, and endoscopy and on testing with the Bilitec probe. Twenty- fundoplication that is too loose. Barium esophagogram, four-hour gastric pH monitoring and hepatobiliary esophageal manometry, endoscopy, and 24-hour pH scanning with technetium 99 m-labeled derivatives of monitoring studies are valuable adjuncts in the evalua- iminodiacetic acid to show the presence of radioactive tion of these patients. material in the stomach help to define the problem further. In carefully selected patients, bile-diversion surgery Abdominal bloating is useful. The duodenal switch consists of division of the duodenum at the juncture of the first and second portion This frequent entity is believed to be due to the trapping with a roux-en-Y jejunal loop anastomosed to the proxi- of swallowed air, which may not be belched easily in the mal duodenum in addition to a highly selective vago- presence of a competent fundoplication. Many patients tomy. Medical management using a prokinetic and a after anti-reflux surgery complain of increased epigastric binding agent such as cholestyramine, however, usually discomfort and flatulence.18 It is likely that patients who suffices. It is important that the patient is advised undergo anti-reflux surgery habitually swallow air to preoperatively of the probability of continued gastric clear the esophagus of refluxed acid. This habit continues symptoms after fundoplication. Etiology of recurrent gastroesophageal reflux disease 219

MECHANISMS OF FAILURE Preoperative diagnosis of the short esophagus, although not standardized, is currently based on demonstrating a non-reducing 5-cm or larger hiatal hernia on Failed repairs requiring reoperation may be the result of an upright barium esophagram, endoscopic demonstra- technical errors, selection of the wrong operation, or tion of stricture formation or Barrett esophagus, or short incorrect primary diagnosis. Technical failure undoubt- esophageal length as measured by manometry. Awad and edly relates to the inexperience of the individual surgeon. colleagues showed that neither a single preoperative test The restoration of a functional acid barrier while avoid- nor any combination of tests was completely accurate.26 ing dysphagia and side effects, such as diarrhea and When each of the preoperative tests was evaluated indi- gastroparesis, requires precise surgical technique and vidually, endoscopy had the highest sensitivity (61 per careful preoperative assessment. cent) and a positive predictability rate of 26.6 per cent; manometric length measurement had the highest speci- Crural disruption ficity rate (78 per cent) and a positive predictability rate of 36.3 per cent. The combination of two or more tests This disorder results in an intrathoracic migration of resulted in a specificity ranging from 63 to 100 per cent the wrap or a para-esophageal hernia and is particularly but a low sensitivity (28–42 per cent). common after laparoscopic anti-reflux procedures for The only reliable way to confirm or exclude esophageal large hiatal hernias.20,21 Contributing factors, in theory, shortening is to demonstrate intraoperatively that the include operator inexperience, short esophagus, inade- gastroesophageal junction rests in the abdominal envi- quate mobilization of the esophagus, and physiological ronment allowing for a tension-free repair. If this precau- factors that would increase pressure or tension at the tion is not observed, then an anti-reflux repair has 27 diaphragmatic hiatus.21 This is particularly true if the a failure rate of approximately 25 per cent. The most patient vomits or retches during the early postopera- effective treatment for the shortened esophagus is a tive period or encounters excessive intra-abdominal pres- lengthening procedure using a Collis gastroplasty. This sure secondary to a fall, heavy lifting, or a car accident. We operation can be done by an open transthoracic approach; advise inclusion of the overlying crural peritoneum when alternatively, a totally laparoscopic or a combined laparo- closing the hiatus. The subdiaphragmatic fascia, which is scopic and thoracoscopically assisted approach can be identified easily on the left limb of the right crus, is used. Currently, the primary problem with laparoscopic included in our crural repair. Although some surgeons esophageal mobilization is exposure, as only 6–8 cm of advocate an anterior crural closure and others recom- distal esophagus can be freed easily when using the mend a prosthetic reinforcement,22,23 we prefer to place laparoscopic approach. The use of longer instruments, an deep 0-Ethibond sutures 1 cm apart that include the peri- incision of the arch of the diaphragm to allow a mediasti- toneum and subdiaphragmatic fascia. A concerted effort nal retractor, and division of the vagal branches to the left is made to preserve the fascia and avoid a muscle-to-mus- lung aid in circumferential esophageal dissection up to cle closure. In addition, patients are placed on an anti- the aortic arch. emetic regimen intraoperatively, which is continued All patients with a possible short esophagus undergo during the first 48 postoperative hours. Restricted activity circumferential esophageal mobilization followed by intra- and lifelong avoidance of weight-lifting are advised. operative endoscopic evaluation of the distance between the gastroesophageal junction and the arch of the crus. Initially, we required a 2-cm intra-abdominal segment of Missed short esophagus the esophagus without tension, but after experiencing one recurrent slipped Nissen we subsequently have used a 3-cm Pathological acid reflux initially produces an inflamma- intraperitoneal length requirement. tory reaction and edema in the lamina propria. However, in long-standing cases, it results in destruction of the muscularis mucosae, forming a stricture down to and Two-compartment stomach including the circular muscle level. Eventually, transmural inflammation causes fibrosis of the outer longitudinal A partitioned stomach is unique to laparoscopic anti- muscle, creating a shortening effect and, in some cases, an reflux surgery and occurs when a point too low on the inability to reduce the gastroesophageal junction to its nor- anterior greater curvature of the stomach is used as mal subdiaphragmatic position. A foreshortened esopha- the anterior wing or a point too distal on the posterior gus may also be found in patients with a failed anti-reflux wing of the fundoplication is selected. This creates a procedure and in those with type III (mixed) hiatal her- pouch of fundus that is isolated from the corpus, created nias. Between three and 14 per cent of patients undergoing by a partitioning line of tension. There is a characteristic anti-reflux surgery have the so-called short esophagus.24,25 X-ray picture at esophagography (Figure 29.1) and 220 Laparoscopic treatment of diaphragmatic herniation

Twisted fundoplication

This disorder may be associated with the Nissen–Rosseti repair and results from failure to mobilize the greater curvature of the stomach from the spleen, diaphragm and pancreas. A lead point on the anterior wall of the stomach is used for the posterior wing and is sutured to another level of the anterior stomach wall. If the proximal distal axis lead point levels are sufﬁciently different, then a twist results and a spiral-type deformity is seen on retroﬂexion at endoscopy. This deformity is associated with dysphagia; a manometric evaluation will show a hypertensive and, sometimes, poorly relaxing fundoplication. The twisted fundoplication is often resistant to esophageal dilation and requires reoperation.

Hiatal stenosis

This phenomenon is associated only with laparoscopic Nissen fundoplication. It has been reported infrequently and must be differentiated from an excessively tight closure. Hiatal stenosis is due to excessive scar forma- Figure 29.1 The proximal compartment is ﬁlled with barium tion, which in turn constricts the esophagus at the hiatal and the distal compartment is ﬁlled with air. level. It is easily recognized at reoperation by intraoperative endoscopy, after taking down the gastric-hepatic adhesions. It can be corrected by incising the hiatus anteriorly. We also inject the hiatoplasty with dexametha- sone. The cause may be due to cautery dissection of the right crura.

Missed neoplasm

A small submucosal tumor causing dysphagia may go unnoticed at endoscopy. Endoscopic ultrasound is a useful adjunct in these circumstances, especially in patients who exhibit weight loss and are suspected to have a benign disorder. All patients with Barrett’s esophagus should undergo a biopsy protocol before operation. At laparoscopic reoperation, one should suspect a malignancy if the dissection is difﬁcult and the tissue is excessively hard.

Figure 29.2 A retroflexed view of the stomach with two Slipped Nissen compartments separated by a fold/partition of tissue. This well-known problem occurs after protrusion of the gastric fundus through the fundoplication. It may be the the endoscopy is diagnostic (Figure 29.2). Patients with result of esophageal foreshortening, failure to anchor the this deformity often have dysphagia, and manometric fundoplication to the esophagus, or incorrect position- evaluation shows a hypertensive fundoplication with ing of the fundoplication on to the stomach rather than incomplete relaxation. The gastric body does not relax the lower esophagus. Esophageal mobilization to achieve with swallowing, thus dysphagia results when the gastric a sufficient intra-abdominal length of esophagus allow- body is used for the fundoplication. Reoperation is ing for a tension-free repair is essential to minimize the required. occurrence of this complication. Etiology of recurrent gastroesophageal reflux disease 221

Vagal-nerve disruption Fundoplication disruption

Injury to both vagus nerves can lead to a marked delay in This is the Achilles heal of Nissen fundoplication and gastric emptying, which in turn may in turn require a may not be avoidable. Disruption may be the incorrect pyloroplasty. Familiarity with the anatomy and careful term in many instances. Clearly, the fundoplication folds dissection of the arch of the right crus will minimize the and tucks are lost with time in some patients and risk of anterior nerve injury. Posterior nerve injury is recurrent reflux disease occurs, but this is based on the probably more common when the nerve is displaced retroflexed endoscopic view. In fact, at reoperation many from the posterior esophagus and is unrecognized as patients have a seemingly intact fundoplication with such. Single-nerve injury or excessive nerve stretching to sutures still holding the right and the left wing serosal make an ample window behind the gastroesophageal surfaces in continuity. Apparently, the suture has pulled junction may create transient gastroparesis. A gastric- out of the full thickness of the stomach wall in one or emptying study should be performed; our criteria for both of the wings, and an effective barrier has been lost. pyloroplasty is a half-time of more than 150 minutes for Tissue attenuation may also be responsible for this pheno- solids or liquids. Vagal-nerve injury is the reason for legal menon. Consequently, Tom DeMeester has recommended consultation and action more frequently than any other a pledgeted repair, which the main author (CJF) of this post-Nissen problem. chapter incorporates with every Nissen fundoplication he performs. Too loose, too tight, or too long fundoplication WRONG OPERATION If the wrap is too floppy, then the pressure created in the distal esophagus is low, favoring recurrent reflux symp- Selection of the optimal operation may be influenced by toms. Conversely, if the fundoplication is too tight, dys- the presence of esophageal foreshortening, defective phagia may occur. Calibration of the fundoplication has esophageal motility, or gastric-outlet or duodenal obstruc- been standardized and shown to prevent long-term dys- tion. The acquired short esophagus is an indication for an 3 phagia. A 60F bougie should be introduced, and the esophageal-lengthening procedure to reduce undue ten- right and left wing lead points should be chosen with the sion on the repair. Significant impairment of esophageal dilator in place. We prefer to overlap the lead points by peristaltic amplitude of contraction, propagation, or 3 cm to create a floppy Nissen fundoplication (Figure 29.3). abnormal peristaltic waves necessitates a floppy Nissen fundoplication to avoid the complication of dysphagia from a functional obstruction. Gastric-outlet obstruction warrants a gastric resection, while an obstructing duodenal stricture is best treated by gastrojejunostomy and Posterior vagotomy. 3 cm Anterior

WRONG DIAGNOSIS

Failure to identify an underlying primary motor disorder, such as achalasia or diffuse esophageal spasm, results in a repair that inevitably fails to relieve and may exacerbate the clinical problem. In such cases, dismantling the fundo- Anterior plication and adding myotomy is required. Preoperative manometry is imperative in this case but is often forgotten by the casual esophageal surgeon. Posterior Esophageal cancer or a malignancy at the gastroesophageal junction can be missed at endoscopy. Care in obtaining a good retroflexed view of the squamocolum- nar junction is necessary. This may be difficult if the patient is unable to hold the air in the stomach. A smaller scope, however, can almost always be placed in the hiatal Figure 29.3 An end-on view of the gastric fundus wings hernia to obtain the view needed. Any suspicion of a neo- overlapped to assure a floppy Nissen fundoplication. plasm warrants biopsy. If the patient is combative when 222 Laparoscopic treatment of diaphragmatic herniation the endoscope is retroflexed within the hernia, then possible. More importantly, the esophagus can be mobi- esophageal perforation can occur. Improved sedation or lized up to the aortic arch and a lengthening procedure, repeat endoscopy at another session is warranted. We if needed, can be performed easily. have discovered four patients with malignancy who had A disrupted fundoplication, a repair that is too tight, been endoscoped recently by an experienced physician or a patient with crus closure failure and an intrathoracic and referred for anti-reflux surgery. Endoscopy by the fundoplication more than 2 cm above the diaphragmatic operating surgeon is a must in our opinion. crus and without additional risk factors for a short esophagus are our primary indications for laparoscopic reoperative surgery. The patient’s symptoms must be DISCUSSION uncontrollable despite aggressive medical therapy (including dilations) to warrant reoperative surgery. Satisfactory results have been shown with laparoscopic reoperative The reasons for poorer outcomes after repeat surgery are surgery (Table 29.2). hypothetical and perhaps uncorrectable (Table 29.1). A Detractors of the laparoscopic approach for reopera- specific classification of mechanisms of failure has not tive surgery are concerned primarily about incomplete been agreed upon, and the best method of correction for dismantling of the fundoplication. This can be difficult, as each mechanism has yet to be determined. Many failures the posterior wing is often densely adherent to the crural are the result of technical errors, whereas others result closure and retroperitoneum. Safe dissection in this area from deteriorating foregut motility or wear and tear on is not possible for inexperienced surgeons. However, the fundoplication. after mobilization, an intraoperative endoscopy with full The best approach for reoperative anti-reflux surgery insufflation and the J-maneuver can prove or disprove is debatable. Currently, we prefer the transthoracic complete dismantling. If blood is seen within the lumen, approach for patients with two or more failed anti-reflux one should check carefully for a perforation. Obviously, if procedures, for any patient with an irreducible hiatal the stomach cannot be inflated fully then a larger perfora- hernia more than 2 cm in size, and for patients with a tion may be present. suspected short esophagus (short esophageal manomet- Vagal-nerve injury is also a concern, as the nerve ric length, stricture formation, or Barrett’s esophagus). is not palpated so easily during laparoscopic surgery. The left transthoracic approach provides maximum Attention to detail and sharp dissection immediately exposure of the hiatus and makes dissection of the adjacent to identifiable structures will usually prevent esophagus from the surrounding tissues safer; with a cir- this complication. If there is suspicion of a vagal nerve cumlinear incision of the diaphragm near its rib attach- injury, then percutaneous endoscopic gastrostomy placement, excellent exposure of the abdominal contents is ment is appropriate at the end of the operation.

Table 29.1 Reported series of reoperations with more than 30 cases Cases More than one Mortality Good/excellenta Satisfactoryb Reference (n) prior repair (%) (%) (%) Skinner (1967)28 43 0 Orringer (1972)29 45 0 3 73 085 Hill (1971)30 63 12 3 81 Polk (1980)31 36 28 4 80 050 Henderson and Marryatt (1981)32 121 0 0 94 Maher et al. (1984)33 55 6 4 80 Little et al. (1986)34 61 27 5 72 Stirling and Orringer35 87 25 3 67 076 Pearson et al. (1987)36 118 22 0 80 Low et al. (1989)37 116 3 86 Siewert et al. (1995)38 50 9 2 70 Stein et al. (1996)39 71 11 1 86 Ellis et al. (1996)40 101 43 1 80 Deschamps et al. (1997)41 185 0.5 88 aCombined total of excellent and good results; bcombined total of excellent, good and fair results; fair results imply significant symptoms. Table 29.2 All published series of laparoscopic reoperation anti-reflux repairs Repairs Conversion Complications Results Follow-up Reference (n) (%) Cause (%) (%) (months) DePaula et al. (1995)17 19 5 Gastric strangulation preventing safe Intraoperative, 15.8; Excellent (84.3) Mean 13 (range 1–26) mobilization of the distal esophagus postoperative, 21 Frantzides and Carlson (1997)8 9 0 – Postoperative, 100 Excellent (100) Range 4–14 O’Reilly et al. (1997)42 8 25 Dense adhesions between left lobe of Intraoperative, 33; Excellent (100) Range 12–42 liver and stomach postoperative, 16.6 Watson et al. (1999)43 27 22 Intra-abdominal adhesions, 0 Good (92.6) Median 12 (range 3–48) perihiatal adhesions Alexander et al. (1996)44 2 0 – 0 Excellent (100) Not clear Croce et al. (1997)45 5 20 Intrathoracic cuff and short esophagus 0 Excellent (100) Range 6–20 Schauer et al. (1999)46 22 4.5 Not mentioned Intraoperative, 13.6; Excellent (73); fair (27) Mean 5.7 (range 0–14) postoperative, 4.5 Curet et al. (1999)47 27 3.7 Poor visualization, gastric perforation Intraoperative, 44.4; Excellent (96); fair (4) Mean 22 (range 1–60) postoperative, 44.4 Soper et al. (1999)21 6 16.6 Dense mediastinal adhesions 0 Excellent (75); poor (25) Not mentioned Floch et al. (1999)48 46 20 Adhesions, bleeding, perforation, Intraoperative, 30.4; Significant improvement 17.1 Ϯ 11.8 tension pneumothorax postoperative, 20 in wellbeing score Szwerc et al.(1999)49 15 0 – 0 Significant improvement Ͼ3 in symptom score Pointner et al. (1999)50 30 7 Bleeding from the spleen, Intraoperative, 18 Significant improvement Median 29 (range 12–45) gastric perforation in quality of life Hunter et al. (1999)51 75 8 Adhesion, gastric perforation Intraoperative, 2.6; Excellent/good (87); Not clear postoperative, 5 fair/poor (13) Awad et al. (2001)52 38 13 Adhesions, bleeding, big PEH, Intraoperative, 16; Excellent (65); Mean 26.5 (range 4–101) calcified Angelchik prosthesis postoperative, 38 fair (21.5); poor (13.5) Serafini et al. (2001)53 28 7 Dense adhesions Intraoperative, 46; Excellent (89); Mean 20 Ϯ 14 postoperative, 21 fair (11)

PEH, para-esophageal hernia. 224 Laparoscopic treatment of diaphragmatic herniation

As more series of reoperative laparoscopic surgery sensory function of the proximal stomach. Br J Surg 2000; 87: become available for review, a consensus concerning 338–43. 20 Dallemagne B, Weerts JM, Jehaes C, Markiewicz S. Causes of treatment for the various mechanisms of failure should failures of laparoscopic antireflux operations. Surg Endosc 1996; result. Until that time, careful attention to preoperative 10: 305–10. evaluation, intraoperative technical detail, and post- 21 Soper NJ, Dunnegan D. Anatomic fundoplication failure after operative care are necessary to minimize the morbidity laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–76. of anti-reflux surgery. 22 Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc 1997; 11: 769–71. 23 Paul MG, DeRosa RP, Petrucci PE. Laparoscopic tension-free repair REFERENCES of large paraesophageal hernias. 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Reoperation for 144S–8S. esophagitis following failed antireflux procedures. Ann Surg 10 Laine S, Rantala A, Gullichsen R, Ovaska J. Laparoscopic vs 1984; 201: 723–7. conventional Nissen fundoplication. A prospective randomized 34 Little AG, Ferguson MK, Skinner DB. Reoperation for failed study. Surg Endosc 1997; 11: 441–4. antireflux operations. J Thorac Cardiovasc Surg 1986; 91: 11 Hiebert CA, O’Mara CS. The Belsey operation for hiatal hernia: a 511–17. twenty-year experience. Am J Surg 1979; 137: 532–5. 35 Stirling MC, Orringer MB. Surgical treatment after the 12 Shirazi SS, Schulze K, Soper RT. Long-term follow-up for failed antireflux operation. J Thorac Cardiovasc Surg 1986; 92: treatment of complicated chronic reflux esophagitis. Arch Surg 667–72. 1987; 122: 548–52. 36 Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and 13 Cuschieri A, Hunter J, Wolfe B, et al. Multicenter prospective fundoplication for complex reflux problems. Ann Surg 1987; 206: evaluation of laparoscopic antireflux surgery. Preliminary report. 473–81. Surg Endosc 1993; 7: 505–10. 37 Low DE, Anderson RP, Ilves R, Hill LD. 15 to 20 year results after 14 Hunter JG, Trus TL, Branum GD, et al. A physiologic approach to the Hill operation. J Thorac Cardiovasc Surg 1989; 98: 444. laparoscopic fundoplication for gastroesophageal reflux disease. 38 Siewert JR, Stein HJ, Feussner H. Reoperations after failed Ann Surg 1996; 223: 673–85. antireflux procedures. Ann Chir Gynaecol 1995; 84: 122. 15 Jamieson GG, Watson DI, Britten-Jones R, et al. Laparoscopic 39 Stein HJ, Feussner H, Siewert JR. Failure of antireflux surgery: Nissen fundoplication. Ann Surg 1994; 220: 137–45. causes and management strategies. Am J Surg 1996; 171: 36–40. 16 Peters JH, Heimbucher J, Kauer WK, et al. Clinical and physiologic 40 Ellis FH, Gibb SP, Heatley GJ. Reoperation after failed antireflux comparison of laparoscopic and open Nissen fundoplication. surgery: review of 101 cases. Eur J Cardiothorac Surg 1996; J Am Coll Surg 1995; 180: 385–93. 10: 225–33. 17 DePaula AL, Hashiba K, Bafutto M, Machado CA. Laparoscopic 41 Deschamps C, Trastek VF, Allen MS, et al. Long term results after reoperations after failed and complicated antireflux operations. reoperation for railed antireflux procedures. J Thorac Cardiovasc Surg Endosc 1995; 9: 681–6. Surg 1997; 113: 545–51. 18 Low DE, Mercer, CD, James EC, Hill LD. Post Nissen syndrome. 42 O’Reilly MJ, Mullins S, Reddick EJ. Laparoscopic management of Surg Gynecol Obstet 1988; 167: 1–5. failed antireflux surgery. Surg Laparosc Endosc 1997; 7: 90–3. 19 Vu MK, Ringers J, Arndt JW, et al. Prospective study of the 43 Watson DI, Jamieson GG, Game PA, et al. Laparoscopic reoperation effect of laparoscopic hemifundoplication on motor and following failed antireflux surgery. Br J Surg 1999; 86: 98–101. Etiology of recurrent gastroesophageal reflux disease 225

44 Alexander HC, Hendler RS. Laparoscopic reoperation on failed 49 Szwerc MF, Wiechmann RJ, Maley RH, et al. Reoperative antireflux procedures: report of two patients. Surg Laparosc laparoscopic antireflux surgery. Surgery 1999; 126: 723–8. Endosc 1996; 6: 147–9. 50 Pointner R, Bammer T, Then P, Kamolz T. Laparoscopic 45 Croce E, Azzola M, Russo R, et al. Laparoscopic re-operation refundoplications after failed antireflux surgery. Am J Surg 1999; from gastro-oesophageal reflux. Hepatogastroenterology 1997; 178: 541–4. 44: 912–17. 51 Hunter JG, Smith CD, Branum GD, et al. Laparoscopic 46 Schauer PR, Ikramuddin S, Piskun G, et al. Reoperative fundoplication failures: patterns of failure and response to laparoscopic antireflux surgery. Surg Endosc 1999; 13: S40. fundoplication revision. Ann Surg 1999; 230: 595–604. 47 Curet MJ, Josloff RK, Schoeb O, Zucker KA. Laparoscopic 52 Awad ZT, Anderson PI, Sato K, et al. The laparoscopic reoperative reoperation for failed antireflux procedures. Arch Surg 1999; antireflux surgery. Surg Endosc 2001; 15: 1401–7. 134: 559–63. 53 Serafini FM, Bloomston M, Zervos E, et al. Laparoscopic 48 Floch NR, Hinder RA, Klingler PJ, et al. Is laparoscopic reoperation revision of failed antireflux operations. J Surg Res 2001; for failed antireflux surgery feasible? Arch Surg 1999; 134: 733–7. 95: 13–18. This page intentionally left blank 30

Reoperation for recurrent gastroesophageal reﬂux disease

THOMAS R. EUBANKS

Characterizing failure 227 Conclusion 234 Patient selection 230 References 234 Operative strategy 230

Successful reoperative anti-reflux procedures are based Esophagitis confirms uncontrolled acid reflux. A tortu- on three principles: precise characterization of the origi- ous path of the distal esophagus implies abnormalities nal procedure’s failure, appropriate patient selection, and of fundoplication position. In some cases, a large para- operative intervention capable of repairing the failure. esophageal hernia can be documented (Figure 30.1). More than 30 000 anti-reflux procedures were performed in the USA in 1998, with the number expected to go well above 50 000 annually in the early 2000s. Symptomatic failure rates of operative intervention range between seven and 15 per cent. Reoperation is required in 1–3.5 per cent of patients,1–3 thus 500–1750 patients will undergo reoperative anti-reflux surgery each year. Symptoms of failed anti-reflux procedures can be divided into three categories: those that are too tight, those that are too loose, and those that are malpositioned. The first are characterized by dysphagia and regurgitation of undigested material, the second by recurrent heartburn and regurgitation, and the third by chest pain, abdominal pain and, occasionally, dysphagia. Although symptoms provide a clue to the etiology of the failed initial procedure, objective assessment is required before planning any further operative intervention.

CHARACTERIZING FAILURE

The objective assessment of a patient being considered for reoperative treatment should include endoscopy, Figure 30.1 Retroﬂexed view of the gastroesophageal junction esophagography, esophageal physiological studies, and, at endoscopy. The lesser curve is at the bottom of the photograph. when indicated, solid-phase gastric-emptying studies. The bulging mucosa above the crus is caused by extrinsic Endoscopy is useful to assess the state of the esophageal compression of the heart on the herniated stomach. This is a mucosa and the orientation of the fundoplication. large para-esophageal hernia after an anti-reﬂux operation. 228 Laparoscopic treatment of diaphragmatic herniation

However, a twisted fundoplication or two-compartment relationships between the esophagus, hiatus, stomach stomach can also be identified as causes for failure and fundoplication. Figure 30.2 shows early images of during endoscopy.3 contrast flowing past the cardia of the stomach and Contrast esophagography is undoubtedly the most into the body. An air-filled fundus can be seen in the pos- valuable anatomical study for evaluating symptoms terior mediastinum, well above the hiatus. Figure 30.3 after anti-reflux surgery. This study shows the positional demonstrates later images of the same study with contrast in the fundus, confirming its position in the mediastinum. The most common reasons for failure of anti-reflux procedures can be identified on contrast

Figure 30.2 Early phase of an esophagogram in the same patient as in Figure 30.1. The contrast is ﬂowing through the esophagus, which is slightly distorted by the large Figure 30.3 Later images in the study shown in Figure 30.2. para-esophageal hernia. Air in the herniated stomach can be The contrast has been cleared from the esophagus and is now seen in the mediastinum. Note the location of the diaphragm. present in the herniated portion of the stomach. The compression The gastroesophageal junction appears to be in the abdomen. of the stomach caused by the hiatus is evident.

Figure 30.4 Esophageal manometry tracing, demonstrating normal propagation of peristalsis along the esophageal body. The patient had occasional decreased amplitudes in the distal esophagus (Ͻ60 mmHg). Reoperation for recurrent gastroesophageal reflux disease 229 esophagography: transdiaphragmatic herniation, slipped The lower esophageal sphincter (LES) pressure also fundoplication, twisted fundoplication, and tight fun- provides helpful information. A defective sphincter sup- doplication. The addition of a marshmallow swallowed ports the diagnosis of a loose fundoplication in patients during the study also gives a good impression of lower with symptoms of recurrent reflux. A non-relaxing esophageal relaxation. sphincter or a sphincter with extremely high pressures Esophageal manometry is essential in all patients confirms a fundoplication that is too tight. Figure 30.5 being evaluated for postoperative symptoms. In patients demonstrates normal LES pressure and relaxation in a with dysphagia and chest pain, manometry identifies patient with symptoms of chest pain after a fundoplica- motility (physiological) abnormalities. Manometry will tion, but no symptoms of reflux. also help in planning the operative strategy to correct Twenty-four-hour pH monitoring is important in all the failed procedure. A patient with poor motility may patients (Figure 30.6). Although the symptom of heart- not be a candidate for a ‘redo’ 360-degree fundoplication. burn would seem to be an accurate predictor of post- Figure 30.4 shows a typical esophageal body tracing, operative acid exposure, 50 per cent of patients who with occasional decreased amplitudes of peristalsis in complain of heartburn after a fundoplication will have the distal esophagus, but confirms the presence of peri- normal acid exposure on pH testing.4 Half of the patients stalsis, a feature required to proceed with an anti-reflux who complain of heartburn but have normal acid expo- procedure. sure will have other etiologies identified as a cause of

Figure 30.5 Manometry tracing showing a normal LES pressure (17–18 mmHg) with complete relaxation during deglutition.

Figure 30.6 Twenty-four-hour pH testing, showing normal amounts of acid reflux in both proximal and distal channels. 230 Laparoscopic treatment of diaphragmatic herniation their symptoms (esophageal motility abnormalities, Regardless of the reason for reoperation, the compli- cardiac dysrhythmia, irritable bowel syndrome). In those cation rates are significantly higher for ‘redo’ procedures. patients who do not complain of heartburn, the study is Major operative complications, such as visceral injury, useful in documenting subclinical, abnormal acid expo- and postoperative problems, such as dysphagia requiring sure, which can be present in 20 per cent of cases.4 dilation, occur twice as often during or following reoper- Solid-phase gastric-emptying studies are helpful in ations compared with primary procedures.8 patients who complain of bloating. These studies do not document vagal injury at the previous operation but they do raise the suspicion of this. Many surgeons will add a OPERATIVE STRATEGY pyloroplasty to the reoperation if the study is abnormal; however, dumping syndrome may occur in up 30 per cent The patient is placed in the low lithotomy position. The of patients.5 If the stomach is atonic, then the patient surgeon stands between the patient’s legs. The assistant may not be amenable to reoperative anti-reflux surgery stands on the patient’s left. A static liver retractor (endo- but instead may require gastrectomy. scope holder) is attached to the right side of the operat- Objective testing helps to confirm the clinical suspicion ing table. A single monitor may be placed at the right of failure of the previous operation and can influence the shoulder of the patient. Electrocautery (thin avascular strategy of the planned corrective procedure. The objec- tissues) and ultrasonic (thick vascular tissues) dissection tive findings should support the clinical suspicion. A capabilities are required. patient with symptoms of reflux (heart burn and regur- Five laparoscopic ports are used. The equipment gitation) will have different objective findings compared available dictates the size of the ports. If a high-quality, with a patient with dysphagia and postprandial chest pain. 5-mm laparoscope, a flexible 5-mm liver retractor, and a 5-mm ultrasonic dissector are available, then all five PATIENT SELECTION ports may be 5 mm in size; otherwise, several of the ports may need to be larger. Although each case is unique, the operative strategy is Laparoscopic revision of anti-reflux procedures is becom- based on complete restoration of the anatomy prior to the ing more common, regardless of whether the original pro- repair of the hernia. The procedure can be divided into cedure was performed via laparotomy or laparoscopy.1–3,6,7 three steps: initial dissection, unwrapping, and rewrapping. The surgeon should be comfortable with the laparoscopic approach in its use for the initial anti-reflux procedures before proceeding with ‘redo’ operations. Initial dissection The selection process in a case with an obvious anatomical defect is straightforward. With such distorted The first objective is to free the viscera from the hiatus. anatomy, the patient and surgeon can be confident that Often, this requires mobilization of the inferior aspect of the repair of the defect will improve symptoms. Less the left lobe of the liver from the fundoplication. The two subtle defects, such as a small posterior herniation, are most common planes encountered during this dissection unlikely to be the cause of significant symptoms, and are the subcapsular plane of the liver and the subserosal reoperation is indicated rarely in these cases. plane of the stomach. Neither is desired, and both are In patients with recurrent symptoms of reflux and a characterized by the presence of unexpected bleeding. fundoplication that is too loose, the decision to reoperate Anterior traction of the liver edge and counter traction is difficult. Symptom control after reoperative therapy is on the stomach facilitate the dissection. Infusing saline significantly less than after the initial operation.7 Further- irrigant under modest pressure (hydrodissection) can more, reoperative anti-reflux surgery normalizes acid help to develop the proper plane. exposure in 74 per cent of patients compared with 83 per After the liver is freed, the next move is to separate the cent in primary operations.4 The medical management crura from the fundus/esophagus complex. The dissection of such a patient is often successful and obviates the need can be initiated at any point in which the anatomy is dis- for operative intervention. cernable. In Figure 30.7, the intraoperative view demon- Patients with obstructive symptoms caused by a tight strates a large para-esophageal hernia with relatively few fundoplication (not malposition) may benefit from adhesions to the liver. The left crus and omental attach- endoscopic dilation. Early dilation (two to six weeks ments to the greater curve could be discerned easily. The postoperatively) can reduce the need for operative inter- adhesions between the omentum and proximal greater vention when symptoms are severe. Up to four per cent curve are divided with electrocautery. Since the short of all patients undergoing anti-reflux procedures will gastric vessels were divided at the original operation, this require endoscopic dilation, but only one per cent will plane was avascular (Figure 30.8). The para-esophageal need operative revision for dysphagia alone.7 hernia allowed a clear view of the anterior aspect of the Reoperation for recurrent gastroesophageal reflux disease 231

Figure 30.7 Initial intraoperative view of the esophageal Figure 30.9 Dissection of right crus. The lesser omentum has hiatus, demonstrating the large para-esophageal hernia. The already been divided (caudate lobe is visible) and adhesions of liver is out of view to the left, the spleen to the right. Note the subhiatal fat and greater omentum are being freed. adhesions to the pericardium at the top of the photograph, which correspond with the endoscopy images in Figure 30.1. mobilization of the esophagus allows identification of the anterior and posterior vagii. If the esophagus is difficult to identify due to adhesions, then a lighted bougie may be passed into the lumen via the mouth. With the anterior esophageal wall exposed in the mediastinum and the anterior surface of the stomach identified, the surgeon can visualize the relative depth of the dissection required to undo the fundoplication.

Unwrapping

The anterior portion of the fundoplication can usually be elevated from the body of the stomach lateral to the sutures forming the fundoplication. The surgeon then locates the inferior extent of the fundoplication and Figure 30.8 Division of the adhesions between the omentum places traction on the right portion of the fundus while and the greater curve of the stomach. This plane is usually the assistant places traction on the left. A bougie placed avascular if the short gastric vessels are divided at the original in the esophagus provides a detectable firmness to the operation. esophagus. The surgeon and the assistant elevate their respective aspects of the fundus anteriorly and inferiorly. crural arch, thus the dissection is carried out from left to Electrocautery, ultrasonic or sharp dissection is then right. The plane between the right crus and the portion of carried out from the inferior aspect of the fundoplication herniated stomach is shown in Figure 30.9. In para- to the superior aspect. This plane is avascular and the esophageal hernias occurring after previous anti-reflux sutures used to construct the prior fundoplication are surgery, no hernia sac will be encountered. encountered (Figure 30.10). Esophageal and vagal injury Freeing the fundoplication/esophageal complex from can be avoided at this step if the surgeon and assistant the crura is an extremely important step for two reasons: focus on proper traction upon the fundoplication. it provides visual confirmation of the course of the When the sutures have been divided and the dissec- esophagus as it travels into the fundoplication and it is tion plane is continued to the previously dissected medi- a safe step, as the fundoplication provides a buffer for astinal esophagus, the fundus should be freed from the errant dissection and thus aids in the avoidance of cardioesophageal junction. With the bougie still in place, esophageal injury. the surgeon elevates the right aspect of the fundoplica- Once the fundoplication/esophageal complex is tion while the assistant provides counter-traction on the circumscribed by surgical tubing, further mediastinal cardia and the anterior vagus. The right portion of the 232 Laparoscopic treatment of diaphragmatic herniation

(a)

Figure 30.10 Close view of the sutures used to create the fundoplication at the original operation. The grasper is used to retract the suture while it is dissected. Encountering sutures is reassuring during this part of the dissection as it conﬁrms the proper dissection plane.

(b)

Figure 30.11 Mobilization of the right portion of the fundoplication. This is an essential step required to restore the original anatomy. The anterior vagus is at risk during this portion of the operation. (c) Figure 30.12 Series of photographs demonstrating the extent fundus is freed from the anterior aspect of the cardia and of stomach herniation. The grasper in (a) remains attached to esophagus, preserving the anterior vagus (Figure 30.11). the same portion of stomach throughout the series. The hiatal This dissection is carried as far posteriorly as possible. defect can be appreciated in (c). The ideal dissection would extend just to the left of the posterior vagus. As the right aspect of the fundus is passed from right to left, through the retro-esophageal cardia. Once the fundus is restored to its anatomical posi- space, the entire fundus and gastric body are freed from tion, the cardiac notch should be clearly identiﬁable, as the hiatal defect (Figure 30.12). should the smooth transition from the right edge of the Dissection of the left aspect of the fundoplication does esophagus to the lesser curve of the stomach. Hopefully, not involve as much work as the right aspect, but it is just the anterior and posterior vagii are visible and intact. as important. The assistant provides the traction on the With traction applied to the esophagus using surgical fundus and the surgeon provides the traction on the tubing, the esophagus is mobilized from its mediastinal Reoperation for recurrent gastroesophageal reﬂux disease 233

Figure 30.13 The esophagus has been mobilized from the Figure 30.14 Closure of the hiatal defect. The ﬁrst suture has mediastinum until 3 cm of intra-abdominal esophagus rests in been placed and is about to be cut. the abdomen without tension. attachments (Figure 30.13). This allows the gastroesophageal junction to return to an intra-abdominal position. Although it is often tempting to avoid complete dissection of the esophagus and stomach during a ‘redo’ operation, the surgeon should recall that the best opportunity for success lies in the ﬁrst ‘redo’ procedure. Subsequent procedures have lower success rates and higher complication rates.

Rewrapping

The ‘redo’ fundoplication is performed similarly to a primary operation. Techniques to prevent recurrent herniation should be emphasized. These include adequate Figure 30.15 Re-creating the fundoplication using the esophageal mobilization, hiatal closure, and anchoring posterior (left) and anterior (right) portions of the fundus. The the fundoplication to the crura. esophagus and subhiatal fat are in the center, encircled by the The crura are re-approximated to decrease the hiatal surgical tubing. opening (Figure 30.14). The fundoplication is re-created by passing the posterior aspect of the fundus from left to right through the retro-esophageal space and approximating it to the anterior aspect of the fundus (Figure 30.15). Figure 30.16 shows the completed fundoplication, which is 3 cm long. The fundoplication is then anchored to the hiatus to help prevent recurrent herniation (Figure 30.17). Figure 30.18 shows the completed fundoplication with the crural closure sutures, fundoplication sutures, and anchoring sutures visible. Intraoperative endoscopy showed an intact ﬂap valve, a symmetric fundoplication, and the absence of the para-esophageal hernia (Figure 30.19). The anchoring sutures help to secure the fundoplication to the hiatus. Since herniation is the most common cause of reoperative hiatal hernia surgery, these sutures may also be impor- Figure 30.16 The fundoplication is complete. Four sutures placed tant for initial operations. Four to six sutures are placed 1 cm apart are shown securing the right and left portions of the between the fundoplication and the crura. The extreme fundoplication. 234 Laparoscopic treatment of diaphragmatic herniation

Figure 30.17 The left portion of the fundoplication is being anchored to the anterior portion of the left crus.

Figure 30.19 Intraoperative endoscopy shows the corrected ﬂap valve and the repaired para-esophageal hernia.

consisting of liquids the ﬁrst week and advancing to regular food by the fourth week is prescribed.

CONCLUSION

Effective reoperative anti-reﬂux surgery can be expected if the reason for failure of the previous operation is known, if it correlates with the patient’s symptoms, and if it is correctable.

Figure 30.18 Completed procedure. This view demonstrates REFERENCES the hiatal closure sutures, several of the anchor sutures (fundoplication to hiatus), and the fundoplication sutures. 1 Horgan S, Pohl D, Bogetti, D, et al. Failed anti-reflux surgery: what have we learned from reoperations? Arch Surg 1999; 134: 809–17. right and left sutures can incorporate the muscular wall of 2 Soper NJ, Dunnegan D. Anatomic fundoplication failure after laparoscopic anti-reflux surgery. Ann Surg 1999; 229: 669–77. the esophagus if it is not too ragged from the previous 3 Hunter JG, Smith D, Branum GD, et al. Laparoscopic fundoplication dissection. The anterior and posterior sutures should not failures: patterns of failure and response to fundoplication revision. incorporate the esophagus, to avoid injuring the vagii. Ann Surg 1999; 230: 595–606. Postoperative care for reoperative anti-reflux pro- 4 Eubanks TR, Omelanczuk P, Richards C, et al. Outcomes of cedures is the same as that for patients undergoing pri- laparoscopic anti-reflux procedures. Am J Surg 2000; 179: 391–5. 5 Rieger NA, Jamieson GG, Britten-Jones R, Tew S. Reoperation after mary repairs. Gastric decompression tubes are not used. failed anti-reflux surgery. Br J Surg 1994; 81: 1159–61. Patients are allowed liquids by mouth on the day of the 6 Watson DI, Jamieson GG, Game PA, et al. Laparoscopic reoperation operation. Pharmacological agents are used to suppress following failed anti-reflux surgery. Br J Surg 1999; 86: 98–101. nausea and emesis. Once the patient is ambulating and 7 Hinder RA, Klingler PJ, Perdikis G, Smith SL. Management of the oral elixirs are controlling postoperative pain, the patient failed anti-reflux operation. Surg Clin North Am 1997; 77: 1083–1098. is discharged from hospital. 8 Pohl D, Eubanks TR, Omelanczuk PE, Pellegrini CA. Management and Patients are instructed to limit exertion (lifting Ͻ7 kg) outcome of complications after laparoscopic anti-reflux operations. to minimize intra-abdominal pressure. A graduated diet Arch Surg 2001; 136: 399–404. 31

Results of laparoscopic treatment of hiatal hernias

PATRICK R. REARDON AND STIRLING E. CRAIG

Type I hiatal hernia repair 235 References 237 Types II, III and IV hiatal hernia repair 236

Four types of hiatal hernias exist. With type I or sliding were returned. There were no results that dealt specifically hiatal hernias, the most common type, the gastroesopha- with type I hiatal hernias. There were multiple articles on geal junction is displaced cranially into the chest. Type II type II, type III, and giant hiatal hernias. and type III hiatal hernias are para-esophageal hernias. In type II hiatal hernias, the gastroesophageal junction is in its TYPE I HIATAL HERNIA REPAIR native position, inferior to the diaphragm. The fundus, and sometimes the body and antrum of the stomach, have rolled cranially into the mediastinum. Type III hiatal hernias are Intraoperative complications reported during laparoscopic mixed para-esophageal hernias. In these hiatal hernias, 360-degree fundoplication include esophageal perfora- both the gastroesophageal junction and a large portion of tion,1–3 gastric perforation,1,2 pneumothorax,2 bleeding,2 the stomach have rolled into the mediastinum. Type IV and conversion to open procedure.2–4 These complications hiatal hernias include the spleen, the colon, or some other should not be affected by small hiatal hernias. The intra- intra-abdominal organ within the hernia. operative complications of type I hiatal hernia repair are When discussing outcomes for laparoscopic repair of outlined in Table 31.1.Postoperative complications include hiatal hernias, the results should focus on two groups of atelectasis, gastric perforations,4 dysphagia,3,4 substernal patients. The first group comprises patients with type I chest pain,3,4 heartburn,3,4 regurgitation,3,4 early satiety,3 hiatal hernias, which account for 90–95 per cent of all death,2 and recurrent hiatal hernia.4 The likelihood of a hiatal hernias. These hernias are generally asymptomatic recurrent hiatal hernia following a laparoscopic 360-degree and do not require repair. They are repaired primarily as fundoplication with a small hiatal hernia or no hiatal part of a fundoplication to treat gastroesophageal reflux hernia is affected by whether the crura are closed. Crural disease. Most surgeons mobilize the distal esophagus in closure has been documented to reduce the occurrence of order to achieve intra-abdominal esophageal length. This recurrent hiatal hernias.4–7 Larger hiatal hernias are also process destroys the phreno-esophageal ligament. At this point, the anatomy resembles the anatomy in the repair of Table 31.1 Type I laparoscopic hiatal hernia repair a small type I hiatal hernia. Therefore, the outcomes for Intraoperative complications Percentage the repair of these hernias are essentially the same as outcomes for laparoscopic 360-degree fundoplication. The Esophageal perforation 0.2–3.03,1 second group comprises patients with types II, III or IV Gastric perforations 1.61 hiatal hernias. These tend to be larger hernias occurring Pneumothorax ?2 2 30 in an older patient population and have different out- Bleeding ?, 1.0 comes. In an online PubMed literature search using the Superscript figures indicate references. keywords ‘hiatal hernia’ and ‘laparoscopic’, 220 citations ? ϭ reported without a percentage. 236 Laparoscopic treatment of diaphragmatic herniation

Table 31.2 Type I laparoscopic hiatal hernia repair Table 31.3 Types II, III and IV laparoscopic hiatal hernia repair Postoperative complications Percentage Intraoperative complications Percentage Gastric perforation 0.3,4 1.06 Dysphagia 7.2,4 4.9,6 4.8,3 9.031 Esophageal perforation 4.0,32 1.9,8 5.0,9 2.3,10 8.3,11 0.512 Substernal chest pain 16.9,4 8.0,3 22.031 Gastric perforations 1.6,32 10.0,14 1.8,13 3.09 Heartburn 5.2,4 2.8,3 12.031 Enterotomy 3.88 Regurgitation 3.5,4 5.43 Pneumothorax 3.6,13 4.0,9 Early satiety 15.63 Hypercarbia 0.832 Atelectasis ?31 Vagus nerve injury 1.813 Pneumothorax 16 Bleeding 1.8,13 1.210 Wound infection 130 Tear of the right crus 2.715 Postoperative herniation 6.2,4 1.0,6 3.4,31, 5.030 Cardiac arrest 0.832 Death 0.31 Death (due to a 1.813 pulmonary embolism) Superscript figures indicate references. ? ϭ reported without a percentage. Superscript figures indicate references. associated with an increased likelihood of recurrent hiatal hernia.5 Most larger hiatal hernias, however, are type II, III valve during the operation and high-volume ventilation or IV. The postoperative complications of type I hiatal during desufflation of the abdomen will usually obviate hernia repair are outlined in Table 31.2. the need for any treatment. Hypercarbia is more common in the repair of these large hiatal hernias due to the TYPES II, III AND IV HIATAL HERNIA REPAIR extensive dissection within the mediastinum leading to increased absorption of carbon dioxide. The problem may be exacerbated by the frequent occurrence of emphysema Laparoscopic repair of a large para-esophageal hernia is a or chronic obstructive pulmonary disease in these elderly technically difficult operation and should be performed patients. During dissection of the large sac associated with only by a surgeon with significant experience of per- these hernias, bleeding may occur.5,11 Vagus nerve injuries forming standard laparoscopic 360-degree fundoplica- may occur secondary to failure to recognize the esophagus tions in patients with no or small type I hiatal hernias. and vagus nerves within the sac.13 Cardiac arrest, and Large hiatal hernias tend to occur in older patients with death due to pulmonary embolism or other causes are rare significant associated comorbidities, which make them occurrences intraoperatively.13 higher operative risks. In addition, because of the rotation Numerous postoperative complications have been of the stomach up into the mediastinum, identification of reported following laparoscopic repair of para-esophageal the anatomy is difficult. The larger hernia sacs may obscure hernias. Some of these complications are minor, but many the location of the esophagus and vagus nerves, and these of them are severe. Many of these complications are related structures are injured more easily in the repair of large or to the fact that these patients present in the sixth and para-esophageal hernias. seventh decades of life. Frequently, the patients are frail and The intraoperative complications of types II, III and IV present with significant other diseases. Some of the compli- hiatal hernias are outlined in Table 31.3. Intraoperative cations may be related to failure to perform an anti-reflux complications include esophageal perforations,8–12 entero- procedure at the time of the hernia repair. The postopera- tomy,8 gastric perforations,8,9,13–15 pneumothorax,9,13 tive complications are outlined in Table 31.4. The need to hypercarbia,13 vagus nerve injury,13 bleeding,11 tearing of perform anti-reflux procedures at the same time remains the right crus,15 gastric leak,16 myocardial infarction,8 a controversial issue. Some of the most common symp- cardiac arrest, pulmonary embolism,8 and death due to toms reported after these procedures, such as dysphagia, pulmonary embolism. When recognized and repaired are related directly to the performance of an anti-reflux intraoperatively, perforations of the esophagus, stomach procedure. Hernia recurrence remains a problem in laparo- and intestine add very little morbidity.5 Delayed recogni- scopic hiatal hernia repair. Symptomatic hernias represent tion of a perforation of a hollow viscus is associated with only a fraction of the total number of recurrences,5,17,18 significant morbidity and a prolonged hospital stay.1,2 and therefore, recurrences in many series may be under- Most cases of pneumothorax do not involve an actual lung reported. Hernia recurrence is more common in para- injury. Most are due to inadvertent injuries to the medi- esophageal hernias than in type I hernias. The larger the astinal pleura during dissection in the chest. Most contain hernia, the more likely is the recurrence.4 Factors associated only carbon dioxide. Whenever possible, a recognized with increased recurrence include a failure to excise the pleural injury should be oversewn. Positive-pressure venti- hernia sac,10,15,19 breakdown of the crural repair,20 short- lation using a positive end expiratory pressure (PEEP) ened esophagus, and large hiatal defects with an inability to Results of laparoscopic traeatment of hiatal hernias 237

Table 31.4 Types II, III and IV laparoscopic hiatal achieve a tension-free repair. Recently, there have been hernia repair increasing reports in the literature of the use of mesh in an attempt to decrease the recurrence rate following repairs of Postoperative complication Percentage hiatal hernias.16,20–28 The mesh may be placed centrally as a Esophageal perforation 1.333 bolster to an already closed hiatus.16,23,26,28 The mesh may Gastric perforations 0.8,32 1.98 be used to span the hiatal defect to create a truly tension- 33 Esophageal stricture 2.6 free repair.16,20,29 The mesh may also be used to close a 10 Gastric obstruction 1.2 relaxing incision placed laterally in the tendinous 33 37 Acute gastric dilation 1.3, 8.3 diaphragm. Delayed gastric emptying 1.813 33 37 Overall, the surgical literature supports the belief that Prolonged gastric atony 2.6, 16.7 the laparoscopic repair of para-esophageal and hiatal Mesh erosion into stomach 2.321 hernias is technically feasible, safe and effective. Given Prolonged ileus 1.0,9 2.715 the age and condition of the patients, the morbidity and Small-bowel obstruction 1.536 13 14 8 10 mortality rates are acceptably low. However, the recur- Dysphagia 3.6, 20.0, 6.0, 21.0, 18 8.3,11 1.612 rence rates in some series have been unacceptably high. GERD symptoms 1.8,13 20.0,14 10.0,8 41.7,11 Recent reports utilizing mesh to reduce the recurrence 3.712 rate are promising and may help reduce the relatively Early satiety 19.08 high recurrence rate that has been the Achilles heel of Gas bloat 1.112 laparoscopic hiatal hernia repair. Hyperflatulence 29.08 Mediastinal seroma 10.014 Transient cervical emphysema 37.5,39 48.834 REFERENCES Breast mastalgia 8.337 10 Pneumothorax 3.2 1 Schauer PR, Meyers WC, Eubanks S, et al. Mechanisms of gastric 24 37 38 Atelectasis 10.0, 8.3, 10.0, and esophageal perforations during laparoscopic Nissen 3.718 fundoplication. Ann Surg 1996; 223: 43–52. Pneumonia 3.5,10 8.311 2 Bowrey DJ, Peters JH. Laparoscopic esophageal surgery. Surg Clin ARDS 1.09 North Am 2000; 80: 1213–42, vii. Pleural effusion 0.8,32 4.09 3 Granderath FA, Kamolz T, Schweiger UM, et al. Long-term results 13 of laparoscopic antireflux surgery. Surg Endosc 2002; 16: 753–7. Respiratory failure 1.8 4 Soper NJ, Dunnegan D. Anatomic fundoplication failure after 9 10 Deep vein thrombosis 2.0, 1.2 laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–76, 676–7. 13 8 9 10 Pulmonary embolus 1.8, 1.9, 3.0, 1.2 5 Oddsdottir M. Paraesophageal hernia. Surg Clin North Am 2000; Myocardial infarction 1.6,32 1.9,8 1.09 80: 1243–52. Atrial fibrillation 6.0,9 16.711 6 Watson DI, Jamieson GG, Devitt PG, et al. A prospective randomized Cardiac arrhythmia 1.813 trial of laparoscopic Nissen fundoplication with anterior vs Congestive heart failure 1.3,33 1.836 posterior hiatal repair. Arch Surg 2001; 136: 745–51. 18 7 Seelig MH, Hinder RA, Klingler PJ, et al. Paraesophageal herniation Cardiac tamponade 3.7 as a complication following laparoscopic antireflux surgery. 9 Stroke 1.0 J Gastrointest Surg 1999; 3: 95–9. Hematoma 1.09 8 Swanstrom LL, Jobe BA, Kinzie LR, Horvath KD. Esophageal motility Hemothorax 3.718 and outcomes following laparoscopic paraesophageal hernia repair Bleeding 8.311 and fundoplication. Am J Surg 1999; 177: 359–63. Retroperitoneal bleeding 3.718 9 Luketich JD, Raja S, Fernando HC, et al. Laparoscopic repair of giant Need for transfusion 0.512 paraesophageal hernia: 100 consecutive cases. Ann Surg 2000; 36 23 232: 608–18. Urinary retention 1.8, 2.9 10 Watson DI, Davies N, Devitt PG, Jamieson GG. Importance of 9 Transient renal failure 1.0 dissection of the hernial sac in laparoscopic surgery for large Urinary-tract infection 7.4,18 2.321 hiatal hernias. Arch Surg 1999; 134: 1069–73. Mediastinal abscess 0.8,32 0.512 11 Behrns KE, Schlinkert RT. Laparoscopic management of Intra-abdominal abscess 2.0,9 0.512 paraesophageal hernia: early results. J Laparoendosc Surg 1996; Wound infection 4.621 6: 311–17. 12 Livingston CD, Jones HL, Jr, Askew RE, Jr, et al. Laparoscopic hiatal Clostridium difficile colitis 1.09 33 hernia repair in patients with poor esophageal motility or Fever of unknown origin 1.3 paraesophageal herniation. Am Surg 2001; 67: 987–91. 15 Incisional hernia 2.7 13 Gantert WA, Patti MG, Arcerito M, et al. Laparoscopic repair of Postoperative herniation 3.6,13 10.0,14 8.0,8 1.0,9 paraesophageal hiatal hernias. J Am Coll Surg 1998; 186: 428–32, 3.5,10 1.112 432–3. Death 2.4,32 0.512 14 Oddsdottir M, Franco AL, Laycock WS, et al. Laparoscopic repair of paraesophageal hernia. New access, old technique. Surg Endosc Superscript figures indicate references. 1995; 9: 164–8. 238 Laparoscopic treatment of diaphragmatic herniation

15 Wu JS, Dunnegan DL, Soper NJ. Clinical and radiologic assessment 24 Athanasakis H, Tzortzinis A, Tsiaoussis J, et al. Laparoscopic repair of laparoscopic paraesophageal hernia repair. Surg Endosc 1999; of paraesophageal hernia. Endoscopy 2001; 33: 590–4. 13: 497–502. 25 Casaccia M, Torelli P, Panaro F, et al. Laparoscopic physiological 16 Hui TT, Thoman DS, Spyrou M, et al. Mesh crural repair of large hiatoplasty for hiatal hernia: new composite ‘A’-shaped mesh. Surg paraesophageal hiatal hernias. Am Surg 2001; 67: 1170–74. Endosc 2002; 27: 27. 17 Velanovich V, Karmy-Jones R. Surgical management of 26 Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior paraesophageal hernias: outcome and quality of life analysis. Dig cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc Surg 2001; 18: 432–7. 1997; 11: 769–71. 18 Hashemi M, Peters JH, DeMeester TR, et al. Laparoscopic repair of 27 Frantzides CT, Madan AK, Carlson MA, Stavropoulos GP. large type III hiatal hernia: objective followup reveals high A prospective, randomized trial of laparoscopic recurrence rate. J Am Coll Surg 2000; 190: 553–60, 560–61. polytetrafluoroethylene (PTFE) patch repair vs simple cruroplasty 19 Edye M, Salky B, Posner A, Fierer A. Sac excision is essential to for large hiatal hernia. Arch Surg 2002; 137: 649–52. adequate laparoscopic repair of paraesophageal hernia. Surg Endosc 28 Granderath FA, Schweiger UM, Kamolz T, et al. Laparoscopic 1998; 12: 1259–63. antireflux surgery with routine mesh-hiatoplasty in the treatment of 20 Basso N, Rosato P, De Leo A, et al. ‘Tension-free’ hiatoplasty, gastroesophageal reflux disease. J Gastrointest Surg 2002; 6: 347–53. gastrophrenic anchorage, and 360 degrees fundoplication in the 29 Paul MG, DeRosa RP, Petrucci PE, et al. Laparoscopic tension-free laparoscopic treatment of paraesophageal hernia. Surg Laparosc repair of large paraesophageal hernias. Surg Endosc 1997; 11: 303–7. Endosc Percutan Tech 1999; 9: 257–62. 30 Zornig C, Strate U, Fibbe C, et al. Nissen vs Toupet laparoscopic 21 Carlson MA, Richards CG, Frantzides CT. Laparoscopic prosthetic fundoplication. Surg Endosc 2002; 16: 758–66. reinforcement of hiatal herniorrhaphy. Dig Surg 1999; 16: 407–10. 31 Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication 22 Huntington TR. Laparoscopic mesh repair of the esophageal hiatus. failures: patterns of failure and response to fundoplication revision. J Am Coll Surg 1997; 184: 399–400. Ann Surg 1999; 230: 595–604, 595–604. 23 Frantzides CT, Richards CG, Carlson MA. Laparoscopic repair of large 32 Mattar SG, Bowers SP, Galloway KD, et al. Long-term outcome of hiatal hernia with polytetrafluoroethylene. Surg Endosc 1999; 13: laparoscopic repair of paraesophageal hernia. Surg Endosc 2002; 906–8. 16: 745–9. 32

Complications and their management

SANTIAGO HORGAN AND ROBERT BERGER

Intraoperative complications 239 Conclusion 247 Postoperative complications 243 References 247

Numerous reports detail the benefits of laparoscopic fun- and Pellegrini.8 The left crus is initially identified, and the doplication, including decreased pain, quicker return to short gastric vessels are divided using an ultrasonic shears. normal daily activities, and shorter hospital stay. However, A no-touch technique for esophageal dissection is used to there are also complications related to the treatment of minimize traumatic manipulation of the esophagus. This gastroesophageal reflux disease (GERD). Mortality reports requires the crura to be separated from the esophagus, and range from zero to two per cent for initial repairs, increas- not vice versa. After visualizing the right crura, circumfer- ing to five per cent for second operations.1,2 The morbid- ential dissection of the esophagus proceeds cephalad while ity, and likewise failure, of laparoscopic fundoplication is using a Penrose drain to manipulate the esophagus. dependent on its definition and length of follow-up. Most The posterior crura should be re-approximated with inter- large, single-institution studies report morbidities of two rupted, nonabsorbable sutures to create a snug fit over a to 26 per cent, with specific identification of failed surgery 56 French Maloney bougie placed within the esophagus. occurring in four to eight per cent.2–4 Table 32.1 displays A short, floppy, 2-cm fundoplication with three sutures is the reported causes and frequencies of these failures (see created and secured to the esophagus but not to the crura also Chapter 29). This chapter discusses the more com- or diaphragm. mon intraoperative and postoperative complications associated with laparoscopic fundoplication, their prevention, Table 32.1 Commonly reported complications and various case the appropriate work-up for their diagnosis, and the reports following laparoscopic Nissen fundoplication appropriate course of action. In addition, any reoperation, whether laparoscopic or open, is known to have a higher Incidence incidence of complications as well as a higher risk of Complication (%) Case report 5–7 recurrence. It should be stressed that conversion from a Failed Nissen 4–8 Pneumomediastinum laparoscopic to open surgery for patient safety should not Para-esophageal 0–7 Pulmonary embolism be considered a complication if performed at the appro- hernia priate time. Reoperation 2–6 Mesenteric thrombosis Dysphagia 1–7 Hiatal stenosis Heartburn/reflux 1–5 Bowel perforation INTRAOPERATIVE COMPLICATIONS Pneumothorax Ͻ2 Delayed gastric perforation Gastric perforation 1.5 Cardiac The ability to adequately visualize and identify the anatomy laceration/tamponade required for performance of a Nissen fundoplication Delayed gastric 1 Injury to major vessels cannot be overemphasized. These concepts are discussed emptying Ͻ elsewhere and will not be re-addressed here. It is prudent, Splenectomy 1 Late diaphragmatic however, to state that our typical fundoplication is per- rupture Hemorrhage 0.5 Necrotizing fasciitis formed using a left crus approach, as described by Horgan 240 Laparoscopic treatment of diaphragmatic herniation

Possible intraoperative complications are discussed ﬁlled with saline. The esophagus should then be insuf- below. This is followed by a discussion on ways to avoid ﬂated with air while observing for bubbles as evidence of encountering these problems initially and what to do if a perforation. they are encountered.

Posterior esophageal dissection Bougie perforation Perforation with a bougie or dilator is a feared complica- Factors causing increasingly difficult dissection of the tion. The best safeguard is to ensure active communication esophagus include prior foregut surgery, extensive history between the person passing the bougie and the surgeon of Barrett’s esophagus causing peri-esophagitis, and prior observing the process. This alone will not guarantee elim- dilation treatments (in which microperforations may ination of the risk of perforation, but it will diminish the have occurred). Meticulous dissection and use of the risk when both parties involved actively assist each other. Penrose drain will help to minimize this complication. In If any resistance is encountered with the passage of the addition, the use of an angled scope (30 or 45 degrees) bougie, then force should not be applied. Either a more will assist in visualizing the posterior aspect of the esoph- experienced person should attempt to pass the bougie agus. The ultrasonic shears are well suited for the lysis and/or re-examination within the abdominal cavity via of adhesions, whereas monopolar cautery devices can the laparoscope should occur. First, verify that the appro- allow for lateral thermal injury and potential delayed priate bougie size is being used (48–60 French are most esophageal perforation. In addition, obese patients often common, depending on the patient’s body habitus and have significant adipose tissue along the greater curve of any history of prior dilations or strictures), and ensure the stomach. In these instances, it is best to place the adequate lubrication of the bougie with a water-soluble patient in a steep reverse Trendelenburg position and jelly. The Penrose drain, typically used to manipulate the place a 4 ϫ 4 gauze within the abdomen, just medial to gastroesophageal junction, should not be manipulated in the superior tip of the spleen (Figure 32.1). This will assist any way while advancing the bougie. It is critical that no in lateral retraction of the adipose for improved exposure tension is placed on the gastroesophageal junction to of the left lateral and posterior aspects of the esophagus. ensure a straight and unobstructed path from the esopha- Should perforation of the esophagus be suspected, then gus into the stomach. Using a blunt grasper, palpation the anesthesiologist should be asked to place an orogastric along the greater curve of the stomach and anterior gastric or nasogastric tube and instill 60 cc of methylene blue to wall will inform the surgeon when the bougie has entered help localize any injury. If the surgeon cannot visualize the stomach. The surgeon also needs to be attentive to an the posterior esophagus adequately, a clean 4 ϫ 4 gauze overly aggressive and easy passage of the bougie to ensure may be placed behind the esophagus before the instilla- it does not pass too far distally, creating a perforation tion of the methylene blue. The gauze is then withdrawn along the greater curve or near the pylorus. Infrequently, and inspected for any evidence suggestive of a leak. If the use of the bougie is impossible because it cannot be methylene blue is not available, then the patient could be passed easily. It is safer to avoid the use of force for placed in a level position while the upper abdomen is advancement than to do so and produce a perforation. With experience, the looseness of the wrap and the crural closure will rarely result in postoperative dysphagia. If perforation of either the intrathoracic or intra- abdominal esophageal occurs, it is critical to recognize and treat the injury early. If recognized immediately, the injury may usually be treated with primary closure using interrupted sutures with placement of the fundoplication over the injury to reinforce the repair. It is also considered safe to place a closed suction drain at the level of the injury for postoperative monitoring. A drain is not mandatory but is dependent on the level of comfort of the surgeon with repairing this type of injury. The drain is removed easily once the patient has shown no significant morbidity after adequate time to heal and there is no evidence of leakage. We recommend removing the drain at least five days after surgery after a normal esoph- Figure 32.1 Placing a gauze sponge at the superior splenic agogram is performed. The patient can be fed after this pole assists in exposure. point. Complications and their management 241

Pneumothorax Hemorrhage

The incidence of pneumothorax occurring during The development of bleeding is always an unnerving esophageal dissection is almost 2 per cent.4 Contributing experience, especially as it is visually magnified when factors are peri-esophagitis from severe Barrett’s disease, performing laparoscopic surgery. Laparoscopic proce- prior endoscopic therapy, large hiatal hernias, and prior dures have the additional complexity of requiring the operations upon this area (i.e. prior fundoplication). judgment necessary to know when to convert to an open There is little to prevent this complication other than operation to obtain control. This question has as many careful, meticulous dissection. Pneumothorax may pres- answers as there are operative cases. In general, there are ent in two ways: the first, and most common, is visualiza- three specific situations in which excessive hemorrhage tion of an opening in the pleura by the operating team. occurs during the performance of laparoscopic fundo- Usually, the patient has no immediate respiratory complications: retraction of the left liver lobe, division of promise, such as increasing end tidal carbon dioxide or the short gastric vessels, and dissection of the superior increased peak airway pressures. Should a rent in the gastrosplenic ligament. pleura occur, then it might be closed using a stitch or The position and type of the liver retractor vary with clip, in order to avert ventilatory compromise. The anes- the surgeon performing the operation. Preventing injury thesiologist may also ventilate the patient manually with is preferable to treating injury, so adequacy and clarity of several large tidal volume breaths to expel carbon dioxide optics are mandatory. This allows identification of any trapped in the pleural space. The operation may then adhesions from prior surgeries or inflammation, and continue while using a lower insufflation pressure then allows the selective division of them with cautery or (8–10 mmHg). Postoperatively, a chest X-ray can be an ultrasonic scalpel. If a laceration or puncture occurs, obtained. The majority of patients will not require a tho- several options are available. First, place a 4 ϫ 4 gauze racostomy tube, as the carbon dioxide is readily absorbed into the abdomen and apply direct pressure to the injury. and a repeat chest X-ray will document resolution of If the bleeding is controlled, the gauze may be held in any pneumothorax. Should the chest radiograph in the place under the liver retractor while the surgery pro- postanesthesia unit reveal a large pneumothorax (у50 ceeds. At the end of surgery, careful removal of the gauze per cent), then a small chest tube may be necessary, and visualization of the injury will confirm whether especially if the patient appears symptomatic. the bleeding has stopped. This will be sufficient for the The second presentation of pneumothorax may be majority of liver injuries. It is also recommended that more dramatic. In this scenario, the anesthesiologist the intra-abdominal pressure is decreased at the time of will suddenly comment on increasing end-tidal carbon this inspection to ensure that the pneumoperitoneum is dioxide, increased peak airway pressures, or decreasing not creating a tamponade effect. If bleeding continues, hemodynamics. If the presentation is limited to end- then one should try the placement of one of the many tidal carbon dioxide, then the surgeon should decrease available hemostatic agents, either liquid or solid, at the the intra-abdominal pneumoperitoneum pressure after site. Other therapies include electrocautery and the safely removing the instruments from the abdomen. The argon-beam coagulator. Only rarely have we found cases anesthesiologist should then ventilate the patient manu- of hepatic bleeding that could not be controlled with one ally to clear any intrapleural collection of trapped carbon or more of these modalities. dioxide. If the patient is experiencing elevated peak air- Division of the short gastric vessels is another step way pressures or decreased hemodynamics, then the same that potentially can result in a hemorrhagic complica- initial approach of lowering the intra-abdominal pressure tion. The majority of surgeons performing fundoplica- and manual ventilation of the patient should occur. If tions today use ultrasonic scalpels. Other possible peak airway pressures do not decrease or if the hemo- techniques include the use of clips followed by their divi- dynamics continue to deteriorate, then tension pneumo- sion or bipolar coagulation. Regardless of the instrument thorax is likely. The decision to place a thoracostomy employed, the standard warning of careful visualization tube should not be delayed. If a chest tube is not available and maintaining patience is applicable. The surgeon immediately, then a 14-gauge angiocatheter needle should elevate the greater curve of the stomach while the should be placed in the second intercostal space at assistant elevates the omentum. The initial opening of the the midclavicular line. To determine the appropriate side, greater sac is usually uncomplicated. The greatest occur- one should auscultate the chest or attempt to visualize the rence of bleeding is seen when approaching the superior pleural tear. However, the placement of an angiocatheter aspect of the greater curve. In this area are the most super- needle is only a temporary measure. This should be fol- ior and posterior short gastric vessels. At this level, the lowed by the introduction of a 28–32 French chest tube assistant should use a blunt grasper to push the greater connected to a closed suction drain. A postoperative chest curve of the stomach medially and inferiorly. This will X-ray should confirm the proper location. allow the surgeon to gently retract the redundant portion 242 Laparoscopic treatment of diaphragmatic herniation

Figure 32.2 Exposure of the most superior-posteriorly located short gastric vessel requires careful dissection and transection. of the fundus in an inferior and medial direction to expose the last short gastric vessel. Once identified, the surgeon should bluntly create an opening posteriorly to the vessel to allow complete visualization of the occlusion of the vessel by the instrument of choice for division (Figure 32.2). Finally, the spleen is in close approximation to this dissection. Again, only careful progression of the surgery will ensure prevention. Multiple reports have shown a decreased incidence of splenic injury with the increasing performance of laparoscopic fundoplication.2,9,10 One Figure 32.3 Short esophagus: The gastroesophageal junction frequent precipitating factor is multiple adhesions from can be seen easily above the diaphragm. The esophagus does not the gastric wall to the spleen. In this situation, a quick show folds, which is usually a sign of a short esophagus. When remedy is to use an endoscopic linear stapler to transect the esophagus appears tortuous, the chances of being able to across the greater curve of the stomach and leave a small reach the abdomen are very high. gastric remnant attached to the splenic hilum. This is a better alternative to incurring uncontrollable bleeding from a tear of splenic capsule and does not exert any sig- of the potential need for a Collis gastroplasty, either laparo- nificant impact on the patient. Again, depending on the scopically or via a thoracic approach. In our experience, degree of injury, direct pressure to the injury is the best however, preoperative identification of a shortened esoph- initial approach if the bleeding is minimal. If bleeding is agus is not always correlated with intraoperative findings profuse, then one should be comfortable in performing (Figure 32.3). Should the esophagus be found to not have laparoscopic splenectomy or have a low threshold for the necessary 2–3-cm length within the abdomen, then conversion to an open surgery to ensure the patient’s proximal circumferential dissection of the esophagus will safety first and foremost. The latter is preferred. free up more thoracic esophagus to reach further into the abdomen. The surgeon should not settle for less than the Shortened esophagus minimum intra-abdominal length, as this will likely lead to slippage of the fundoplication, migration of the wrap into the thoracic cavity, or improper placement of the wrap on The concept of a shortened esophagus generates much to the upper stomach rather than the esophagus. controversy. If appropriate preoperative work-up was performed, then the barium swallow and esophageal manometry should indicate the length of intra-abdominal Large hiatal hernia esophagus, ideally 2–3 cm. Patients with severe or long- standing esophagitis and long-segment Barrett’s esopha- This should be identified preoperatively by barium swal- gus are at increased risk of esophageal shortening. If low, esophageal manometry, or esophagogastroduodeno- identified preoperatively, the patient should be informed scopy (EGD). If the hernia is no larger than 4 cm, then it Complications and their management 243 can be repaired primarily with standard crural closure, and verbal reassurance, as these complaints drop to five using interrupted nonabsorbable sutures. If the hernia is per cent after three months.12 The surgeon must ques- large or if the diaphragm is thinned, then closure of the tion patients about their diet and activity in the immedi- hernia primarily without undue tension may not be pos- ate postoperative period to differentiate between patients sible. Reinforcement of the repair using pledgets made of who require radiographic studies and patients who expanded polytetrafluoroethylene (ePTFE; W. L. Gore & require only reassurance. Instructing patients preopera- Associates) can be attempted. These should be cut into tively about necessary diet restrictions and activity limi- small rectangular shapes and placed perpendicular to the tations will avert many from overzealous eating or fibers of the crura to buttress the repair. If the closure exercising. During questioning, often the surgeon can remains under tension or if the surgeon is still unable identify whether the patient has eaten certain foods to close the hiatus completely, then a prosthetic patch (breads, meats, raw vegetables) at too early a time and should be placed. Previously, polypropylene mesh was may be experiencing obstruction, or whether they have used, but this led to migration and erosion into the overexerted themselves (weight-lifting, heavy manual stomach and/or esophagus. Currently, most surgeons labor, etc.) too early (before two months). For patients prefer the use of ePTFE mesh because of the markedly who complain of these symptoms, the easiest and most decreased risk of erosion. We use the technique described prudent study to obtain is a barium swallow. This reveals by Huntington.11 A relaxing incision is made to the right the anatomy responsible for the majority of early com- of the right crus to allow a tension-free primary closure plications. If the barium swallow study is equivocal, then of the hiatus. This allows the crura to be in direct contact it is reasonable to undertake an EGD examination if the with the esophagus rather than the mesh. The ePTFE symptoms persist after six to eight weeks. Repeat studies patch is then placed over the relaxing incision in order to of 24-hour pH monitoring and esophageal manometry cover the defect, and is secured with either sutures may be pursued if the symptoms of reflux, asthma, or tacks. It is critical that the placement of these tacks or cough or hoarseness persist after a trial of antisecretory sutures is not into the esophagus, pericardium, inferior medication. Finally, persistent gastric bloating may vena cava, or aorta. necessitate gastric emptying studies.

Gastric necrosis/perforation Bloating/nausea/epigastric pain/increased flatulence Injury to the gastric fundus is most likely to occur during the manipulation of the tissues to provide exposure, dur- A majority of patients will return to the clinic with specific ing passage of the wrap, or during the division of the complaints of feeling bloated, occasional nausea, epigas- short gastric vessels and causing thermal injury. If identi- tric pain, and generally an increased incidence of flatu- fied, a primary closure of the perforation is required. This lence. This is due to the patient’s habit of swallowing saliva may be accomplished by over-sewing the perforation in a and air to neutralize the presence of acid in the esophagus. two-layered fashion using an inner absorbable suture and Once a fundoplication is performed, this air progresses a nonabsorbable outer suture. This requires the ability to through the bowel rather than retrograde through the perform intracorporeal suturing. The surgeon perform- esophagus, as before surgery. This is an expected event ing the laparoscopic fundoplication should possess postoperatively. Because of this, it is important to inform this skill. The second option is to use an endoscopic linear the patient in preoperative counseling to decrease anxiety stapler. An endoscopic Babcock grasper can be used to levels when it does occur. Most patients will have signifi- approximate both edges of the defect and incorporate cant improvement in these symptoms with just several them into the stapler line. If one is unsure of the security weeks of expectant management, which includes a critical of the repair, then a closed suction drain may be placed review of their current diet. One important question to near the site of perforation at the end of the case. ask patients postoperatively is whether their symptoms of reflux have been treated. Often, reflux patients are of the POSTOPERATIVE COMPLICATIONS anxious type and tend to concentrate on a new type of problem once the reflux has been treated. If the patient is unable to tolerate liquids at any time Following laparoscopic fundoplication, patients gener- or the patient has persistent nausea and vomiting, then ally present with complaints in either the early (Ͻ30 the surgeon should obtain a barium swallow as an initial days) or late (Ͼ30 days) timeframe. Early complaints diagnostic test to evaluate the post-surgical anatomy. If of dysphagia, nausea, bloating, and early satiety are no gross abnormality is seen, an EGD may be warranted. reported by 20–40 per cent of patients.12,13 A large por- Some patients will self-medicate with previous antacids tion of these patients will do well after careful questioning or proton-pump inhibitors as they are almost dependent 244 Laparoscopic treatment of diaphragmatic herniation upon them. If the barium study shows no anatomical careful re-approximation of the posterior crura. Careful defect and the patient feels better with medical therapy, attention to ensure the closure is tension-free is also para- then one can continue to follow the patient and treat on mount. We generally close the crura, beginning at the an as-needed basis. most inferior portion, using interrupted 0-Silk sutures placed 0.5 cm apart. After two or three sutures are placed, a 56 French Maloney dilator is passed, and the tightness of Para-esophageal herniation the crura closure is assessed. Closure is then tailored to ensure that it is snug, with no obvious gaps, but not overly An occurrence of para-esophageal hernias of up to seven restrictive. If a para-esophageal hernia develops postoper- per cent was noted when laparoscopic fundoplication was atively, then the wrap should be taken down completely to 9,14 initially performed. Patients present with persistent assist in visualizing any technical complications that may nausea, vomiting, and intolerance of solids. This may occur have contributed to the early failure of the wrap. In addi- at any time following surgery, but usually it is early (within tion, this allows better visualization in the repair and re- one to two weeks) and generally it follows a report of sus- approximation of the crura while assessing the possibility tained coughing and/or straining associated with heavy that an overlooked shortened esophagus was present at lifting or Valsalva-type maneuvers. The best initial work- the initial surgery. up is to obtain a barium swallow. Abnormal anatomy is revealed in 90 per cent of patients (Figure 32.4). This radiographic finding alone, with a symptomatic patient, is Slipped Nissen justification enough to return to the operating room for urgent repair before strangulation of the herniated viscera The term ‘slipped Nissen’ refers to one of several anatom- occurs. The incidence of para-esophageal hernia has ical complications following laparoscopic fundoplication. decreased as more surgeons are routinely performing It is most often discovered by a barium swallow study after complaints of dysphagia, early satiety, or symptomatic complaints of recurrent reflux type symptoms. The barium swallow may display one of the following anatomic failures (see Figures 32.5–32.8.): • gastroesophageal junction and wrap above the diaphragm; • gastroesophageal junction only above the diaphragm; • para-esophageal herniation; • malformation of the wrap. Regardless of the type of failure, the patient will require the fundoplication to be redone. If none of these anatomical failures are seen on the initial radiographic

Figure 32.4 Para-esophageal herniation following fundoplication. Note the position of a portion of the stomach above the diaphragm. Figure 32.5 Type IA hernia. Complications and their management 245

study, then an EGD should be performed. This may show that the wrap was performed too tightly, placed too low on the stomach, or placed at an increased angulation, causing the lower esophagus to twist. Treatment for these complications requires advanced laparoscopic skills if the repair is to be attempted laparoscopically. Success rates at tertiary centers with advanced laparoscopic training programs are reported to be as high as 85–91 per cent.7,13 If one is to undertake such an effort, then keep in mind that the best time to attempt this is within the first week, before numerous dense adhesions are encountered. The ideal approach is to undo the initial fundoplication completely. This entails careful and deliberate dissection of the wrap from the anterior stomach wall, removal of the posterior crural sutures, and mobilization of the esophagus. This will ensure that there is sufficient esophageal length within the abdomen and that it is not under significant tension. If the esophagus does not allow for at least Figure 32.6 Type IB hernia. 2 cm of intra-abdominal length, then further circumferential mobilization of the esophagus is required. If this does not obtain more length, then the patient may require a Collis gastroplasty. Also, it is advisable to ensure sufficient mobilization of the fundus and greater curve of the stomach so that no tension or torque exists after creation of the wrap. After completely mobilizing the previous wrap, then the cause of the patient’s complaint is generally evident.

Vagal nerve injury

Identification of the vagus nerves is paramount in performing laparoscopic fundoplication. It is generally agreed that the magnification afforded by the laparoscope enhances the ability of the surgeon to visualize these Figure 32.7 Type II hernia. structures. The left vagus will be seen as it progresses from its lateral to anterior position on the gastric wall. It may be obscured by the anterior fat pad just inferior to the gastroesophageal junction. The right vagus will course posteriorly behind the stomach. Meticulous dissection and a bloodless field are critical at this point of dissection. It is best to visualize, but not dissect, both vagi at their normal anatomical positions. This will decrease the possibility of retraction, thermal injury from cauterization, or transection of the nerve. A no-touch technique avoids directly grasping or manipulating the vagi and esophagus. This will decrease injury and irritation of the nerves and ultimately decrease complaints of postoperative dysphagia secondary to postoperative edema. If a patient suffers a vagal nerve injury, then symptoms of delayed gastric emptying may include bloating, early satiety, regurgitation, and diarrhea.15 Most patients are not studied preoperatively with a gastric-emptying test. However, if these symptoms are present during Figure 32.8 Type III hernia. the initial clinical visit, then it is prudent to obtain a 246 Laparoscopic treatment of diaphragmatic herniation baseline measurement. Some authors advocate perfor- Diagnosis of achalasia is best confirmed with mance of a pyloroplasty at the time of fundoplication if esophageal manometric studies. The lower esophageal the patient has evidence of delayed gastric emptying. sphincter should be identifiable and demonstrate a non- However, most authors do not advocate this, as studies relaxing and hypertensive pressure value. Development have shown that gastric emptying times generally improve of achalasia after a fundoplication has been reported, but following fundoplication. In addition, a symptomatic most cases are probably the result of inadequate pre- patient may be tried on several prokinetic medications operative evaluation. Treatment for achalasia is dilation, (e.g. metoclopramide, erythromycin) before undertaking botulism toxin injection, or cardiomyotomy. If a surgical surgery. cure is undertaken, then the fundoplication will need to Patients who return with complaints of postprandial be taken down completely, cardiomyotomy performed, weakness, palpitations, diaphoresis, and feelings of anxiety and a partial fundoplication carried out. may be experiencing postprandial hypoglycemia. This was Radiographic evidence of a wrap that is too tight is reported in several cases and confirmed with the perfor- best appreciated with a barium marshmallow-swallow mance of an oral glucose tolerance test.16 Postprandial study. Liquids may pass easily through the wrap, but hypoglycemia may be associated with a vagal nerve injury, foods with thicker consistency may become lodged above thus causing early dumping and a hyperinsulin response the wrap. The best therapy is an initial attempt at dila- to the glucose load. This probably represents a neuro- tion using either pneumatic dilatation or bougies of an praxic injury because it resolves with time and does not increasing diameter. Most frequently, this will be success- require treatment. ful if the complaint of dysphagia presents within the first three months. If the complaint of dysphagia arises more Ileus than three months after surgery, then dilation may be attempted but it is less likely to be successful. Finally, the hiatal opening may be the source of dyspha- Ileus following laparoscopic fundoplication is usually gia following fundoplication. If the crura are approximated mild due to the short time of the operation and minimal too tightly, then complaints will be almost immediate fol- manipulation of the bowel. Most surgeons will not place lowing surgery. Several authors have reported scarring at a nasogastric tube postoperatively as it is rarely required the hiatal opening, causing a stricture seen on postopera- and most patients start a liquid diet the same night as tive barium swallow.17 It is suspected that the use of surgery. If a patient does experience intolerance of diathermy near the diaphragm is the source of injury. liquids, then placement of a nasogastric tube and decom- Treatment involves surgical incision of the scarred pression of the stomach is required. In addition, a low diaphragm to release the tension at this site. threshold for obtaining a barium swallow with small Complications arising more than 30 days after suc- bowel follow-through can rule out any anatomical cessful fundoplication may originate from anatomical reason for ileus. Any treatment will be dictated by the failure or from functional problems. Anatomical failures clinical condition and results of testing of the patient. include essentially the same difficulties listed above, in the ‘early’ categories. Regardless of the timing of presen- Dysphagia tation, a barium swallow should be the first test obtained, followed by esophageal manometry, 24-hour pH studies, Immediate postoperative dysphagia is attributed to post- or EGD, depending upon the symptoms of the patient. operative edema from the surgical dissection. Late dys- The management of these problems is similar to those phagia may be from scarring at the hiatus, missed or new presented above. onset of achalasia, increasing dysmotility, worsening Barrett’s esophagus, esophagitis, or new development of esophageal carcinoma. At the time of diagnostic work- Recurrent reflux up, barium swallow should be the first test performed. Anatomical deviations from standard surgical results will Patients who return with complaints of persistent or usually be identified. Occasionally, retained food is noted unrelenting reflux warrant a thorough work-up to on the study. Whether the dysphagia occurs early or late ensure adequate anatomical integrity and functional will play a role in the determination of how quickly a success of the fundoplication. Again, start with a barium patient should be taken back to the operating room for swallow study to assess anatomical changes and any evi- reconstruction. If it occurs early on, then it is most likely dence of herniation of the stomach or the wrap itself. If that a technical error has occurred. If it occurs late, then this appears normal, then a 24-hour pH study may show a trial with antisecretory medications may be warranted, objective data relative to a functional failure of the fun- as the success of repeat fundoplications decreases with doplication. Finally, EGD may show persistent irritation each attempt at surgical repair.12,13 of the esophagus from refluxate as well as confirm proper Complications and their management 247 placement of the wrap. If these studies all appear normal 2 Evans S, Jackson P, Czerniach D, et al. A stepwise approach to and show no definitive pathology, then it is reasonable to laparoscopic Nissen fundoplication. Arch Surg 2000; 135: 723–8. 3 Soper N, Dunnegan D. Anatomic fundoplication failure after give the patient a trial of antisecretory medications. If laparoscopic antireflux surgery. Ann Surg 1999; 229: 669–77. symptomatic relief is obtained from these, then it is best 4 Watson D, de Beaux A. Complications of laparoscopic antireflux to medicate the patient. Little is to be gained by attempt- surgery. Surg Endosc 2001; 15: 344–52. ing further surgery if the initial fundoplication is seen 5 Pohl D, Eubanks T, Omelanczuk P, Pellegrini C. Management and to be anatomically correct and providing a mechanical outcome of complications after laparoscopic antireflux operations. Arch Surg 2001; 136: 399–404. barrier towards reflux. 6 Hunter J, Smith D, Branum G, et al. Laparoscopic fundoplication failures. Patterns of failure and response to fundoplication revision. Ann Surg 1999; 230: 595–606. CONCLUSION 7 Horgan S, Pohl D, Bogetti D, et al. Failed antireflux surgery. What have we learned from reoperations? Arch Surg 1999; 134: 809–17. Laparoscopic fundoplication affords a good to excellent 8 Horgan S, Pellegrini, C. Surgical treatment of gastroesophageal result in more than 90 per cent of patients with refractory reflux disease. Surg Clin North Am 1997; 77: 1063–82. 9 Carlson M, Frantzides C. Complications and results of primary and chronic GERD. There is a 1.3 per cent chance of com- minimally invasive antireflux procedures: a review of 10735 1,9 plications. However, the majority of complications are reported cases. J Am Coll Surg 2001; 193: 428–39. minor and can be limited in occurrence if careful attention 10 Collet D, Cadiere G. Conversions and complications of laparoscopic to preoperative symptoms, diagnostic work-up, and app- treatment of gastroesophageal reflux disease. Am J Surg 1995; ropriate intraoperative techniques are followed. The use 169: 622–6. 11 Huntington T. Laparoscopic mesh repair of the esophageal hiatus. of careful laparoscopic technique will help minimize J Am Coll Surg 1997; 184: 399–400. intraoperative complications. Postoperative complications 12 Perdikis G, Hinder R, Wetscher G. Nissen fundoplication should always be studied with X-ray, endoscopy, 24-hour for gastroesophageal reflux disease: laparoscopic Nissen pH study, and manometry if an early solution and explana- fundoplication – technique and results. Dis Esophagus 1996; 9: tion cannot be found. As more surgeons acquire advanced 272–7. 13 Hinder R, Klinger P, Perdikis G, Smith, S. Management of the failed laparoscopic techniques, the general surgeon’s scope of antireflux operation. Surg Clin North Am 1997; 77: 1083–98. advanced laparoscopic procedures will also continue to 14 Watson D, Jamieson G, Devitt P, et al. Paraoesophageal hiatus broaden. Fundamentals, however, will not change; there- hernia: an important complication of laparoscopic Nissen fore, solid, practical judgment should always be used with fundoplication. Br J Surg 1995; 82: 521–3. the patient’s safety and outcome at the forefront of the 15 Hunter R, Metz D, Morris J, Rothstein R. Gastroparesis: a potential pitfall of laparoscopic Nissen fundoplication. Am J Gastroenterol surgeon’s considerations. 1996; 91: 2617–18. 16 Zaloga G, Chernow B. Postprandial hypoglycemia after Nissen fundoplication for reflux esophagitis. Gastroenterology 1983; REFERENCES 84: 840–2. 17 Watson D, Jamieson G, Mitchell P, et al. Stenosis of the esophageal hiatus following laparoscopic fundoplication. Arch Surg 1995; 130: 1 Rantanen T, Salo J, Sipponen J. Fatal and life-threatening 1014–16. complications in antireflux surgery: analysis of 5,502 operations. Br J Surg 1999; 86: 1573–7. This page intentionally left blank PART 5

Laparoscopy in the pediatric hernia patient

33 History 251 35 Diaphragmatic herniation 257 34 Anatomy and physiology 255 36 Complications and their management 261 This page intentionally left blank 33

History

RAJEEV PRASAD AND THOM E. LOBE

Pediatric laparoscopy 251 Laparoscopic inguinal herniorrhaphy 252 Laparoscopic exploration of the contralateral groin 251 References 254

Laparoscopy in pediatric hernia patients has undergone relatively recent advance. While initially used solely for a rapid, albeit delayed, evolution. While laparoscopic diagnosis, its use has expanded. It is now used routinely herniorrhaphy was being popularized in adults, the for cholecystectomy, appendectomy and pyloromy- approach was considered to be cumbersome, unneces- otomy, as well as more complex procedures, including sary, and even contraindicated in children. The percep- fundoplication, colectomy, and pull-through procedures tion that a child would outgrow the repair, particularly for Hirschsprung’s disease and high imperforate anus. one involving mesh, dominated early thoughts about the Initially, herniorrhaphy was not considered an appro- laparoscopic approach. Other considerations, such as the priate laparoscopic procedure in infants and children. physiological stress of laparoscopy in infants and children Pediatric surgeons believed that a child would outgrow and the size and availability of appropriate instruments, herniorrhaphy as it was applied in adults because the initially precluded pediatric laparoscopic herniorrhaphy. child had not reached its full development and size. Also, However, once these barriers were overcome in other the physiological impact of the procedure in infants and pediatric surgical maladies, it was inevitable that hernior- children was unknown and initially overestimated. rhaphy would be revisited. With steady progress, pediatric surgeons have applied their endoscopic skills to pediatric hernia patients, and today many surgeons prefer this LAPAROSCOPIC EXPLORATION OF THE approach for the repair of inguinal, ventral and diaphrag- CONTRALATERAL GROIN matic hernias in infants and children. Routine open exploration of an asymptomatic con- PEDIATRIC LAPAROSCOPY tralateral groin during surgery for a clinically apparent unilateral hernia is common practice among pediatric surgeons. Supporters of this approach base their view on the Gans and Berci were among the first to describe reported 29 per cent incidence of the future development laparoscopy in pediatric patients when they published of a symptomatic hernia on the unexplored side.2 Others their experience with ‘visualization of the contents of the cite a lower incidence of bilateral hernia and feel that the peritoneal cavity by means of a small telescope introduced increased cost and risk of damage to cord structures in through the anterior abdominal wall after establishment males precludes the safe exploration of a clinically asymp- of pneumoperitoneum’.1 Since then, this approach has tomatic groin.3 been rediscovered. New instruments and techniques have Many alternative methods of detecting a contralateral been developed, and there is a greater understanding of hernia have been described, including simple pneumo- the physiological impact of pneumoperitoneum in infants peritoneum and external inspection of the inguinal canal, and children. herniography, ultrasonography, and the passage of dilators Laparoscopy in general has experienced a huge across the lower abdomen through the open hernia sac.4–7 growth in its application in pediatric surgery. This is a Lobe and Schropp first introduced laparoscopy to aid in 252 Laparoscopy in the pediatric hernia patient the recognition of a patent processus vaginalis in the con- that this operation should not be carried out in boys as it tralateral asymptomatic groin during open unilateral was not possible to exclude the cord structures from the inguinal herniorrhaphy in 1992.8 In this initial series of 22 endoscopic loop ligature. In 1998, Schier described his patients, an infra-umbilical 3-mm port was placed and a technique of placing two to three Z-sutures laparoscop- 2-mm, zero-degree telescope was used to visually inspect ically using intracorporeal suturing and knot-tying tech- the contralateral groin. Fifty per cent of the patients with a niques to close the neck of the hernia sac.15 Again, the clinically negative groin had an occult hernia, and the procedure was limited to girls to avoid the risk of possi- technique was 96 per cent accurate in detecting such her- ble damage to the spermatic cord in boys. nias. Wolf and Hopkins used the same method in 38 boys Montupet and Esposito were the first to report and noted a 52.6 per cent incidence of bilateral hernia.9 successful laparoscopic herniorrhaphy in boys.16 They Chu and colleagues were the first to perform both insuf- specifically applied the laparoscopic approach to boys to flation and laparoscopy through the open hernia sac to avoid the risks of inadvertent removal of a segment of the visualize the contralateral groin, thus introducing non- vas deferens, as well as the possible risk of testicular dam- puncture laparoscopy;10 in their series of 74 children, 29 age (atrophy or high position in the scrotum), which can per cent had a second hernia, and there were no false pos- occur with the traditional open repair. In their series, 45 itives or false negatives. Fuenfer and coworkers described boys underwent laparoscopic repair in which an intra- an improved technique in 1996 in which a 14-gauge corporeal purse-string suture was placed around the angiocath was introduced through the open hernia sac for neck of the hernia sac. There were no intraoperative or intraperitoneal insufflation. A second 14-gauge catheter post-surgical complications, but two patients developed was inserted through the abdominal wall on the contralat- a recurrent hernia that required a second laparoscopic eral side of the abdomen, and a 1.2-mm laparoscope was repair. Schier reported his further experience of laparo- passed through this port for direct, in-line visualization of scopic hernia repair in 2000, concluding that the tech- the contralateral groin.11 They noted a 21 per cent inci- nique was simple for the experienced laparoscopist, that dence of bilaterality in 110 children. Another technique cosmesis was superb, and that the procedure was safe in described in 1996 employed a 5-mm, 30-degree or 70- both sexes.17 degree telescope through the open hernia sac.12 This Other reports have described the utility of laparoscopy report, which stratified patients by age, noted that patients for direct inguinal hernias and suspected recurrent her- older than 24 months had only a five per cent incidence of nias.18,19 Schier reported that the laparoscopic approach bilaterality, whereas patients younger than 24 months had allowed for easier detection of direct hernias as compared a 42.9 per cent incidence of a contralateral hernia. Thus, with the traditional open approach. Out of 109 patients, they were able to identify patients who might benefit from five (4.5 per cent) had a direct inguinal hernia. Most of contralateral surgery as well as those in whom surgery and these hernias were in boys and were on the right side. The its possible complications could be avoided. Other tech- prevalence of direct hernias was higher in this series as niques have since been described, including the use of a compared with the traditionally accepted rate (0.2–0.9 30-degree rigid bronchoscope with a working channel per cent) based on two large series of open hernia through which a catheter can be introduced and used to repairs,20,21 suggesting that direct hernias may go unrec- probe a suspected patent processus vaginalis, providing ognized during open repair, and that these cases may even better diagnostic accuracy.13 represent some of the recurrences after prior repair for indirect inguinal hernia. The conclusion was that laparoscopic repair for direct inguinal hernias is more reliable LAPAROSCOPIC INGUINAL HERNIORRHAPHY than open surgery as it is unlikely that an incorrect diagnosis will be made using laparoscopy. Regarding recurrent hernias, Perlstein and Du Bois noted that 44 per As laparoscopy evolved in children, pediatric surgeons cent of children undergoing laparoscopy for recurrent began to investigate the feasibility of laparoscopic repair inguinal hernias were found to have unsuspected find- of inguinal hernias. Theoretical advantages included ings, including indirect (missed sacs and true recur- excellent visual exposure, minimal dissection (and thus rences), direct (unilateral and bilateral), and femoral (all less trauma to the inguinal canal and spermatic cord), bilateral) defects.19 and an improved cosmetic result as compared with the Innovative techniques have recently been described for traditional open approach. In 1997, El-Gohary reported use in pediatric laparoscopic inguinal hernia surgery. Endo a series of 28 girls in whom herniorrhaphy was accom- and Ukiyama introduced the endo-needle, a 19-gauge plished laparoscopically using one or more endoscopic hollow needle with a notched tip and pre-attached suture loops placed at the base of the inverted hernia sac.14 He designed specifically for laparoscopic extraperitoneal reported that this was an expeditious, effective, and cos- closure of the patent processus vaginalis.22 They used this metically superior operation. However, he recommended instrument in 61 girls and reported no complications or History 253

Figure 33.1 Demonstration of the positions of the telescope, the lateral port for the grasper, and the site for insertion of the ligature passer during laparoscopic inguinal herniorrhaphy in children. Figure 33.3 Intraoperative photograph of the nonabsorbable ligature having been passed around the lateral half of the hernia sac.

through the stab incision and the muscle layers to the level of the peritoneum, or hernia sac. Once the lateral half of the hernia sac is encircled, the suture-passer pierces the peritoneum. The ligature is drawn intraperitoneally with the grasper as the passer is withdrawn (Figure 33.3). The empty suture-passer is then passed medially around the hernia sac (again just superficial to the peritoneum), and the peritoneal cavity is entered at the same point as before. The ligature is then passed through the eyelet of the Figure 33.2 Close-up view of the ligature-passer used in instrument using the grasper so that it can be withdrawn laparoscopic herniorrhaphy. externally. The ligature is tied extracorporeally, completing an extraperitoneal high ligation of the sac (Figure 33.4). recurrences. Lee and Liang performed micro-laparoscopic The vas deferens and spermatic vessels are seen easily dur- high ligation in 450 patients, with good results.23 They ing the ligature placement in males, and it is a relatively reported no complications of the surgery and a remark- straightforward task to find the tissue plane between ably low recurrence rate (0.88 per cent). these structures and the hernia sac, ensuring that they In 2001, we began to use a unique technique using are not included in the ligature. After cutting the excess miniature laparoscopic equipment in which a curved suture, the knot retracts subcutaneously. Steri-Strips stainless steel awl is used to pass a ligature circumferen- (3M Healthcare) are all that are required for skin closure. tially around the neck of the hernia sac. A 1.7-mm needle The technique adheres to the essential principles of scope is introduced through a 2-mm port in or near the hernia surgery. We reliably identify and ligate the her- umbilicus, and the abdomen is insufflated with carbon nia sac at the level of the internal ring. Additionally, there dioxide gas to 12 mmHg (Figure 33.1). We place a second is no disruption of the tissues of the inguinal canal. 2-mm port in the right lateral abdomen. We find this posi- In males, the spermatic vessels and vas deferens are well tion to be the most useful for traction for both right- and visualized during the circumferential passage of the left-sided hernias. A 1.7-mm laparoscopic grasper, placed suture, ensuring that they are excluded from the repair. through this second port, is used to manipulate the peri- The contralateral inguinal canal is also easily inspected toneum near the hernia defect (right and/or left sides). for the presence of a hernia, which is repaired if present. The suture-passer (Figure 33.2), introduced through a Our patients have had minimal postoperative discom- stab incision anterolateral to the internal ring, is used to fort, and all resume normal activities immediately after place a 2-0 nonabsorbable ligature circumferentially at the surgery. There is no longitudinal skin incision in the neck of the hernia sac. To accomplish this, the suture- abdominal wall (only three to four stab incisions), so the passer, with the tie in place through its eyelet, is passed cosmetic result is superior and the risk of infection is less 254 Laparoscopy in the pediatric hernia patient

4 Powell RW. Intraoperative diagnostic pneumoperitoneum in pediatric patients with unilateral inguinal hernias: the Goldstein test. J Pediatr Surg 1985; 20: 418–21. 5 Ducharme JC, Bertrand R, Chacar R. Is it possible to diagnose inguinal hernia by X-ray? A preliminary report on herniography. J Can Assoc Radiol 1967; 18: 448–51. 6 Evez I, Kovalivker M, Schneider N, et al. Elective sonographic evaluation of inguinal hernia in children – an effective alternative to routine contralateral exploration. Pediatr Surg Int 1993; 8: 415–18. 7 Brown RK. Hernia diagnosis by transperitoneal probing of the contralateral groin. Surg Gynecol Obstet 1964; 118: 123. 8 Lobe TE, Schropp KP. Inguinal hernias in pediatrics: initial experience with laparoscopic inguinal exploration of the asymptomatic contralateral side. J Laparoendosc Surg 1992; 2: 135–40. 9 Wolf SA, Hopkins JW. Laparoscopic incidence of patent processus vaginalis in boys with clinical unilateral inguinal hernias. J Pediatr Surg 1994; 29: 1118–21. 10 Chu C, Chou C, Hsu T, et al. Intraoperative laparoscopy in unilateral hernia repair to detect a contralateral patent processus Figure 33.4 Intraoperative photograph of the closed indirect vaginalis. Pediatr Surg Int 1993; 8: 385–8. 11 Feunfer MM, Pitts RM, Georgeson KE. Laparoscopic exploration hernia defect after laparoscopic high ligation of the hernia sac. of the contralateral groin in children: an improved technique. J Laparoendosc Surg 1996; 6 (suppl 1): S1–4. 12 Zitsman JL. Transinguinal diagnostic laparoscopy in pediatric than that of the open approach. In our experience, we inguinal hernia. J Laparoendosc Surg 1996; 6 (suppl 1): S15–20. 13 Saad SA, Goldfarb MA, Danikas D. Groin laparoscopy in pediatric have not noted a single infection in any of the 2-mm stab patients with clinical unilateral hernia: an improved technique incisions. Finally, there have been no major complica- using the bronchoscope. Pediatr Endosurg Innov Tech 1999; tions and only one recurrence in our patients. We believe 3: 59–65. that this technique, as well as others that utilize a circum- 14 El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls. ferential high-ligation of the hernia sac, as opposed to Pediatr Endosurg Innov Tech 1997; 1: 185–8. 15 Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998; simple suture closure of the defect with either a purse- 33: 1495–7. string or similar suture, is the most effective means of 16 Montupet P, Esposito C. Laparoscopic treatment of congenital repair. There are no gaps in the closure, particularly inguinal hernia in children. J Pediatr Surg 1999; 34: 420–3. medially, where recurrences might occur. Early data in 17 Schier F. Laparoscopic surgery of inguinal hernias in children – the literature suggest a lower recurrence rate with these initial experience. J Pediatr Surg 2000; 35: 1331–5. 22,23 18 Schier F. Direct inguinal hernias in children: laparoscopic aspects. extraperitoneal, high-ligation techniques. Pediatr Surg Int 2000; 16: 562–4. 19 Perlstein J, Du Bois JJ. The role of laparoscopy in the management of suspected recurrent pediatric hernias. J Pediatr Surg 2000; REFERENCES 35: 1205–8. 20 Fonkalsrud EW, de Lorimier AA, Clatworthy HW. Femoral and direct hernias in infants and children. JAMA 1965; 192: 101–3. 1 Gans SL, Berci G. Peritoneoscopy in infants and children. J Pediatr 21 Wright JE. Direct inguinal hernia in infancy and childhood. Surg 1973; 8: 399–405. Pediatr Surg Int 1994; 9: 161–3. 2 McGregor DB, Halverson K, McVay CB. The unilateral pediatric 22 Endo M, Ukiyama E. Laparoscopic closure of patent processus inguinal hernia. Should the contralateral side be explored? vaginalis in girls with inguinal hernia using specially devised J Pediatr Surg 1980; 15: 313–17. suture needle. Pediatr Endosurg Innov Tech 2001; 5: 187–91. 3 Given JP, Rubin SZ. Occurrence of contralateral inguinal hernia 23 Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic following unilateral repair in a pediatric hospital. J Pediatr Surg herniotomy in infants and children. Pediatr Endosurg Innov Tech 1989; 24: 963–5. 2002; 6: 25–8. 34

Anatomy and physiology

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Anatomy 255 References 256 Physiology 255

ANATOMY tissue and has not caused any wound complications in our experience. A comprehensive review of the anatomy of the inguinal canal is beyond the scope of this chapter. Chapter 6 PHYSIOLOGY describes this anatomy, which does not differ significantly from the adult patient. However, certain aspects of the anatomy of the abdominal wall should be considered in Physiological factors to consider during pediatric laparo- the context of laparoscopy. The layers of the abdominal scopic hernia surgery are essentially identical to those for wall must be traversed during port placement. The initial any other intra-abdominal laparoscopic procedures per- port that we place is the infra-umbilical port through formed in children. The cardiovascular and respiratory which the 1.7-mm telescope is placed. We choose to place effects of pneumoperitoneum are the issues that most this in an infra-umbilical position to reduce the risk of often raise interest for the surgeon and anesthesiologist infection. Ideally, the port traverses the midline. The fascia alike. The extremes of patient positioning, postoperative of the external abdominal oblique, internal abdominal pain management, and postoperative nausea and vomit- oblique, and transversus abdominus muscles, which join ing also deserve consideration. anterior to the rectus muscles inferior to the arcuate line, Insufflation of carbon dioxide gas is essential for are penetrated. The urachus, or median umbilical liga- proper visualization during pediatric laparoscopic her- ment, is in this area and should be avoided. The lateral nia surgery. In general, lower volumes and pressures port, through which a grasper is placed for traction, (6–12 mmHg) are required than in adult patients. We use traverses the same muscles. Structures near the internal a Veress needle inferior to the umbilicus for insufflation inguinal ring, where the hernia sac is ligated, must be con- and placement of the telescope. In our hands, the risks of sidered. In our technique, the suture is passed through all visceral injury and pre-peritoneal insufflation are low layers of the abdominal wall that are superficial to the peri- with this technique. Carbon dioxide approaches the ideal toneum or hernia sac. In males, the spermatic vessels, the insufflating gas, and is the gas used most often.1 It does genital branch of the genitofemoral nerve, and the vas def- not support combustion, and residual intraperitoneal gas erens pass superficial to the sac, and great care is taken not is absorbed rapidly and subsequently excreted. The major to include these structures in the ligature. The external drawback of carbon dioxide is its rapid intravascular iliac vessels are near but deep to the ligature. They should absorption across the peritoneal lining, which can lead to be visualized and, obviously, avoided. Similarly, the infe- hypercapnea during long procedures. This is generally rior epigastric vessels, which are branches of the external not of concern in pediatric laparoscopic inguinal hernia iliac vessels, are easily identified and avoided. Once tied surgery, as the procedures are relatively short. and cut, the permanent suture that we use to perform the The pneumoperitoneum itself creates cardiovascular, high ligation of the sac retracts into the subcutaneous respiratory and neurological effects in infants and 256 Laparascopy in the pediatric hernia patient children. In an investigation involving 12 healthy infants, anesthesia is our choice. Conversely, Tobias and colleagues a pressure of 10 mmHg resulted in a decrease in aortic have suggested that general face-mask anesthesia plus blood flow and cardiac stroke volume and an increase in spontaneous ventilation with concurrent caudal block systemic vascular resistance, when compared with con- may be useful for short diagnostic procedures.7 However, trols.2 These changes, however, were reversed after peri- this would likely be cumbersome for actual herniorrha- toneal exsufflation and caused no clinically deleterious phy, which occasionally can be a difficult and long effects in healthy infants. In a study of the effects of procedure. pneumoperitoneum in pediatric hernia patients, a pres- Postoperative pain management is less of a concern sure between 6 and 12 mmHg did not cause clinically sig- for laparoscopic herniorrhaphy compared with open nificant changes in cardiac index or systemic vascular inguinal hernia repair. In our experience, patients seem resistance.3 These cardiac effects may be exaggerated by to have less discomfort and very rarely require a narcotic patient positioning during laparoscopy, particularly with analgesic. Stretching of the peritoneum and phrenic the reverse Trendelenburg position when venous return nerves secondary to peritoneal insufflation, which can and cardiac output are further decreased.4 However, in result in shoulder pain, has not occurred in our experi- the Trendelenburg position, as may be used for laparo- ence. Complete exsufflation is important in avoiding this scopic hernia surgery, venous return is augmented and postoperative complaint. Local anesthetic infiltration at blood pressure returns to normal or supranormal levels. the puncture sites as well as perioperative caudal block Other potential sources of cardiovascular compromise may be useful adjuncts to ameliorate postoperative pain. during laparoscopic hernia surgery include vasovagal In the vast majority of cases, our patients have required reflex, myocardial sensitization by halothane, hypo- only paracetamol (acetaminophen) for pain control. They volemia, and venous gas embolism.1 are all able to return to immediate unrestricted activ- Deleterious respiratory effects during laparoscopy are ity. Postoperative nausea and vomiting, which can be the result of upward displacement of the diaphragm. This problematic after laparoscopy, has not occurred in our may result in early closure of small airways, an increase experience with pediatric laparoscopic herniorrhaphy. in peak airway pressure, and a reduction in functional residual capacity.1 These effects may be accentuated with positive-pressure ventilation and Trendelenburg posi- REFERENCES tioning in herniorrhaphy. Tobias and colleagues demonstrated that an intra-abdominal pressure of 15 mmHg in 1 Pennant JH. Anesthesia for laparoscopy in the pediatric patient. children during inguinal laparoscopy increased the air- Anesthesiol Clin North Am 2001; 19: 69–88. way pressure by a mean of 3 cm water, and end-tidal car- 2 Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic bon dioxide increased by a mean of 3 cm water.5 These effects of pneumoperitoneum during laparoscopic surgery in values returned to normal within ten minutes of the healthy infants: assessment by continuous esophageal aortic blood completion of surgery. flow echo-Doppler. Anesth Analg 1998; 88: 468–9. 3 Sakka SG, Huettemann E, Petrat G, et al. Transoesophageal Increased intra-abdominal pressure can also result in echocardiographic assessment of haemodynamic changes during increased intracranial pressure and, thus, a decrease in cere- laparoscopic herniorrhaphy in small children. Br J Anaesth 2000; bral perfusion pressure.6 Consequently, it may be inadvis- 84: 330–4. able to perform laparoscopic hernia surgery in patients 4 Joris JN, Noirot DP, Legrand MJ, et al. Hemodynamic changes with the potential for neurological complications. during laparoscopic cholecystectomy. Anesth Analg 1993; 76: 1067. 5 Tobias JD, Holcomb GW, Brock JW, et al. Cardiorespiratory changes Control of pain and anxiety in the perioperative period in children during laparoscopy. J Pediat Surg 1995; 30: 33. is no different for laparoscopic hernia surgery than for 6 Bloomfield GL, Ridings PC, Blocher CR, et al. Effects of increased other laparoscopic operations, except for certain adjuncts intra-abdominal pressure upon intracranial and cerebral that may be useful specifically for the pediatric hernia perfusion pressure before and after volume expansion. patient. Premedication is a matter of routine surgical care. J Trauma 1996; 40: 936. 7 Tobias JD, Holcomb GW, Brock JW, et al. General anesthesia by Atropine is useful to prevent some of the possible deleteri- mask with spontaneous ventilation during brief laparoscopic ous cardiorespiratory events that may occur, such as the inspection of the peritoneum in children. J Laparoendosc Surg vasovagal reflex. Intraoperatively, general endotracheal 1994; 3: 379. 35

Diaphragmatic herniation

RAJEEV PRASAD AND THOM E. LOBE

History 257 Surgical technique: Morgagni hernia 258 Patient selection 257 Results 259 Surgical technique: Bochdalek hernia 257 References 259

HISTORY hypertension, and who are on either oxygen by nasal cannula or minimal conventional ventilator settings. Older children who present either incidentally or with minimal In 1848, the anatomist Vincent Bochdalek described symptoms are also suitable candidates.2 two postmortem cases of diaphragmatic hernia. In 1902, Heidenhaim was the first to successfully repair such a defect in a child. Four decades later, Ladd and Gross described the repair of a diaphragmatic hernia in an infant. SURGICAL TECHNIQUE: BOCHDALEK Thereafter, there was a steady increase in the success of HERNIA repair of diaphragmatic hernias up to the 1970s, when survival reached a plateau and the physiological effects Posterolateral Bochdalek hernias may be approached of persistent pulmonary hypertension and bilateral pul- through either the chest or the abdomen, depending on monary hypoplasia were better appreciated. Since then, the preference of the surgeon. Supporters of the thoraco- there has been slower progress in the surgical approach to scopic route state that the herniated viscera are reduced this disease. The greatest advance has been with the appli- easily with carbon dioxide insufflation.3,4 Those who cation of extracorporeal membrane oxygenation (ECMO). support the laparoscopic approach state that the instru- The most significant change in the postnatal management ments are manipulated more easily and that the reduced of diaphragmatic hernias since ECMO has been the advent viscera can be inspected easily for possible injury.5 of minimally invasive techniques of repair. In 1995, van For thoracoscopic repair, at least three ports are nec- der Zee and Bax described the laparoscopic repair of a essary: two 3-mm working ports and a 5-mm port for posterolateral diaphragmatic hernia in a six-month old the camera (Figure 35.1). Carbon dioxide insufflation, infant.1 Since then, anterior Morgagni and posterolateral as stated above, helps to reduce the herniated viscera. A Bochdalek defects have been treated with minimally inva- hernia sac, if present, is resected as the defect is sutured sive techniques by experienced laparoscopists in stable, less (Figure 35.2).2 If a hypoplastic lung is present, as is often critically ill infants. the case, then visualization is actually easier. Following completion of the repair, a pleural catheter is placed PATIENT SELECTION through the 5-mm port site. For laparoscopic repair, three to five ports are needed. An umbilical port is used to pass a 5-mm, 30-degree The minimally invasive approach to diaphragmatic her- telescope. Two working ports (one 3 mm, one 5 mm) nias should be considered only in infants who are hemo- are essential. Additionally, a port for a liver retractor and dynamically stable, who are without signs of pulmonary an extra port for retraction by an assistant are useful. 258 Laparascopy in the pediatric hernia patient

Figure 35.1 Port placement for the thoracoscopic repair of a Figure 35.3 Port placement for Morgagni hernia repair. Bochdalek hernia.

Figure 35.4 Laparoscopic view of a Morgagni hernia repair using nitinol clips and a porcine submucosal patch. Figure 35.2 Endoscopic view of a thoracoscopic Bochdalek hernia repair. pentalogy of Cantrell. These defects are often asymptomatic. They may not be diagnosed until well after the The viscera are reduced into the abdominal cavity, and neonatal period, either as an incidental ﬁnding on chest the sac, if present, is resected ﬁrst. We close the defect radiography or during the work-up of respiratory symp- with 2-0 Ethibond (Ethicon, Inc.) sutures placed in an toms in an older child. interrupted fashion. The viscera are inspected for injury Morgagni hernias are repaired through the abdomen. at the completion of the repair. Three ports are necessary. A 5-mm port at the umbilicus is used to place a 30-degree telescope, and a 3-mm right SURGICAL TECHNIQUE: MORGAGNI abdominal port and a 5-mm left abdominal port are placed HERNIA for instruments (Figure 35.3). The hernia contents are then reduced. The sac is resected, and the hernia defect is closed using 2-0 Ethibond sutures placed in an interrupted fash- Morgagni hernias occur as anterior retrosternal or ion. More recently, we have repaired a Morgagni hernia parasternal defects. Embryologically, they occur where laparoscopically using an alternative closure device. In this the septum transversum joins the chest wall in the area case, we used clips of nitinol, a shape-memory metal where the mammary vessels pass from the chest to the (U-CLIP,Coalescent), to secure a prosthetic patch over the abdomen. These defects are rare, accounting for only one defect (Figure 35.4). Alternatively, a running suture of to two per cent of congenital diaphragmatic defects. barbed Prolene (Ethicon, Inc.) is used by some surgeons to Associated anomalies can occur, particularly heart complete the repair in order to prevent slippage of the defects, as this type of hernia is one component of the suture.4 Diaphragmatic herniation 259

Morgagni hernias, as well as Bochdalek hernias that are patients who are asymptomatic before the discovery of the large, may require the insertion of a prosthetic patch, as defect. Often, feeding can be initiated in the immediate stated above, for adequate closure. Expanded polytetraﬂu- postoperative period, and the patient can be discharged oroethylene (ePTFE) (Gore-Tex™,W.L. Gore & Associates, 24–48 hours following operation. Inc.) or porcine small-intestinal submucosal (Surgisis™, Cook Surgical) patches are both suitable. A potential advantage of the latter is that the tissue collagen replaces REFERENCES the collagen of the Surgisis, which may enhance the strength and longevity of the closure. 1 Van der Zee DC, Bax NM. Laparoscopic repair of congenital diaphragmatic hernia in a 6-month old child. Surg Endosc 1995; 60: 448–50. RESULTS 2 Ferro MM. Video-assisted repair of diaphragmatic defects. In: Lobe TE, ed. Pediatric Laparoscopy. Georgetown, TX: Landes Bioscience, 2002, in press. The results of Bochdalek and Morgagni herniorrhaphy are 3 Farmer DL, Sydorak R, Harrison MR, et al. Thoracoscopic repair of similar. The postoperative course of the patient is highly neonatal congenital diaphragmatic hernia. Pediatr Endosurg Innov dependent on the preoperative condition of the patient.2 Tech 2000; 4: 98. In patients who do not require mechanical ventilation or 4 Berchi FJ, Allal H, Cano I, et al. Diaphragmatic conditions in infants and children: endosurgery repair perspectives. Pediatr Endosurg are weaned from it preoperatively, the postoperative Innov Tech 2001; 4: 65. course is usually straightforward. Postoperative pain is 5 Smith J, Ghani AJ. Morgagni hernia: incidental repair during minimal, and the recovery is often rapid, particularly in laparoscopic cholecystectomy. Laparoendosc Surg 1995; 5: 123–5. This page intentionally left blank 36

Complications and their management

RAJEEV PRASAD AND THOM E. LOBE

Anesthetic complications 261 Hydrocele and testicular atrophy 262 Surgical complications 261 References 262 Recurrence 262

ANESTHETIC COMPLICATIONS Chen and colleagues reviewed the surgical complications that occurred in all patients undergoing laparoscopy or thoracoscopy over a five-year period.3 Thoracoscopy Anesthetic complications include deleterious cardio- was performed in 62 children, with a 13 per cent rate vascular and respiratory effects, such as decreased cardiac of conversion to thoracotomy, and laparoscopy was output, hypercapnea, shunting and atelectasis due to peri- performed in 574 children, with a 2.6 per cent rate of toneal insufflation, and the extremes of patient position- 1 conversion to laparotomy. The reasons for conversion to ing. Premedication, which includes the use of atropine, laparotomy included hemorrhage, esophagotomy during may alleviate these effects. The choice of anesthetic agent fundoplication, and malpositioned fundoplication. A case may differ in laparoscopic hernia surgery. For instance, of a gastric volvulus after fundoplication and gastrostomy nitrous oxide is avoided due to the increased incidence of required a laparotomy in the postoperative period and bowel distention, which will obscure the view during was the result of a malpositioned gastrostomy tube. Other laparoscopy. A balanced anesthetic technique using con- complications in the postoperative period included two trolled ventilation with inhalation agents (sevoflurane, children who developed hernias at the umbilical trocar desflurane or isoflurane), intravenous opioids, and non- 2 sites used for contralateral groin exploration. Trocar- depolarizing muscle relaxants is preferred. Patient selec- site cellulitis developed in three patients after laparo- tion is important, and those patients at greater risk than scopic gastrostomy in which the tube was brought out usual for the above complications, such as premature through the left upper quadrant port site. Other compli- infants or children with cardiopulmonary disease, should cations following laparoscopy included five instances of not be considered for laparoscopic herniorrhaphy. pelvic abscess after appendectomy, small-bowel obstruction after jejunostomy as well as after combined SURGICAL COMPLICATIONS appendectomy/cholecystectomy, one case of enterocolitis after pull-through for Hirschsprung’s disease, and one case of pneumonia after splenectomy. There were no deaths, Adherence to meticulous technique is the best way to and complications were noted to decline with increased prevent surgical complications. The laparoscopist should experience. consider their experience and level of comfort before Thus far, we, and others who perform laparoscopic embarking on or continuing difficult operations. One herniorrhaphy, have experienced very few surgical com- should attempt more complex operations only after sim- plications. In their series of 450 patients undergoing pler operations are mastered. Also, one should always laparoscopic herniorrhaphy, Lee and Liang had no oper- consider the option to open when difficulty is encoun- ative complications.4 Schier and coworkers reported a tered. Of course, this possibility should always be pre- series of 933 laparoscopic herniorrhaphies in boys and sented to the patient and family preoperatively. girls in whom no intraoperative complications occurred 262 Laparoscopy in the pediatric hernia patient other than minor bleeding from peritoneal vessels in ipsilateral hernia, to be a relative contraindication for three patients.5 We have had one conversion to open laparoscopic hernia repair in infants and children. Others, herniorrhaphy following pre-peritoneal insufflation. however, repair these defects laparoscopically. Postopera- This resulted in distortion of the pre-peritoneal plane tive hydrocele as a complication of laparoscopic hernior- through which the ligature and passer must be directed. rhaphy is a different entity. We have not yet seen any The subsequent open procedure was completed unevent- postoperative hydroceles in our series of patients. In their fully. There have been no cases of hemorrhage or visceral large series, Schier and colleagues reported a 0.4 per cent injury in our series of patients. incidence of postoperative hydroceles.5 Testicular atrophy, presumably from damage to the spermatic vessels or a high-riding testis (iatrogenic cryptorchidism), are also RECURRENCE concerns, but these seem to occur only rarely. We have not encountered either of these complications, and Schier and colleagues have had only one patient with a high- The reported recurrence rate after traditional open riding testis postoperatively.5 It is difficult to predict inguinal herniorrhaphy is 0.9 per cent. In their multicen- which patients will develop either of these complications ter experience, Schier and colleagues had a recurrence rate postoperatively. Again, meticulous technique is likely to of 3.4 per cent, higher than that for open repair.5 Their be the best measure for preventing these rare but real technique of closure with either a purse-string suture or a complications. Z-suture potentially left a gap in the herniorrhaphy medially, because they noted that all recurrences occurred at the medial margin between the suture and the epigastric REFERENCES vessels. Other reported series with smaller numbers of patients have had recurrence rates between zero and 4.4 per cent.6–9 Lee and Liang used a circumferential closure 1 Pennant JH. Anesthesia for laparoscopy in the pediatric patient. as their herniorrhaphy technique, and their recurrence Anesthesiol Clin North Am 2001; 19: 69–88. 4 2 Tobias JD. Anesthetic considerations for laparoscopy in children. rate in 450 cases was only 0.88 per cent. In our experi- Semin Laparosc Surg 1998; 5: 60. ence in approximately 50 patients with a follow-up of ten 3 Chen MK, Schropp KP, Lobe TE. Complications of minimal access to 15 months, there have been no recurrences. We also use surgery in children. J Pediatr Surg 1996; 31: 1161–5. a circumferential ligature placed at the neck of the hernia 4 Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic sac, which leaves no gap. This may be a more effective herniotomy in infants and children. Pediatr Endosurg Innov Tech 2002; 6: 25–8. means of closure of the hernia defect. 5 Schier F, Montupet P, Esposito C. Laparoscopic inguinal Perlstein and Du Bois used diagnostic laparoscopy in herniorrhaphy in children: a three center experience with 933 19 patients with recurrent inguinal hernias.10 Seventeen repairs. J Pediatr Surg 2002; 37: 395–7. indirect hernias and one femoral hernia were repaired at 6 El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls. the original procedure. One child had no hernia identi- Pediatr Endosurg Innov Tech 1997; 1: 185–8. 7 Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998; fied during the primary procedure. Overall, 11 recur- 33: 1495–7. rences were indirect hernias, four were direct hernias, 8 Montupet P, Esposito C. Laparoscopic treatment of congenital and four were found to be femoral hernias. Forty-four inguinal hernia in children. J Pediatr Surg 1999; 34: 420–23. per cent of these patients had unsuspected findings at 9 Schier F. Laparoscopic surgery of inguinal hernias in diagnostic laparoscopy (contralateral indirect, direct or children – initial experience. J Pediatr Surg 2000; 35: 1331–5. 10 Perlstein J, Du Bois JJ. The role of laparoscopy in the management femoral hernias). Recurrent hernias themselves can be of suspected recurrent pediatric hernias. J Pediatr Surg 2000; 35: managed effectively with laparoscopy and laparoscopic 1205–8. repair.11 Direct hernias can be detected at the time of 11 Schier F. Direct inguinal hernias in children: laparoscopic aspects. repair of recurrences, suggesting that they might have Pediatr Surg Int 2000; 16: 562–4. been missed at the initial operation.

HYDROCELE AND TESTICULAR ATROPHY

We consider a non-communicating hydrocele that is present preoperatively, alone or in conjunction with an PART 6

Future considerations

37 Robotics and hernia surgery 265 38 Socioeconomic issues 273 This page intentionally left blank 37

Robotics and hernia surgery

AMIT TRIVEDI AND GARTH H. BALLANTYNE

AESOP robotic arm 265 Conclusion 272 Da Vinci and Zeus tele-robotic systems 268 References 272 Tele-robotic laparoscopic ventral and incisional hernia repair 270

Over the past several years, there has been an ever-increas- refine the skills needed to perform more challenging cases ing presence of robotics in the operating room. These with the use of robotics. devices have been designed to help the surgeon overcome the limitations of conventional open surgery and laparo- AESOP ROBOTIC ARM scopic surgery. These limitations range from the decreasing availability of qualified surgical assistants, through the limited dexterity offered by conventional laparoscopic The AESOP robotic arm uses proprietary speech- instruments, to the lack of a three-dimensional operating recognition technology as the interface between the sur- field.1 The potential advantages of such systems set the geon and the robotic arm. Simple voice commands are stage for the next major change in the field of surgery. As used to direct the field of view of the laparoscope. The availability increases and costs decline, proficiency with advantages of this technology include 24-hour availabil- such devices will be required by all future generations of ity, thereby eliminating the need for an assistant to hold surgeons. Additionally, the demands of patients for a the camera for a wide variety of laparoscopic operations, robotic operation are expected to increase as more media including inguinal hernia procedures. Additionally, the attention is placed on this technology. field of view is controlled by the surgeon and is com- Currently there are three Food and Drug Administra- pletely free of tremor and straying. tion (FDA)-approved devices on the market that facilitate surgery: the AESOP robotic arm (Computer Motion, AESOP solo-surgeon laparoscopic Inc.), the da Vinci tele-robotic system (Intuitive Surgical), hernia repair and the Zeus tele-robotic system (Computer Motion Inc.). The use of these devices has a definite learning Since 1995, over 500 laparoscopic totally extraperitoneal curve that often deters busy surgeons from investing the (TEP) and transabdominal pre-peritoneal (TAPP) patch time required to become proficient in this technology.2 hernia repairs have been performed at our institution This chapter aims to serve as an introduction to the use using the AESOP robotic arm. The majority of these have of robotic devices in laparoscopic hernia surgery by out- been TEP repairs performed by a single practitioner as a lining the potential advantages of the technology. The solo surgeon operation.3 aforementioned devices have been used in inguinal, ven- Because AESOP uses voice recognition as the inter- tral and diaphragmatic hernias. The frequency with which face between surgeon and the robotic arm, before using these cases are encountered by the general surgeon makes AESOP for the first time each surgeon must create a voice hernia surgery an ideal platform on which to develop and card that recognizes his or her individual voice. Frequent 266 Future considerations use at our institution allows AESOP to be set up in less by the use of an ‘S’-retractor. This maneuver exposes the than ten minutes. posterior rectus sheath. Using blunt finger dissection, the space between the rectus muscle anteriorly and the poste- Technique rior rectus sheath is developed. A stay suture is placed, which encompasses the anterior rectus sheath laterally After bilateral pneumatic compression boots are placed on and the midline fascia. the patient, general anesthesia is induced and a Foley The patient is dropped into a Trendelenburg position catheter is placed to decompress the bladder. A single dose (Figure 37.2). An Origin Medsystems balloon dissector is of preoperative antibiotics is given approximately one hour then inserted into the space between the rectus muscle and before incision. The surgeon puts on the voice-control the posterior rectus sheath. It is passed down gently paral- headset before scrubbing and performs the operation from lel to the midline until the tip reaches the pubic bone. Care the side opposite to the hernia. Laparoscopic monitors are is taken during this step to keep a slightly upward slant to placed at the foot of the bed (Figure 37.1). The AESOP the balloon dissector tip, so as to avoid inadvertent entry robotic arm is mounted on the table before prepping the into the peritoneal space and possible bowel injury. A patient. The central articulated arm of AESOP is posi- 10-mm, zero-degree telescope is inserted through the tioned over the patient’s umbilicus. Once the patient is trocar, and the balloon is inflated according to the man- draped, a sterile plastic sleeve is placed over the robotic arm ufacturer’s specifications under direct visualization. The and the arm is positioned manually over the operative field. balloon is kept inflated for approximately five minutes to A 1-cm vertical para-umbilical incision is made on the allow for hemostasis. Next, the balloon is withdrawn and ipsilateral side of the hernia. The incision is made approx- the pre-peritoneal space is insufflated to a pressure of imately 0.75 cm lateral to the umbilicus. The incision is 12 mmHg. Once the pre-peritoneal space is insufflated, a carried down through the fat until the anterior rectus 5-mm trocar is placed in the suprapubic position and sheath is identified clearly. A 0.75-cm vertical incision is another 5-mm trocar is placed in the midline between then made through the anterior rectus sheath, exposing the umbilical port and the suprapubic port. the underlying rectus fibers. The medial edge of the rectus At this point, the laparoscope is changed to a 45-degree, muscle is identified and the fibers are then pushed laterally 10-mm telescope. Trial and error have established that this angled telescope offers the best field of view and the least interference with the working ports. The telescope is pre- mounted with a coupler that enables the telescope to be attached to the AESOP robotic arm via a strong magnet. The telescope is positioned such that the angle is looking upwards and the operative horizon is horizontal. Once positioned, the AESOP robotic arm will maintain these

Figure 37.1 Set-up of the operating room for a solo-surgeon laparoscopic inguinal hernia repair. An electronically integrated operating room facilitates advanced laparoscopic operations. The laparoscopic equipment is suspended from the ceiling by booms, allowing easy movement. The laparoscopic equipment can be controlled either by the scrub nurse via a touch screen Figure 37.2 Position of the patient and the surgeon for solo- (not draped in this photograph) or by the surgeon via voice. surgeon robot-assisted laparoscopic hernia repair. The patient is An array of flat-screened digital and analog monitors are in a mild Trendelenburg position. A three-trocar technique is distributed around the feet of the patient. This ensures that used: one port for the video-telescope and two ports for the the surgeon can view the laparoscopic video image in an surgeon’s right and left hands. A voice-controlled robot, AESOP, ergonomically comfortable position throughout the operation. holds the video-telescope. Robotics and hernia surgery 267 preset angles as it is directed to move the camera anywhere Moreover, the need to connect and disconnect sophis- in the operative field. It has been our consistent experience ticated equipment for each operation leads to equipment that the camera does not have to be removed or manipu- malfunction. Electronic integration of operating rooms lated until the placement of the mesh. The constant need facilitates advanced laparoscopic operations, improves to remove the camera for cleaning is reduced considerably turnover times, and provides a more pleasant working with AESOP compared with the use of surgical assistants. environment. Computer Motion first introduced voice Additionally, the surgeon’s anatomical orientation is control for AESOP and then extended it to other laparo- maintained much better when using an angled camera in scopic electronic equipment with HERMES. Storz a confined space with the use of AESOP. Lastly, the opera- Endoscopy has recently introduced a similar system – tive surgeon retains control over the now tremor-free field SESEM – that uses both touch-control panels and voice of view.4 The simple voice commands available to the sur- control (Figure 37.1). These integrated control systems geon with AESOP include ‘move in’,‘move out’,‘move left’, facilitate advanced laparoscopic operations by permitting ‘move right’,‘move up’,and ‘move down’. the surgeon to control most aspects of the operating room. In the TEP method, the hernia sac is bluntly dissected AESOP decreases the ‘footprint’ of the camera holder. free from the surrounding fat and cord structures. Once In many laparoscopic operations, the camera holder inter- this is done, the camera is disconnected from the robotic feres with the excursion arcs of the surgeon’s arms. The arm and removed. A large piece of Prolene mesh is passed surgeon and the camera holder often stand in uncom- through the umbilical port and into the pre-peritoneal fortable positions. In contrast, AESOP permits the sur- space. The camera is reinserted, and the mesh is positioned geon to stand erect in an ergonomically comfortable to cover the direct, indirect and femoral spaces. A minimal position (Figure 37.3). There is no crossing of arms with number of spiral tacks is used to secure the mesh in place.5 the camera holder. AESOP decreases the fatigue of the The pre-peritoneal space is deflated and the ports are surgeon in these solo operations. withdrawn. The fascia is closed at the umbilical port and a subcutaneous suture of the ports is preformed after 0.25 per cent bupivacaine infiltration.

Advantages The advantages of using the AESOP robotic arm in this setting are clear. The use of the arm facilitates a solo-surgeon operation, provides a stable camera platform, further integrates the surgeon’s control of the operating room, and promotes an ergonomically advantageous posture. Solo-surgeon operations have been also reported for laparoscopic cholecystectomy, laparoscopic Nissen fundoplication, and laparoscopic colectomy.4,6 In our hospital, the number of surgical residents available to assist in operations is dropping. As a result, we frequently perform these operations with the assistance of only a scrub nurse or technician. The use of AESOP keeps both of the assistant’s hands free to pass instruments, prepare the mesh, and maintain surgical counts. AESOP provides a stable camera platform. The video image remains properly oriented to the horizon. This avoids motion sickness in the operating-room staff and helps to maintain the surgeon’s orientation within the operative ﬁeld. Telephone calls, conversations with the nurses, and boredom do not distract from AESOP. The video image does not wander off the operative ﬁeld, Figure 37.3 The surgeon wears a microphone through which and the number of times the telescope requires cleaning he or she controls the robotic camera-holder and laparoscopic is decreased.6 equipment. The voice-controlled robotic camera holder works Advanced laparoscopic operations increase the com- unobtrusively, without interfering with the stance or arm plexity of the operating-room environment. The need to movements of the surgeon. The overhead surgical light supports roll various electronic towers and auxiliary equipment a video camera in its center for telecasting outside views of the into the operating room slows turnover of operations. operation. 268 Future considerations

The use of AESOP for laparoscopic hernia operations Da Vinci allows for the steady flow of the operation without breaking the momentum with distractions such as cam- The da Vinci tele-robotic surgical system was designed era cleaning or a moving operative field. Additionally, the from scratch to perform tele-robotic operations within a consistency of the dissection required in laparoscopic virtual operative field. Da Vinci telecasts a true three- hernia repairs aids in the learning curve of the robot. dimensional field of view. This is accomplished with a After more than 500 laparoscopic hernia repairs by a special 12-mm laparoscope that has two smaller 5-mm single surgeon at our institution, operative times are telescopes within it. The video images from the two 5-mm now typically 45 minutes for a unilateral hernia repair telescopes remain separate and are projected on to two and 60 minutes for a bilateral repair. separate monitors within the surgeon’s console. The surgeon sees the left console with their left eye and the right DA VINCI AND ZEUS TELE-ROBOTIC monitor with their right eye, much like using field binocu- SYSTEMS lars (Figure 37.4). This telecast system purposely isolates the surgeon’s field of view. The surgeon gets the sense of immersion within a virtual three-dimensional operative The FDA has approved two tele-robotic surgical systems field. This helps the surgeon to maintain their orientation for use in general surgical operations within the USA: the within the operative field despite their remote location. da Vinci (Intuitive Surgical) and the Zeus (Computer The surgeon controls the robotic instruments by plac- Motion, Inc.). The two tele-robots differ in certain features ing their hands within the masters (Figure 37.4 insert). (see below). In tele-robotic surgery, the surgeon sits at a A foot pedal determines whether the masters are control- computer console remote from the patient (Figure 37.4). ling the camera or two robotic surgical instruments. The The computer controls robotic surgical instruments that da Vinci robotic instruments offer hand-like motions. perform the operation. The computer translates the The robotic instruments move with seven degrees of free- motions of the surgeon’s hands into motions of the robotic dom, like the human wrist. These hand-like motions instruments and refines the motion by eliminating tremor overcome the limitations of traditional straight laparo- and allowing for motion scaling. The FDA currently scopic instruments. Da Vinci also offers motion scaling. requires the surgeon who performs the operation to be in The computer translates coarse movements of the sur- the same operating room as the patient; however, the tech- geon’s hands into finer motions of the robotic instru- nology permits the surgeon to sit thousands of miles away ments. Buttons on the surgeon’s console set the motion from the patient. Marescaux performed a tele-robotic scaling to one-, three- or five-to-one scales. The computer laparoscopic cholecystectomy on a patient in Strasbourg, also performs a fast Fourier transform (FFT) on the France while sitting at a Zeus surgeon’s console in New hand motions. This allows identification and filtering York Cit y. 7 of periodic motions such as tremors. This adds to the precision of robotic surgical instruments. The da Vinci robotic tower holds three robotic arms (Figure 37.5). The robotic arms are attached to laparoscopic trocars. The tower does not attach to the operating table. The robotic arms must be separated

Figure 37.4 Surgeon’s console and hand masters for da Vinci tele-robotic surgery. The surgeon views a virtual three- Figure 37.5 The da Vinci electronics tower and four robotic arms. dimensional operative field through binoculars in the surgeon’s The electronics tower holds the video and electronics equipment console. The surgeon places his or her hands into the masters, for the stereoscopic telescope. In this prototype, the robotic tower which translate the motions of the surgeon’s hands into motions holds four robotic arms. One arm holds the camera and the other of the robotic instruments (insert). three hold robotic laparoscopic surgical instruments. Robotics and hernia surgery 269 from the trocars whenever the surgical table is reposi- The three modified AESOP arms attach directly to the tioned. The FDA has recently approved use of a fourth surgical table (Figure 37.7). The surgical instruments are arm with the da Vinci system, which became available inserted into the abdomen through standard laparo- commercially in 2003. scopic trocars. Movements of the surgical table do not require repositioning of the AESOP arms. This is advan- Zeus tageous in advanced laparoscopic procedures, such as colectomy, in which the patient is repositioned several Zeus evolved from AESOP. Zeus consists of a surgeon’s times during the course of the operation. console and three modified AESOPs that attach directly We believe that these tele-robotic surgical systems to the surgical table. The surgeon sits at a computer con- offer specific technologic solutions to specific limitations sole with an open architecture (Figure 37.6). The sur- of traditional laparoscopic surgery. Both Zeus and da geon maintains direct visual contact with the patient and Vinci project three-dimensional operative fields. This the operative field. The surgeon controls movements of helps the surgeon to maintain their orientation and the camera with voice commands and controls the also helps to avoid complications generated by past robotic instruments with the two hand interfaces (Figure pointing. The hand-like motions of the robotic instru- 37.6 insert). This permits simultaneous control of all ments replace the extreme limitations of straight laparo- three robotic arms. The voice-control system, Hermes, scopic instruments. Motion-scaling and tremor-filtration can also control other electronics equipment in the oper- increase significantly the precision of laparoscopic tasks ating room. such as suturing. The surgeon sits in an ergonomically Zeus offers a three-dimensional image but with a comfortable position at the computer console. technology that is different to that of da Vinci. In the Surgeons face a learning curve before mastering Zeus system, alternating images from the left and right tele-robotic surgery. Before the use of these devices, video cameras are projected on to the main monitor. surgeons and operating-room staff must attend an Polarizing filters permit the surgeon’s right eye to see FDA-approved training course. After completion of this only the right image and the left eye the left image. This causes a three-dimensional image to project out from the two-dimensional monitor. Zeus provides hand-like motions for the robotic instruments. The Zeus instruments move with six degrees of freedom, compared with the seven of da Vinci. This means that the surgeon must compensate for one less degree of freedom by moving the robotic arm in various directions.

Figure 37.6 Zeus surgeon’s console and hand device. The surgeon sits at a computer console with an open architecture. Figure 37.7 Zeus robotic arms. The three robotic arms attach The surgeon sees the operative field in a three-dimensional video directly to the surgical table. The camera holder is a modified projection from the main monitor. Other flat-screen monitors AESOP that is voice-controlled by the surgeon. The two other display controls for the surgical instruments. The insert shows arms are AESOPs that have been modified to hold robotic the Zeus hand interface. surgical instruments. 270 Future considerations course, individual hospitals may have specific require- placed on the anterior axillary line above and below the ments for granting privileges towards the use of this camera port (Figure 37.8). emerging technology.8 In our hospital, we require that This operation begins by using a solo-surgeon tech- surgeons practice tele-robotic operations in live animal nique. The scrub technician changes the instruments as models, act as a first assistant in five to ten operations, needed. The first assistant, although scrubbed, is used only and are then observed by a proctor for an additional when a fourth port is placed or for emergency laparotomy. five to ten operations. This process for granting clinical At the end of the procedure, the assistant surgeon is privileges has successfully introduced tele-robotic surgery required to help pass the fixation sutures through the safely into clinical practice at our hospital. abdominal wall. The surgeon is seated comfortably at the operative console and views the operation through the three-dimensional imaging system within the console. TELE-ROBOTIC LAPAROSCOPIC VENTRAL At this point, the surgeon has full control over the opera- AND INCISIONAL HERNIA REPAIR tive field. Foot pedals are used to control the camera movements, and ergonomically positioned fingertip controls are used to manipulate the surgical instruments in We obtained two da Vinci systems in November 2000. We real time within the patient. initiated our clinical experience with da Vinci by performing a series of tele-robotic laparoscopic cholecystectomies.9 After demonstrating that we could perform cholecystectomies with outcomes similar to our standard laparoscopic cholecystectomy, we used the da Vinci system for Nissen fundoplication, colectomy, and incisional ventral hernia repair. The use of tele-robotic systems for a wide range of general, urology and cardiac surgery procedures has been described elsewhere.10–14 We have found that the da Vinci tele-robotic surgery system facilitates the performance of a laparoscopic Stoppa ventral hernia repair.

Technique for laparoscopic repair of incisional or ventral hernias with the use of the da Vinci tele-robotic system

The tele-robotic team at our institution consists of a nurse, (a) a scrub technician, a scrubbed laparoscopic fellow who serves as ﬁrst assistant, and an attending surgeon.15 Each member of the team has completed the FDA-approved training session. The patient is positioned supine on the table. Bilateral pneumatic compression boots wrap both legs. After the induction of general anesthesia, an orogastric tube and urinary catheter are inserted. The patient is shaved and prepared with an iodine-containing solution. The abdominal wall skin is covered with an impermeable plastic drape. A single dose of antibiotics is given one hour before surgery. A sterile plastic covering is placed over the three robotic arms (two arms for the surgeon’s right and 8mm left hands, one arm for the laparoscope). 12mm Trocar placement varies somewhat with the location of 8mm the incisional hernia. The trocars are inserted as far away as possible from the defect. We select the side of the patient (b) away from the previous operation for trocar insertion. If the patient had previously undergone sigmoid colectomy, Figure 37.8 (a) Trocar placement for a tele-robotic Stoppa for example, we would insert our trocars on the patient’s repair of an incisional ventral hernia. (b) A three-trocar right side. For a midline hernia, three incisions are used: technique is used. The 12-mm stereoscopic telescope is inserted the camera port is placed at the level of the umbilicus in through the 12-mm trocar. The two robotic surgical instruments the mid-axillary line and the remaining two ports are are inserted through the 8-mm trocars. Robotics and hernia surgery 271

The first part of the operation involves reducing the A Storz suture-passer is inserted through the abdominal hernia and lysis of any adhesions to the anterior abdom- wall at each of the stab incisions and used to retrieve the inal wall. A 30-degree telescope is used. Angulation of the ends of the Gore-Tex sutures (Figure 37.10). Once all of telescope upwards improves visualization of the anterior the suture ends are retrieved, they are tied. The edge of the abdominal wall. The hernia can usually be reduced with mesh is inspected. The mesh needs to sit firmly against the use of two graspers and a hand-over-hand technique the anterior abdominal wall. Pleats between the sutures are with gentle downward pressure to avoid tearing or injur- flattened out with 5-mm surgical tacks (Autosuture). ing the hernia contents. Once this is done, any adhesions The abdomen is deflated and the trocars are removed. to the anterior abdominal wall can be lysed easily, using The fascial defect of the 12-mm trocar is closed with an the electrocautery hook, harmonic scalpel scissors, or absorbable suture. The skin edges of the three trocar sites surgical scissors (Figure 37.9). Working on the underside are closed with absorbable subcutaneous sutures. All of the abdominal wall is facilitated greatly by the wounds are covered with impermeable dressings. dexterous instruments. After adequate lysis of adhesions, the fascial defect is Advantages usually evident. The limits of the defect are marked on the abdominal wall and measured. We like to overlap the mesh We have found that the da Vinci facilitates laparoscopic at least 2.2 cm beyond the perimeter of the hernia defect. repair of ventral and incisional hernias. The da Vinci pro- DualMesh Plus (W. L. Gore & Associates) is fashioned so vides a stable camera platform, permits a solo-surgeon that a degree of overlap is achieved. We place Gore-Tex approach to the lysis of adhesions, helps to maintain the sutures every two inches around the perimeter of the surgeon’s orientation within the operative field, promotes mesh. The sutures are tied with two throws to the mesh dissection on the anterior abdominal wall, and simplifies and the ends are left long. The head, foot, and left and right sides of the mesh are marked on the light side of the mesh with a marking pen. The pneumoperitoneum is deflated. The perimeter of the mesh is traced on to the plastic drape that covers the hernia defect. The position of the sutures is also marked. The mesh is rolled tightly into a cylinder, with the tails of the sutures rolled within. The mesh is inserted into the abdominal cavity through the 12-mm trocar and unfurled maintaining the proper orientation. The pneumoperitoneum is maintained at this point at a pressure of 10 mmHg. The labels on the light side of the mesh are visualized easily with the video camera. Small stab incisions are made in the skin at the positions of the sutures. (a)

(b) Figure 37.10 Passing sutures through the abdominal wall to fix Figure 37.9 Robotic scissors and atraumatic Cadierre grasper. the dual-sided mesh in place. The da Vinci’s stereoscopic view The adhesions are divided with robotic instruments. The Cadiere facilitates passing the sutures. A suture-passer drags the sutures grasper retracts the bowel, and the adhesions to the abdominal through the abdominal wall (a). Two robotic graspers are used to wall are divided with scissors. hand the sutures to and from the suture-passer (b). 272 Future considerations the passage of the fixation sutures through the abdominal Tele-robotic surgery remains in a period of rapid evo- wall. The da Vinci holds the video camera. The robot does lution. Newer generations of both da Vinci and Zeus con- not tire and does not wander from the operative field. tinue to be developed rapidly. Whether tele-robotics will This stable camera platform avoids the eye fatigue gener- become the standard of care in the near future remains ated by a constantly moving, human-held video camera. uncertain. Nonetheless, even at this early juncture, tele- Although all laparoscopic surgeons have been trained robotic surgical systems address some of the specific limi- to operate from a two-dimensional monitor, the true tations of standard laparoscopic surgery. Tele-robotic three-dimensional virtual operative field provides imme- surgical systems maintain a stable camera platform, diate advantages and rapidly became our preferred field immerse the surgeon in a three-dimensional virtual oper- of view. The surgeon comprehends more easily the three- ative field, move the surgical instruments with six or seven dimensional virtual operative field. Our impression is degrees of freedom, and further improve the ergonomics that this makes it easier for us to maintain our orientation for the surgeon. Tele-robotics also have the potential usage and helps to avoid past pointing injuries. in very remote settings, such as the battlefield and outer Straight laparoscopic instruments often fail to reach space. the anterior abdominal wall. The wrist-like motion generated by seven degrees of freedom overcomes this shortcoming and simplifies lysis of the adhesions to the REFERENCES anterior abdominal wall. This maneuver is awkward at best with conventional straight laparoscopic instruments 1 Ballantyne GH. The pitfalls of laparoscopic surgery: challenges for because of their anterior position. Straight laparoscopic robotics and telerobotic surgery. Surg Laparosc Endosc Percutan instruments are often limited from reaching the anterior Tech 2002; 12: 1–5. abdominal wall by the point of fixation of the trocar at 2 Talamini MA. Surgery in the 21 century [editorial]. Ann Surg 2001; 234: 8–9. the abdominal wall. The angulated movements of the 3 Fan P. Surgical grand rounds presentation: laparoscopic hernia robotic instrument tips permit the attack of the adhe- repair. Hackensack University Medical Center, April 3, 2001. sions from a wide variety of angles. 4 Merola S, Weber P, Wasielewski A, Ballantyne GH. Comparison of Three-dimensional imaging also assists in the passage laparoscopic colectomy with and without the aid of a robotic of the fixation stitches through the abdominal wall. camera holder. Surg Laparosc Endosc Percutan Tech 2002; 12: 46–51. Although this process can be accomplished with two- 5 Felix EL. Laparoscopic extraperitoneal hernia repair. In: Eubanks dimensional video cameras, novice laparoscopic surgeons SW, ed. Mastery of Endoscopic and Laparoscopic Surgery. accomplish this task more quickly in a three-dimensional Philadelphia: Lippincott Williams & Wilkins, 2000: 443–55. operative field. 6 Geis WP, Kim HC, Brennan EJ, Jr, et al. Robotic arm enhancement to accommodate improved efficiency and decreased resource utilization in complex minimally invasive surgery procedures. Stud Health Technol Inform 1996; 29: 471–81. CONCLUSION 7 Marescaux J, Leroy J, Gagner M, et al. Transatlantic robot-assisted telesurgery. Nature 2001; 413: 379–80. 8 Ballantyne GH, Kelley WE, Jr. Granting clinical privileges for Many surgeons perform advanced laparoscopic opera- telerobotic surgery. Surg Laparosc Endosc Percutan Tech 2002; 12: 17–25. tions with standard twentieth-century technologies. 9 Hourmont K, Pereira S, Wasielewski A, et al. Robotic versus Nonetheless, standard laparoscopy presents certain telerobotic laparoscopic cholecystectomy: duration of surgery and limitations that impede the learning of advanced skills outcomes. Surg Clin North Am 2003; in press. and prevent many surgeons from performing advanced 10 Cadiere GB, Himpens J, Vertruyen M, Favretti F. The world’s first laparoscopic operations. Robotics offers technological obesity surgery performed by a surgeon at a distance. Obes Surg 1999; 9: 206–9. solutions to some of these shortcomings. We have found 11 Cadiere GB, Himpens J, Vertruyen M, et al. Evaluation of that AESOP provides a stable camera platform, maintains telesurgical (robotic) Nissen fundoplication. Surg Endosc 2001; a stable relationship with the horizon, adequately replaces 15: 918–23. a human camera-holder, and lets the surgeon stand in an 12 Gould JC, Melvin WS. Computer-assisted robotic antireflux ergonomically comfortable position. Voice-control sys- surgery. Surg Laparosc Endosc Percutan Tech 2002; 12: 26–9. 13 Shah J, Rockall T, Darzi A. Robot-assisted laparoscopic Heller’s tems help to integrate the operating room and to keep the cardiomyotomy. Surg Laparosc Endosc Percutan Tech 2002; 12: surgeon in control of an ever more complicated operating 30–32. environment. In our hospital, robot-assisted laparoscopic 14 Horgan S, Vanuno D, Benedetti E. Early experience with robotically pre-peritoneal inguinal hernia repair in an integrated assisted laparoscopic donor nephrectomy. Surg Laparosc Endosc operating room is our standard of care. We believe that Percutan Tech 2002; 12: 64–70. 15 Ballantyne GH, Hourmont K, Wasielewski A. Telerobotic this technique permits the surgeon the best opportunity laparoscopic repair of incisional ventral hernias using intra- to replicate the operation in a high-volume mode with peritoneal prosthetic mesh (Stoppa technique): report of two excellent clinical outcomes. cases. J Soc Laparoendosc Surg 2003; in press. 38

Socioeconomic issues

KARL A. LEBLANC, ANDREW N. KINGSNORTH AND ZINDA Z. LEBLANC

Economics of hernia repair 274 Economics of laparoscopic surgery 278 Economics of day-case surgery 275 Payment changes 280 Incentives and day-case hernioplasty 276 Conclusion 281 Return to normal activity and work 276 References 281

Economic evaluations of new and existing healthcare Economic Cooperation and Development (OECD) coun- interventions are an essential input into decision-making. tries, and the USA.3 Healthcare systems around the world face steady increases It is no longer sufficient to consider the clinical or in expenditure as a result of demographic change and therapeutic effects of healthcare interventions: purchasing improvements in medical technology. Increasingly, payers choices will be predicated on studies that identify, measure must choose which interventions will be provided and and value what is given up when an intervention is used which will not be reimbursed from limited public or pri- (the cost) and what is gained (improved patient health vate funds. This creates difficult choices, as systems are no outcomes). This requires explicit economic evaluation of longer limited by what is technically possible to improve healthcare interventions. Purchasers have a fixed budget the health of patients but by what is practically possible and are aware of the opportunity costs of interventions. given resource constraints. In a situation where resources Increasingly, they are likely to require evidence of effec- are scarce, all choices about who will be treated have an tiveness and cost-effectiveness, and they may develop opportunity cost – the value of the benefit foregone. Health contracts and enforce protocols to ensure this. economics and the techniques of economic evaluation aim Economic evaluation values both inputs (costs) and to maximize the amount of health that is produced within outcomes (consequences) of an intervention, comparing the scarce resources available. In the UK, the National more than one alternative. This builds upon clinical eval- Institute for Clinical Excellence (NICE) synthesizes evi- uations that assess efficacy (can an intervention work in dence and reaches a judgment as to whether on balance the experimental circumstances?) and effectiveness (does it intervention can be recommended as a cost-effective use of work in normal clinical practice?) to assess efficiency National Health Service (NHS) resources.1 In 2000, NICE (does it provide the greatest benefit at least cost?). The published recommendations for the use of laparoscopic type of economic evaluation depends upon the outcome hernia surgery. It recommended its use outside centers of measure chosen: expertise only in cases of bilateral inguinal hernia or recurrent inguinal hernia. In the UK in 1996, approximately ten • Cost-minimization analysis is appropriate only when per cent of hernia repairs were carried out laparoscopi- the outcomes of two or more interventions have cally.2 Since the publication of the NICE guidelines, this fig- been demonstrated to be equivalent, in which case ure has decreased dramatically and supports the concept the least costly alternative is the most efficient, and that the application of clinical pathways can reduce costs. only cost analysis is required. Such measures are important in the UK, where the num- • Cost-effectiveness analysis includes both costs and bers of medical staff and the annual NHS budget are well outcomes using a single outcome measure, usually a below those in other European countries, Organization for natural unit. This allows comparisons between 274 Future considerations

treatments in a particular therapeutic area where should technological innovations such as laparoscopic effectiveness is unequal, but not between therapeutic surgery be introduced? All such pioneering innovations areas where natural outcome measures differ. should be evaluated in well-designed trials. There are • Cost-utility analysis combines multiple outcomes difficulties in implementing randomized controlled trials into a single measure of utility (e.g. a quality- of surgical techniques due to the difficulties of blinding, adjusted life year, QALY). This allows comparisons but a carefully designed trial can mitigate these prob- between alternatives in different therapeutic lems. Clinical trials protect the safety of patients and categories with different natural outcomes. ensure that new technologies produce effective healthcare. • Cost-benefit analysis links costs and outcomes by Economic evaluations ensure that such health gains are expressing both in monetary units, forcing an purchased at least cost. The guidelines applied to phar- explicit decision about whether an intervention is maceutical products, intended to protect society’s health worth its cost. Various techniques have been used to and scarce resources, should also be applied to surgical attach monetary values to health outcomes, but the innovations, but this is a difficult task to institute. technique remains rare in health economics. The principle of evaluating innovative surgical interventions was accepted by the Department of Health in the Considerations in cost-effectiveness are particularly UK in a press release in 1995, which announced that major relevant at a time when healthcare costs are escalating innovations were to be ‘scrutinised, evaluated and then, if disproportionately in relation to gross national product approved, fast tracked throughout the health service’.6 A in many westernized countries.4 The value of any indi- major advance should, under a new system, be subjected to cated treatment is directly proportional to treatment clinical trials, and a central register would give information outcome and inversely proportional to treatment cost. on approved operations. Purchasers could then consult the Evaluation of both the numerator (outcome quality) and register as a measure of the effectiveness of various opera- the denominator (cost) of the equation are subject to tions and procedures. This register, the Safety and Efficacy many methodological limitations. The value depends on Register of New Interventional Procedures (SERNIP), is whether it is viewed from the perspective of the patient, managed by the Academy of Medical Royal Colleges and surgeon, hospital, employer, payer or industry. Moreover, funded by the Department of Health. Doctors are asked cost does not equate with charge. In hernia surgery, the to register new techniques that they intend to pilot, and total cost includes pretreatment (diagnostics), treatment, to check the register to discover the current status of new post-treatment medical care including complications invasive procedures.7 An advisory committee convened by and recurrence, and societal and employer costs, which SERNIP will then assess all known data and assign the include insurance, worker’s disability compensation, procedure to one of four categories: worker replacement costs, and loss of productivity. Each 1 Safety and efficacy unsatisfactory – procedure must sector of the treatment process has variable fixed and not be used. semi-fixed costs. The trends to eliminate general anes- 2 Safety and efficacy established – procedure can be used. thesia and to perform conventional herniorrhaphy in an 3 The procedure is sufficiently similar to one of ambulatory setting have been cost-beneficial. Ideally, cost established safety and efficacy to raise no reasonable containment could be achieved by performing all elective doubts and can be used. inguinal hernia repairs at ambulatory surgical centers for 4 Safety and efficacy are not established – controlled a standardized charge. evaluation is needed. Technological innovation in surgery and in other areas (e.g. diagnostic innovation) is not regulated in the same The proposed system is voluntary and controlled clin- way as innovative pharmaceutical therapies. A new phar- ically. In time, economic evaluation of innovative invasive maceutical product is subjected to rigorous clinical trials procedures will be required, as is the case for pharmaceu- to identify evidence of safety and efficacy, before licensing tical products. In the majority of other countries, includ- for public use. Increasingly, new and existing pharmaceu- ing the USA, such a system does not exist at any level. tical products are also subjected to well-defined economic evaluation to show evidence of effectiveness and efficiency. Guidelines issued by the UK Department of Health state ECONOMICS OF HERNIA REPAIR that ‘the economic evaluation of pharmaceuticals should become part of taking decisions about treatment’, and set out clear guidelines regarding how a high-quality Hernia repair is an established and effective procedure. economic evaluation should be carried out.5 Its relatively fixed cost and high volume among surgical The careful procedures that control the introduction procedures mean that economic evaluation of the proce- of innovative pharmaceutical products are essential for dure itself has become a priority. Hernias create pain and innovative surgical and diagnostic therapies. How, then, discomfort for patients and limit their ability to work or Socioeconomic issues 275 carry out other productive activities. While the increased on as outpatients. Additionally, because of the increasing risk of surgical procedures in elderly people means that trend of incisional herniorrhaphy by the laparoscopic repair of some small direct hernias may not be manda- method, many incisional and ventral hernias are per- tory, there would seem to be clear clinical and economic formed with a length of stay of 23 hours or less.15,16 arguments in favor of carrying out hernia repairs among Economic appraisal is unlike surgical decision- the majority of the working population.8 making. Economists analyze the results of their inter- J.W. Hurst, a health economist, has compared the ben- ventions by comparing them within different scenarios: efits and costs of hernia repair with the benefits and costs as the scenarios change – employment prospects, labor of home dialysis for renal failure, and with the benefits relations, etc. – the economics change too. Surgeons are and costs of a successful renal transplant.9 Drawing on a used to evaluating their outcomes over time with the sce- measure of health status that measures two dimensions of nario held constant. For instance, with day-case surgery health (disability and distress), and using Department of and a constant surgeon-related scenario, one impact of Health and Social Security (DHSS) cost data, Hurst calcu- shortening the patients’ stay will be empty beds, which lated the health status yield per pound sterling for the the surgeon will perceive as the currency of an ‘efficiency three selected treatments. Using this cost-benefit equa- saving’. The economist would not call this a saving; the tion, uncomplicated hernia repair comes out better than concept of opportunity cost means that no benefit has a successful renal transplant, and a renal transplant is bet- accrued until the empty beds (resources) are put to some ter value than continuous home hemodialysis. Memories alternative use. Benefit is thus not necessarily the same to of Cecil Wakeley’s aphorism crowd in to confirm that the surgeon as to the economist. refined clinical judgment may well be as valuable in Any economic appraisal of day-case surgery must, evaluating the benefits of clinical care as the statistical therefore, first address the crucial issue of the term gymnastics of contemporary health economists.10 ‘benefit’.Are the benefits to be: Innovations in the procedure of hernia repair and the • more surgery, using the freed resources to undertake management of patients should, however, be subject to a greater volume of surgery or more complex economic evaluation, ideally based upon a randomized innovative surgery? controlled trial. The recent developments in hernia repair, • a redeployment of the freed resources towards a such as the expansion of day-case surgery in Europe, different client group, e.g. elderly or mentally ill require a clinical and economic base. However, the expe- people? rience from the Shouldice clinic in Canada and the results • a reduction in overall health service expenditure by from the USA support the use of limited hospitalization the amount saved? for the repair of hernias. Laparoscopic inguinal hernia surgery has not been proven to represent an economic A day-case surgery policy will need to be appraised in benefit for the unilateral primary hernia. There may be the short run and in the long run. Short-run benefits may some benefit for the patient with bilateral and/or recur- be very difficult to gain; for instance, a reduction in surgi- rent herniation. Other laparoscopic hernia surgeries, such cal bed requirements by 15 may confer no benefit since as hiatal and incisional hernia repair, have reduced the one cannot eliminate half a 30-bed ward and reduce staff length of hospitalization significantly. costs by 50 per cent overnight. While there may be no short-term gains, the long-term gains could be substantial and allow explicit alterations to existing surgical and nursing practice. Consequently, new hospital provision ECONOMICS OF DAY-CASE SURGERY could include fewer traditional inpatient surgical wards and instead have dedicated day-case units. In the USA, Reductions in length of stay for many surgical and other there are, in fact, many centers that are free-standing and inpatient procedures result from improvements in surgical dedicated to day-case surgery or short-stay procedures. procedures reducing recovery time, changing preferences Stepping through the looking-glass, more day-case of patients, and financial and political pressures on hospi- surgery will need less capital expenditure on surgical tals to reduce costs. Day-case surgery is often preferred inpatient facilities, and fewer nursing staff will need to be by patients, and it may encourage early mobilization and employed for the same volume of work in the long term. reduce the risk of hospital-acquired infection.11 Day-case The quantification of savings accruing from a day-case treatment for hernia repair may result in good outcomes policy is difficult; four approaches have been advanced: for lower costs than other organizational forms of care.12,13 • Comparing the bills paid by patients in private The Royal College of Surgeons recommends that at least practice.17 30 per cent of elective hernioplasties should be performed • The analytical device of holding the level of service on a day-case basis.14 In the USA, however, all but the most constant and estimating the benefits that could be ill or infirm individuals with inguinal hernias are operated bought with the now unused resources.18 276 Future considerations

• The technique of comparing average per diem greater demand will initially be met and the queue inpatient and outpatient costs.19 Farquharson reduced. If there is no queue and no excess demand, then produced the seminal paper advocating this type of reducing costs should allow premises to be closed and economic evaluation.20 staff made redundant, with considerable reduction in • Comparing and computing the one-year costs of a fixed and variable costs. The cost of doing an extra case day-care facility with the one-year costs of a after hours in a day-case unit, when staff must be paid traditional in-patient unit.21 overtime, is a very high marginal price – a fact to be remembered when case-scheduling is considered. Bailey, an economist from the Audit Commission in If day-case surgery is used to cut unit costs and increase the UK, has proposed an alternative strategy to deter- the overall volume of surgery, then this extra burden of ris- mine the resources that might be released as a result of ing productivity will fall on the surgeons and nurses. There a change from inpatient to day-case while treating an are reports of the proportion of day cases rising to close equivalent patient.22 He states that the costs of day sur- to 40 per cent in some units, with consequent increases gery are substantially less than inpatient care, but it is in surgical throughputs. Ultimately, the increased output misleading to interpret such measures as savings. The may demand an alteration on the supply side of the equa- resource implications of more day surgery should be tion, and more doctors and nurses may then need to be estimated directly by looking at precisely what changes employed to cope with increased demand.24 While the are planned to take place. relationship between demand and output of a surgical In conclusion, there is evidence that the unit costs of service is elastic in the short term, in the longer term supply day-case surgery are much lower than inpatient care: inevitably must be increased to allow greater output. This is of the order of 40–75 per cent per treatment episode, particularly evident in many areas in the USA, where there however calculated. These lower unit costs will free up are nursing and anesthesia staff shortages. resources to carry out more surgery or for alternative uses. It must be apparent that there is no economic incen- Day-case surgery has been found to be superior to in- tive for surgeons and other hospital employees to expand patient surgery in terms of wound infection and return to day-case surgery. Substantial savings can be achieved work, although this finding is not statistically significant.23 only by maintaining constant the quantity of surgery Day-case surgery is also becoming increasingly acceptable carried out, by not allowing day cases to increase the out- to patients. A dedicated five-day care unit allows more put, and by closing premises and dismissing redundant resources to be saved compared with day cases in a tradi- staff. The development of free-standing centers, however, tional theater suite and ward, where all the resources can- will transfer these cases to these centers and allow more not be redeployed easily, particularly in the short run. This efficient use of the hospital staff and/or relocate these is consistent with the conclusions of a US review of cost- employees. effectiveness of management of hernia by Millikan and Deziel.4 These authors concluded that the most cost- effective approach to hernia repair would use an ambulatory surgical center with open-mesh repair for primary RETURN TO NORMAL ACTIVITY AND WORK inguinal hernia and failed primary suture repair. There is enormous variation in reported times for return INCENTIVES AND DAY-CASE HERNIOPLASTY to normal activity and work. For instance, in a socialized system of healthcare where patients’ expectations and the insurance system still favor hospitalization, length To date, resource savings from day-case surgery in the of hospital stay after hernia surgery may be in excess of NHS have been used largely to expand surgical services eight days.25 Even in the USA, where ambulatory surgery either quantitatively or qualitatively. Every hospital units are quite commonplace, the length of stay may be experienced this phenomenon in the 1970s. It has been several days in institutions where reimbursement is not quantified and shown that as resources are liberated by controlled as strictly as the private sector, although this is day-case work, they are used up in other surgical endeav- rapidly becoming uncommon. Customers of the Metro- ors. This extra work sucks in further resources, and the politan Life Insurance Company surveyed by a nationwide overall surgical budget becomes larger. claims questionnaire revealed a length of stay that aver- Increasing the proportion of day cases in the surgical aged 2.9 days.26 In the US army, average hospital stay for unit mix will lead to a fall in the average cost of each hernia surgery is 4.6 days.27 In reality, housing conditions, patient treated. This may enable more cases to be oper- the distance from home to hospital, and the availability ated upon; even though the marginal costs of doing each of home nursing care (spouse, relative, friend) are the extra case within normal working hours are low, the major factors affecting early discharge after hernia repair.28 aggregated cost to the hospital will be higher, although These societal issues are more frequently problematic with Socioeconomic issues 277 other larger procedures. Payers, however, seldom provide appears to be the most important factor affecting clinical consideration for these important matters that involve outcome and return to activities. Callesen and coworkers patient care. have demonstrated that well-defined recommendations The technique adopted has little predictive value for and improved pain management can shorten convales- early postoperative pain and analgesic consumption. cence.32 One hundred patients having elective hernior- Kawji and colleagues, in a study of 240 patients who had rhaphy under local anesthesia and managed analgesia been treated with Lichtenstein under general anesthesia, were recommended to have one day of convalescence for Lichtenstein under local anesthesia, laparoscopic trans- light/moderate work and three weeks of abstinence from abdominal pre-peritoneal (TAPP), Shouldice operation, strenuous physical activity. The overall median absence or pre-peritoneal Wantz procedure, found that the only from work was six days; unemployed patients returned technical factor significantly reducing analgesic require- to activities in just one day, those in light/moderate work ment during the first three perioperative days was the use returned in six days, and those in heavy jobs returned by of intraoperative local anesthesia.29 Lau and Lee studied 25 days. A more detailed prospective study of return to postoperative pain by linear analogue scores in 239 patients work after inguinal hernia repair has been undertaken by having inguinal herniorrhaphy with a variety of tech- Jones and colleagues.33 Data were collected by personal niques.30 With multiple regression analysis, older patient interviews, written surveys, and medical record reviews age was the only independent factor of pain, a finding in in 235 patients, the main outcome measures being actual keeping with anecdotal experience of surgeons used to and expected return to work. Age, educational level, operating on patients under local anesthesia. income level, occupation, symptoms of depression, and The French Association for Surgical Research investi- the expected day of return to work (ten days) accounted gated the feasibility of discharge within 48 hours of for 61 per cent of the variation in actual (12 days) return inguinal hernia repair in 500 consecutive men with uni- to work. lateral, uncomplicated non-recurrent inguinal hernias. Advice given in the UK on driving after groin-hernia Of 411 patients suitable for early discharge, 107 (26 per surgery varies widely because there is no evidence-based cent) eventually stayed for more than 48 hours, early information.34 In a postal questionnaire sent to 200 sur- discharge was declined by 84, and early discharge was geons, the advice ranged from it being acceptable to drive contraindicated in 42 (these patients had local or general on the same day of surgery (three per cent of respon- complications), which finally resulted in one-day surgery dents) to suggesting that patients wait six to eight weeks being performed in only 51 (ten per cent) of the patients. before driving (nine per cent of respondents); the most These results emphasize the need for careful preoperative common response was that patients should wait two evaluation, which includes not only the hernia and the weeks (37 per cent of respondents). Amid has stated that patient’s general medical condition, but also any social the recovery period is dependent solely on the amount of conditions, such as isolation, flights of stairs, or lack of a postoperative discomfort, which should be minimal and telephone, that may limit the ability to discharge a patient should not usually require narcotic analgesia.35 Amid soon after surgery. recommends that patients can resume driving as early Advice concerning return to normal activity has been as one week or less after surgery, depending on their managed poorly by surgeons. Recent studies indicate comfort and whether they are using narcotic analgesics. that factors limiting a patient’s return to activity and Those who drive different types of vehicles need different work are governed principally by the perceived amount advice. An additional consideration should be the com- of postoperative pain. Socioeconomic factors strongly plexity of the operative procedure. Intra-abdominal pro- influence this perception over and above the actual procedures will require longer periods of convalescence than cedure performed or the anatomy involved.31 In a case- inguinal hernia repair. controlled comparison of patients receiving workers’ It must be apparent that there is no economic incen- compensation compared with patients having commer- tive for surgeons and other hospital employees to expand cial insurance, seven surgeons from a single clinic com- day-case surgery. Substantial savings can be achieved pared 22 consecutive workers’ compensation patients only by maintaining constant the quantity of surgery with 22 commercial insurance patients. All patients had carried out, by not allowing day cases to increase the out- received open hernioplasty, and the duration of post- put, and by closing premises and dismissing redundant operative pain and the days off work were compared. The staff. Such a policy is unlikely to make surgeons who take differences between the two groups were striking: the up day-case surgery popular. However, the experience in median duration of postoperative pain in the workers’ the USA, where day surgery is quite commonplace, has compensation group was 27 days, with 36.5 days off proven that the patients and their surgeons are quite sat- work. In the commercial insurance patients, the duration isfied with these economics. In fact, many patients are of postoperative pain was 7.5 days and they went back to dismayed when they are told that their medical condition work after only 8.5 days. Personal motivation, therefore, dictates a hospital stay of even one night. 278 Future considerations

ECONOMICS OF LAPAROSCOPIC SURGERY therapies rather than open surgery. It is important to remember that lengths of inpatient stay were falling for many years, and the additional savings from laparoscopic Since the pioneering laparoscopic removal of a gall surgery may be lower than anticipated. History, however, bladder by French surgeon Phillippe Mouret in 1987, the has proven that many of these worries have not resulted introduction and rapid diffusion of laparoscopic surgical in a decline in the use of laparoscopic surgery. In most techniques was accepted with unbridled enthusiasm, and procedures, except for inguinal hernia repair, the trend is often without question, by many surgeons, the media upward. and the general public. The years that have passed since Complication rates are important determinants of the then have allowed a more rational approach to many overall costs of any surgical procedure. Complications of these procedures. The majority of laparoscopic adap- with laparoscopic surgery procedures, such as bile-duct tations of the general surgical operations have proven to injuries with laparoscopic cholecystectomy, have been be cost-effective due to the diminution in the length of well documented (see Table 1 in Soper et al.38). Most bile- hospital stay. The great exception is laparoscopic repair duct injuries occur early in a surgeon’s experience, high- of inguinal hernias, which is always more costly. lighting the need for careful training and accreditation of Some economic arguments have been used to support surgeons, and clinical practice guidelines.39 The rate of the rapid diffusion of laparoscopic surgery. Studies often conversions from laparoscopic operations to open opera- quote reductions in the length of inpatient hospital stay tions ranges from 1.8 to 8.5 per cent, and tends to be high- in comparison with standard surgical procedures and est early in a surgeon’s experience.38 The cost implications imply that this will necessarily save hospitals money. This of complication rates include increased operating time, is, however, not necessarily the case, and hospital man- increased length of inpatient stay, increased care burden agers are increasingly questioning the appropriateness of on families or other caregivers, and increased time for the procedures that involve purchase of sophisticated and patient to return to work or normal activities. The current expensive capital equipment and considerably increased rates of complications, however, have now established the operative time, resulting in lower patient throughput for laparoscopic cholecystectomy as the standard of care for surgical procedures. Available time in the operating gallbladder disease because they are comparable, whether theatre is a scarce resource, and although operating time open or laparoscopic. in laparoscopic surgery declines as experience increases, A recent systematic review of the effectiveness and Cuschieri estimated that on average it will continue to safety of laparoscopic cholecystectomy showed that effec- take about one-third longer than the corresponding con- tiveness of this procedure is similar to that of open and ventional operation, with the excess of time over open mini-cholecystectomy.40 Complete alleviation of symp- surgery the higher the more complicated the basic oper- toms was achieved in 60–70 per cent of patients. However, ation.36 Time, however, has proven that once past the safety profiles differ, with more technical support and learning curve, many of these operations are only as long specialized surgical equipment required for the laparo- as or are shorter than that of the open method. Many of scopic procedure. Differences in complication rates were these comparisons may be flawed because there are ‘slow difficult to assess because of methodological problems operators’ and ‘quick operators.’ Many of the operations and differences between studies. In particular, studies discussed in this book are commonly performed with often do not have sufficient statistical power to identify less operative time than their open counterparts in clinically important differences in outcomes, particularly centers with surgeons skilled in these procedures. bile-duct injury, because the rate of adverse events is low. The effect of length of inpatient stay on health service Sculpher argues that laparoscopic surgery has a differ- resource use is an important issue in many studies. ent ‘production function’ to conventional surgical tech- Cuschieri estimates that discharge may, on average, niques, i.e. it requires a different mix of inputs to the be expected to be within less than 48 hours.36 This is production process, more inputs of theater and medical thought to result in cost-savings from earlier discharge staff time, more sophisticated equipment, and fewer and earlier return to normal activities, including work. inputs of inpatient bed days.37 The overall effect on However, economists such as Sculpher note that this may hospital costs and on overall costs to society is unclear not always be the case.37 First, a reduction in the demand and requires economic evaluation. Evaluation should be for hospital beds may not result in cash-savings unless it long-term in order to include any effects of different allows ward closures. At one time, this was felt to be re-admission rates, and should include not only hospital unlikely as laparoscopic surgery represented a small pro- costs and effects but also the burden on community- portion of all hospital procedures. Other arguments were based services, patients and carers, which may change that laparoscopy did not release other resources used for due to earlier discharge. surgical procedures, particularly theater time, and that The ‘production function’ description of surgery is some laparoscopic procedures replaced non-invasive useful in considering other issues. The appropriate level Socioeconomic issues 279 of individual and center specialization should be deter- be more expensive than the laparoscopic approach (open, mined by evidence of economies of scale. If a center spe- US$1150; laparoscopic, US$1179).46 In many centers, cializes in laparoscopic surgery, then this may influence however, this has been a stimulus for surgeons to abandon costs per patient, as theater time may be reduced as famili- the procedure altogether (willingly or unwillingly). The arity with the procedure increases. In addition, outcomes insurance industry has refused to reimburse hospitals and may be improved, particularly by reduced complication surgeons for the procedure, leading to the rapid demise of rates. However, the appropriate level of individual and the procedure. Medicare in the USA actually pays sur- center specialization requires careful evaluation: could the geons less to perform these operations laparoscopically alleged benefits of centralization be matched by careful than through the open technique (see below). training and treatment protocols at local levels? Identifi- These realities have resulted in the trend of many cen- cation of the conditions necessary for the production of ters to utilize this operation only in the bilateral situation efficient laparoscopic procedures is absent but inhibits and for recurrent hernias. The success for this diagnosis is neither unsubstantiated assertions by policymakers nor proven.47,48 The ongoing studies of the Medical Research significant investments in new facilities. Council (MRC) Laparoscopic Groin Hernia Trial Group The repair of inguinal hernias with the laparoscopic support the move to specialist surgeons to perform this method continues to raise many questions, particularly operation.49 Based upon the experience in the USA, this regarding economics. Whereas it is generally accepted appears to be the trend. that this technique is effective for these hernias, the costs Data comparing open versus laparoscopic repair of associated with this method causes many surgeons to inguinal hernias are now voluminous, and a detailed question the usefulness of this technique. In 1996, the analysis of all the factors is beyond the scope of this chap- benefits were unclear.41 In 2003, the clinical efficacy is not ter. Suffice to say that the vast majority of reports have generally questioned. The cost issues have been resolved identified the same findings that are commonly known. for the most part. It is more expensive to perform the That is, in general the laparoscopic operation is more minimally invasive method except in a very few areas that expensive but postoperative pain is diminished and the have managed to eliminate the use of disposable instru- return to work is notably shorter. The learning curve and ments and tissue-expansion balloons. the payors of these operations will force this procedure Evidenced-based studies have definitely revealed that into the hands of a few skilled surgeons with excellent the levels of pain and subsequent convalescence after outcomes. Even in this case, this will be for bilateral and laparoscopic repair are decreased when compared with recurrent hernias. Studies such as that by Lawrence and open repair.42 This is particularly true with the compari- coworkers used a UK randomized controlled trial as the son of pure tissue repairs, but it has also been found with basis of an economic evaluation of laparoscopic versus open prosthetic repairs. However, some studies have open inguinal hernia repair, on data collected from 104 reported that while these patients experience less pain day-case patients.41 The mean total health service cost of postoperatively, the return to work interval was not dif- laparoscopic repair was £1074, compared with £489 for ferent after TAPP repair. The opinion of these authors open repair. Linking this additional cost with the addi- was that the increase in costs did not justify the operation tional pain-free days in the laparoscopic group showed unless the operative costs could be reduced.43 Another an additional cost per pain-free day of £109 (95 per cent study found that laparoscopically repaired patients returned confidence interval, £41–393). The authors concluded to their usual activities seven days earlier than those of that there were strong arguments against the intro- the open group. The incremental cost for this time frame duction of laparoscopic hernia repair until evidence on was £55 548 per QALY over the open method. This report long-term outcomes becomes available. Such studies, showed that there might be specific situations in which although important, are few. Hekkinnen and colleagues this laparoscopic repair may be a viable alternative, conversely proved that the overall societal costs are less particularly when reusable rather than disposable instru- with the laparoscopic method.50 Regardless, the cost– ments were used because these costs were decreased benefit structure of the insurance industry does not significantly.44 appreciate the societal costs as do the individual patient The operative costs that are increased with the laparo- and surgeon. Therefore, this limited use of the laparoscopic approach are the use of disposable instruments, scope to repair inguinal hernias will probably be perma- balloon dissection devices, balloon trocars, additional nent in the USA. In other countries, such as those in personnel, and the length of the operation. These costs Europe, a more critical look at these issues may be possi- can be reduced to the extent that the cost of the operation ble because of the public nature of the healthcare system. can approach that of the open procedure. Lorenz has This is needed. shown that by the deliberate attempt to decrease costs, the Unlike those of laparoscopic inguinal herniorrhaphy, laparoscopic approach can be less expensive to the hospi- the clinical and economic benefits are clearer with the tal.45 Beets and Dirksen found that the open approach can laparoscopic repair of incisional and ventral hernias. 280 Future considerations

Many papers in the literature have demonstrated the evaluated the cost of the repair.16,54 In both papers, the short period of hospitalization seen with this approach laparoscopic method was associated with less cost than to this problem.15,16,51,52 It is generally believed by surgeons the open repair. This is based primarily upon the proficient in this technique that this method lessens the decreased length of stay of laparoscopically repaired length of hospitalization for the patients. Five publica- patients. This occurred even when the additional costs of tions have compared open and laparoscopic repair of any re-admissions were included in the overall determi- incisional and ventral hernias (Table 38.1).16,53–56 In all nation. Interestingly, the work by DeMarie and col- of these series, laparoscopic repair was associated with leagues evaluated the costs based upon open repair using fewer complications and fewer days of hospitalization a polypropylene product versus the laparoscopic repair than those of open method. Only two of these papers using an expanded polytetrafluoroethylene (ePTFE) patch.16 Therefore, based upon the limited study that has been done on this operation, it appears that laparoscopic Table 38.1 Results of comparative analysis of open and herniorrhaphy for incisional and ventral hernia is the laparoscopic incisional and ventral herniorrhaphy economically preferred choice. Laparoscopic These issues are discussed more frequently with the Open repair repair Ref. repair of inguinal and incisional hernias. The use of the laparoscope to repair the other hernias discussed in this Operative time, 45–259* 70–211* 54 textbook appears to compare favorably with open repair. range (min) 27–148 45–170 55 Decreased length of stay, decreased morbidity, and a more 60–180 30–180 53 rapid return to normal activity have been shown. 25–220 18–225 56 N/A N/A 16 Operative time, 97.6* 128.5* 54 average (min) 78.5 95.4 55 PAYMENT CHANGES 111.5 87 53 82 58 56 Despite the points discussed above, the financial realities N/A N/A 16 of governmental reimbursement in the USA have declined Length of hospital N/A N/A 54 continuously.We selected the comparison of the payments stay, range (days) 2–26* 1–17* 55 3–21* 1–15* 53 from Medicare in the USA since 1993 for four hernia oper- N/A N/A 56 ations (Figure 38.1). Unless noted otherwise, all of these 0.5–14* 0.5–3* 16 are inguinal hernia repairs. It is readily apparent that these Length of hospital 4.9 1.6 54 levels of payment have not changed significantly in nine stay, average (days) 6.5* 3.4* 55 years. These payments do not reflect the inflationary 9.06* 2.23* 53 increases in office overheads and the enormous elevations 2.8 1.7 56 in the cost of medical liability insurance. Additionally, the 4.4* 0.8* 16 payment for the repair of bilateral inguinal hernias is 1.5 Complication rate 31 15 54 times the payment for the repair of a single hernia. Because (%) 36.7* 17.9* 55 of this, some surgeons simply cannot afford to repair bilat- ?53 eral hernias at the same time. Instead, these are repaired 36 10 56 N/A N/A 16 sequentially in two separate procedures. It is particularly Recurrence rate 12.5 1 54 disturbing that payment for the repair of an incisional (%) 34.7 11 55 hernia (US$636.69) is less than the repair of a recurrent 2053incarcerated inguinal hernia (US$644.07). The differences 20.7 2.5 56 800 0 4.8 16 Open 700 Cost, range (US$) 1987–12 611* 3555–5235* 54 Recurrent 600 N/A N/A 55 Recurrent N/A N/A 53 500 incarcerated N/A N/A 56 400 Incisional 6574–18 448 5323–11223 16 300 US dollars Laparoscopic Cost, average (US$) 7299* 4395* 54 200 inguinal N/A N/A 55 100 Laparoscopic N/A N/A 53 0 recurrent N/A N/A 56 inguinal 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 12 461 8273 16 Figure 38.1 Medicare reimbursement in real dollar values *Statistically significant difference. from 1993 to 2002. Socioeconomic issues 281 in the complexity of the operations, potential morbidity, gaps about its clinical and economic attributes. The poten- and length of postoperative care are obvious to every tial clinical and economic benefits of laparoscopic inguinal surgeon. The financial realities of the practice of surgery hernia repair are particularly unclear given the need for in the USA are subtly affecting the ethics of surgery. general anesthesia and the possibility of rare but serious Laparoscopic repair of primary inguinal hernias is injuries to intra-abdominal organs. This procedure bene- reimbursed less than that of the open repair. There is no fitted from large-scale clinical trials and economic evalua- consideration given to the extra level of expertise and tions for inguinal hernia repair. The use of laparoscopy in training that is required to perform that operation. One the repair of many of the other hernias of the abdominal could postulate that the financial disincentive is placed to wall seems to have a strong economic benefit, however. discourage the use of the procedure in these patients The future development of advanced techniques and because of the extra cost associated with the operation. even the availability of even the simplest of hernia repairs This is especially troubling, as this will inhibit its use in may become more difficult due to the negative financial patients who might benefit from that method of repair. consequences of governmental payment schedules. At the time of writing, there is no code in which to bill for the laparoscopic incisional hernia repair, although one should be available soon. In the USA, access to healthcare by the recipients of REFERENCES governmental healthcare is being affected adversely. Many people cannot find physicians who will accept these low 1 Sculpher M, Drummond M, O’Brien B. 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Note: References to figures are indicated by ‘f’ and references to tables are indicated by ‘t’ when they fall on a page not covered by the text reference. abdominal bloating, after fundoplication anatomy 255 vascular injury 91 218, 243–4 complications in 261–2 visceral injury 92–3 abdominal wall, anterior anatomy see diaphragmatic hernia repair laparoscopic assisted ventral hernia anterior abdominal wall anatomy history 257 repair 163–4 achalasia 198–9 patient selection 257 para-esophageal hernia repair 206–7 adhesiolysis, and bowel injury 163 surgical technique with prosthetic biomaterials 17–21 adhesives 11–12 Bochdalek hernia 257–8 and recurrent gastroesophageal reflux AESOP robotic arm 266–8 Morgagni hernia 258–9 disease 217–22 alkaline reflux gastritis 218 history of laparoscopy in 251–4 and return to work 276–7 Allison’s procedure 174–5 physiology 255–6 with transfascial sutures 134–5 Alloderm prosthetic material 22–4 cigarette smoking, and hernia ventral/incisional hernioplasty Anatomical Mesh 21 formation 36 bowel injury 161–3 anatomy clinical studies, ventral/incisional comparative studies 157–9 anterior abdominal wall see anterior hernioplasty gastrointestinal complications 166 abdominal wall anatomy comparative studies 157–9 postoperative pain 166 in children 255 series comparisons 155–7 prosthetic mesh fixation 107–8 diaphragm 179–83 collagen defects 46 prosthetic mesh infection 164–5 inguinal/femoral region see Collis gastroplasty 198 recurrence rates 166–8 inguinal/femoral anatomy colostomy, parastomal hernias see series comparisons 156t, 157 peritoneal cavity 41–2 parastomal hernias seroma 165–6 pre-peritoneal space 42–3 compartmented stomach, after see also recurrence rates and total extraperitoneal (TEP) patch fundoplication 219–20 Composix prosthetic biomaterials 21–2 technique 66–7, 68f complication rates congenital hernias 257–9 anesthetic complications 89 laparoscopic method comparisons 83–4 connective tissue damage in children 261 laparoscopic vs open methods 84–6 and hernia formation 36 Angimesh prosthetic material 17–18 complications and pathophysiology 46 anterior abdominal wall anatomy 104–5 in children 255–6, 261–2 convalescence after surgery 276–7 and cosmetic results 109 diaphragmatic hernia repair 235–7 Cooper’s ligament 42–3 and functional outcomes 109–10 economic evaluation 278 cosmetic outcomes, ventral/incisional and hernia formation 105–6 fundoplication hernioplasty 109 and hernia repair methods 106–7 intraoperative 239–40 crural disruption, after fundoplication 219 and prosthetic biomaterial fixation 107–8 bougie perforation 240–1 cyanoacrylate fixation 12 and scar healing 108–9 esophageal perforation 240 arcuate line 42f, 44 gastric injury 243 da Vinci tele-robotic system 268–9 hemorrhage 241–2 ventral/incisional hernioplasty 270–2 balloon trocars 9 large hernia 243 day-case surgery, economic evaluation barium swallow 188, 190 pneumothorax 241 275–6 Bassini, E 34 short esophagus 242–3 denervation hernias bilateral hernia 62 postoperative anatomy 151, 152f in children 251–2 dysphagia 246 formation of 105–6 bioadhesives 11–12 gastrointestinal symptoms 243–4 surgical repair biochemical changes, and hernia ileus 246 indications/contraindications 152 formation 36 para-esophageal hernia 244 operative technique 152–3 biological prosthetic materials 22–4 recurrent reflux 247 outcomes 153 Biomesh prosthetic materials 17–18 slipped Nissen 244–5 diaphragm bladder injury 92 symptom assessment 243 anatomy 179–83 Bochdalek hernia 257–8 vagal nerve injury 245–6 and hernia surgery 184–5 bone complications 93 inguinal/femoral hernioplasty physiology 183–4 bowel injury 161–3 anesthesia 89 diaphragmatic hernia bowel obstruction 92–3 hydrocele 90 in children 257 laparoscopic repair 111–13 laparoscopic access 89–90 fundoplication see fundoplication nerve injury 91–2 history of surgery for calcitonin gene-related peptide organ complications 90 Allison, P 174–5 (CGRP) 45–6 prosthetic mesh problems 93 in children 257 Cheatle, GL 34 recurrence rates 93–4 early surgery 173 children seroma 90–1 laparoscopic approach 175–6 284 Index diaphragmatic hernia (Contd) fascia transversalis 42–4 symptom assessment 187–8 Nissen fundoplication 175 pathophysiology 46 recurrent disease 217 short esophagus 174 femoral canal 45 clinical presentation 217–18 outcomes of surgery 235–7 femoral hernioplasty evaluation after failed surgery 190–1 para-esophageal hernias see history 76 incorrect diagnosis 221–2 para-esophageal hernias incidence of femoral hernias 75–6 incorrect surgery 221 from traumatic injury 209–10 postoperative management 77 mechanisms of failure 219–21 acute herniation 210–12 surgical technique 76–7 surgery for chronic herniation 212–14 femoral nerve 45 indications 222–4 types of hiatal hernia 235 femoral sheath 45 patient selection 230 see also gastroesophageal reflux fibrin adhesive agents 11–12 preoperative evaluation 227–30 disease (GERD) fixation devices 11–12 surgical technique 230–4 diarrhea, after fundoplication 218 EndoAnchor device 27–8 surgical treatment diffuse esophageal spasm 198–9 helical coil devices 27 individualization of therapy 199–200 disposable instruments 7–8 Salute device 27, 28f operative technique dissecting instruments 8 staple devices 25–7 Collis gastroplasty 197–8 double-crown technique Fortagen prosthetic material 22–4 crural closure 195–6 indications/contraindications 133–4 Fortaperm prosthetic material 22–4 esophagomytomy 198–9 instrumentation 135–6 fundoplication 194 mobilization 194–5 operating room set-up 137 anatomical considerations 184–5 modified Toupet 196–7 outcomes 141 complications Nissen fundoplication 196 postoperative management 141 intraoperative 239–40 pyloroplasty 199 preoperative management 135–6 bougie perforation 240–1 patient preparation 194 prosthetic biomaterials 136–7 esophageal perforation 240 see also diaphragmatic hernia surgical technique 137–41 gastric injury 243 gastrointestinal complications transfascial suture comparison 134–5 hemorrhage 241–2 after fundoplication 243–4 driving, after surgery 277 large hernia 243 after ventral/incisional hernioplasty 166 DualMesh prosthetic biomaterials 18–21 pneumothorax 241 recurrent gastroesophageal disease in ventral/incisional hernioplasty postoperative 217–19 double-crown technique 136–7 dysphagia 246 genitofemoral nerve 45 parastomal hernias 146–7 gastrointestinal symptoms 243–4 injury to 91–2 series comparisons 156t, 157 ileus 246 giant prosthetic reinforcement of the transfascial suture technique 117–18 para-esophageal hernia 244 visceral sac (GPRVS), history 36 Dulex prosthetic biomaterial 18–21 recurrent reflux 247 Glucamesh prosthetic biomaterial 21–2 dysphagia, after fundoplication slipped Nissen 244–5 Glucatex 3D prosthetic biomaterial 21–2 217–18, 246 symptom assessment 243 grasping instruments 8 vagal nerve injury 245–6 economic evaluation 273–4 short esophagus 242–3 hand-assisted laparoscopy (HAL) 12–13 day-case surgery 275–6 failure of Hasson trocar 8–9 hernia repair 274–5 clinical presentation 217–18 health economics laparoscopic surgery 278–80 mechanisms of failure 219–21 day-case surgery 275–6 payment methods 280–1 history 175–6 economic evaluation 273–4 return to work 276–7 Nissen fundoplication see Nissen hernia repair surgery 274–5 electrosurgery 10 fundoplication laparoscopic surgery 278–80 employment, return to after surgery 276–7 operative technique payment methods 280–1 EMS stapler 25–6 Collis gastroplasty 197–8 and return to work 276–7 EndoAnchor fixation device 27–8 crural closure 195–6 helical coil fixation devices 11, 27 Endopath EMS stapler 26 esophagomytomy 198–9 hemorrhage endoscopy 188, 190, 227–8 mobilization 194–5 with fundoplication 241–2 endosopic gastroplasty 194 modified Toupet 196–7 with inguinal/femoral hernioplasty 91 enterotomy 161–3 pyloroplasty 199 Henry, AK 34 epigastric hernia 106 outcomes of surgery 235–6 hepatocyte growth factor/scatter factor ergonomics 13 preoperative evaluation (HGF/SF) 45–6 esophageal hiatus 181–3 esophageal manometry 188–9 Hermesh prosthetic biomaterials 17–18 esophageal manometry 188–9, 190, 228f, pH monitoring 189–90 Hertra prosthetic biomaterials 17–18 229 symptom assessment 187–91 Hesselbach’s triangle 43 esophageal perforation, with fundoplication for recurrent disease Hessert’s triangle 46 240–1 patient selection 230 hiatal hernia see diaphragmatic hernia esophagography 228–9 preoperative evaluation 227–30 hiatal stenosis 220 esophagomytomy 198–9 surgical technique 230–4 history expanded polytetrafluoroethylene (ePTFE) diaphragmatic hernia in children 257 products gastric blood vessel injury 241–2 diaphragmatic hernia surgery composite products 21–2 gastric emptying studies 230 Allison, P 174–5 flat, single-component products 18–21 gastric injury 243 early surgery 173 in ventral/incisional hernioplasty 126 gastroesophageal reflux disease (GERD) laparoscopic approach 175–6 double-crown technique 136–7 diaphragmatic anatomy 179–83 Nissen fundoplication 175 fixation 108 and surgical repair 184–5 early surgery 33 obstructed/incarcerated bowel 112–13 diaphragmatic physiology 183–4 femoral hernioplasty 76 parastomal hernias 146–7 fundoplication see fundoplication fixation devices 25–8 and scar healing 108–9 non-surgical treatment 193–4 intraperitoneal onlay of mesh (IPOM) series comparisons 156t, 157 preoperative evaluation procedure 47–8 transfascial suture technique 117–18 esophageal manometry 188–9 laparoscopic general surgery 3–5 external oblique muscle 44, 104 pH monitoring 189–90 laparoscopic hernia repair 37–9 Index 285

nonoperative management 33 obturator hernioplasty see obturator Marcy, HO 33–4 obturator hernioplasty 76 hernioplasty Marlex prosthetic biomaterial 17–18 open hernia repair 33–6 outcomes history 34–5 ventral/incisional hernioplasty 99–100 laparoscopic method comparisons Mersilene prosthetic biomaterial 18 hydrocele 90 83–4 mesh prosthetics see prosthetic biomaterials in children 262 laparoscopic vs open methods 83–6 modified Toupet fundoplication 196–7 hypertensive lower-esophageal perineal hernia 79–80 Morgagni hernia 258–9 sphincter 198–9 prevascular hernia 80 muscular denervation see denervation sciatic hernia 77–9 hernias ileostomy, parastomal hernias see supravesical hernia 79 Mycromesh prosthetic biomaterials parastomal hernias total extraperitoneal (TEP) patch 18–21 ileus 246 technique see total extraperitoneal myopectineal orifice 35, 36f, 44–5 ilio-hypogastric nerve 45 (TEP) patch technique ilio-inguinal nerve 45 transabdominal pre-peritoneal (TAPP) Nanticoke Hernia Stapler 26 iliopubic tract 42–3 patch technique see transabdominal National Institute for Clinical Excellence imaging systems 12 pre-peritoneal (TAPP) patch (NICE) 273 see also robotic devices technique needle drivers 11 incarcerated bowel repair 111–13 injuries neoplasia, and recurrent gastroesophageal incarcerated inguinal hernia 63 from laparoscopic access 89–90 reflux disease 220, 221–2 incisional hernias traumatic diaphragmatic injuries see nerves diagnosis 125 traumatic diaphragmatic injuries anatomy 45 incidence 125 from trocars 8–10 injury to 91–2 pre-peritoneal hernioplasty see see also complications with prosthetic biomaterial pre-peritoneal hernioplasty instrumentation fixation 108 repair methods 125–7, 129–30 disposable 7–8 and recurrent gastroesophageal risk factors 125 dissecting and grasping instruments 8 reflux disease 221, 245–6 see also ventral/incisional hernioplasty energy sources 10–11 Nissen fundoplication infants see children ergonomics 13 anatomical considerations 184–5 infection, with prosthetic biomaterials 93, fixation devices 11–12, 25–8 complications 220, 244–5 113, 164–5 hand-assisted laparoscopy 12–13 history 175 inferior epigastric vessels 41 robotic devices see robotic devices preoperative evaluation 187–91 injury to 91 trocars 8–10 surgical technique 196 infertility, and prosthetic mesh 93 videoendoscopy systems 12 non-cutting trocar 10 inguinal canal 44 internal inguinal ring 41–2 nutcracker esophagus 198–9 inguinal/femoral anatomy internal oblique muscle 44, 104 Nyhus, LM 34 femoral canal 45 intestinal complications 92–3, 161–3 femoral sheath 45 intestinal stomas, parastomal hernias oblique muscles 44 inguinal canal 44 see parastomal hernias obstructed bowel repair 111–13 myopectineal orifice 44–5 Intramesh prosthetic biomaterials 17–18 obturator artery, injury to 91 nerves 45 intraperitoneal onlay of mesh (IPOM) obturator hernioplasty oblique muscles 44 procedure history 76 peritoneal cavity 41–2 advantages and disadvantages 51 incidence of obturator hernias 76 pre-peritoneal space 42–3 history 37, 47–8 postoperative management 77 spermatic cord 44 operating room set-up 48–9 surgical technique 76–7 transversalis fascia 43–4 patient selection 48 Omni-Tack 26–7 inguinal/femoral hernioplasty postoperative management 51 open hernia repair complications surgical technique 49–51 and anterior abdominal wall anesthesia 89 irreducible inguinal hernia 63 anatomy 106–7 hydrocele 90 ischemic orchitis 90 history 33–6 laparoscopic access 89–90 for incisional hernias 126–7 nerve injury 91–2 laparoscopic assisted ventral hernia laparoscopic method comparison organ complications 90 repair 163–4 economic evaluation 279–80 prosthetic mesh problems 93 laparoscopic hernia repair outcomes of surgery 84–6 recurrence rates 93–4 history 37–9 for ventral/incisional hernias 129–30, seroma 90–1 open method comparison 84–6 157–9 vascular injury 91 laparoscopic surgery for para-esophageal hernias 202 visceral injury 92–3 economic evaluation 278–80 optical view trocar 9 economic evaluation 279 history 3–5 Origin tacker 27 femoral hernioplasty lateral cutaneous nerve of thigh 45 outcome of surgery history 76 Lichtenstein repair inguinal/femoral hernioplasty incidence of femoral hernias 75–6 history 35–6 laparoscopic method postoperative management 77 laparoscopic method comparison comparisons 83–4 surgical technique 76–7 84–5 laparoscopic vs open methods 84–6 history lipomas 80–1 ventral/incisional hernioplasty in children 252–4 liver injuries 241 comparative studies 157–9 early surgery 33 low Spigelian hernia 81 cosmetic results 109 nonoperative management 33 lower-esophageal sphincter 183–4 denervation hernias 153 open hernia repair 33–6 lumbar hernias double-crown technique 141 intraperitoneal onlay of mesh (IPOM) anatomy 151, 152f functional outcomes 109–10 procedure see intraperitoneal onlay surgical repair lumbar hernias 153 of mesh (IPOM) procedure indications/contraindications 152 parastomal hernias 148–9 lipomas 80–1 operative technique 152–3 pre-peritoneal hernioplasty 129–30 low Spigelian hernia 81 outcomes 153 series comparisons 155–7 286 Index pain composite products 21–2 AESOP robotic arm 266–8 after fundoplication 218 flat, single-component products tele-robotic systems 268 after ventral/incisional hernioplasty 166 17–18 da Vinci system 268–9 management in children 256 history 34–5 in ventral/incisional hernioplasty and return to work 277 preformed products 21 270–2 para-esophageal hernias in ventral/incisional hernioplasty Zeus system 269–70 after fundoplication 244 108, 126 round ligament, lipoma 80–1 outcomes of surgery 236–7 double-crown technique 136–7 surgical repair obstructed/incarcerated bowel Safety and Efficacy Register of New anatomical considerations 202 112–13 Interventional Procedures indications/contraindications 201–2 and scar healing 108–10 (SERNIP) 274 laparoscopic vs open methods 202 postoperative complications see Salute fixation device 11, 27, 28f operating room set-up 203 complications scar healing 108–9 operative technique 203–7 pre-peritoneal hernioplasty sciatic hernioplasty 77–9 postoperative management 207–8 comparison with other techniques scrotal hernioplasty 63 preoperative evaluation 202–3 129–30 Sepramesh prosthetic biomaterial 21–2 types of 201 indications 127 seroma 90–1, 165–6 parastomal hernias laparoscopic vs open methods 129–30 shielded trocar 9–10 assessment 144 operating room set-up 127 short esophagus outcomes 148–9 outcomes 129 Collis gastroplasty 197–8 postoperative management 147–8 patient preparation 127 and fundoplication 242–3 surgical repair postoperative management 129 history of surgery for 173–4 indications/contraindications 144–5 surgical technique 127–9 and recurrent gastroesophageal reflux methods 144 tele-robotic systems 270–2 disease 219 preoperative preparation 145 see also total extraperitoneal (TEP) Shouldice technique 84–5 surgical technique 145–7 patch technique skin types of 143–4 pre-peritoneal space, anatomy 42–3 complications 93 Parietene prosthetic biomaterial 17–18 prevascular hernioplasty 80 cosmetic outcomes 109 Paritex prosthetic biomaterials 18, 21–2 processus vaginalis smoking, and hernia formation 36 partitioned stomach, after anatomy 44 socioeconomic issues fundoplication 219–20 pathophysiology 45–6 day-case surgery 275–6 pathophysiology 36, 45–6 Prolene prosthetic biomaterials 17–18 economic evaluation 273–4 pectineal ligament 42–3 Prolite prosthetic biomaterial 17–18 hernia repair 274–5 pediatric hernia prosthetic biomaterials laparoscopic surgery 278–80 anatomical considerations 255 history 34–5, 37–9 and payment methods 280–1 complications infection 93, 164–5 and return to work 276–7 anesthesia 261 non-synthetic materials 22–4 Soft Tissue Patch prosthetic hydrocele 262 and outcome of surgery, laparoscopic vs biomaterial 18–21 recurrence rates 262 open methods 85–6 spastic disorders of esophagus 198–9 surgical complications 261–2 synthetic materials spermatic blood vessels, injury to 91 testicular complications 262 composite products 21–2 spermatic cord diaphragmatic hernia repair flat, single-component products 17–21 anatomy 44 history 257 preformed products 21 lipoma 80–1 patient selection 257 see also individual surgical procedures Spigelian hernia 81 surgical technique Protack device 27 spiral tack fixation devices 11, 27 Bochdalek hernia 257–8 protease/antiprotease imbalance, and splenic injury 242 Morgagni hernia 258–9 hernia formation 36 staple fixation devices 11, 25–7 pathophysiology 44, 45–6 pyloroplasty 199 stomach complications, after physiological considerations 255–6 fundoplication 219–20 pediatric laparoscopy, history 251–4 radially expanding trocar 10 Stoppa procedure 36 pelvic anatomy Reconix prosthetic biomaterial 18–21 strangulated bowel repair 113 anterior abdominal wall see anterior rectus abdominus muscle 104 Stretta Procedure 193–4 abdominal wall anatomy recurrence rates supravesical hernioplasty 78 inguinal/femoral region see gastroesophageal reflux disease (GERD) surgical ergonomics 13 inguinal/femoral anatomy see gastroesophageal reflux disease Surgipro prosthetic materials 17–18 pelvic hernia repair see femoral hernioplasty; (GERD), recurrent disease Surgisis prosthetic materials 22–4 obturator hernioplasty hiatal hernia repair 235–7 suture passers 11 perineal hernioplasty 79–80 inguinal/femoral hernioplasty 93–4 synthetic biomaterials peritoneal cavity, anatomy 41–2 laparoscopic vs open methods 84–6 composite products 21–2 pH monitoring 189–90, 190–1, 229–30 pediatric hernia 262 flat, single-component products 17–21 phreno-esophageal ligament 181 total extraperitoneal (TEP) patch preformed products 21 physiology technique 84 see also prosthetic biomaterials in children 255–6 transabdominal pre-peritoneal (TAPP) diaphragm 183–4 patch repair 62–3, 84 tack fixation devices 11, 27 inguinal region 45–6 ventral/incisional hernioplasty 166–8 TAPP technique see transabdominal plug-and-patch technique, history 37 comparative studies 158t, 159 pre-peritoneal (TAPP) patch pneumothorax 206, 241 series comparisons 156t, 157 technique polyester biomaterials reflux esophagitis see gastroesophageal tele-robotic systems 268 composite products 21–2 reflux disease (GERD) da Vinci system 268–9 flat, single-component products 18, 19f respiration ventral/incisional hernioplasty 270–2 preformed products 21 and incisional hernias 106 Zeus system 269–70 in ventral/incisional hernioplasty 126 and laparoscopy in children 256 TEP technique see total extraperitoneal polypropylene mesh (PPM) products robotic devices 13 (TEP) patch technique Index 287 testicular complications operating room set-up 55, 56f ventral/incisional hernioplasty in children 262 postoperative management 63 anterior abdominal wall anatomy 104–5 inguinal/femoral hernioplasty 90 preoperative evaluation 54–5 and hernia formation 105–6 thermal energy sources 10 recurrence rates 93–4 and repair methods 106–7 3D Max prosthetic biomaterial 21 for recurrent hernia 62–3 complications total extraperitoneal (TEP) patch technique for scrotal hernia 63 bowel injury 161–3 AESOP robotic arm 266–8 surgical technique 56–61 gastrointestinal complications 166 anatomical considerations 66–7, 68f transfascial suture technique postoperative pain 166 complications adhesiolysis 120–1 prosthetic mesh infection 164–5 anesthesia 89 advantages/disadvantages 134–5 seroma 165–6 hydrocele 90 indications/contraindications 115–16 denervation hernias see denervation laparoscopic access 89–90 instrumentation 118–19 hernias nerve injury 91–2 patient preparation 118 double-crown technique see organ complications 90 postoperative management 123–4 double-crown technique with prosthetic mesh 93 preoperative evaluation 116–17 economic evaluation 279–80 seroma 90–1 prosthetic biomaterials 117–18 history 99–100 vascular injury 91 insertion/fixation 122–3 laparoscopic assisted hernia visceral injury 92–3 surgical technique 120 repair 163–4 history 38 trocar placement 119–20 lumbar hernias see lumbar hernias indications/contraindications 65–6 trocar selection 119 obstructed/incarcerated bowel 111–13 instrumentation 68 transversalis fascia 42–4 outcomes open method comparison 84–5 transversus abdominus muscle 104–5 comparative studies 157–9 postoperative management 73 traumatic diaphragmatic injuries 209–10 cosmetic 109 preoperative evaluation 68 acute herniation 210–12 functional 109–10 recurrence rates 93–4 chronic herniation 212–14 series comparisons 155–7 surgical technique 69–73 Trelex prosthetic biomaterial 17–18 parastomal hernias see parastomal transabdominal pre-peritoneal (TAPP) trocars hernias comparison 83–4 design of 8–10 pre-peritoneal hernioplasty see transabdominal pre-peritoneal (TAPP) injury from 89–90 pre-peritoneal hernioplasty patch technique tumors, and recurrent gastroesophageal prosthetic biomaterial fixation 107–8 AESOP robotic arm 266–8 reflux disease 220 recurrence rates 166–8 for bilateral hernia 62 twisted fundoplication 220 scar healing 108–9 complications transfascial suture technique see anesthesia 89 ultrasonic dissection 10–11 transfascial suture technique hydrocele 90 ultrasonically activated trocar 10 Zeus tele-robotic system 268–9, 270–2 laparoscopic access 89–90 umbilical hernia 106 videoendoscopy systems 12 nerve injury 91–2 urinary bladder injury 92 da Vinci tele-robotic system 268–9 organ complications 90 US Surgical Corporation stapler 26 ventral/incisional hernioplasty 270–2 prosthetic mesh 93 Usher, FC 34–5 visceral injury 89–90, 92–3, 243 seroma 90–1 with fundoplication 241–2 vascular injury 91 vagal nerve injury 221, 245–6 with para-esophageal hernia repair 206 visceral injury 92–3 vas deferens complications 90, 93 and trocar design 8–10 history 37–8 vascular injury 89–90, 91 indications/contraindications 53–4 with fundoplication 241–2 work, return to after surgery 276–7 instrumentation 55 with prosthetic biomaterial fixation 107–8 open method comparison 54, 84–5 and trocar design 8–10 Zeus tele-robotic system 269–70