Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Abbreviations
CGRP
CT
DES
DPL
ECG
ECMO
EGD
ePTFE
GER
GERD
GPRVS
HAL
IEM
IPOM
LES
LIVH
MIS
MRI
NSEMD
PCA
PEH
PFA
PONV
PPM
PTFE
TAPP
TEP
TLESR
calcitonin gene-related peptide
computerized tomography
diffuse esophageal spasm
diagnostic peritoneal lavage
electrocardiogram
extracorporeal membrane oxygenation
esophagogastroduodenoscopy
expanded polytetrafluoroethylene
gastroesophageal reflux
gastroesophageal reflux disease
giant prosthetic reinforcement of the
visceral sac
hand-assisted laparoscopy
ineffective esophageal motility
intraperitoneal onlay of mesh
lower esophageal sphincter
laparoscopic incisional and ventral
hernioplasty
minimally invasive surgery
magnetic resonance imaging
non-specific esophageal motility
disorder
patient-controlled analgesia
para-esophageal hernia
platelet function assay
postoperative nausea and vomiting
polypropylene mesh
polytetrafluoroethylene
transabdominal pre-peritoneal
total extraperitoneal
transient lower-esophageal sphincter
relaxation
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-Sane, 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
PART
1
Overview
1 Laparoscopic general surgery
2 Technological and instrumentation aspects of
laparoscopic hernia surgery
3
7
3 Prosthetic biomaterials for hernioplasty
4 Fixation devices for laparoscopic hernioplasty
17
25
1
Laparoscopic general surgery
ROGER K.J. SIMMERMACHER
References
5
Fortunately the time when many surgeons and their
patients thought that laparoscopy should be a purpose
rather than a means to an end has passed. Although the
scopic approach has become the gold standard for some
indications, it has not brought completely new ideas on
how to handle surgical diseases, but it has changed our
certain approach in order to facilitate the postoperative
recovery of the patient. Principally, a surgical disease
should be managed by a surgeon. Who, in order to treat
his or her patient optimally, is not limited by technology
(a scalpel for open surgery or the laparoscope for some of
us) rather than trying to find the best treatment modality by chance, which migh
t include techniques still to be
envisioned.1 For many of us, laparoscopy is, or was, the
first expansion of our rather limited armamentarium.
As with many things in surgery, Hippocrates is credited
as the first physician to have used a tool to obtain a better
view of the human interior, in his case the rectum.2 Further development of this
idea, however, was hampered for
nearly 2000 years due to a lack of progression in technological innovation.3 The
evolution of laparoscopic surgery
parallels the evolution of two distinct technical factors,
which are the basis for all current endoscopic interventions: the invention and
development of a lens system that
could be connected to a computer-chip television camera
and an effective lighting system via fiber-optic delivery
were the essential prerequisites for the current possibilities
of laparoscopic technology. This allowed other surgeons
and their assistants to handle the endoscope while actively
participating and assisting in the scopic procedures. It is
difficult to state with certainty who should be credited with
performing the first human laparoscopy, complete with
pneumoperitoneum. However, at the beginning of the
twentieth century, three names are mentioned: Kelling,4
Jacobaeus5 and Ott.6 Jacobaeus was the first physician to
mention thoracoscopy, a procedure that he initially felt had
a better chance than laparoscopy for further development.
In 1927, the first textbook dealing with thoracoscopy
and laparoscopy was published by Korbsch in Munich,
Germany. After World War II, the development of laparoscopic investigations into
the human body was led mainly
by European gynecologists. An extensive overview of their
contributions into the development of endoscopic surgery is beyond the scope of
this chapter, but some of their
advancements are interesting and worth consideration.7
Once technical innovations allowed more than one person to view through the lapa
roscope at the same time, it
was only a few years before Phillipe Mouret of Lyon,
France performed the first human laparoscopic cholecystectomy in 1987. This even
t initiated an explosion of
experiments that has brought us to the current position of
4 Overview
appendectomy.13 Laparoscopic appendectomy had been
reported as early as 1977 in a paper from The Netherlands,14
and since then there has been an ongoing discussion about
the merits of the laparoscopic approach in the surgical
treatment of appendicitis. A recent review by Fingerhut
concluded that because many of the surgical aspects of
the open appendectomy have improved so greatly, the
apparent advantages of a laparoscopic approach are hard
to demonstrate.15 It is acknowledged, however, that local
cultural factors, as well as operative experience, are important considerations
that should dictate the strategic
decisions of any individual surgeon and/or hospital.15
Recently, a randomized clinical trial in children, which
compared both approaches, demonstrated clearly that
laparoscopic appendectomy did not offer advantages
over the open method.16 These findings are disputed
heavily by others.17 Advantages of laparoscopic appendectomy appear to be limite
d to obese patients and
patients whose preoperative diagnosis is not clear-cut.18
Another organ system that received a lot of attention
in the early years of laparoscopy was the upper gastrointestinal tract.19 The in
itial interest began with the treatment of duodenal ulcers and gastroesophageal
reflux
disease.20 Since its introduction of laparoscopic surgery of
the upper gastrointestinal tract, has become the gold standard for the surgical
treatment of gastroesophageal reflux
disease (GERD).21 It is frequently performed in daycare
situations,22 although there can be persistent complaints
years after the operation.23
According to the French literature, gastric ulcers
should be approached laparoscopically at the initial operation,24 as both retros
pective25 and prospective26 analyses
have shown excellent results and low conversion rates.25
Other diseases of the stomach for which laparoscopy is
frequently performed in some centers with standardized
laparoscopic methods include achalasia,26,27 perforated
peptic ulcer,28 and gastric cancer. With respect to bariatric
surgery, there appear to be current differences between
the use of the gastric bypass (more popular in the USA)
and the application of adjustable bands on the stomach
(more popular in Europe). The laparoscopic approach for
both procedures continues to grow rapidly, but randomized controlled trials comp
aring the different methods are
needed urgently.29
Laparoscopy offers an important advantage in the
treatment of many types of intra-abdominal cancers, as
it allows staging of the disease prior to any intended
resection. However, careful patient selection is necessary
to effectively limit the number of unnecessary laparotomies.30,31 Additionally,
intraoperative laparoscopic ultrasonography may become mandatory in the future b
ecause
it allows more accurate pretreatment staging.32 Preoperative staging will allow
the correct operation to be chosen
from one of the many different types of resections that
are feasible.3336
Introduction of improved techniques for intracorporeal hemostasis, stapling and
knot-tying make it possible
4
5
6
7
8
9
10
Scott-Conner CEH, Arregui M. Visions of things that will come to
pass. Surg Laparosc Endosc Percutan Tech 1999; 9: 856.
Edmondson JM. History of the instruments for gastrointestinal
endoscopy. Gastrointest Endosc 1991; 37: S2757.
Gunning JE. The history of laparoscopy. J Reprod Med 1974; 12:
2226.
Kelling G. ber Oesofagoscopie, Gastroscopie und Klioscopie.
Munch Med Wochenschr 1902; 41: 25971.
Jacobaeus HC. ber die Mchligkeit die Zystoscopie bei
Untersuchung serser Hhingen auszuwenden. Munch Med
Wochenschr 1910; 57: 209092.
Ott D. Die direkte Beleuchtung der Bauchhhle, der Harnblase, des
Dickdarms und des Uterus zu diagnostischen und operativen
Zwecken. Rev Med Tcheque 1901; 2: 279.
Taniguchi E, Ohashi S, Takiguchi S, Kanno H, Oriyama T, Ikuma K,
et al. Laparoscopic surgery assisted by a transvaginal approach.
Surg Laparosc Endosc 1999; 9: 536.
Zacks SL, Sandler RS, Rutledge R, Brown RS, Jr. A populationbased cohort study c
omparing laparoscopic cholecystectomy and
open cholecystectomy. Am J Gastroenterol 2002; 97: 33440.
Ludwig K, Patel K, Wilhelm L, Bernhardt J. Prospective study on
patients outcome following laparoscopic vs. open
cholecystectomy. Zentralbl Chir 2002; 127: 416.
Podnos YD, Gelfand DV, Dulkanchainun TS, et al. Is intraoperative
cholangiography during laparoscopic cholecystectomy cost
effective? Am J Surg 2001; 182: 6639.
25
26
27
28
29
30
31
32
33
34
Phillips EH, Rosenthal RJ, Caroll BJ, Fallas MJ. Laparoscopic transcystic common
bile duct exploration. Surg Endosc 1994; 8: 1389.
Berci G, Morgenstern L. Laparoscopic management of common bile
6 Overview
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
Laparoscopic hernia surgery, like other types of minimally
invasive surgery (MIS), has been shaped and impacted
by the emergence of new surgical techniques and the
assimilation of new and evolving medical technologies.
To address the technological and instrumentation aspects
of laparoscopic herniorrhaphy comprehensively could
extend the discussion from a macro-perspective dealing
with issues of operative suite design and integration of
technology to a micro-view focusing on, for example, the
tines of a dissecting instrument. Such a dissertation is
beyond the scope of this chapter. Instead, we will focus
upon the instruments, equipment and material used in
laparoscopic hernia surgery and the related technological
advances that have facilitated a widening adoption of
various laparoscopic hernia procedures. Some topics that
are dealt with in greater detail in later chapters, such as
methods of mesh fixation and surgical energy sources, will
receive more cursory mention in this chapter, in the context of specific instrum
ent use and development. Ergonomic considerations in surgical instrument and equ
ipment
design, so often overlooked yet so vital to optimal surgical
performance, will also be addressed.
Ergonomics
Conclusion
References
13
13
14
8 Overview
1020.2 Although reusable instrumentation is subject
to the wear and tear of repeated use and sterilization,
disposable instruments may be imprecise.3 Reposable
instruments, which combine reusable and disposable
components, represent a compromise between the two
instrument types.
Laparoscopic dissecting and grasping
instruments
Although laparoscopic dissectors and graspers conform
to a basic design, the configurations of the end-effectors
vary in terms of size, shape and surface. Different types
of dissection (sharp or blunt dissection, micro- or
macro-exposure) require instruments with different dissecting tips. Sharp-tipped
instruments, including laparoscopic shears and needle-nose dissectors, facilita
te fine
spreading and micro-dissection. Blunt dissectors, such as
the Reddick-Olsen, may reduce the risk of inadvertent
injury to adjacent structures, but their utility in fine dissection and micro-ex
posure is limited. Tapered tips that
fall somewhere in the continuum from sharp to blunt
end-effectors constitute the majority of commonly used
dissectors. Tapered, narrow-tipped dissectors, such as the
Maryland/Kelly or DeBakey laparoscopic instruments,
have proved useful during laparoscopic hernia repair, from
dissection in para-esophageal herniorrhaphy to creation
of the peritoneal flaps in transabdominal pre-peritoneal
inguinal herniorrhaphy. Additionally, the Maryland/Kelly
dissectors have curved jaws, which facilitate dissection
around structures. The curved tips of the Maryland/Kelly
dissector allow clear visualization of the operative target
and the tip of the instrument, unlike the shadowing that
may occur about the symmetrically tapered, flat-tipped,
duckbill dissector.
Effective tissue grasping is made possible by the surface
topography of the instrument tips. The fine ridges and
grooves provide friction during grasping, limiting slippage
and therefore tissue trauma. The delicate serrations of the
DeBakey clamp provide atraumatic tissue handling. This
curved instrument is thus ideally suited for the fine dissection and the gentle
manipulation of the bowel required
during adhesiolysis and reduction of hernia contents. In
contrast, ratcheted instruments with thick serrations are
poorly suited for bowel handling, but they are designed for
constant grasping, such as gallbladder retraction. Other
dissectors have tines that appose incompletely along the
proximal jaws of the instrument, allowing the instrument
to hold tissue atraumatically in that space.
The laparoscopic handle and the hinge mechanism
of the jaws greatly impact the function of grasping and
dissecting instruments. Instruments with coaxial or
articulating shafts provide the surgeon with greater freedom of movement in rest
ricted working spaces. Locking
or ratcheted instruments may reduce muscular fatigue
during grasping, but they are not appropriate for dissection, which requires mor
e dynamic handling. Similarly,
single-action jaws, in which one jaw remains fixed, are
effective for grasping but less so for dissection. Furthermore, the symmetry of
double-action jaws makes these
instruments better suited for fine dissection.
The diameter of the instrument also affects function
and performance. Micro-instruments (23 mm diameter) have been applied to a variet
y of minimally invasive
procedures, including laparoscopic hernia repair.4,5 These
needlescopic dissectors have relatively elastic shafts and
short end-effectors with limited spread. Thus, limitations
inherent in the design of 2-mm graspers and dissectors
have in turn limited the use of such needlescopic instruments in laparoscopic he
rnia surgery.
Unique to laparoscopic totally extraperitoneal inguinal
hernia repair is the balloon dissector, commonly used in
North America to develop the pre-peritoneal plane. A
variety of balloon dissectors are available, most furnished
with a guiding trocar and obturator for initial placement
beneath the rectus muscle. With inflation of the balloon,
a pre-peritoneal working space is created. Although this
device provides a simpler and more timely alternative
to manual dissection, it is imperative that the surgeon is
familiar with the laparoscopic pre-peritoneal anatomy to
recognize the appropriate plane of dissection and to avoid
associated complications.
Trocars
Careful consideration of trocar type and placement is
imperative in the successful conduct of laparoscopic hernia repair. Quite simply
, trocars are the portals through
which the laparoscopic instruments are passed. At the
same time, trocars represent potential weapons, and their
misplacement can contribute to the morbidity and even
mortality of a laparoscopic procedure. The incidence of
trocar-related injury is low but significant. The incidence
of hollow viscus perforation varies between 0.04 and
0.14 per cent.613 Major retroperitoneal vascular injury has
been reported in 0.030.1 per cent, carrying a substantial
mortality rate of nine per cent.912,14 Major vascular
injury is a very common cause of death in laparoscopy,
second only to anesthetic complications.14 In an effort to
increase the safety of trocar insertion, a variety of trocar
designs has been introduced.
The previously stated pros and cons of reusable
instrumentation also hold for trocars. Reusable, metal
trocars may provide better grip to the skin and abdominal wall compared with pla
stic, disposable trocars.
Several trocar designs have been developed to prevent
slippage and leakage of pneumoperitoneum. The Hasson
trocar, typically used as an initial trocar after peritoneal
10 Overview
consists of an exposed blade for abdominal wall entry and
a plastic shield that is released upon peritoneal entry to
safely cover the cutting blade. Many disposable trocars
incorporate this mechanism. Importantly, this feature does
not guarantee protection against trocar entry injuries.
Pyramidal and conical trocar tips have also been
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
inguinal herniorrhaphy, the reusable trocar resulted in a
lower complication rate.15 Trocar vascular and visceral
injuries are thought to be related to the force required
for trocar insertion. However, the size of the abdominal
wall defect created by the trocar has been shown to be
inversely proportional to the entry force.16 In an animal
study, it was demonstrated that conical tips require
greater entry force than pyramidal trocars yet subsequently produce smaller abdo
minal wall defects.
To decrease the insertion force and possibly reduce
visceral injury, innovative trocar designs have been
coupled with various energy sources. However, these new
designs have not yet been proven in human application
in laparoscopic hernia surgery; studies have been limited
almost entirely to animal models. Electrosurgical trocars
utilize thermal energy to create the abdominal wall opening for passage of the t
rocar. This has been found to
reduce the force required for entry without detrimental
effects on wound healing at the trocar site after laparoscopic cholecystectomy.1
7 Taking advantage of the
decreased thermal spread associated with ultrasonic dissection, an ultrasonicall
y activated trocar has been designed
with an associated decrease in insertion time and force as
well as a smaller increase in abdominal pressure during
insertion compared with conventional conical trocars.18
The applicability of these trocars is yet to be seen in
patients with multiple previous surgeries or with ventral
hernias, where the proximity of adhered bowel may
predispose the patient to thermal visceral injury.
Another substantial concern in the treatment of
hernia patients is recurrent herniation. In a retrospective
review of 320 patients (including two patients with
concomitant para-esophageal hernia repair), the overall
incidence of trocar site herniation after laparoscopic fundoplication was found
to be three per cent.19 As herniation at trocar sites has been reported repeated
ly in the
literature,1921 the size of the defect created by trocars is a
key factor. The size of the trocar site defect is influenced
by the tip shape, trocar size, and mechanism of entry.
The radially expanding trocar utilizes a needle puncture
followed by insertion of a blunt, radially expanding
obturator through the needle tract. This alternative to
the traditional cutting trocar has been associated with
less postoperative pain, improved postoperative patientrated wound scores, decre
ased intraoperative and postoperative complications, and smaller fascial defects
.2224
Similarly, other non-bladed trocars have also been
demonstrated to cause smaller abdominal wall defects
12 Overview
adhesions.37 While an inflammatory reaction was also
noted in this study, the density of adhesions and the
percentage of expanded polytetrafluoroethylene (ePTFE)
prosthetic patch coverage by adhesions was decreased in
the fibrin glue cohort. The majority of fibrin sealant
studies associated with hernia repair have been conducted in animal models. The
hemostatic properties of
fibrin glue in hernia repair were notable in one of the few
published human studies. In patients with coagulopathic
disorders, fibrin glue was noted to reduce postoperative
bleeding after inguinal herniorrhaphy.38
The cyanoacrylates, a class of tissue adhesives traditionally used in wound mana
gement, have been examined
for use in laparoscopic hernia repair. Internal use
of this tissue adhesive was previously limited due to
the potential toxicity associated with early formulations.
However, newly designed formulations have been studied
for their applicability in hernia repair, although these studies remain limited
to animal models. In an examination of
octylcyanoacrylate tissue adhesive for fixation of ePTFE in
a rabbit incisional hernia model, less force was required for
displacement of adhesive-fixed mesh than for suture or
spiral tack fixation.39 In addition, the octylcyanoacrylate
adhesive stimulated an inflammatory reaction that
delayed cellular migration into the ePTFE interstices, so
the clinical implications of this finding are unclear.
VIDEOENDOSCOPIC SYSTEM
The videoendoscopic system has become the eyes of
the laparoscopic surgeon. With the limited tactile feedback 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
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 stereoscopic visual cues.
The current videoendoscopic system begins with a
rod-lens laparoscope with coaxial illumination and fiberoptic light bundles. Ill
umination is provided by a highintensity but cold broadband light source. Most sys
tems
employ a high-quality solid-state camera equipped with
a charged-coupled device and a three-chip array for
color separation (red, green, blue). This provides optimal
color fidelity. Standard display systems utilize National
Television Committee Standard video with a resolution
of no less than 640 ! 480 pixels. Improving upon standard composite video system
s, which combine luminance
and chrominance signals, S-video separates the signals and
offers superior color saturation. Most cathode-ray tube
monitors in use are curved and are therefore associated
with a degree of distortion. Flat-screen monitors eliminate
this distortion, but they remain cost-prohibitive in
many institutions and may provide poorer resolution and
movement lag.
Advances in imaging technology have led to the development of new systems to add
ress current optical and
ergonomic limitations. Head-mounted displays reduce
should be selected not only for function but also for ease of
use and proper individual surgical fit. Currently, this selection may not be acc
omplished easily for surgeons with
smaller hands. The operating table should be positioned
so that the instrument handles are at the surgeons elbow
level.46 Similarly, the video monitor should be positioned
at or slightly above eye level. Suspended mobile monitors
may facilitate this adjustment. The monitor should be in
alignment with the operative target and the surgeon. Foot
pedals that control energy sources should be placed within
a small radius from the surgeons feet to avoid stiffening
and straining to maintain balance.
Patient position is also crucial. The patient should
be positioned to allow gravity to assist with operative
exposure, reducing the exertion needed from the surgeon
and assistants for retraction. For example, the patient
is placed in mild reverse Trendelenburg position during para-esophageal hernia r
epair. Similarly, the patients
arms should be tucked during ventral herniorrhaphy to
provide freedom of movement by the surgeon and assistants about the operating ta
ble. Attention to these details
in positioning and operative set-up should greatly
improve operative efficiency.
CONCLUSION
As with other types of MIS, laparoscopic hernia repair
evolved through the merger of innovative technology
and new surgical techniques. The wide array of available
instrumentation for tissue dissection, the development of
14 Overview
new tools for mesh fixation, and the application of novel
techniques have all facilitated and expanded the role of
laparoscopy in the treatment of a variety of hernia defects.
With continuing technological advances and attention to
ergonomic factors, the outcome and efficiency of laparoscopic hernia repair are
certain to improve.
REFERENCES
20
21
22
23
24
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Melzer A. Endoscopic instruments: conventional and intelligent.
In: Toouli J, Gossot D, Hunter J, eds. Endosurgery. New York:
Churchill Livingstone, 1996: 6995.
Fengler TW, Pahlke H, Kraas E. Sterile and economic
instrumentation in laparoscopic surgery. Surg Endosc 1998; 12:
12759.
Park AE, Mastrangelo MJ, Jr, Gandsas A, et al. Laparoscopic
dissecting instruments. Semin Laparosc Surg 2001; 8: 4252.
Tagaya N, Aoki H, Mikami H, et al. The use of needlescopic
34
35
36
37
38
39
40
41
De Giuli M, Festa V, Denoye GC, Morino M. Large postoperative
umbilical hernia following laparoscopic cholecystectomy. A case
report. Surg Endosc 1994; 8: 9045.
Patterson M, Walters D, Browder W. Postoperative bowel
obstruction following laparoscopic surgery. Am Surg 1993; 59:
6567.
Bhoyrul S, Payne J, Steffes B, et al. A randomized prospective study
of radially expanding trocars in laparoscopic surgery. J Gastrointest
Surg 2000; 4: 3927.
Yim SF, Yuen PM. Randomized double-masked comparison of
radially expanding access device and conventional cutting tip
trocar in laparoscopy. Obstet Gynecol 2001; 97: 4358.
Lam TY, Lee SW, So HS, Kwok SP. Radially expanding trocar: a less
painful alternative for laparoscopic surgery. J Laparoendosc Adv
Surg Tech A 2000; 10: 26973.
Liu CD, McFadden DW. Laparoscopic port sites do not require
fascial closure when nonbladed trocars are used. Am Surg 2000;
66: 8534.
Tucker RD. Laparoscopic electrosurgical injuries: survey results and
their implications. Surg Laparosc Endosc 1995; 5: 31117.
Nduka CC, Super PA, Monson JR, Darzi AW. Cause and prevention
of electrosurgical injuries in laparoscopy. J Am Coll Surg 1994; 179:
16170.
Mueller W, Fritzsch G. Medicotechnical basics of surgery using
invasive ultrasonic energy. Endosc Surg Allied Technol 1994; 2:
20510.
Birch DW, Park A, Shuhaibar H. Acute thermal injury to the canine
jejunal free flap: electrocautery versus ultrasonic dissection.
Am Surg 1999; 65: 3347.
El-Banna M, Abdel-Atty M, El-Meteini M, Aly S. Management of
laparoscopic-related bowel injuries. Surg Endosc 2000; 14:
77982.
Park A, Gagner M, Pomp A. Laparoscopic repair of large incisional
hernias. Surg Laparosc Endosc 1996; 6: 1238.
Rosenthal D, Franklin ME. Use of percutaneous stitches in
laparoscopic mesh hernioplasty. Surg Gynecol Obstet 1993; 176:
4912.
LeBlanc KA. The critical technical aspects of laparoscopic
repair of ventral and incisional hernias. Am Surg 2001; 67:
80912.
Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral
and incisional hernia repair in 407 patients. J Am Coll Surg 2000;
6: 64550.
Dion YM, Charara J, Guidoin R. Bursting strength evaluation.
3
Prosthetic biomaterials for hernioplasty
KARL A. LEBLANC
Synthetic prosthetic biomaterials: flat, single-component
products
17
Synthetic prosthetic biomaterials: preformed products
21
Synthetic prosthetic biomaterials: composite products
21
Almost all hernia repairs that are performed laparoscopically utilize some form
of prosthetic biomaterial. One
notable exception is the infrequent small hernias found
during laparoscopic incisional and ventral hernioplasty,
which are merely sutured. The early pioneers in laparoscopic inguinal hernia rep
air generally used polypropylene mesh (PPM) products, but a few attempted to use
expanded polytetrafluoroethylene (ePTFE). Incisional
and ventral hernioplasty utilized ePTFE when it was first
described. Currently, PPM and ePTFE prostheses are
the preferred biomaterials for the laparoscopic repair of
inguinal and incisional hernias, respectively. The preferences for each of these
operations and the choice of
prostheses are described in the following chapters. This
chapter will present the currently available materials that
are used for the laparoscopic repair of hernias.
The biomaterials can be subdivided into many classes.
The broadest distinction is between synthetic and nonsynthetic products. These c
an be subdivided further into
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
above will be assumed.
SYNTHETIC PROSTHETIC BIOMATERIALS:
FLAT, SINGLE-COMPONENT PRODUCTS
Most of these products are manufactured from polypropylene. The major difference
s between the meshes are
the size of the monofilaments used in the structure of the
mesh and the size of the pores (interstices) of the mesh
Non-synthetic prosthetic biomaterials
Conclusion
References
22
24
24
Table 3.1 Flat, single-component polypropylene biomaterials
and manufacturers
Biomaterial
Manufacturer
Angimesh
Biomesh P1
Biomesh P3
Biomesh 3D
Hertra 1, 2
Hermesh 3, 4, 5
Intramesh NK1, NK2, NK8
Marlex
Parietene
Prolene
Prolene Soft Mesh
Prolite
Prolite Ultra
Surgipro (Monofilament)
Surgipro (Multifilament)
Trelex
Angiologica
Cousin Biotech
Cousin Biotech
Cousin Biotech
HerniaMesh
HerniaMesh
Cousin Biotech
C. R. Bard, Inc.
Sofradim International
Ethicon
Ethicon
Atrium Medical Corp.
Atrium Medical Corp.
U.S. Surgical Corp., Inc./Tyco
U.S. Surgical Corp., Inc./Tyco
Meadox Medical Corp.
itself (i.e. the weight of the mesh). These two factors influence the thickness,
stiffness, shrinkage rates, inflammatory
response, potential for development of adhesions to the
product, and resulting changes in the elasticity of the
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.
One of the problems that has been seen in the past
with the repair of incisional hernias is fistulization.1 This
has also been seen with laparoscopic inguinal repair.2
These real and potential complications of PPM may be
18 Overview
(a)
(d)
(b)
(c)
(e)
(f)
Figure 3.1 Comparison of the weaves of PPM products: (a) Hetra 1, (b) Hetra 2,
(c) Prolene, (d) Prolene Soft Mesh, (e) Marlex, and (f) NK Mesh.
related to the weight of the polypropylene within the
mesh. Newer, lighter-weight meshes have been developed
(Table 3.1) that, theoretically, are designed to overcome
many of the adverse effects of the heavier meshes.
However, the lighter products are very soft and pliable,
and consequently the use of them within the pre-peritoneal space created for the
repair of inguinal hernias can
be somewhat difficult. Manipulation can be particularly
troublesome because of other difficulties, such as obtaining 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
repair.
Although not as prevalent or plentiful as PPM, polyester products are used in th
e repair of inguinal hernia in
several countries (Table 3.2). The use of polyester is generally prescribed beca
use of its pliability and conformability to the inguinal floor. However, the use
of polyester
biomaterial has been associated with fistulas.3 Figure 3.2
shows the differences between the polyester products.
The Parietex and Biomesh meshes are woven into a threedimensional weave rather t
han the two-dimensional
weave that is most familiar to flat meshes. This is said to
make them even more pliable and to allow a greater
degree of tissue penetration.
As with other biomaterials, ePTFE products were
initially developed many years ago for open repair of
inguinal hernias. The use of these single-component
Table 3.2 Polyester prostheses and manufacturers
Biomaterial
Manufacturer
Biomesh A1
Biomesh A3
Biomesh 3D
Mersilene
Parietex TEC
Parietex TECR
Parietex TET
Cousin Biotech
Cousin Biotech
Cousin Biotech
Ethicon
Sofradim International
Sofradim International
Sofradim International
patches compromises about 85 per cent of the published
reports on the repair of incisional and ventral hernias.
The prevalence of use of ePTFE is based upon the fact
that there has never been a reported case of fistulization
subsequent to the intraperitoneal placement of this
product. In addition, ePTFE results in very minimal
adhesions to itself. The currently available products
are listed in Table 3.3 and shown in Figure 3.3. There
has been some concern regarding the extent and nature
of tissue penetration into ePTFE. However, this was
based upon an earlier product that is no longer used in
the laparoscopic arena. Recent studies have confirmed
that the level of tissue penetration and attachment
strength of the newer DualMesh is superior to that of
PPM at only three days post-implant.4 Other postoperative data also support the
inhibition of adhesions to
ePTFE.5
L.
L.
L.
L.
L.
L.
R.
L.
L.
R.
L.
20 Overview
(a)
(b)
(d)
(c)
(a)
Figure 3.3 ePTFE biomaterials: (a) DualMesh, (b) DualMesh Plus,
(c) DualMesh Plus with Holes, and (d) Dulex.
(b)
Figure 3.4 Emerge biomaterial (a) with the silicone unpeeled and (b) as it is pe
eled off the DualMesh.
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 an
d 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.
which could expose the PPM. The products are available
in numerous sizes, so cutting will seldom be necessary.
The last five products listed in Table 3.4 have absorbable
components. Parietex composite consists of a threedimensional polyester mesh (li
sted in Table 3.3) that has
been incorporated by hydrophilic collagen. Paritene composite uses the PPM that
is listed in Table 3.1 and has the
same collagen layer as Parietex composite. The absorbable
collagen is no longer present by the fourteenth postoperative day. At the time o
f writing, long-term studies using
these biomaterials are in progress.
Sepramesh (Figure 3.8) is PPM coated on one surface
with carboxymethylcellulose and hyaluronate foam. This
foam will be absorbed in about seven days to leave the
NON-SYNTHETIC PROSTHETIC
BIOMATERIALS
Several products based upon biological materials are
now available (Table 3.5). The use of a non-synthetic
biomaterial for the repair of hernias may be the better
approach. However, long-term studies and biocompatibility evaluations will be ne
eded to confirm their usefulness. All have been processed to eliminate the risk
of
transmission of viral or other diseases. These generally
are pure or nearly pure collagen that will be incorporated
and/or replaced by the patients own collagen over time.
The hernia is repaired by the neofascia that subsequently
develops. The majority of implantations of these biomaterials have been via open
operation, but their use
with laparoscopic technique is undergoing evaluation.
Inc.
Inc.
Inc.
Laboratories plc
(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.
Alloderm (Figure 3.9) is manufactured from cadaveric skin. Its width is limited
by the size of the dermatome that is used to harvest the material. Surgisis ES
and Surgisis Gold (Figure 3.10) are four- and eight-ply,
respectively, porcine small-intestinal submucosa. The
manufacturing process causes the nodules that are seen
on the Surgisis Gold. Fortagen and Fortaperm are also
processed porcine submucosa of the small intestine
(Figure 3.11). These latter two products are very similar
Figure 3.12 Permacol.
in appearance. They are five layers thick, the layers being
cross-linked together to provide greater strength. Fortagen
will be replaced by the native collagen, similar to Surgisis,
but Fortaperm becomes a permanent prosthetic similar
to that of the synthetic biomaterials described above.
Permacol (Figure 3.12) is porcine dermis with indications similar to the other p
roducts.
24 Overview
At the time of writing, all of these biomaterials are relatively new and clinica
l experience is generally limited.
There may be particular application in the site of infections
that are associated with tissue loss or following hernia
repair with synthetic meshes. These cannot be used in
the presence of an intestinal fistula because the enteric
contents will dissolve the collagen in the product.
REFERENCES
1
2
3
CONCLUSION
Laparoscopic hernioplasty is dependent upon the use of
prosthetic biomaterial and the in-growth that ensues. A
variety of synthetic and non-synthetic biomaterials are
available for implant. Surgeons should be aware of all of
the available products. The selection of the ideal prosthesis should be based up
on experimental, clinical and longterm follow-up data. Newer biomaterials will p
robably
be developed in the future that may enhance the repair of
hernias.
4
5
6
7
8
9
Losanoff JE, Richman BW, Jones JW. Entero-colocutaneous fistula: a
late consequence of polypropylene mesh abdominal wall repair:
case report and review of the literature. Hernia 2002; 6: 1447.
Klein AM, Banever TC. Enterocutaneous fistula as a postoperative
complication of laparoscopic inguinal hernia repair. Surg Laparosc
Endosc 1999; 9: 602.
Leber GE, Garb JL, Alexander AI, Reed WP. Long-term complications
associated with prosthetic repair of incisional hernias. Arch Surg
1998; 133: 37882.
LeBlanc KA, Bellanger DE, Rhynes VK, et al. Tissue attachment
strength of prosthetic meshes used in ventral and incisional hernia
repair. Surg Endosc 2002; 16: 15426.
Koehler RH, Begos D, Berger D, et al. Adhesion formation to
intraperitoneally-placed mesh: reoperative clinical experience after
laparoscopic ventral incisional hernia repair. Am J Surg; in press.
Pajotin P. Laparoscopic groin hernia repair using a curved prosthesis
without fixation. J Coelio-Chir 1998; 28: 648.
LeBlanc KA. Tack hernia a new entity. JSLS 2003; in press.
Kramer K, Senninger N, Herbst H, Probst W. Effective prevention of
adhesions with hyaluronate. Arch Surg 2002; 137: 27882.
Amid P. Hyaluronate does not prevent adhesions. Arch Surg 2002;
137: 131314.
4
Fixation devices for laparoscopic hernioplasty
KARL A. LEBLANC
Early devices
Later devices
Latest devices
25
27
27
Laparoscopic hernioplasty requires the use of a prosthetic biomaterial. Conseque
ntly, a method of fixation
will be necessary for all but the smallest of incisional and
some of the inguinal hernia prostheses. The earliest
attempts to repair inguinal hernias laparoscopically were
performed with the suture fixation of the mesh to the
structures of the inguinal floor. This was a very tedious
task, which greatly hindered the adoption of this new
technology. Manufacturers of instruments responded
with the development of different devices that delivered
metal fixation to secure the biomaterial to the inguinal
floor. The use of these devices is, of course, an integral
part of all laparoscopic hernia repairs. There have been a
number of these products that have not been successful
or even brought to large-scale production. These and the
newer instruments are discussed below.
The classification of these devices is arbitrary. Regardless of the product that
is used by the surgeon, it is critical that each is used properly. Few surgeons
are afforded
the opportunity to use these instruments for the first time
in the laboratory setting. Therefore, it is recommended
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 devic
es without exposing the patient to
untoward consequences.
Conclusion
References
a series of 13 patients in whom he closed the peritoneal
opening of the sac using Michel clips. All but the last
patient in this series were repaired through an open incision. The thirteenth pa
tient was repaired in 1979 under
laparoscopic guidance with a special stapling device. The
three-year follow-up of this patient revealed him to be
free of an identifiable recurrence. Ger and colleagues
continued their efforts to repair these hernias laparoscopically. They reported
the closure of the neck of the
hernia sac using a prototypical instrument called the
Herniostat in beagles (Figure 4.1).2 This device was never
produced commercially, but it was certainly ahead of
its time.
Schultz and colleagues published the first patient
series of laparoscopic herniorrhaphy in 1990.3 Rolls
of polypropylene were stuffed into the hernial orifice,
which was then covered by two or three flat sheets of
polypropylene mesh (2.5 ! 5 cm) over the defect. These
26 Overview
Figure 4.2 Ethicon EMS stapler and the staples that it fired.
modified this technique by inverting the hernia sac and
performing a high ligation with sutures or with an endoscopic stapling device us
ed 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 abd
ominal
wall covering the internal inguinal ring and secured it
with a stapling device. The success of these repairs led
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
their first ten patients repaired with the IPOM technique.6 They secured an expa
nded polytetrafluoroethylene (ePTFE) patch to the inguinal floor with staples th
at
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 advers
e results in 2030 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
was attached with the Endopath EMS stapler (Ethicon
Endosurgery, Inc.) (Figure 4.4). After a follow-up of up
to 20 months, the recurrence rate was 2.4 per cent. They
noted a significant decrease in postoperative pain and an
earlier return to normal activity compared with the open
repair of the hernia defect.
These early hernia repairs continued to become modified in many different aspect
s, including approaches to
the inguinal area, prosthetic biomaterials, and fixation
devices. The devices that followed, such as the EMS,
allowed the placement of multiple staples without the
need to reload after each use. U.S. Surgical Corporation,
Inc. released its stapler, which was similar in concept
(Figure 4.5). This device required a 12-mm trocar rather
than the 10-mm trocar used by the EMS staplers. The
Figure 4.3 Nanticoke Hernia Stapler and staples. These
devices are conformed into a more rounded shape than the
EMS staples.
Figure 4.4 Endopath EMS stapler.
Figure 4.5 Endo-universal stapler of USSG.
Figure 4.6 Endopath EAS stapler.
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
Figure 4.12 EndoAnchor instrument.
The most recently developed product is the EndoAnchor by Ethicon Endosurgery, In
c. (Figure 4.12). This
allows the entire device to be loaded into either a
3-mm or a 5-mm shaft. To place this product into the
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
end of the outer shaft (Figure 4.13). The anchor is contained within the end of
the needle. The anchor is released
into the tissues as the trigger is released. Once this occurs,
the nitinol anchor assumes its shape after that movement
(Figure 4.14). The upper protrusions of the shaft of the
nitinol are the portion of the device that remains in
the tissues. The lower, larger hooks are positioned over
the prosthesis to hold it in place. Currently, there is only
a limited release of this device.
Laparoscopic hernioplasty requires fixation of the biomaterial. The devices desc
ribed above are almost all in
use today. The effectiveness of the newer products will
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
mechanism of delivery and the concept that is applied in
the shape of the final delivered device is important.
Emerging technologies will continue to deliver newer
products for this operation.
REFERENCES
1
Ger R. The management of certain abdominal herniae by
intra-abdominal closure of the neck of the sac. Ann R Coll Surg
Engl 1982; 64: 3424.
2 Ger R, Monro K, Duvivier R, et al. Management of inguinal hernias
by laparoscopic closure of the neck of the sac. Am J Surg 1990;
159: 37073.
3 Schultz L, Graber J, Pietrafitta J, et al. Laser laparoscopic
herniorrhaphy: a clinical trial, preliminary results. J Laparoendosc
Surg 1990; 1: 415.
PART
2
Laparoscopic inguinal/femoral
hernioplasty
5
6
7
8
9
History
Anatomy and physiology
Intraperitoneal onlay mesh approach
Transabdominal pre-peritoneal approach
Totally extraperitoneal approach
33
41
47
53
65
10 Femoral and pelvic herniorrhaphy
11 Results of laparoscopic inguinal/femoral
hernia repair
12 Complications and their management
75
83
89
5
History
MICHAEL S. KAVIC AND STEPHEN M. KAVIC
Hernia paradigm
Open hernia repair
Genesis of hernias
33
33
36
A hernia has been defined as the protrusion of a loop or
knuckle of an organ or tissue through an abnormal
opening.1 In their earliest state, hernias of the abdomen
and pelvic side wall begin as a protrusion of peritoneum
through a fascial defect. They are rarely symptomatic,
and typically they are undetectable on physical examination. In order to underst
and the development of laparoscopic hernia repair, it is necessary to review how
the
approach to hernias and hernia repair has evolved
throughout history.
HERNIA PARADIGM
Before recorded or written history, humans are thought
to have managed hernia with taxis. From its Greek origin,
meaning the drawing up in rank and file, taxis for hernia
involved the use of finger or hand pressure to reduce the
displaced organ or tissue. Support after reduction, utilizing a belt or girdle t
o maintain the herniated content,
would have been a logical extension of taxis. Thus the first
paradigm for hernia management is most likely to have
been one of conservative, nonoperative management.
The date of the first operation for hernia and change
in the nonoperative paradigm is unknown. However,
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.
George Moritz Ebers (183798), a professor of Egyptology at the University of Berl
in, purchased an ancient
papyrus while traveling in Egypt in 1873. The papyrus
contained a collection of older works dating back to
30002500 BC. Ebers prepared a partial translation of
Laparoscopic hernia repair
Conclusion
References
37
39
39
the papyrus in 1875, which was later completed by
Bendix Ebbell, a Norwegian physician. Ebbells study of
the papyrus suggested that the ancient Egyptians had
attained a high level of surgical skill and had developed
procedures for hernia and aneurysm management.2
Interestingly, then, in the first preserved written record of
medical practice, the paradigm for hernia management
included surgical intervention.
History 35
until the seminal work of Francis Usher (190880).
Usher, in the 1950s, became interested in hernia recurrence and attempted to rep
air hernias with freeze-dried
homographs and lyophilized dura mater.15 None of these
materials proved satisfactory, so Usher turned his attention to synthetic materi
als. Various forms of plastic had
been tried before, but because of their rigidity, tendency
to fragment, and susceptibility to infection, none was
found to be satisfactory for hernia repair. Usher persisted
in his investigation of plastic materials and learned of a
new polyolefin plastic (polypropylene, i.e. Marlex) that
could be extruded as a monofilament, did not fragment,
and was inert. Usher worked closely with the company
that produced Marlex (Phillips Petroleum Co.), and had
the material woven into a mesh and tested in animal studies. He found that polyp
ropylene mesh was tolerated well
in sterile and infected fields, and he began to use Marlex
mesh in humans in 1958.16,17 Usher made many original
contributions to the field of hernia repair, which Read
lists elegantly in a scholarly retrospective of Ushers life:15
duce pulmonary emphysema.35 There are other conditions of systemic illness and
stress (pulmonary emphysema, ruptured abdominal aortic aneurysm, burns) that cau
se an enhanced leukocyte
count and the discharge of proteases and oxidants from
leukocytes. These conditions may, in part, be responsible
for the biochemical changes that lead to damage of the
collagenous connective tissues in the groin and cause
hernia formation in non-smokers in a manner similar to
smokers. Because of these findings and the work of others,
it was Cannon and Reads opinion that: The surgeons
approach to inguinal herniation should consider more
than the anatomic and technical detail. It must now
embrace biochemistry, because he is dealing with a local
manifestation of a generalized lesion of connective tissue.36
History 37
LAPAROSCOPIC HERNIA REPAIR
With little fanfare and without much notice, Ger
reported the first laparoscopic hernia repair in a paper
published in 1982.37 This study conducted from August
through November 1977 examined the effectiveness of
stainless-steel clips to secure the peritoneal opening of
known abdominal hernias during laparotomy for other
major abdominal procedures. In the thirteenth and final
case of the series, an operating laparoscope was used to
visualize the peritoneal defect of a right indirect inguinal
hernia. The neck of the hernia sac was closed with a
specially devised stapling device passed through a port
placed in the right iliac fossa. The staple was constructed
of tantalum and measured 12.5 mm long in the open
position. Ger reported that the first patient to be treated
by laparoscopic closure of the neck of the sac was under
the care of Dr P. Fletcher of the University of the West
Indies, Jamaica.37
Gynecologists have been responsible for many of the
innovations in laparoscopy, and hernia repair has been
no exception. In 1990, Popp published a report of the
coincidental repair of an inguinal hernia during laparoscopic uterine myomectomy
.38 In this paper, Popp
related that the hernia margins were apposed and
secured by endosutures tied extracorporeally. A patch of
dehydrated dura mater was applied to the sutured area to
further cover the repair site.
Early on, several prominent laparoscopic surgeons
advocated repair of inguinal hernia by plugging the
hernia defect. At the annual meeting of the American
Association of Gynecological Laparoscopists (AAGL) in
1989, Bogojavlensky showed a video that demonstrated
repair of an indirect inguinal hernia with a laparoscopic
stuffing technique.39 The hernia canal was filled with a
plug of polypropylene mesh, and the internal ring was
closed with suture placed laparoscopically.
In 1990, Schultz and colleagues reported on a plugand-patch technique for hernia
repair that expanded on
the initial work described by gynecologists.40 In their technique, the sac of an
indirect inguinal hernia was visualized
with a laparoscope and grasped on its superior margin
with forceps. The peritoneum was incised, and the sac was
removed from the musculofascial defect. The hole in the
muscle was then filled with rolls of polypropylene mesh
tied with dissolvable suture. It was thought that the rolled
polypropylene mesh would expand to completely fill the
canal once the suture tie was absorbed. After the defect was
filled with rolled mesh, one or two pieces of 1 ! 2-inch
mesh were laid over the defect, and the cut edges of peritoneum were brought tog
ether (over the mesh patch) and
secured with endoclips. In 1991, Corbitt independently
described a similar technique; however, he further ligated
the inverted hernia sac with an endoscopic linear stapler.41
Both Schultz and Corbitt abandoned the technique of plugand-patch repair because
of excessive hernia recurrence
and changed their technique to one that utilized a large
prosthesis of polypropylene mesh in the pre-peritoneal
History 39
adhesion formation. The rough side is placed in apposition to the abdominal wall
, where its rough surface
encourages tissue adhesion. The graft is fixed circumferentially with staples or
tacks and anchored with transfascial stay sutures placed at the four cardinal p
oints of
the graft. Carbajo and colleagues prospectively compared
laparoscopic with open prosthetic repair of large incisional hernias.57 Their st
udy suggested that laparoscopic
repair reduces complication rates and hernia recurrence
compared with open methods.
complex pathophysiological, biochemical, molecular, and
perhaps genetic derangements that are, even today, not
well understood. Study of the groin by several generations
of surgeon-scientists has provided an appreciation of the
dynamic mechanisms that protect the myopectineal orifice in the normal state. Cu
rrent understanding suggests
that the entire myopectineal window must be secured if a
complete cure of groin hernia is to be accomplished.56
Achievement of the perfect operation may be an
unobtainable goal, but pursuit of the perfect operation is
neither unreasonable nor undesirable.
CONCLUSION
The successful repair of groin hernia can be accomplished in many ways. Conventi
onal anterior herniorrhaphy, as described by Bassini and Shouldice, or
anterior hernioplasty, as advocated by Lichtenstein, are
effective procedures. These repairs, however, limit their
focus to the upper aspect of the myopectineal orifice and
neglect the lower aspect. They have been successful in
large measure because of the application of sound surgical principles to secure
the hernia defect and because the
large majority of groin hernias pass through the indirect
or direct inguinal ring.
Laparoscopic access has advanced the art of hernia
repair, as the entire myopectineal orifice with its multiple
openings can be approached and exposed. Bilateral groin
hernias can be repaired without a large incision or multiple incisions. Hernias
that may have been missed during
anterior repair (contralateral inguinal, femoral, occult
hernias) can be examined and repaired.58 Surgical
trauma to skin, subcutaneous tissue, fascia and muscle is
reduced. Moreover, the spermatic cord is not manipulated circumferentially, offe
ring the possibility that
testicular vein thrombosis and testicular atrophy will be
lessened. Hernias that recur after open procedures can be
repaired laparoscopically without transgressing scarred
tissue of the previous procedure.
Over the past two decades, laparoscopic hernioplasty
has evolved from an experimental procedure to one of
proven efficacy. Groin hernia repair is not a simple exercise, and its practice
requires skill and attention to detail.
Differing clinical situations demand different anatomic
approaches. Anterior open repair should probably be
considered for pediatric patients and for patients with
severe cardiopulmonary compromise, when repair may
be performed under local anesthesia. Bilateral inguinal
hernias, recurrent hernias, and unilateral hernias with a
6
Anatomy and physiology
B. PAGE AND PATRICK J. ODWYER
View from the peritoneal cavity
Pre-peritoneal space
Transversalis fascia
Oblique muscles
Inguinal canal
Spermatic cord
41
42
43
44
44
44
A thorough knowledge of the anatomy and function of the
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
certainly led to injuries to vessels and nerves in this region,
which otherwise could have been avoided. In addition,
failure to recognize the importance of the anatomy by surgical trainees and prac
ticing surgeons has slowed progress
in minimal-access approaches to hernia repair via the
pre-peritoneal space.
Myopectineal orifice
Femoral canal and sheath
Nerves
Pathophysiology and conclusion
References
44
45
45
45
46
VIEW FROM THE PERITONEAL CAVITY
A starting point for any surgeon contemplating laparoscopic hernia repair is to
view the normal anatomy of
the pelvis through the laparoscope (Figure 6.1) of a
patient undergoing another laparoscopic procedure, e.g.
cholecystectomy. With a head-down tilt of 1530 degrees,
first observe the natural boundaries between the pelvic
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
(urachus)
Medial umbilical ligament
Lateral umbilical ligament
Lateral fossa
Medial fossa
Supravesical fossa
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 iliopsoas fascia. It can be
seen emerging between the psoas
and iliacus muscle, passing beneath the iliopubic tract,
and innervating the muscles in the anterior compartment of the thigh and the ski
n of the anteriomedial
aspect of the lower thigh and leg.
Also of importance to the hernia surgeon are the ilioinguinal and ilio-hypogastr
ic nerves (Figure 6.6). The
former is usually smaller than the latter and is sometimes
absent. These are both sensory nerves that arise from
the first lumbar nerve. The ilio-inguinal nerve passes
through the inguinal canal and becomes superficial at the
external ring to innervate the skin of the scrotum and the
medial upper thigh. Damage to the ilio-inguinal nerve in
the inguinal canal causes sensory loss as the motor fibers
are already given off to the conjoint tendon. The iliohypogastric nerve emerges
through the external oblique
aponeurosis to innervate the suprapubic skin.
PATHOPHYSIOLOGY AND CONCLUSION
A better understanding of the physiology of the inguinal
region may lead ultimately to novel methods of preventing
and treating inguinal hernias. In children, fusion of the
7
Intraperitoneal onlay mesh approach
MORRIS FRANKLIN
Patient selection
Operating room set-up
Operative technique
48
48
49
It has been over 100 years since Bassini ushered in a new
era of hernia surgery with the introduction of his triplelayer technique to repa
ir the inguinal floor. Since then,
surgeons have developed a myriad of new methods of hernia repair in an attempt t
o improve the results. However,
despite a century of advances in hernia surgery, recurrence continues to plague
the general surgeon and is the
primary reason why no single technique of herniorrhaphy
has become universally accepted. The repair of inguinal
hernias has probably produced more variety in technique
than any other operation performed by the general surgeon today. Complexity of t
he anatomy, the variety in size
and location of the defect, and the multiplicity of the
presentations of a hernia have contributed to this
uncertainty regarding the optimal repair.1
After minimally invasive surgery proved to be successful in the treatment of bil
iary, gastric and colon diseases,
surgeons attempted to find a method of successfully
repairing inguinal hernias laparoscopically. It was felt that
the attendant benefits of decreased postoperative pain and
disability seen in other minimally invasive procedures
could be realized in hernia patients as well. The first report
of a laparoscopic technique of inguinal herniorrhaphy was
by Ger and colleagues in 1990,2 who advocated simple closure of the neck of the
hernia sac. This was soon followed
by reports of plugging of the inguinal canal or direct defect
with a prosthetic mesh, as described by Schultz and colleagues3 in 1990 and by C
orbitt4 in 1991. After unacceptable early recurrence rates, these methods were a
bandoned
in favor of newer techniques that combined the advantages of a tension-free repa
ir utilizing a synthetic mesh
with the transabdominal approach of laparoscopy.
Postoperative management
Conclusion
References
51
51
51
The three most popular procedures to emerge were the
transabdominal pre-peritoneal (TAPP) patch, the totally
extraperitoneal (TEP) patch, and the intraperitoneal
onlay mesh (IPOM) repairs. In the TAPP technique,
the peritoneum is incised intra-abdominally and a preperitoneal space is develop
ed. A prosthetic mesh is then
introduced into this space, placed over the abdominal wall
8
Transabdominal pre-peritoneal approach
REINHARD BITTNER, CLAUS-GEORG SCHMEDT AND BERNHARD JOSEF LEIBL
Principles
Preoperative management
Instrumentation
Operative room set-up
Operative technique
53
54
55
55
56
The introduction of laparoscopic operating techniques
opened up the possibility of using this method to
implant mesh into the pre-peritoneal space to repair an
inguinal hernia. By sparing the patient a large abdominal
incision in the inguinal region1 or in the midline,2 one
can expect a decrease in the number of wound complications, less postoperative p
ain, and consequently a faster
recovery of normal physical activity and return to work.
In contrast to pre-peritoneal mesh insertion via a minimized anterior approach,3
the laparoscopic method
provides clear visibility when dissecting the inguinal
region with safe, wrinkle-free placement of a large mesh.4
Laparoscopic hernioplasty with pre-peritoneal placement
of a large mesh (transabdominal pre-peritoneal (TAPP)
repair) represents a synthesis between proven conventional operative techniques
and the advantages of a minimally invasive approach.
PRINCIPLES
Indications
The mode of operation of TAPP follows the law of
physics according to Pascal.2 As a result of pre-peritoneal
placement of the prosthesis, i.e. between abdominal
pressure and the weak point in the abdominal wall, the
pressure that initially caused the hernia now acts as a
stabilizer for reconstruction. If the mesh chosen is
Special remarks
Postoperative management
Conclusion
References
61
63
63
63
sufficiently large, then laparoscopic pre-peritoneal hernioplasty can be seen as
a completely tension-free method of
hernia repair, which dispenses with any and all kinds
of fixation. In contrast to this, the success of an anterior
mesh implant (Lichtenstein) depends on a strong external
oblique aponeurosis and on a row of well-placed fixation
sutures.
Laparoscopic hernioplasty can be used on any type of
hernia, with the exception of huge, non-reducible scrotal
hernioplasty:
or vessels (Figure 8.8). Clumsy and obscure use of electrocoagulation and placem
ent of clips are strictly prohibited.
Any bleeding that occurs must be controlled immediately to keep the site clearly
visible and to avoid increased
light absorption, which would cause insufficient lighting
0.4
0.5
1.0
1.1
0.8
0.6
1.1
2.7
14
15
21
19
9
Totally extraperitoneal approach
ED FELIX
Principles
Preoperative management
65
66
The surgical approach to inguinal hernia repair has
undergone a slow evolution since Bassini introduced the
first true anatomical repair over 100 years ago.1 Initially,
surgeons were fixated on tissue to tissue repairs. Then,
Lichtenstein and coworkers2 and Stoppa and colleagues3
demonstrated that tension-free reinforcement of the
abdominal wall with mesh eliminates one of the major
causes of recurrence, the intrinsic or acquired weakness
of the groin; the emphasis of hernia repair then switched
dramatically. Ten years later, laparoscopic surgeons took
the tension-free repair one step further by introducing a
repair that reinforced the groin, avoided missed hernias,
and reduced postoperative recovery.
Many early attempts at a laparoscopic approach, however, fell quite short of thi
s lofty target. There seemed to be
a wide variability in the results reported by surgeons.
Many complications as well as early failures were reported.
It quickly became apparent, however, that success with this
approach was dependent upon the level of laparoscopic
expertise of the surgeon and the ability of the surgeon to
apply proper techniques to appropriate patients.4
At first, the majority of surgeons were limited to a single
laparoscopic approach, the transabdominal pre-peritoneal
(TAPP) approach, but soon the totally extraperitoneal
(TEP) approach became a viable alternative. Arguments
between laparoscopic surgeons on which approach was
better were common, but now most surgeons realize that
each approach works well when applied appropriately in
the hands of an experienced laparoscopic surgeon.5
The purpose of this chapter is to describe an approach
to the laparoscopic TEP repair of inguinal hernias that has
resulted in a recurrence rate of less than one per cent in
over 2000 repairs in our center. The indications and
contraindications to the use of the approach, the operative
Postoperative management
References
73
74
method, and the potential complications and their
management will be described.
PRINCIPLES
A surgeon must be experienced in conventional anterior
approaches as well as both laparoscopic approaches
(TAPP and TEP) in order to make a rational decision on
which hernioplasty best fits an individual patient and hernia. The laparoscopic
approach that is chosen depends
(b)
Figure 9.10 TAPP double-buttress mesh approach.
Figure 9.11 Mesh anchored with tacks.
that any wrinkles or folds are removed. If aberrant obturator vessels are presen
t coursing over the pubis, they
must be avoided otherwise serious bleeding can result.
Other anchors are placed into the mesh and transversalis
fascia medial to the inferior epigastric vessels, whereupon
the mesh is smoothed out in a lateral direction, making
10
Femoral and pelvic herniorrhaphy
CHRISTINE A. ELY AND MAURICE E. ARREGUI
Demographics
History of repair
Techniques
Postoperative care
75
76
76
77
Femoral and pelvic hernias are much less common than
inguinal hernias. If these hernias are diagnosed preoperatively, they are certai
nly amenable to laparoscopic
repair. However, if they are not diagnosed preoperatively,
these cases are the perfect situation for the application of
diagnostic laparoscopy followed by laparoscopic repair.
Inguinal ligament
Less common
Femoral hernia
(anatomically
less weak)
Most common
Inguinal hernia
(Anatomically
weakest)
Pectineus muscle
Rare
Obturator hernia
(Anatomically least weak)
Figure 10.1 Surgical anatomy of the obturator and inguinal
region. Lateral view of the right side of the pelvis, showing the
sites of inguinal, femoral and obturator hernias. From Carter JE.
Hernias. In: Howard FM, Perry CP, Carter JE, et al., eds. Pelvic
Pain: Diagnosis and Management. Philadelphia: Lippincott
Williams & Wilkins, 2000: 385413, with permission.
Rare and unusual hernias
Conclusion
References
77
81
82
In this chapter, we will focus on our technique of
repair of femoral and obturator hernias, since the obturator hernia is by far th
e most common of the pelvic
hernias (Figure 10.1). Our technique and postoperative
care will be reviewed. In addition, we will comment on
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
Spigelian hernias.
DEMOGRAPHICS
Femoral hernias are much less common than inguinal
hernias, with an incidence of two to four per cent of all
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 re
pair 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
0.050.07 per cent of all groin hernias. They typically
occur in an emaciated, dehydrated, multiparous female
patient. The patients may have a positive Howship
Romberg sign or a palpable upper-thigh mass. The
HowshipRomberg sign is positive when medial thigh and
hip pain is created or exacerbated by adduction and
medial rotation of the thigh and relieved by thigh flexion.3
More often, however, symptoms are vague, and patients
frequently present with small-bowel obstruction with
either intermittently incarcerating or strangulated small
bowel. Ones level of suspicion, therefore, needs to be high.
Superficial transverse
perineal muscle
External anal sphincter
b
Levator ani muscle
c
Coccygeus muscle
d
Gluteus maximus muscle
Figure 10.6 The female perineum, showing possible sites of perineal hernias. A p
rimary perineal hernia may occur anterior or
posterior to the superficial transversus perineal muscle. An anterior hernia pro
trudes through the urogenital diaphragm, lateral to the
urinary bladder and vagina (a, b). Anterior hernias occur only in women. A poste
rior 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: 385413, with permission.
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:
41516, with permission.
Figure 10.8 Laparoscopic view of lipoma of the cord. Cord
structures can be seen medially.
11
Results of laparoscopic inguinal/femoral
hernia repair
KETAN M. DESAI AND NATHANIEL J. SOPER
TEP versus TAPP repair
Laparoscopic versus open tissue repair
Laparoscopic versus open mesh repair
Summary
83
84
85
86
Over 750 000 inguinal hernia repairs are performed in the
USA annually. Historically, many techniques for the tissue
repair of groin hernias have been used, including the
Bassini, McVay, Cooper and Shouldice repairs. Currently,
the tension-free repair of Lichtenstein and the mesh-plug
procedure dominate the majority of surgical practices.
Since the introduction of laparoscopic cholecystectomy
in the late 1980s, advancements in minimally invasive surgery have led surgeons
to investigate laparoscopic techniques for treating inguinal hernia while still
providing a
durable repair. Accepted indications for laparoscopic hernia repair are recurren
t and bilateral inguinal hernias in a
patient at low anesthetic risk. However, considerable debate
over laparoscopic inguinal hernia repair, not seen with
other laparoscopic procedures, has diminished the enthusiasm for adopting this t
echnique for unilateral, primary
inguinal hernias.
The emergence of laparoscopic groin hernia surgery is
multifactorial. Following open repair, high rates of postoperative patient disco
mfort, pain, and increased time
away from work, coupled with recurrence rates that
ranged from one to ten per cent, influenced surgeons to
explore alternative repair methods. Early attempts at
laparoscopic inguinal hernia repair included intraperitoneal onlay mesh (IPOM) t
echniques, simple inguinal
ring closure, and plug-and-patch repair. However, these
early laparoscopic approaches were abandoned secondary
to an unacceptable rate of recurrence and the formation
of intra-abdominal adhesions, except at a few centers (see
Chapter 7). Today, the two predominant laparoscopic
Laparoscopic femoral hernia repair
References
Further reading
86
86
87
approaches for the repair of inguinal hernia include the
transabdominal pre-peritoneal (TAPP) and the totally
extraperitoneal (TEP) approaches. These two laparoscopic procedures, based upon
the open Stoppa repair,
provide pre-peritoneal mesh reinforcement of the iliopubic tract.
8
30
22
36
12
12
35
17
12
1.3
0
0
5
0
0.2
0
0
0
2.9
0
0.6
2
pitfalls that are unique to entry into the peritoneal cavity.
However, early problems with nerve entrapment and
hernia recurrence secondary to inadequate mesh size
following either procedure have resulted in significant
morbidity.
Outcome measures following groin hernia repair
include postoperative pain, complications, return to work,
patient satisfaction, and cost, as well as long-term hernia
recurrence rates. Comparisons of laparoscopic approaches
have revealed lower rates of postoperative pain following
TEP repair; however, operating times and return to normal activity were generall
y similar. Recurrence rates following either laparoscopic repair were variable (
Table 11.1).
Non-randomized (usually sequential) trials comparing
TEP versus TAPP approaches have reported lower recurrence rates following the TE
P technique. However, in a
number of these trials the differences were not statistically
significant, with subsequent randomized studies reporting similar recurrence rat
es irrespective of laparoscopic
procedure.
Evaluations of these two laparoscopic techniques have
demonstrated a slightly lower complication rate following
TEP repair. Reports of bowel injury and small-bowel
obstruction secondary to intra-abdominal adhesions were
more common following the TAPP approach than the TEP
approach. The difference in complication rates between the
two accepted laparoscopic approaches may result from
remaining completely extraperitoneal during TEP dissection and repair. However,
initial experience with TAPP may
have provided surgeons with the additional skills and
knowledge to perform a superior TEP repair.
In general, due to the small number of comparative
studies, firm conclusions on the relative merits of the different techniques are
difficult to obtain. However, TEP
repair may have some advantages regarding complications and postoperative pain.
Despite these potential differences, surgeons should be skilled in both minimall
y
invasive repairs, due to conversions and recurrences
requiring the alternative procedure.
LAPAROSCOPIC VERSUS OPEN
TISSUE REPAIR
Although we currently use the Lichtenstein (tension-free)
repair for open inguinal herniorrhaphy, the Shouldice
technique appears to have similar advantages in terms of
short recovery time and low recurrence rates. Laparoscopic repair has been compa
red with a number of open
repair methods, with varying results. A number of early,
small trials failed to demonstrate a clear benefit following
laparoscopic repair. More recent randomized trials comparing laparoscopic and op
en suture repair have reported
superior outcomes following the laparoscopic approach
in terms of less postoperative pain and a faster return to
normal activity. Although operative times of the laparoscopic approaches have be
en reported to be significantly
longer than with open suture methods in a number of
studies, wound complications and overall recurrence
rates were similar (Table 11.2). In addition, general anesthesia was used in the
vast majority of laparoscopic cases
as opposed to local, epidural or spinal anesthesia in the
open group. Despite this, several trials have shown earlier
hospital discharge and less postoperative pain (early
and late) in patients undergoing laparoscopic repair. A
randomized comparison of extraperitoneal laparoscopic
repair with various open approaches by Liem and colleagues revealed longer proce
dure times for the laparoscopic repair.13 However, the laparoscopy group had
lower analgesia requirements, less postoperative pain, and
an earlier return to work. The recurrence rate was slightly
lower in the laparoscopy group, as were wound infections
and chronic postoperative pain.
Mesh
Mesh
Mesh
Mesh
TEP
TAPP
TEP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TAPP
TEP
TEP
6
2
5
0
0
1
0
0
3
7
5
8
0
2
3
3
3
2
4
0
1
0
0
14
0
2
13
0
6
2
Laparoscopic repair of groin hernias is generally
reserved for bilateral and recurrent hernias. However, the
benefits of laparoscopic repair for primary, unilateral hernias have been demons
trated. Patients with primary, unilateral hernias may recover more rapidly after
TAPP repair
than after an open approach, as assessed by analgesia
requirement and functional status. In a randomized clinical
12
Complications and their management
RICARDO V. COHEN, CARLOS A. SCHIAVON, SRGIO ROLL AND JOS C.P. FILHO
Anesthesia
Events related to laparoscopic access
Organ involvement
Hydrocele
Seroma
Vascular injury
89
89
90
90
90
91
The modern era of the treatment of inguinal/femoral
hernias has evolved over the past 155 years. From truss
support to elective outpatient procedures, the surgical
techniques to treat these patients have progressed, such
that now surgeons are able to employ the use of laparoscopy
to approach these hernias. Laparoscopic approaches allow
the inspection of the inguinal and femoral areas bilaterally,
thereby avoiding unexpected non-diagnosed contralateral
hernias. This method of hernioplasty has been shown to
reduce postoperative pain and disability and allows the
treatment of bilateral defects in one sitting. But, as in
all operative procedures, complications exist. Nothing is
more effective in the prevention of the occurrence of
complications as ones awareness and fear of them.
In this chapter, complications and their management
will be focused on the two most commonly performed
laparoscopic inguinal hernia repairs, the transabdominal
pre-peritoneal (TAPP) approach and the totally extraperitoneal (TEP) technique.
ANESTHESIA
It has been suggested that the general anesthesia needed
for laparoscopic herniorrhaphy is a major drawback, and
open procedures are preferred because they can be
performed under local anesthesia. However, numerous
reports have revealed the relative absence of anesthesiarelated complications, p
robably associated with proper
patient selection.4,5 If a medical contraindication, other
Neuropathy
Visceral complications
Mesh-related problems
Recurrence
Conclusion
References
91
92
93
93
94
94
90
Laparoscopic inguinal/femoral hernioplasty
conversion rate to laparotomy was 85 per cent. The two
most important risk factors were inexperienced surgeons
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.
Complications are theoretically different depending
upon the laparoscopic technique (TAPP or TEP). In TEP,
because there is no invasion of the abdominal cavity, major
intracavity injuries are very rare. However, there have
been reports of enterotomies resulting from the tearing of
adhesions during extraperitoneal balloon dissection.5
Another complication related to the laparoscopic
approach is trocar site incisional hernia. Although quite
uncommon, this is associated particularly with TAPP
repair. Because the incidence varies from five to 15 per
cent, it is recommended that all port sites over 5 mm
should be closed in order to avoid this postoperative
complication.
ORGAN INVOLVEMENT
Almost all organ complications that follow the laparoscopic treatment of inguina
l/femoral hernias are similar
to those that follow open techniques. The morbidity rate
in open operations is approximately ten per cent.6 Tetik
and colleagues in 1994,7 Phillips and colleagues in 1995,8
and Crawford and Phillips in 19989 reported complication rates in the order of 1
1 per cent. Roll and coworkers,
in a large Brazilian multicenter trial of 4000 operated
patients, found that the rate of complications was seven
per cent.10 Felix and colleagues in 1999 reported an incidence of complications
of 6.1 per cent.11 All authors
demonstrated that the incidence of the complications
were significantly higher in the period of the learning
curve and could be reduced to less than one per cent with
greater experience.
Testicular complications
The two pertinent complications concerning the testicle
are ischemic orchitis and testicular atrophy. Postoperative
inflammation of the testicle occurs within 2472 hours following the procedure. Th
e associated pain is severe, usually requiring aggressive and effective analgesi
a. Ischemic
orchitis may progress, resulting in testicular atrophy, a
process that may be observed over several months. The
mechanism of this complication originates from an intense
venous congestion within the testicle, secondary to thrombosis of the veins with
in the spermatic cord. The initiating
trauma is seen during dissection of the spermatic cord
from the hernia sac, whether for direct, indirect or femoral
hernias, or the TAPP or TEP procedure. The incidence of
testicular complications is lower with laparoscopy than
with the conventional techniques, ranging from 0.3 to
5 per cent.12
Vas deferens complications
92
Laparoscopic inguinal/femoral hernioplasty
(a)
of the pain. Electromyography may also be helpful.
The management is controversial and multimodal.
Initial efforts at clinical control with non-steroidal antiinflammatory drugs, r
est, and eventually infiltration with
local anesthetics are frequently helpful. If inguinodynia
persists, and sensory/motor deficit is present on examination, then immediate ex
ploration 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 wit
h positive Tinels sign, then removal of
the staple/tack or mesh or neurectomy may be required.
If re-exploration is undertaken, care must be exercised during the removal of th
e staples/tacks and/or
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
(b)
Laparoscopic hernia repair is associated with urinary
complications with an incidence of 1.55 per cent,
including retention, infection and hematuria.26 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 preperitoneal space or space of
Retzius, such as a prior
laparoscopic hernia repair or prostatectomy.
Intestinal complications
(c)
Figure 12.1 (a) TAPP anatomical view: (1) Coopers ligament;
(2) vas deferens; (3) spermatic cord; (4) nerve area below the
iliopubic tract; (5) iliopubic tract; (6) internal ring. (b) Black
area, triangle of doom; red area, trapezoid of disaster.
(c) Recurrence Mesh invagination in the defect.
iliopubic tract, are the most effective tools to avoid
neuralgia paresthetica that may follow the laparoscopic
approach to groin hernias.
The ilio-inguinal nerve and the ilio-hypogastric nerve
are more superficial structures, making them easier to
injure in open repair than in the laparoscopic method.
Diagnosis can be made after careful anatomical localization
Bowel obstruction is almost unheard of with conventional
94
Laparoscopic inguinal/femoral hernioplasty
REFERENCES
Table 12.1 Recurrences in large multicenter trials
No.
hernias
Recurrence
(%)
Mean
follow-up
(months)
1
2
Reference
Repair
Tetik et al.
(1994)7
TAPP
TEP
553
457
0.7
0.4
13
Fitzgibbons
et al. (1995)27
TAPP
TEP
562
87
5
0
23
Phillips et al.
(1995)8
TAPP
TEP
1944
578
1
0
22
3
migration of the mesh;
mesh slit (the slit is the site of the recurrence);
folding or invagination of the mesh into the defect;
displacement of the mesh by hematoma.
The first reports with the abandoned laparoscopic
plug or plug-and-patch reported recurrence rates of
25 per cent.30 As experience and knowledge of the anatomy
and mesh size have grown, so recurrence rates have
decreased. Evaluation of large multicenter trial results
reveals the low recurrence rates for TEP (Table 12.1).
Tetik and coworkers reported a 0.4 per cent incidence of
recurrence in TEP,7 whereas no recurrences were reported
in 578 patients by Phillips and colleagues8 or in 87 repairs
by Fitzgibbons and colleagues.27 It is important to stress
that the vast majority of surgeons throughout the world
began their experience and learned the TAPP procedure
first; TEP came later, bringing more comfort with the
anatomy and handling the mesh better. Adoption of the
TEP technique by many of these surgeons occurred later,
thereby providing a higher level of comfort with the
anatomy, and better handling and sizing of the mesh
for the laparoscopic procedure. This may explain the
relatively lower recurrence rates with TEP than with
TAPP in these large trials.
CONCLUSION
Over the past 15 years, laparoscopic hernioplasty has
made the transition from an experimental to a proven
procedure. With increasing laparoscopic skills, many
surgeons are now faced with the question of when to
recommend a laparoscopic approach to their patients.
Complication and recurrence rates, although initially
higher than traditional repairs, have now fallen to equal
or lower levels at centers experienced in laparoscopic
techniques. Prospective randomized trials prove that when
patients are selected properly and surgeons are trained,
TAPP or TEP repairs may be performed with reasonable
rates of complications and recurrence.
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Arvidsson D, Smedberg S. Laparoscopic compared with open
hernia surgery: complications, recurrences and current trends. Eur
J Surg 2000; 585: 4047.
Moreno-Egea A, Aguayo JL, Canteras M. Intraoperative and
postoperative complications of totally extraperitoneal
laparoscopic inguinal hernioplasty. Surg Laparosc Endosc 2000;
10: 3033.
Baadsgard SE, Egelblad K. Major vascular injury during
gynecologic laparoscopy: report of a case and review of published
cases. Acta Obstet Gynecol Scand 1989; 68: 2835.
Champault G, Cazacu F, Taffinder N. Serious trocar accidents in
laparoscopic surgery: a French survey of 103,852 operations. Surg
Laparosc Endosc 1996; 6: 36770.
Topal B, Hourlay P. Totally preperitoneal endoscopic inguinal
hernia repair. Br J Surg 1997; 84: 613.
Bendavid R. Complications of groin hernia surgery. Surg Clin N Am
1998; 78: 10892000.
Tetik C, Arregui M, Castro D. Complications and recurrences
associated with laparoscopic repair of groin hernias: a multiinstitutional retro
spective analysis. In: Arregui M, Nagan RF, eds.
Inguinal Hernia: Advances or Controversies? Oxford: Radcliffe
Medical Press, 1994: 494500.
Phillips EH, Arregui M, Caroll BJ, et al. Incidence of complications
following laparoscopic hernioplasty. Surg Endosc 1995; 9: 1621.
Crawford DL, Phillips EH. Laparoscopic repair and groin hernia
surgery. Surg Clin N Am 1998; 78: 104762.
Roll S, Cohen R, Miguel P, et al. Laparoscopic transabdominal
inguinal hernia repair with preperitoneal mesh. Surg Endosc 1994;
8: 485.
Felix EL, Harbetson N, Vartanian S. Laparoscopic hernioplasty.
Significant complications. Surg Endosc 1999; 13: 32831.
Cohen RV. Laparoscopic transabdominal preperitoneal hernia
repair. Doctoral thesis presented to the Department of Surgery,
University of Sao Paulo, Brazil. Sao Paulo, Brazil: University of Sao
Paulo Press, 1996: 4357.
Ferzli G, Massad A, Albert P. Extraperitoneal endoscopic inguinal
PART
3
Laparoscopic incisional and
ventral hernioplasty
13
14
15
16
17
18
History
Anatomy and physiology
Laparoscopic repair in the emergent setting
Herniorrhaphy with the use of transfascial sutures
Pre-peritoneal herniorrhaphy
Hernioplasty with the double-crown technique
99
103
111
115
125
133
19 Parastomal hernia repair
20 Lumbar hernia and denervation hernia repair
21 Results of laparoscopic incisional and ventral
hernia repair
22 Complications and their management
143
151
155
161
13
History
KRISTI L. HAROLD, BRENT D. MATTHEWS AND B. TODD HENIFORD
Laparoscopic ventral herniorrhaphy
Adoption of procedure
99
100
Ventral hernias present a challenging surgical problem.
Approximately 311 per cent of all laparotomy incisions
develop a fascial defect, resulting in 90 000 ventral hernias
repairs each year.1 Due to the high rate of recurrence with
simple suture closure, the techniques of hernia repair
have evolved from primary repair to those employing
biomaterials. More recently, surgeons options have
expanded to include repairs using minimally invasive
approaches.
Primary repairs involve suturing of the aponeurotic
layers of the abdominal wall to close defects, along with
unique variations such as the vest-over-pants technique
developed by William J. Mayo in 1895. To repair large
defects, in the 1920s Gibson introduced the concept of
relaxing incisions, which allowed closure of the abdominal wall in the midline w
ith reduced tension.2 Despite the
various and inventive techniques for primary repair, the
recurrence rate after primary repair remained unacceptably high, spurring the de
velopment of biomaterials
to repair abdominal wall defects in the first half of the
twentieth century.
The first biomaterials employed for hernia repair were
metallic. Silver wire mesh, tantalum mesh, and stainlesssteel mesh were all used
in an attempt to create stronger
hernia repairs. The metallic prostheses, however, led to
problems such as erosion, fragmentation, fistulas, and
patient intolerability. Hence, a variety of synthetic polymeric meshes were deve
loped, leading to a revolution in
hernia repair. Francis Usher introduced monofilament
polypropylene mesh in 1958, and today this is the most
commonly used mesh. Polyester mesh, which is very
popular in Europe, was also introduced in the 1950s.
Expanded polytetrafluoroethylene (ePTFE) was added
Conclusion
References
100
100
to the armamentarium of biomaterials in the 1970s and
has become a popular prosthetic for ventral/incisional
hernia repair.3
The introduction of tension-free repair with biomaterials has drastically reduce
d the recurrence rate of
abdominal wall hernias. In several studies, the addition
of prosthetic mesh has reduced hernia repair failure
by more than 50 per cent.4 Nevertheless, the techniques
developed by Stoppa and others to employ meshes
for repair involve large areas of tissue-flap dissection
and create significant patient morbidity, including
Number of
articles published
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
18
19
11
13
9
12
8
13
3
3
CONCLUSION
The future of laparoscopic ventral and incisional hernia
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.
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
invasive approach is a positive milestone in the history of
hernia surgery.
REFERENCES
1
2
3
4
5
6
7
8
9
Mudge M, Hughes LE. Incisional hernias: a 10-year prospective
study of incidence and attitudes. Br J Surg 1985; 72: 7071.
Flament JB, Palot J, Burde A, et al. Treatment of major incisional
hernias. In: Bendavid R, Abrahamson J, Arregui M, et al., eds.
Abdominal Wall Hernias: Principles and Management. New York:
Springer-Verlag, 2001: 50816.
DeBord JR. The historical development of prosthetics in hernia
History 101
10
11
LeBlanc KA. The critical technical aspects of laparoscopic
repair of ventral and incisional hernias. Am Surg 2001; 67:
80912.
Leber GE, Garb JL, Alexander AI, Reed WP. Long-term
complications associated with prosthetic repair of incisional
hernias. Arch Surg 1998; 133: 37882.
12
Arca MJ, Heniford BT, Pokorny R, et al. Laparoscopic repair of
lumbar hernias. J Am Coll Surg 1998; 187: 14752.
13 LeBlanc KA, Bellanger DE. Laparoscopic repair of paraostomy
hernias: early results. J Am Coll Surg 2002; 194: 2329.
14 Matthews BD, Bui H, Harold KL, et al. Laparoscopic repair of
traumatic diaphragmatic hernias. Surg Endosc 2003; in press.
14
Anatomy and physiology
KARL A. LEBLANC
Anatomy and function
Anatomy of a hernia
Anatomical considerations in the repair of
abdominal wall defects
Effects of biomaterial placement in laparoscopic
herniorrhaphy
103
105
106
Maturation of the hernia repair
Cosmetic result
Functional result
Conclusion
References
108
109
109
110
110
107
The abdominal wall is a complex structure with a multitude of components, includ
ing skin, muscles, aponeuroses, fat and mesothelium. This musculo-aponeurotic
structure is attached to the vertebral column posteriorly,
the pelvic bones inferiorly, and the ribs superiorly. The
integrity of the abdominal wall is essential for protecting
the underlying organs, allowing for movement of the
trunk of the body, providing assistance in respiration,
and preventing herniation of the intra-abdominal contents. Breaches in this inte
grity can occur with incisions,
drainage tubes, and postoperative complications. Furthermore, the closure of the
incisions is affected by the method
of closure, the type of suture used, and the development of
wound sepsis. Recent studies have even identified that
the suture technique, the suture length to wound length
ratio, and the suture tension have an effect on the ultrastructural composition
of the regenerating tissue and
collagen composition.1
Despite the importance of this portion of the body,
many surgeons have little knowledge of the anatomical
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
that requires access to the abdomen and sometimes the
retroperitoneum. The factors that influence both the
prevention and development of hernias are frequently
overlooked during the closure of wounds. The result can
be predisposition to a fascial defect that will allow extraabdominal migration o
f the contents of the abdomen.
This hernia, in turn, can result in complications such as
incarceration, strangulation, loss of domain, and significant cosmetic deformiti
es. Therefore, the approximation
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 emerge
nt 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 fl
uid
replacement. Appropriate antibiotic therapy should be
administered before making the first incision. If there
is evidence of a septic situation, then pulmonary artery
catheters, arterial lines and ventilators must be available.
A review of our technique is published elsewhere,1 but
important points will be described here. The abdominal
wall is shaved and prepped in its entirety. The one wellestablished advantage of
the laparoscopic repair of ventral/
incisional hernias when compared with open techniques
is fewer wound problems. In addition, the mesh becomes
infected less frequently. We treat the mesh like a vascular
graft and avoid any contact with the skin, etc. An Ioban
(3M Healthcare) protective drape is used to cover all the
skin. Using this approach, we have never encountered a
patient who has developed a postoperative infection of
the prosthesis when placed laparoscopically.
Safe access to the peritoneal cavity is of utmost importance, especially when de
aling with distended loops of
bowel. As we first described, our procedure of choice is the
use of a balloon-tipped Hasson-type trocar lateral at the
Figure 15.1 Hasson cannula at left costal margin.
costal margin (Figure 15.1). This is carried out through a
10-mm incision using the S-shaped Hasson retractors.
Each layer is incised under direct vision and the muscle
layers are spread with a tonsil-type clamp. The retractors
hold the muscle aside while a number 11 blade is used to
incise each layer of fascia. Again, in several hundred repairs
we have never injured any viscera with this method and we
have never been unable to gain access. An angled laparoscope (30 or 45 degrees)
is very beneficial since it allows
viewing of almost any area, depending upon how the angle
is directed. A good 5-mm laparoscope allows use of 5-mm
working ports, which keeps 10-mm holes to a minimum.
The amount of bowel distention in the case of an
16
Herniorrhaphy with the use of
transfascial sutures
KARL A. LEBLANC
Indications
Contraindications
Preoperative evaluation
Prosthetic biomaterials
115
116
116
117
Laparoscopic incisional and ventral hernioplasty (LIVH)
was first described in 1993.1 The concepts of this technique are equivalent to t
he tension-free repair of inguinal
hernias, which has become popular in the past two
decades. The open tissue repair of incisional hernias has a
recurrence rate of 2552 per cent. The use of a prosthetic
biomaterial to repair these fascial defects lowers the recurrence rate to 1123 pe
r cent. The rate of recurrence with
the laparoscopic approach has been reported to be from
1 to 9 per cent.26 It is important to note that in most of
these reports, the results included the early experiences of
the authors as well as the repairs that occurred with the
knowledge gained from that experience (see Chapter 21).
The repair of incisional and ventral hernias by this
approach should be considered an advanced laparoscopic technique. It is best to
have the assistance of a
surgeon experienced in performing this particular procedure for at least the fir
st ten to 15 patients if possible.
Of course, to optimize outcome, conversion from the
laparoscopic technique to the open method should be
done at the earliest sign of difficulty. In our experience,
this will be necessary in 3.5 per cent of patients.
Approximately one-third of these will be due to an injury
to the bowel.5 Others have reported that conversion to
the open procedure was necessary in seven per cent of
patients, with a bowel injury rate of four per cent.6 Once
past the learning curve, the participation of an assistant
surgeon who is knowledgeable in advanced laparoscopic
techniques is generally considered optimum for the
repair of all but the smallest defects. Finally, there are a
Intraoperative considerations
Postoperative considerations
Conclusion
References
118
123
124
124
few different methods that are used to perform this procedure; these are describ
ed in Chapters 17 and 18.
INDICATIONS
17
Pre-peritoneal herniorrhaphy
SRGIO ROLL, WAGNER C. MARUJO AND RICARDO V. COHEN
Incisional hernias
Principles of treatment
Indications for laparoscopic repair
Laparoscopic transabdominal pre-peritoneal repair
Personal series results
125
125
127
127
129
INCISIONAL HERNIAS
Incidence
Incisional hernias represent one of the more common
complications of abdominal surgical procedures. The true
incidence of incisional hernias has not been well defined,
although a number of reports suggest that 313 per cent
of patients undergoing laparotomy will develop a fascial
defect in their abdominal scar.1 The majority of incisional hernias occur within
the first postoperative year.
However, the limited follow-up of most series may
underestimate late hernia occurrence.
Diagnosis
Most patients with small, uncomplicated incisional hernias are asymptomatic or h
ave only minor or intermittent complaints. However, these postoperative hernias
may be a significant source of morbidity. Patients with
incisional hernias alter their lifestyles so as not to exacerbate their abdomina
l wall hernia and often complain of
their esthetic appearance or suffer from discomfort, pain
or, occasionally, intestinal obstruction.
Predisposing factors
Predisposing factors for the development of incisional
hernias include advanced age, male gender, and systemic
Comparative studies of open versus laparoscopic repair
Advantages and disadvantages of different
laparoscopic techniques
Conclusion
References
129
130
130
131
diseases such as obesity, cancer, chronic hepatic and
cardiopulmonary failures, severe anemia, and malnutrition.2,3 The underlying pat
hological process, such as
prostatism, radiotherapy, steroid therapy, and operative
technical issues are also fundamental factors. Although
clinical experience seems to suggest that vertical celiotomy
and certain types of suture (e.g. continuous suture and
mass tissue closure) may increase the risk of incisional
Repair strategies
Although the modern era of hernia repair began more
than a century ago, controversies continue to exist regarding the optimal surgic
al technique to repair incisional
hernias. Open techniques involve a large incision and
extensive subcutaneous and intra-abdominal dissection,
and often necessitate the placement of drains. Complication rates range from 8 t
o 19 per cent after open ventral
repair.14,15 Fistula rates after elective open hernia mesh
repair vary from 2 to 5 per cent.6 Moreover, the infected
prosthesis should be excised, demanding another, more
complicated repair. Transabdominal approaches carry
the risk of injury to the viscera adherent to the undersurface of the scar. The
basic strategy of the open repair is
based upon the Stoppa technique: the peritoneal cavity
should not be entered and the mesh is secured to the fascial edges in the pre-pe
ritoneal space.16 However, the risk
of re-entering the site of a previous incision is an inadvertent enterotomy. The
open repair does allow the
concomitant excision of a usually wide, irregular and
unesthetic scar. If this is the case, it is not unusual to
enter the abdominal cavity.
Surgical laparoscopy has become an increasingly popular method of treatment for
many diseases because it
potentially offers cost-savings as a result of shorter hospital stays, less post
operative pain, and a more rapid
return to work.17 Laparoscopic hernioplasty has been
reported to be a safe and feasible technique, with low
morbidity and low rates of early recurrence. LeBlanc and
Booth first reported the laparoscopic approach to repair
incisional hernias in 1993,18 and several series have now
demonstrated the efficacy of minimally invasive surgery
in incisional hernia repair. Laparoscopic repair involves
no long incision, no wide fascial dissection or flap
creation, and usually no drains. It also minimizes the
manipulation of a potentially contaminated site because
the trocars are placed far from the original wound.19
Additionally, the pneumoperitoneum facilitates the necessary adhesiolysis in ord
er to identify the edges of the
defect and the hernia sac. Enterotomy rates in selected
laparoscopic series of ventral hernia repair, including
incisional hernias and many with previous open mesh
repair, vary from 0 to 14 per cent (Table 17.1). Mesh
infection rates vary from 0.5 to 12 per cent.12 One of the
drawbacks of the laparoscopic approach is that it does
not allow an esthetic reconstruction of the abdominal
wall since the old scar that covers the hernia defect is
left untouched. The need for an overall esthetic result
0
0
0
5
4
17
10
35
5
2
0
0
2
1
1
4.9
1.6
6.5
3.4
9
2
18
20
53
24
27
27
2
2
17
6
2
0
*Prospective study.
mean follow-ups were 24 months for the laparoscopic
group and 53 months for the open procedure. The hernia
recurred in six (11 per cent) patients in the laparoscopic
group and in 17 (34 per cent) patients in the open repair
group, but the investigators could not make a meaningful
comparison of the recurrence rates because of the large
difference in the follow-up periods. They found that the
laparoscopic procedure took longer to perform, but it
was associated with fewer complications and shorter
postoperative hospital stays.
In the only prospective randomized study of laparoscopic repair versus open repa
ir, Carbajo and colleagues
randomized 60 patients over a three-year period into two
homogeneous groups to be operated on for major ventral hernias using mesh.28 Wit
h an average follow-up of
27 months, they noted that two hernias in the open repair
group and none in the laparoscopic group recurred. They
concluded that laparoscopic repair offers several advantages over the classic su
rgical repair of abdominal wall
18
Hernioplasty with the double-crown technique
SALVADOR MORALES-CONDE AND SALVADOR MORALES-MNDEZ
Principles
Double-crown surgical technique
Results of our series
133
135
141
Laparoscopic surgery continues to advance in achieving
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
series still have a limited follow-up, the technique has
shown lower rates of recurrence than the open methods,
making it a procedure that solves a long-standing
challenge to the surgeon.
Nevertheless, there are certain points of controversy
that should be clarified, starting with the simple fact of
establishing more precise indications. In addition, a multitude of more specific
technical details should be discussed, including how to perform adhesiolysis, h
ow to
manage the hernia sac, the postoperative seroma, the
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
tacks. We have developed a laparoscopic procedure without sutures for the repair
of ventral hernias, a technique
we have come to call the double-crown technique.
This system avoids the use of external (transfascial)
sutures by fixing the mesh with a double crown of
tacks alone (Figure 18.1). This ensures proper anchorage
of the mesh, decreasing surgery time and diminishing
Conclusion
References
142
142
Hernia
Figure 18.1 Double-crown technique for laparoscopic ventral
hernia repair. External sutures are avoided, and the mesh is fixed
with a double crown of tacks alone.
postoperative pain at this level, and with the same recurrence rate as described
by groups using transfascial
sutures.
PRINCIPLES
Indications and contraindications
Indications for the double-crown technique are the
same as indications for laparoscopic hernia repair with
transfascial sutures. Basically, all ventral hernias can
be repaired by laparoscopy as the standard procedure.
Emergency operations performed in cases of strangulated hernias must be analyzed
on an individual basis to
0
0
0
0
2.86
2
4.87
1.97
3.98
19
Parastomal hernia repair
KARL A. LEBLANC
Types of hernia
Principles of management
Indications and contraindications to surgery
Preoperative preparation
Operative techniques
143
144
144
145
145
Hernias that develop at the site of the various intestinal
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 irrigation, leakage of
the fluids produced, a significant cosmetic deformity, or as complications of th
e hernia, such
as intestinal obstruction or strangulation. The presence
of a large protrusion may make repair a necessity irrespective of its other side
effects because of a significant
cosmetic deformity. Herniation is less frequent with
ileostomy than colostomy, but the overall incidence of
parastomal herniation is difficult to quantify.
Burns, in 1970, found 16 paracolic hernias among
307 colostomates, an incidence of five per cent.1 Other
authors have quoted figures that range from five to 48 per
cent.26 It is apparent that few (approximately 20 per
cent) of these hernias are repaired surgically. This may be
due to the lack of significant symptoms in the majority of
these patients and/or the age or infirmity of these individuals, which may prohi
bit surgical intervention.7,8 The
incidence of para-ileostomy hernia is between five and
ten per cent, while that of para-urostomy stomas in
urological practice is between two and ten per cent.9,10
However, one radiological study of 28 ileostomies using
clinical and computerized tomography (CT) evaluation
found that the rate of herniation was 35 per cent; this was
the same whether the ileum exited through or lateral to
the rectus muscle.11
Postoperative management
Results
Conclusion
References
147
148
149
149
TYPES OF HERNIA
The anatomy of the herniation is variable. Four principal
types can be identified:
POSTOPERATIVE MANAGEMENT
Patients are usually maintained in the surgical unit, which
allows for a one-night postoperative stay. The gastric and
urinary tubes are discontinued in the recovery room.
Patients are allowed a liquid diet immediately, although
most have a short-term ileus. The diet is advanced as tolerated. Abdominal binde
rs, which are used routinely for
129: 41319.
Porcheron J, Payan B, Balique JG. Mesh repair of paracolostomal
hernia by laparoscopy. Surg Endosc 1998; 12: 1281.
Bickel A, Shinkarevsky E, Eitan A. Laparoscopic repair of
paracolostomy hernia. J Laparoendosc Adv Surg Tech 1999; 9:
3535.
Voitk A. Simple technique for laparoscopic paracolostomy hernia
repair. Dis Colon Rectum 2000; 43: 14513.
LeBlanc KA, Bellanger DE. Laparoscopic repair of para-ostomy
hernias: early results. J Am Coll Surg 2002; 194: 2329.
De Ruiter P, Bijnen AB. Successful local repair of paracolostomy
hernia with a newly developed prosthetic device. Int J Colorectal
Dis 1992; 7: 1324.
Sugarbaker PH. Peritoneal approach to prosthetic mesh repair of
paraostomy hernias. Ann Surg 1985; 201: 3446.
Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of
incisional and parastomal hernias after major genitourinary or
abdominal surgery. J Endourol 2001; 15: 1759.
LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
incisional and ventral herniorrhaphy in 100 patients. Am J Surg
2000; 180: 1937.
20
Lumbar hernia and denervation hernia repair
KARL A. LEBLANC
Anatomy
Indications and contraindications for surgery
Operative technique
151
152
152
Primary and acquired lumbar hernias are quite uncommon. There have been about 30
0 cases of primary hernias reported in the literature.1 Acquired lumbar hernias
are the result of flank incisions for renal or other retroperitoneal operations,
notably anterior lumbar interbody
fusion. These acquired hernias can also be the result of
division of the anterior branches of nerves that originate
from T6 to T12. In these latter circumstances, there is no
fascial defect with these denervation injuries, so they are
not true hernias. These pseudo-hernias are difficult to
treat surgically. Rarely, they can also be seen with diabetic
radiculopathy.
Approximately 55 per cent of these hernias are primary, 25 per cent are acquired
, and the remainder are
congenital in origin.2 The latter can sometimes be bilateral. Primary lumbar her
nias are found most frequently
on the left side; two-thirds of these are seen in men.3,4
ANATOMY
The lumbar area is bounded above by the twelfth rib,
below by the iliac crest, behind by the erector spinae
muscles (sacrospinalis), and in front by the posterior
border of the external oblique (a line passing from the tip
of the twelfth rib to the iliac crest). Within this area, two
triangles are described: the superior lumbar triangle (of
Grynfelt) and the inferior lumbar triangle (of Petit). The
superior lumbar triangle is an inverted triangle: its base
is the twelfth rib, its posterior border is the erector spinae
muscles, its anterior border is the posterior margin of
the external oblique, and its apex is at the iliac crest
Results
Conclusion
References
153
153
154
inferiorly. The base of the inferior lumbar triangle is the
iliac crest, its anterior border is the posterior margin of
the external oblique muscle, its posterior border is the
anterior edge of the latissimus dorsi muscle, and its apex
is superior (Figure 20.1).
Lumbar hernias may contain a variety of intraabdominal organs. Hernias of the co
lon are the most frequent, but small intestine, stomach and spleen are also
likely candidates for herniation. A particular curiosity is
the sliding hernia of the colon, which causes intermittent
obstructive symptoms.
21
Results of laparoscopic incisional and
ventral hernia repair
RODRIGO GONZALEZ AND BRUCE J. RAMSHAW
Results of series
Results of comparative studies
155
157
Although the principles of abdominal wall repair are
well established and the complication rate has decreased
significantly over the past decade, the complication and
recurrence rates for open incisional hernia repair are far
from ideal. A prospective, randomized, multicenter study
recently reported a 46 per cent recurrence rate after primary open repair of ven
tral hernias when a prosthetic
material was not employed.1 Others have reported recurrence rates of 25 per cent
and 52 per cent for fascial defects
smaller and larger than 4 cm, respectively.24 Recurrences
are also associated with the number of repairs performed,
with 1843 per cent after initial repair and over 50 per cent
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,
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
recurrence rate compared with primary repairs,1,5 but
they have been associated with other types of complications, including wound inf
ection, seromas, mesh extrusion, fistula formation, and adhesions.57 Infections c
an
occur in up to 15 to 45 per cent of open mesh repairs and
may also correlate with recurrence rates.1,8 This high
infection rate is thought to be secondary to the large incision with which the m
esh is in contact and the wide dissection necessary for adequate mesh placement.
The
laparoscopic technique involves access to the abdominal
cavity away from the defect, avoiding placement of the
mesh through a large incision, thereby reducing the probability of contamination
and infection.9 It also allows
Conclusion
References
159
160
fixation of a large mesh without subcutaneous tissue dissection in patients with
large hernia defects.1012
Laparoscopic ventral hernia repair is based on the
method described by Stoppa for open incisional hernia
repair,4 reported to have the lowest recurrence rate.
It involves posterior reinforcement of the abdominal
wall with a large piece of prosthetic material based on
Laplaces law. The large surface area of the mesh allows
substantial ingrowth of tissue for permanent mesh fixation, and the intra-abdomi
nal pressure tends to hold the
mesh in apposition to the posterior abdominal wall over
18
100
49
100
415
44
202
17
100
64
20
159
100
7
20
39
26
100
58
55
41
33
37
49
33
20
18
42
75
23
25
104
98
130
101
93
87
100
20
155
34
7
68
108
49
120
210
89
105
101
85
62
152
88
97
50
240
130
89
119
2002
32
89
114
Patients
(n)
Conversion
rate
(%)
Hospital
stay
(days)
Seroma
rate
(%)
Infection
rate
(%)
Mesh
removed
(%)
Follow-up
(months)
Recurrence
rate
(%)
0
0
0
0
3
6
8
4
3
0
1
4
0
2
9
0.5
0
4
0
0
14
7
2
4.1
3
2.3
2
3.5
3.3
2.9
1.9
3.2
1.2
4.3
1.6
1.8
1.8
1.2
1.7
3.5
5
4
10
0
9
0a
16
36
14
33
10
0
3b
5a
2
18
7
5
15
16
11
4
10
4
9
2
3
8
2
4
6
3
0
0
2
2
2
5
2
2
4
0
3
1
4
0
0
1
4
0
2
0
0
2
2
1
1
0
0
1
10
8
15
30
7
18
13
12
20
22
30
27
23
23
35
51
10
12
49
19
0
0
4
0
1
4
6
8
2
9
9
6
2
6
3
3
5
1
12
9
2
0
16
2
3
1.9
7.5
1.5
26
3.3
2.2
Table 21.2 Results of comparative studies between laparoscopic and open ventral
hernia repair
Reference
Technique
Patients
(n)
Holzman et al. (1997)41
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open
Laparoscopic
Open with mesh
Open without mesh
Laparoscopic
16
20
49
56
30
30
174
79
18
21
14
14
23
31
90
119
86
Park et al. (1998)42
Carbajo et al. (1999)43*
Ramshaw et al. (1999)10
DeMaria et al. (2000)44
Chari et al. (2000)45
Robbins et al. (2001)13
Wright et al. (2002)12
*Prospective randomized study.
Previous
repairs
(n)
Hernia
size
(cm2)
Operating
room time
(min)
Length
of stay
(days)
Postoperative
complication
rate (%)
Infection
rate (%)
Seroma
rate (%)
Follow-up
(months)
Recurrence
rate (%)
4
8
9
16
22
23
51
36
3
11
28
6
15
148
105
105
99
141
140
34
73
79
12
112
98
128
78
95
112
87
82
58
78
124
102
70
131
5
1.6
6.5
3.4
9.1
2.2
2.8
1.7
4.4
0.8
5.5
5
2.5
1.5
1.5
31
23
37
18
50
20
26
15
72
57
14
14
28
22
24
6
5
2
0
18
0
3
0
33
10
0
7
30
16
13
10
9
0
5
2
4
67
13
50
19
12
4
9
19
10
54
24
27
27
21
21
24
24
32
24
24
13
10
35
11
7
0
21
3
0
6
6
9
1
34
35
36
37
38
39
40
41
42
43
44
45
46
Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic
incisional/ventral herniorrhaphy: a five-year experience. Hernia
1999; 4: 20914.
Koehler RH, Voeller G. Recurrences in laparoscopic incisional
hernia repairs: a personal series and review of the literature.
JSLS 1999; 3: 293304.
Balique JG, Alexandre JH, Arnaud JP, et al. Intraperitoneal
treatment of incisional and umbilical hernias: Intermediate results
of a multicenter prospective clinical trial using an innovative
composite mesh. Hernia 2000; 4 (suppl): S1016.
Farrakha M. Laparoscopic treatment of ventral hernias. Surg
Endosc 2000; 14: 11568.
Carbajo MA, del Olmo JC, Blanco JI, et al. Laparoscopic treatment
of ventral abdominal wall hernias: preliminary results in 100
patients. JSLS 2000; 4: 1415.
Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience
with the four-before laparoscopic ventral hernia repair. Am Surg
2000; 66: 4659.
Heniford BT, Ramshaw BJ. Laparoscopic ventral hernia repair.
A report of 100 consecutive cases. Surg Endosc 2000; 14: 41923.
Heniford BT, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral
and incisional hernia repair in 407 patients. J Am Coll Surg 2000;
190: 64550.
Szymanski J, Voitk A, Joffe J, et al. Technique and early results of
outpatient laparoscopic mesh onlay repair of ventral hernias. Surg
Endosc 2000; 14: 5824.
Chowbey PK, Sharma A, Khullar R, et al. Laparoscopic ventral
hernia repair. J Laparoendosc Adv Surg Tech A 2000; 10: 7984.
Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of
incisional and parastomal hernias after major genitourinary or
abdominal surgery. J Endourol 2001; 15: 1759.
LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
incisional and ventral herniorrhaphy. Our initial 100 patients.
Hernia 2001; 5: 415.
Birgisson G, Park AE, Mastrangelo MJ, et al. Obesity and
laparoscopic repair of ventral hernias. Surg Endosc 2001; 15:
141922.
Moreno-Egea A, Lirn R, Girela E, Aguayo JL. Laparoscopic
repair of ventral and incisonal hernias using a new composite
mesh (Parietex). Surg Laparosc Endosc Percutan Tech 2001;
11:1036.
Bageacu S, Blanc P, Breton C, et al. Laparoscopic repair of
incisional hernia. A retrospective study of 159 patients. Surg
Endosc 2002; 16: 3458.
Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications
with laparoscopic intraperitoneal expanded
polytetrafluoroethylene patch repair of postoperative ventral
hernia. Surg Endosc 2002; 16: 7858.
Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral
and incisional hernioplasty. Surg Endosc 1997; 11: 325.
Park A, Birck DW, Lovrics P, et al. Laparoscopic and open incisional
hernia repair: a comparison study. Surgery 1998; 124: 81622.
Carbajo MA, Martn del Olmo JC, Blanco JI, et al. Laparoscopic
treatment vs open surgery in the solution of major incisional and
abdominal wall hernias with mesh. Surg Endosc 1999; 13:
25052.
DeMaria EJ, Moss JM, Sugerman HJ. Laparoscopic intraperitoneal
polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral
hernia. Prospective comparison to open prefascial polypropylene
mesh repair. Surg Endosc 2000; 14: 3269.
Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of
laparoscopic incisional hernia repair. Surg Endosc 2000; 14:
11719.
Susmallian S, Gewurtz G, Ezri T, Charuzi I. Seroma after
laparoscopic repair of hernia with PTFE patch: is it really a
complication? Hernia 2001; 5: 13941.
22
Complications and their management
SAMUEL K. MILLER, STEPHEN D. CAREY, FRANCISCO J. RODRIGUEZ AND ROY T. SMOOT, JR
Bowel injury
Laparoscopic assisted hernia repair
Mesh infection
Seroma
Postoperative/suture pain
161
163
164
165
166
A ventral hernia is any protrusion through the anterior
abdominal wall with the exception of the inguinal area.
Ventral defects include those found in the umbilical, epigastric, Spigelian, inc
isional, and parastomal locations.
Five to fifteen per cent of laparotomies will result in ventral
incisional hernias, with the incidence of incisional hernia
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
hernia repairs annually.
Over the past decade, techniques for the laparoscopic
approach to ventral hernia repair have been developed.
Potential advantages include avoidance of large incisions
with associated flaps and drains, tension-free repairs
stabilized by intra-abdominal pressures (Laplaces law),
reduced length of stay with reduced convalescence and
more rapid return to full activity, and lower complication
and recurrence rates.
A review of the literature on laparoscopic ventral and
incisional hernia repair as well as our clinical experience
over ten years was undertaken. A Medline search demonstrated 18 articles suitabl
e for analysis. These articles
contained data on complications and recurrences. This
chapter will give an overview of the complications associated with laparoscopic
ventral and incisional hernia
repairs, and will suggest strategies to address these complications. Table 22.1
lists the articles chosen for review.
In comparison to open hernia repairs, overall complication rates for laparoscopi
c hernia repairs are much
lower. Complication rates reported for recent series of
open repairs may be high as 2734 per cent.16,19,21,22
Prolonged ileus/persistent nausea and vomiting
Recurrence of hernia
Conclusion
References
166
166
168
168
Review of laparoscopic hernia repairs demonstrates an
overall complication rate ranging from five to thirty per
33.6
18
15
24
21
12
20
17
51
30
27
23
31
1.0
4.2
1.1
0
0
11.0
2.5
0
8.8
9.3
7.0
9.3
2.0
4.8
7.1
3.4
11.8
2.7
25
25
5
13
30
18
19
11
21
19
14
15
16
10
13
16
24
17
22.7
65/1541
4.2
233/1530
15.2
1572
Table 22.2 Series reporting bowel injuries
Reference
Holzman et al. (1997)3
Toy et al. (1998)4
Ramshaw et al. (1999)9
Koehler and Voeller (1999)11
Roth et al. (1999)12
Chari et al. (2000)13
Heniford et al. (2000)18
Reporting no injuries
Total
Cases
(n)
Enterotomies
(n)
Complications
(%)
20
144
79
34
75
14
407
799
1
2
3
2
2
2
6
0
5.0
1.4
3.8
5.9
2.7
14.3
1.5
0
1572
17
1.1
occurred in a patient requiring lysis of densely adherent
small-intestinal loops to the polypropylene mesh. The
other patient presented on the fifth postoperative day with
an enterocutaneous fistula, and required removal of the
patch and segmental resection of the small bowel. Kyzer
and coworkers had two recognized small-bowel injuries,
which were both converted to open laparotomy: one
required a bowel resection and the other required simple
suture closure.10 Roth and colleagues had two cases of
intraoperative enterotomies recognized at the time of
operation: in one case, the operation was converted to
an open procedure; the second enterotomy was closed
laparoscopically, but no prosthetic patch was placed.12
Chari and coworkers, in a small casecontrol study,
describe two patients with enterotomies in the laparoscopic group.13 One patient
required removal of the
mesh due to infection. The second enterotomy resulted
in a prolonged postoperative course, with respiratory
failure and sepsis; the patient survived.
Finally, Heniford and colleagues, with the largest
retrospective study involving 407 patients, describe
six patients with small bowel enterotomies.18 Minimal
spillage was noted in four cases. These four patients had
their enterotomies repaired laparoscopically and the hernia repairs completed. T
he fifth patient was converted to
an open repair. None of the five patients had infectious
complications or recurrence of the hernia. The sixth
patient had an unrecognized enterotomy and subsequently underwent a laparotomy w
ith resection of a
short segment of small bowel and removal of the mesh.
Bowel injury can occur during initial entry into the
peritoneal cavity, although no such injury has been
1
5
0
1.4
0.6
6.7
3.6
1.9
5.9
2.7
4.8
1.0
3.2
2.7
0
1572
22
1.4
ere defined as fluid collections over the mesh that lasted for six to ten weeks.
18
They stated that no long-term complications occurred,
regardless of whether the seromas were aspirated.
Most fluid collections can simply be observed, because
they will resolve spontaneously over four to ten weeks.
Therefore, we recommend observation for the vast majority of postoperative serom
as.14,23 Not all authors agree,
however. Carbajo and colleagues described ten seromas, all
of which were managed with aspiration.15 No comments
Table 22.4 Series reporting seromas
Reference
Holzman et al. (1997)3
Toy et al. (1998)4
Franklin et al. (1998)5
Tsimoyiannis et al. (1998)7
Park et al. (1998)8
Ramshaw et al. (1999)9
Koehler and Voeller (1999)11
Roth et al. (1999)12
LeBlanc et al. (2000)14
Carbajo et al. (2000)15
Heniford et al. (2000)18
Personal series (2002)
Reporting no seromas
Total
Cases
(n)
Seromas
(n)
Complications
(%)
20
144
176
10
56
79
34
75
96
100
407
182
193
1
23
2
1
2
2
2
3
7
10
8
8
0
5.0
16.0
1.1
10.0
3.6
2.5
5.9
4.0
7.3
10.0
2.0
4.4
0
1572
69
4.4
AND VOMITING
Several authors report prolonged ileus or persistent nausea and vomiting followi
ng these procedures. The cumulative reported incidence is two per cent.3,4,8,9,1
2,14,18,20
Other authors have also reported prolonged ileus and
persistent nausea and vomiting, but they did not comment
further.
We generally do not use nasogastric tubes in the postoperative period. If patien
ts develop nausea, this is treated
with anti-emetics, such as ondansetron hydrochloride
4 mg every four hours, as necessary. If patients develop
protracted emesis along with their ileus, a nasogastric
tube will be placed, but this will be removed as soon as
possible. Early ambulation and activity are encouraged to
prevent ileus.
RECURRENCE OF HERNIA
Overall recurrence rates for open ventral incisional hernia repairs have been hi
gh and range from 30 to 60 per
cent.4,2937 A review of the literature demonstrates that
laparoscopic hernia repair has lowered this dramatically
to approximately four per cent (with a mean follow-up
period of 22.5 months) (Table 22.1).
Several factors are reported to increase the risk of
recurrence after ventral hernia repairs. These include
infection at the original operation38 and size of the original hernia.31 Other a
uthors have noted wound infections, obesity, advanced age, pulmonary complicatio
ns,
hepatic insufficiency, and male gender as risk factors for
recurrence.6 Park and colleagues report higher recurrences with larger hernias,
hernias in a central or midline
location compared with lateral hernias, and wound complications after hernia rep
air.8 Roth and coworkers, on
the other hand, found no association between the size
and the number of previous repairs, age, postoperative
complications, or location of recurrence.12 Koehler and
Voeller warn us to consider occult liver disease in any
hernia recurrence that cannot be explained by infection
or collagen-vascular disease, and they give supporting
references.11,39,40 LeBlanc and colleagues state that their
recurrences are generally associated with large and multiple defects, the use of
only one method of fixation for
the prosthetic patch, and an inadequate patch size.14
Hesselink and coworkers noted a 41 per cent cumulative
13
14
15
16
17
18
19
20
21
22
23
24
REFERENCES
Mudge M, Hughes LE. Incisional hernia: a 10 year prospective
study of incidence and attitudes. Br J Surg 1985; 72: 701.
2 Munson JL. Problems in General Surgery 1985; 2: 589614.
3 Holzman MD, Purut CM, Reintgen K, et al. Laparoscopic ventral
and incisional hernioplasty. Surg Endosc 1997; 11: 325.
25
1
26
Toy FK, Bailey RW, Carey S, et al. Prospective, multicenter study of
laparoscopic ventral hernioplasty. Preliminary results. Surg Endosc
1998; 12: 9559.
Franklin ME, Dorman JP, Glass JL, et al. Laparoscopic ventral and
incisional hernia repair. Surg Laparosc Endosc 1998; 8: 2949.
Costanza MJ, Heniford BT, Arca MJ, et al. Laparoscopic repair of
recurrent ventral hernia. Am Surg 1998; 12: 11217.
Tsimoyiannis EC, Tassis A, Glantzounis G, et al. Laparoscopic
intraperitoneal onlay mesh repair of incisional hernia. Surg
Laparosc Endosc 1998; 8: 3602.
Park A, Birch DW, Lovrics P. Laparoscopic and open incisional
hernia repair: a comparison study. Surgery 1998; 124: 81622.
Ramshaw BJ, Esartia P, Schwab J, et al. Comparison of laparoscopic
and open ventral herniorrhaphy. Am Surg 1999; 65; 82732.
Kyzer S, Alis M, Aloni Y, Charuzi I. Laparoscopic repair of
postoperation ventral hernia. Early postoperation results. Surg
Endosc 1999; 13: 92831.
Koehler RH, Voeller G. Recurrence in laparoscopic incisional hernia
repairs: a personal series and review of the literature. JSLS 1999;
3: 293304.
Roth JS, Park AE, Witzke D, Mastrangelo MJ. Laparoscopic
incisional/ventral herniorrhaphy: a five year experience. Hernia
1999; 4: 20914.
Chari R, Chari V, Eisenstat M, Chung R. A case controlled study of
laparoscopic incisional hernia repair. Surg Endosc 2000; 14:
11719.
LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic
incisional and ventral herniorrhaphy in 100 patients. Am J Surg
2000; 180: 1937.
Carbajo MA, Martin del Olmo JC, Blanco JI, et al. Laparoscopic
treatment of ventral abdominal wall hernias: Preliminary results of
100 patients. JSLS 2000; 4: 1415.
DeMaria EJ, Moss JM, Surgerman HJ. Laparoscopic intraperitoneal
polytetrafluoroethylene (PTFE) prosthetic patch repair of ventral
hernia. Surg Endosc 2000; 14: 3269.
Reitter DR, Paulsen JK, Debord JR, Estes NC. Five-year experience
with the Four-Before laparoscopic ventral hernia repair. Am Surg
2000; 5: 4659.
Heniford TB, Park A, Ramshaw BJ, Voeller G. Laparoscopic ventral
and incisional hernia repair in 407 patients. JACS 2000; 190:
64550.
Robbins SB, Pofahl W, Gonzales RP. Laparoscopic ventral
hernia repair reduces wound complications. Am Surg 2001; 9:
896900.
Kozlowski PM, Wang PC, Winfield HN. Laparoscopic repair of
incisional and parastomal hernias after major genitourinary or
abdominal surgery. J Endourol 2001; 15: 1759.
Leber GE, Garb JL, Alexander AI, Reed WP. Long-term
complications associated with prosthetic repair of incisional
hernias. Arch Surg 1998; 133: 37882.
White TJ, Santos MC, Thompson JS. Factors affecting wound
complications in repair of ventral hernias. Am Surg 1998; 64:
27680.
Park A, Heniford BT, LeBlanc KA, Voeller GR. Laparoscopic repair of
incisional hernias. Part 2: surgical technique. Contemp Surg 2001;
57: 22538.
Brill AI, Feste MD, Hamilton TL. Patient safety during laparoscopic
monopolar electrosurgery principles and guidelines. J Soc
Laparoendosc Surg 1998; 2: 2215.
Vancille TG. Active electrode monitoring; how to prevent
unintentional thermal injury associated with monopolar
electrosurgery at laparoscopy. Surg Endosc 1998; 12: 100912.
Temudom T, Siadati M, Sarr MG. Repair of complex giant or
recurrent ventral hernias by using tension-free intraperitoneal
prosthetic mesh (Stoppa technique): lessons learned from our
initial experience (fifty patients). Surgery 1996; 120: 73844.
PART
4
Laparoscopic treatment of
diaphragmatic herniation
23
24
25
26
27
28
History
Anatomy and physiology
Preoperative evaluation
Gastroesophageal reflux disease
Para-esophageal hernias
Traumatic and unusual herniation
173
179
187
193
201
209
29 Etiology of recurrent gastroesophageal
reflux disease
30 Reoperation for recurrent gastroesophageal
reflux disease
31 Results of laparoscopic treatment of hiatal hernias
32 Complications and their management
217
227
235
239
23
History
RAYMOND C. READ
Initial experience
Short esophagus
Phillip Allisons contribution
Rudolph Nissens contribution
173
173
174
175
Even though Barrett did not introduce the term reflux
oesophagitis until 1950,1 this entity is now considered
to be the most common chronic disease afflicting the
Western world. Forty per cent of the population complain
of occasional heartburn, and a third of these require longterm medical treatment
. A significant minority progress
to Barretts metaplasia. Other complications include
esophagitis, ulceration, stricture, herniation and neoplasia, many of which requ
ire surgery. The purpose of this
chapter is to trace the evolution of such therapy.
INITIAL EXPERIENCE
Herniation of abdominal contents through the diaphragm
has been recognized for centuries. According to Reid, the
lesion was first documented by Sennertus in 1541 at postmortem examination.2 Boy
le described the clinical findings in 1812.3 Successful repair was accomplished
by
Potemski in 1889.4 Congenital diaphragmatic herniation
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
and post-traumatic protrusion at autopsy, but it was
not until 1908 that the former, discovered fortuitously
at laparotomy, was dealt with in a living person. Even
Part of this review was presented at the third Annual Scientific Meeting
of the American Hernia Society, Toronto, 15 June 2000, and has been
published previously as Contribution of Allison and Nissen to laparoscopic hiatal
herniorrhaphy in Hernia 2002; 5: 200203.
Laparoscopic approach
Conclusion
References
175
176
176
though diaphragmatic hernias were considered rare,
Hedblom reviewed almost 400 cases (19 at the Mayo
Clinic) operated upon worldwide by 1925. The following
year, Akerlund published his radiological studies;8 these
were performed with barium, the patient being placed in
the Trendelenburg position, as recommended by Soresi.9
Most surgeons operated only on large protrusions
(mainly para-esophageal) because of their known risk of
History 175
Unfortunately, Allisons repair, which was adopted
widely, proved unsatisfactory because a significant number of patients suffered
symptomatic relapse. Collis cited
these results in recommending a return to anterior closure of the defect in the
dome of the diaphragm.22 This
surgeon, who also worked in the UK (Birmingham), had
described in 1957 an operation for patients with hiatus
hernia and short esophagus that has stood the test of
time.23 This involved constructing a neo-esophagus from
the Magenstrasse of the stomach. Hiebert and Belsey provided an explanation for th
e failure of Allisons procedure
when they documented incompetence of the gastric cardia
in the absence of hiatal herniation.24 The problem was
primary incompetence of the intrinsic gastroesophageal
sphincter of Code and colleagues.25
RUDOLPH NISSENS CONTRIBUTION
This distinguished thoracic surgeon (18961981), the
son of a surgeon, was an assistant between 1921 and 1933
to Professor Sauerbruch of Munich and Berlin. Being
Jewish, Nissen was forced to emigrate to Turkey, from his
Fatherland despite being wounded in the lung during
World War I. In 1931, he performed the worlds first successful pneumonectomy on a
12-year-old girl with a torn
left mainstem bronchus. While in Istanbul, he undertook
a transthoracic gastroesophagectomy for benign ulceration of the cardia.26 He la
ter learned that this was the second such resection to be accomplished successfu
lly, the
first being performed by the Japanese in 1933. It is interesting that Sauerbruch
pioneered the procedure experimentally in the dog in 1906. Since almost all pre
vious
attempts had failed in humans because of anastomotic
leakage, Nissen buried the anastomosis of the transected
esophagus in the fundus of the stomach. He brought up
two folds in the manner of a Witzel gastrostomy.
Amazingly, while he was Chief of Surgery at Basel,
Switzerland, 17 years after this operation he obtained
follow-up information from a relative of the patient.
The patient was well and had no symptoms of reflux
esophagitis. Two years later, Nissen decided to perform
fundoplication alone for esophageal reflux disease. He
undertook this procedure in a man and a woman who
each had the signs and symptoms of reflux esophagitis
without evidence of hiatal herniation. Nissen reported
success in 1956.27 In agreement with modern thought,28
he believed that hiatus herniation was the result rather
than the cause of reflux esophagitis. Therefore, in cases of
symptomatic hiatus herniation, he paid no attention to
the hernial sac, considered closure of the defect unnecessary, and with short es
ophagus performed transthoracic
fundoplication. He always conducted the procedure over
a large-bore bougie to prevent postoperative dysphagia,
and stitched the fundoplication to the esophageal wall
to obviate slippage. He mobilized the lesser curvature of
the stomach, being careful to preserve the vagi and their
branches. The left gastric vasculature rather than the short
gastric vessels was divided. A nasogastric tube was left
History 177
5
6
7
8
9
10
11
12
13
14
15
16
17
Holt C. Child that lived two months with congenital diaphragmatic
hernia. Philos Trans 1701; 22: 922.
Heidenhain L. Geschichte eines Fallas von chronischer
Incarceration des Magens in einer angeborenen Zwerch fellhernie
welcher durch Laparotomie geheilt wurde, mit anschliessen
den Bemerkungen ueber die Moglichkeit. Das Kardiocarcinom der
Speiserohre zu reseciren. Deutsch Ztschr Chir 1905; 76: 394403.
Hedblom CA. Diaphragmatic hernia: a study of three hundred and
seventy eight cases in which operation was performed.
JAMA 1925; 85: 94753.
Akerlund A. Hernia diaphragmatic Hiatusoesophagei vom
anatomischen und rontgenologischen Gesicfhtspunkt. Acta Radiol
1926; 6: 322.
Soresi AL. Diaphragmatic hernia, its unsuspected frequency: its
diagnosis, technique for radical cure. Ann Surg 1919; 69: 25470.
Harrington SW. Diagnosis and treatment of various types of
diaphragmatic hernia. Am J Surg 1940; 50: 377446.
Adams HD, Lobb AW. Esophagoaortal hiatus hernia. N Engl J Med
1954; 250: 1438.
Boeremia I, Germs R. Anterior geniculate gastropexy for hiatal
hernia of the diaphragm. Zentralbl Chir 1955; 80: 158593.
Hayward J. The treatment of fibrous stricture of the esophagus
associated with hiatal hernia. Thorax 1961; 16: 4564.
Harrington SW. The surgical treatment of the more common types
of diaphragmatic hernia. Ann Surg 1945; 122: 54668.
Findlay L, Kelly B. Congenital shortening of the esophagus and
the thoracic stomach resulting therefrom. J Laryngol Otol 1931;
46: 797816.
Kelly AB. Some oesophageal affections in young children.
J Laryngol Otol 1936; 51: 7899.
Allison PR, Johnstone AS, Royce GB. Short esophagus with simple
peptic ulceration. J Thorac Surg 1943; 12: 43257.
18
19
20
21
22
23
24
25
26
27
28
29
30
Allison PR, Johnstone AS. The esophagus lined with gastric
mucous membrane. Thorax 1953; 8: 87101.
Lortat-Jacob JL. Les malpositions cardia-tuberositaires.
Arch Mal App Dig 1953; 42: 75074.
Olsen AM, Harrington SW. Esophageal hiatal hernias of the
short esophagus type: etiologic and therapeutic considerations.
J Thorac Surg 1948; 17: 189209.
Allison PR. Reflux esophagitis, sliding hiatal hernia and the
anatomy of repair. Surg Gynecol Obstet 1951; 92: 41931.
Collis JL. Review of surgical results of hiatus hernia. Thorax 1961;
16: 11423.
Collis JL. An operation for hiatus hernia with short esophagus.
J Thoracic Surg 1957; 34: 76878.
Hiebert CA, Belsey RHR. Incompetency of the gastric cardia
without radiologic evidence of hiatal hernia, the diagnosis and
management of 71 cases. J Thorac Cardiovasc Surg 1961; 42:
35271.
Fyke FE, Code CF, Schlegel JF. The gastroesophageal
sphincter in healthy human beings. Gastroenterologia 1956;
86: 13547.
Nissen R. Die Transpleurale Resektion der Kardia. Deutsche Ztschr
Chir 1937; 249: 31116.
Nissen R. Gastropexy as the lone procedure in the surgical repair
of hiatus hernia. Am J Surg 1956; 92: 38992.
Dunne DP, Paterson WG. Acid-induced esophageal shortening
in humans: a cause of hiatus hernia? Can J Gastroenterol 2000;
10: 84750.
Lau WY, Leow CK, Li AKC. History of endoscopic and laparoscopic
surgery. World J Surg 1997; 21: 44453.
Awad ZT, Filipi CJ. Commentary: the short esophagus, pathogenesis,
diagnosis and current surgical options. Arch Surg 2001; 136:
11314.
24
Anatomy and physiology
MARK A. REINER
Anatomy
Physiology
Surgical considerations for diaphragmatic repair
in patients with gastroesophageal reflux disease
179
183
Conclusion
References
185
185
184
In an attempt to elucidate the etiological factors that
contribute to gastroesophageal reflux disease (GERD), it
is necessary to have a full understanding of normal diaphragmatic anatomy and ph
ysiology. Pathological reflux
occurs when there are anatomical and physiological
abnormalities at the gastroesophageal junction and crura.
These abnormalities are influenced by postural changes
and gradients between intra-abdominal and intrathoracic
pressures. Corrective surgery must include a proper
diaphragmatic repair in order to minimize the potential
for recurrence. Postoperative management must be
tailored to the patients age, the size of the hiatal defect,
and the patients lifestyle.
ANATOMY
The diaphragm separates the abdominal and thoracic cavities. It is composed of a
non-contractile central tendon
and three peripheral or skeletal muscular components, the
sternal, costal, and lumbar or crural.1 The central tendon
connects all of the muscular components by acting as a
central focal point from which these three muscle groups
radiate. The sternal portion of the muscular component
originates from the undersurface of the sternum and may
be considered as an independent structure or as the medial
aspect of the costal segment.1,2 The costal portion originates from the undersur
face of the lower six costochondral junctions, extending on to these ribs, and t
hen ending
by interdigitating with the transversus abdominis muscles
bilaterally. The lumbar or crural segment originates from
the first three lumbar vertebrae.1 These segments have
four components: the medial and lateral lumbosacral
arches or internal and lateral arcuate ligaments, and the
right and left crura.1,3 The medial lumbosacral arch (internal arcuate ligament)
drapes over the psoas muscle; it is
fixed to the transverse processes of the first and second
lumbar vertebra, and fuses into the lateral portion of the
contiguous crus. The lateral lumbosacral arch (external
arcuate ligament) covers the quadratus lumborum and
becomes fixed to the first lumbar vertebrae and twelfth
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 continuation of the subper
itoneal fascia. Its attachments are
the anterior portion of the cardia of the stomach, the
lower 4 cm of the esophagus, and the left and right sides
of the crura around the esophageal hiatus. It terminates
on the left by merging into the gastrophrenic ligament
and on the right into the pars condensa of the lesser
omentum (Figure 24.3).4,7 The phreno-esophageal ligament is the only structure t
hat establishes a direct connection between the lower esophageal sphincter and t
he
crural diaphragm. This structure has been considered an
important factor in preventing reflux. It tends to be
stretched and distracted in hiatal hernias.710 When this
occurs, it minimizes or eliminates any positive effect
that a normal ligament will have on reflux prevention.
This stretching, when seen in conjunction with a hiatus
hernia, allows a segment of gastric cardia to herniate
through the hiatus into the mediastinum, shortening the
length of the abdominal esophagus. When this occurs in
the presence of a hypotensive or atonic lower-esophageal
sphincter (LES), the patient will experience the symptoms
of GERD. The etiology of this laxity remains obscure,
but it has been attributed to a variety of factors, including
atrophic changes as seen with age, chronic stretching
secondary to each peristaltic contraction,10 obesity, pregnancy, surgical destru
ction, and trauma. Since the physiological benefits of the phreno-esophageal lig
ament are
diminished in the presence of a hiatus hernia, wide
dissection of the ligament in anti-reflux surgery has
no detrimental effect. Adequate dissection of the crura,
proximal stomach, and lower esophagus are mandatory
in order to perform an adequate repair. This condition
is not present in patients having upper-esophageal surgery for conditions other
then reflux disease, such as a
Heller myotony for achalasia. Minimal dissection of the
phreno-esophageal ligament in these cases may help
minimize postoperative GERD.
The structural anatomy of the normal esophageal
hiatus has a significant impact in preventing reflux disease.
In its normal form, it is elliptical in shape and present
in the muscular portion of the diaphragm (Figure 24.4).
The hiatus is located at the level of the tenth thoracic
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
aorta at this stage because of its proximity to the posterior
aspect of the defect.
PHYSIOLOGY
The physiology of diaphragmatic function has a direct
effect on the presence or absence of symptomatic reflux.
A brief review of the etiological factors causing GERD
is warranted before we consider how to integrate the diaphragmatic repair into t
he surgical treatment of reflux
disease. Reflux occurs when gastric contents are regurgitated into the esophagus
. The normal stomach resides in
an area of higher pressure than the thoracic esophagus. In
order for reflux not to occur, a pressure barrier must exist
between these areas of low and high pressure. A segment
of esophagus approximately 2 cm long, of which at least
1 cm usually resides intra-abdominally, called the LES, is
the junction between the two different pressure zones
(Figure 24.8). The presence of pathological reflux is
dependent on failure of the LES. Three factors come into
Figure 24.8 Anatomy of the lower
esophageal sphincter.
play. The first two are the normal average pressure and
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
GERD under the conditions of rest, changing body positions, ingestion of moderat
e amounts of food and drink,
and physical activity that results in significant increases in
intra-abdominal pressures. A functional change in any
one of these components, without a corresponding compensatory adjustment in anot
her of the other components, will result in GERD. An example of this adjustment
can be demonstrated in a patient with a shortened LES
segment. Reflux would occur unless there was a compensatory rise in the LES pres
sure. There is, however, one
situation in which there is an alteration in the balance
between these three factors that is physiologically normal
and the most common cause of non-pathological reflux:
transient lower esophageal sphincter relaxation (tLESR).
This occurs when there is gastric distention secondary to
ingestion of excess food, air, or gas, such as is seen with
carbonated beverages. This is unrelated to swallowing or
esophageal peristalsis, and it may have a neuromuscular
Anotomy/physiology 185
Esophagus
Pledget
Crural closure
Figure 24.9 Posterior crural repair.
sports, where sudden abdominal impact could cause a
significant and rapid rise in intra-abdominal pressure.
Caution must also be given to weight-lifters, who possess
thicker and stronger muscular diaphragms, about lifting
practices that could disrupt the repair.
5
6
7
8
CONCLUSION
The surgical treatment of GERD can be addressed successfully and safely only aft
er fully understanding the
normal anatomy and physiology of the diaphragm, the
lower esophageal forces that prevent and cause reflux, and
the abnormal anatomical defects found in patients with
hiatus hernias. Failures can be kept to a minimum by the
diligent performance of a meticulous posterior repair of
the diaphragm before completing the fundoplication.
REFERENCES
9
10
11
12
13
14
15
1
Goss CM, ed. Grays Anatomy, 28th edn. Philadelphia: Lea &
Febiger, 1966.
2 Poole DC, Sexton WL, Farkas GA, et al. Diaphragm structure and
function in health and disease. Med Sci Sports Exerc 1997; 29:
73854.
3 Agur AMR, Lee MJ, eds. Grants Atlas of Anatomy, 10th edn.
Philadelphia: Lippincott Williams & Wilkins, 1999.
4 Delattre JF, Aviss C, Marcus C, Flament JB. Functional anatomy of
the gastroesophageal junction. Surg Clin North Am 2000; 80:
24160.
16
17
18
Delattre JF, Palot JP, Ducasse A. The crura of the diaphragmatic
passage. Anat Clin 1985; 7: 271.
Allison PR. Reflux esophagitis, sliding hiatal hernia, and the
anatomy of repair. Surg Gynecol Obstet 1951; 92: 41931.
Postlethwait RW. Surgery of the Esophagus, 2nd edn. Norwalk, CT:
Appleton-Century-Crofts, 1986.
Eliska O. Phrenoesophageal membrane and its role in
the development of hiatal hernia. Acta Anat (Basel) 1973; 86:
13750.
Marchand P. A study of the forces productive of gastroesophageal
regurgitation and herniation through the diaphragmatic hiatus.
Thorax 1957; 12, 189202.
Kahrilas PJ. Suoraesophageal complications of reflux disease and
hiatal hernia. Am J Med 2001; 111: 51S5S.
DeMeester TR, Peters JH, Bremner CG, Chandrasoma P. Biology
of gastroesophageal reflux disease: pathology relating to
medical and surgical management. Annu Rev Med 1999; 50:
469506.
Richter J. Do we know the cause of reflux disease? Eur J
Gastroenterol Hepatol 1999; suppl 1: 839.
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: 268794.
Kahrilas P. The role of hiatus hernia in GERD. Yale J Biol Med 1999;
72: 10111.
Orlando RC. Overview of the mechanisms of gastroesophageal
reflux. Am J Med 2001; suppl 8A: 174S7S.
Patti MG, Goldberg HI, Arcerito M, et al. Hiatal hernia size
affects lower esophageal sphincter function, esophageal acid
exposure, and the degree of mucosal injury. Am J Surg 1995;
171: 1826.
Soper NJ, Dunnegan D. Anatomic fundoplication failure
after laparoscopic antireflux surgery. Ann Surg 1999; 229:
66977.
Hunter JG, Smith CD, Branum GD, et al. Laparoscopic
fundoplication failures. Ann Surg 1999; 230: 595606.
25
Preoperative evaluation
MARCO G. PATTI AND PIERO M. FISICHELLA
Preoperative evaluation for anti-reflux surgery
Esophageal manometry
Ambulatory pH monitoring
187
188
189
Laparoscopic Nissen fundoplication is one of the operations performed most frequ
ently by general surgeons
today. The past decade has seen a progressive increase in
the number of laparoscopic Nissen fundoplications performed throughout the USA d
ue to the recognition that
although the laparoscopic approach gives results similar
to those obtained with the open approach (excellent control of symptoms in about
90 per cent of patients), it is
also associated with shorter hospital stay, less postoperative discomfort, and f
aster recovery time.15 The increased
number of patients referred for surgical treatment has
allowed us to improve the understanding of the pathophysiology of the disease an
d to define the technical elements that play a role in the performance of an eff
ective
and durable fundoplication.2
Traditionally, gastroenterologists have referred patients
for surgery based on clinical evaluation and findings of
endoscopy, particularly if they had a poor response to acidreducing medication.
Today, however, this approach is
unacceptable for the following reasons: (1) many patients
undergo surgery for control of symptoms in the absence of
esophagitis; (2) more patients are referred for treatment
of atypical symptoms of gastroesophageal reflux disease
(GERD) such as cough or chest pain;6,7 and (3) because of
the efficacy of proton-pump inhibitors, in patients who do
not respond to these medications a diagnosis other than
GERD should be sought.8,9 Therefore, a careful and complete preoperative evaluat
ion is of key importance for the
success of the operation.
Evaluation for failed anti-reflux surgery
References
190
191
PREOPERATIVE EVALUATION FOR
ANTI-REFLUX SURGERY
All patients who are candidates for laparoscopic fundoplication should undergo t
he following preoperative evaluation in order to determine whether abnormal refl
ux is
present, whether the symptoms are caused by the reflux,
and whether complications of GERD, such as Barretts
esophagus, are present, and to define the anatomy and
pathophysiology of the disease in the individual patient.
Symptomatic evaluation
Patients are questioned regarding the presence of typical
ESOPHAGEAL MANOMETRY
This test provides information about the length and resting pressure of the LES
and the quality of esophageal
peristalsis (amplitude, duration and velocity of the peristaltic waves). In most
patients with GERD referred for
surgery, the LES is hypotensive. However, in some
patients, the resting pressure of the LES is normal, and it
is assumed that transient LES relaxations account for the
majority of reflux episodes.16 Regardless of the mechanism underlying the abnorm
al reflux, a fundoplication
restores the function of the LES by increasing the pressure and length of the sp
hincter13 or by decreasing the
frequency of episodes of transient LES relaxation.17 In
addition, esophageal manometry provides information
about esophageal peristalsis, which is the most important factor in acid clearan
ce.18 Among 1006 consecutive
patients with GERD confirmed by pH monitoring, we
found that peristalsis was normal in 56 per cent of
patients, severely abnormal in 21 per cent of patients
(ineffective esophageal motility, IEM), and mildly abnormal in 23 per cent of pa
tients (non-specific esophageal
motility disorder, NSEMD) (Figure 25.1). Patients with
Endoscopy
Endoscopy is usually the first test performed to confirm
a symptom-based diagnosis of GERD. However, the
approach has the following pitfalls:
26
Gastroesophageal reflux disease
J. BARRY McKERNAN AND CHARLES R. FINLEY
Treatment
Discussion
193
200
Over the past decade, there has been a significant shift in
the role of surgery for the treatment of gastroesophageal reflux disease (GERD).
Anti-reflux surgery, once reserved for severe disease refractory to medical the
rapy, is
now considered appropriate for many patients without
mucosal complications. Several factors have contributed
to the growing acceptance of surgery for reflux disease.
One such factor is the appreciation that abnormal reflux
can result in serious esophageal complications, such as
ulcerations, strictures, and the development of Barretts
metaplasia. It is well recognized that many of the extraesophageal symptoms obse
rved in patients with GERD,
including laryngitis, erosion of dental enamel, and pulmonary disorders (asthma,
chronic cough, bronchitis),
are due to refluxed gastric material entering the oropharyngeal cavity and lungs
. Although medical therapy with
proton-pump inhibitors is fairly effective in controlling
heartburn and esophagitis, it is less effective in controlling these extra-esoph
ageal symptoms.
Current evidence suggests that treatments directed at
restoring normal competence to the lower esophageal
sphincter (LES) will be more effective than those aimed
at controlling acid secretion.1,2 The introduction of safe
and effective minimally invasive anti-reflux procedures
has contributed greatly to the shift in the role of surgery for treating GERD. M
edical therapy is directed at
alleviating uncomfortable symptoms, whereas surgery is
directed towards repairing the functional defect. Laparoscopic anti-reflux proce
dures are comparable to their
open counterparts in terms of high rates of symptom
relief coupled with low rates of complications, but they
offer advantages in terms of shorter hospital stay, quicker
recovery, and cost-savings.35
For many patients, operative therapy has become an
alternative rather than a last resort to treat their abnormal
References
200
reflux and prevent the development of complications associated with GERD. The la
paroscopic approach, as in cholecystectomy, adrenalectomy and splenectomy, has r
eplaced
the open technique as a method of choice. Patients considered candidates for lap
aroscopic anti-reflux surgery are
those who have failed medical therapy, those who cannot
afford medical therapy, those who have recurrence of
symptoms, those with extra-esophageal manifestations or
strictures, and those with para-esophageal hernias. Previous
open abdominal surgery, either for reflux disease or for
8
9
10
11
12
Orlando RC. The pathogenesis of gastroesophageal reflux
disease: the relationship between epithelial defense, dysmotility,
and acid exposure. Am J Gastroenterol 1997; 92 (suppl 4):
3S5S, 5S7S.
Stein HJ, Barlow AP, DeMeester TR, Hinder RA. Complications of
gastroesophageal reflux disease: role of the lower esophageal
sphincter, esophageal acid and acid/alkaline exposure, and
duodenogastric reflux. Ann Surg 1992; 216: 3543.
Bowry, DJ, Peters JH. Current state, techniques, and results of
laparoscopic antireflux surgery. Semin Laparosc Surg 1996; 6:
194212.
Dallemagne B, Weerts JM, Jeahes C, Markiewics S. Results of
laparoscopic Nissen fundoplication. Hepatogastroenterology 1998;
45: 133843.
Spechler SJ. Veterans Affairs Gastroesophageal Reflux Disease
Study Group. Comparison of medical and surgical therapy for
complicated gastroesophageal reflux disease in veterans.
N Engl J Med 1992; 326: 78692.
Triadafilopoulos G, Dibaise JK, Nostrant TT, et al. Radiofrequency
energy delivery to the gastroesophageal junction for the treatment
of GERD. Gastrointest Endosc 2001; 53: 40715.
Filipi CJ, Lehman GA, Rothstein RI, et al. Transoral, flexible
endoscopic suturing for treatment of GERD: a multicenter trial.
Gastrointest Endosc 2001; 53: 41622.
Finley CR, McKernan JB. Laparoscopic antireflux surgery at an
outpatient surgery center. Surg Endosc 2001; 15: 8236.
McKernan JB, Finley CR. Experience with optical trocar in
performing laparoscopic procedures. Surg Laparosc Endosc
Percutan Tech 2002; 12: 969.
OBoyle CJ, Watson KI, Jamieson GG, et al. Division of short
gastric vessels at laparoscopic Nissen fundoplication. A prospective
double-blind randomized trial with 5-year follow-up. Ann Surg
2002; 235: 16570.
Huntington TR. Laparoscopic mesh repair of the esophageal hiatus.
J Am Coll Surg 1997; 184: 399400.
Thor KB, Silander T. A long-term randomized prospective trial of
the Nissen procedure versus a modified Toupet technique.
Ann Surg 1989; 210: 71924.
27
Para-esophageal hernias
HUGO BONATTI, BEATE NEUHAUSER AND RONALD A. HINDER
Treatment of para-esophageal hernias
Preoperative management
Surgical procedure
201
202
203
Hiatal hernias are common disorders in the western population.1 The overall inci
dence of hiatal hernias has been
reported to lie between ten and over 20 per cent.2 Hiatal
hernias are categorized into four groups, as determined
by Hill and Tobias in 1968.3 Type I hiatal hernias, also
known as sliding hiatal hernias, account for the most
common group ("80 per cent) and are characterized by
a sliding herniation of the gastroesophageal junction
through the hiatus into the chest. Para-esophageal hernias (PEHs) account for th
e remaining three groups:
type II represent a herniation of the fundus of the
stomach through the hiatus with a fixed gastroesophageal junction in the normal
position; type III are the
most common PEHs, and represent a combination of
type I and type II with a displaced gastroesophageal junction as well as herniat
ion of parts of the stomach into the
chest; type IV are composed of a large PEH combined
with a large hiatal defect containing not only the stomach
but also other intra-abdominal organs, such as colon or
spleen. PEHs are observed more commonly in the elderly
population. In our series of 117 patients undergoing
laparoscopic PEH repair, the median age was 68 years
(range 3995); 12 patients were over the age of 80 years.
Sixty per cent of patients were female.
TREATMENT OF PARA-ESOPHAGEAL
HERNIAS
The only curative treatment available for PEH is surgery.
The principles are complete reduction of the hernia from
the chest, repair of the hiatal defect, and fundoplication.
Postoperative management
Conclusion
References
207
208
208
Indications for surgical repair
PEH may occur with or without symptoms. PEH can
remain asymptomatic for long periods, but these patients
require close observation.4 On closer examination, the
patient may eventually report distinct symptoms, such as
coughing, chest pain or epigastric pain, which the patient
may relate to other causes.5 The more common complaints associated with symptoma
tic PEH are dysphagia,
gastroesophageal reflux (GER), epigastric pain, chest pain,
Figure 27.14 Giant hiatal defect with a tear in the right crus
after failed primary closure.
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 th
e gas in
the pleural space may be expelled by forceful lung inflation at the time of rele
ase of the pneumoperitoneum.
Figure 27.15 Closure of the large defect using a Gore-Tex patch.
28
Traumatic and unusual herniation
SERGIO G. SUSMALLIAN AND ILAN CHARUZI
Diaphragmatic injuries
Acute diaphragmatic herniation
Surgical treatment of acute diaphragmatic injuries
Chronic diaphragmatic hernia
209
210
211
212
The diaphragm is a thin muscle with a full-time job. It
is innervated by the ipsilateral phrenic nerve and has
an abundant blood supply.1 The anatomical role of the
diaphragm consists of dividing the two large cavities of
the human body and maintaining its different pressures.2
Its presence separates and contains the viscera of the
abdominal and thoracic cavities. The symptoms related
to diaphragmatic injuries are caused by the incapacity to
contain the abdominal viscera in the cavity favored by
the pressure gradient.1
During inspiration, the diaphragm contracts physiologically, acquiring a flat sh
ape. During expiration, it
relaxes passively and acquires a dome shape. This concept is important for under
standing and diagnosing
diaphragmatic injury in the various chest and abdominal
levels of penetrating trauma.
Diaphragmatic injury is not common, but its incidence has increased over the pas
t few years, probably
because of the increased frequency of high-speed motorvehicle accidents.35 Additi
onally, early recognition has
become more feasible with the diagnostic procedures that
are now available. It is also conceivable that early recognition of signs and sy
mptoms of a possible diaphragmatic
injury can result in the correct treatment being given, so
avoiding chronic injuries. The diagnosis of diaphragmatic
injury is influenced strongly by the severity of the associated lesions.68
Sennertus in 1541 was the first to report a diaphragmatic injury, in a postmorte
m examination.9 He described
a strangulated stomach herniated through a left diaphragmatic defect seven month
s after a stab wound. In 1579, Par
described the consequences of diaphragmatic herniation in
blunt and penetrating injuries.10 He found a strangulated
Surgical treatment of chronic diaphragmatic injuries
Conclusion
References
213
214
215
colon through a small defect in the diaphragm. In 1853,
Bowditch became the first physician to diagnose a posttraumatic diaphragmatic he
rnia in vivo.11 In 1886, Riolfi
performed the first repair of a diaphragmatic herniation
after a stab wound,12 while Walker in 1900 was the first surgeon to repair a dia
63.5
51
25.5
11
9
6.5
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
Lee WC, Chen RJ, Fang JF, et al. Rupture of the diaphragm after
blunt trauma. Eur J Surg 1994; 160: 47983.
Jackimczyk K. Blunt chest trauma. Emerg Med Clin North Am 1993;
11: 8196.
Meyers BC, McCabe CJ. Traumatic diaphragmatic hernia. Occult
marker of serious injury. Ann Surg 1993; 218: 78390.
Colliver C, Oller DW, Rose G, Brewer D. Traumatic intrapericardial
diaphragmatic hernia diagnosed by echocardiography. J Trauma
1997; 42: 11517.
Muysoms F, Verhelst H, Schroe H, De Jongh R. Traumatic
intrapericardial diaphragmatic hernia. J Accid Emerg Med 1997;
14: 156.
Aldhoheyan A, Jain SK, Hamdy M, Alsebayel MJ. Traumatic
intrapericardial diaphragmatic hernia. Injury 1992; 23: 3312.
Naunheim FS. Adult presentation of unusual diaphragmatic
hernias. Chest Surg Clin North Am 1998; 8: 35969.
Sukul DM, Kats E, Johannes EJ. Sixty-three cases of traumatic
injury of the diaphragm. Injury 1991; 22: 3036.
Shackleton KL, Stewart ET, Taylor AJ. Traumatic diaphragmatic
injuries: spectrum of radiographic findings. Radiographics 1998;
18: 4959.
Israel RS, McDaniel PA, Primack SL, et al. Diagnosis of
diaphragmatic trauma with helical CT in a swine model. Am J
Roentgenol 1996; 167: 63741.
Worthy SA, Kang EY, Hartman TE, et al. Diaphragmatic rupture:
CT findings in 11 patients. Radiology 1995; 194: 8858.
Kamelgard JI, Harris L, Reardon MJ, Reardon PR. Thoracoscopic
repair of a recurrent diaphragmatic hernia four years after initial
trauma, laparotomy and repair. J Laparoendoscop Adv Surg Tech
1999; 9: 1715.
Domene CE, Volpe P, Santo MA, et al. Laparoscopic treatment of
diaphragmatic hernia. J Laparoendosc Adv Surg Tech 1998; 8:
2259.
Yoshida J, Iwai T, Koike E, et al. Thoracoscopic repair of
diaphragmatic eventration sustained at knife injury: a case report.
29
Etiology of recurrent gastroesophageal
reflux disease
ZIAD T. AWAD AND CHARLES J. FILIPI
Clinical presentation
Mechanisms of failure
Wrong operation
217
219
221
Gastroesophageal reflux disease (GERD) is a common
disease that accounts for approximately 75 per cent of the
pathology of the esophagus. Forty per cent of the adults in
the USA have occasional heartburn, and ten per cent experience heartburn daily.1
,2 It is estimated that 20 per cent of
patients with GERD develop serious complications, such
as ulceration, stricture, and Barretts metaplasia. Although
medical therapy may be effective, it is often required for a
protracted period of time. In addition, prolonged therapy
often requires escalated dosages, and discontinuation of
medications may result in an early recurrence of symptoms. Surgery has improved
because of a better understanding of the underlying pathophysiology of GERD and
technical refinements of operative techniques.3,4 A controlled, randomized trial
showed superiority of surgical
therapy for the treatment of severe GERD, with less frequent side effects than w
ith non-surgical management.5
Other investigators have provided evidence to favor antireflux surgery over medi
cal treatment.6,7
The advent of minimally invasive surgery has revolutionized the surgical treatme
nt of GERD, leading to a significant increase in the number of cases performed.
Studies
have shown that the functional results of laparoscopic
anti-reflux procedures are equal to those of open surgery,
but with significantly less postoperative morbidity and
a shorter hospital stay.810 The surgical management of
GERD sometimes fails, whether performed open or
laparoscopically, and may require reoperation for optimal
results. Failure of open fundoplication occurs in 930 per
cent of patients,3,11,12 whereas published failure rates of
laparoscopic Nissen fundoplication are 217 per cent.6,1316
The lower published rates for laparoscopic surgery probably
Wrong diagnosis
Discussion
References
221
222
224
reflect the fact that laparoscopic fundoplication is a relatively new technique
rather than it being intrinsically better. However, the early adopters of the la
paroscopic
approach were usually more skillful individuals who were
likely to be quite compulsive in the indications and techniques of these operati
ons. Therefore, it is hoped that with
longer follow-up this procedure will reveal its superiority.
Reoperations for failed or recurrent GERD are technically more demanding due to
adhesions from previous surgery and obscured anatomy. The relatively fragile wal
ls of
the esophagus, gastric cardia, and fundus are easily damaged or breached, leadin
g to postoperative leak with potentially lethal complications. In addition, the
recognized and
repaired injury may impair the precise reconstruction
required to obtain a good functional result. Reoperative
anti-reflux surgery has a morbidity and mortality of 440
per cent and 04.9 per cent, respectively.17 The overall clinical results after re
operation even those obtained by experienced surgeons are significantly less fav
orable than
outcomes for first-time repairs. The incidence of unsatisfactory results is at l
east doubled after reoperation.
Furthermore, the greater the number of previous failed
repairs, the greater the incidence of poor results.
CLINICAL PRESENTATION
Dysphagia
Approximately 3040 per cent of patients suffer from
some form of dysphagia in the early postoperative
period. This, however, decreases to approximately five
Pain
Some patients complain of pain, mainly in the lower thoracic region, the epigast
rium or the left shoulder, following fundoplication. This is believed to be due
to suture
placement in the diaphragmatic hiatus, producing referred
pain; it may also be the result of esophageal muscle
spasm. These symptoms can be treated expectantly, and
occasionally they respond to a calcium-channel blocker
such as nifedipine or diltiazem.
Diarrhea
After fundoplication, approximately eight per cent of
patients have diarrhea. The reason for this may be
increased gastric emptying, excessive liquid intake, or a
post-vagotomy effect. In those cases in which the cause is
not clear, gastric-emptying studies or, for completeness
of vagotomy, a sham feeding pancreatic polypeptide test
may help to resolve the question.19 A pyloroplasty is
appropriate when the gastric-emptying study has a halftime of more than 150 minu
tes. Most patients can be
treated effectively with anti-diarrhea medication; only
rarely is surgical intervention, such as the reversal of a
10-cm jejunal loop, necessary.
Alkaline reflux gastritis
Some patients complain of epigastric discomfort in conjunction with their preope
rative complaints of heartburn and acid regurgitation. Careful evaluation of the
se
patients may identify excessive bile in the stomach at
endoscopy and on testing with the Bilitec probe. Twentyfour-hour gastric pH moni
toring and hepatobiliary
scanning with technetium 99 m-labeled derivatives of
iminodiacetic acid to show the presence of radioactive
material in the stomach help to define the problem further. In carefully selecte
d patients, bile-diversion surgery
is useful. The duodenal switch consists of division of the
duodenum at the juncture of the first and second portion
with a roux-en-Y jejunal loop anastomosed to the proximal duodenum in addition t
o a highly selective vagotomy. Medical management using a prokinetic and a
binding agent such as cholestyramine, however, usually
suffices. It is important that the patient is advised
preoperatively of the probability of continued gastric
symptoms after fundoplication.
185
22
9
11
43
Mortality
(%)
3
0
3
4
0
0
4
5
3
0
0
3
2
1
1
0.5
Good/excellenta
(%)
Satisfactoryb
(%)
73
85
81
80
50
94
80
72
67
76
80
86
70
86
80
88
Combined total of excellent and good results; bcombined total of excellent, good
and fair results; fair results imply significant symptoms.
16.6
20
Szwerc et al.(1999)49
15
0
Pointner et al. (1999)50
30
7
Hunter et al. (1999)51
75
8
Awad et al. (2001)52
38
13
Serafini et al. (2001)53
28
7
Frantzides and Carlson (1997)8
OReilly et al. (1997)42
PEH, para-esophageal hernia.
Conversion
(%)
Cause
Dense mediastinal adhesions
Adhesions, bleeding, perforation,
tension pneumothorax
Follow-up
(months)
Intraoperative, 15.8;
postoperative, 21
Postoperative, 100
Intraoperative, 33;
postoperative, 16.6
0
Excellent (84.3)
Mean 13 (range 126)
Excellent (100)
Excellent (100)
Range 414
Range 1242
Good (92.6)
Median 12 (range 348)
Excellent (100)
Excellent (100)
Excellent (73); fair (27)
Not clear
Range 620
Mean 5.7 (range 014)
Excellent (96); fair (4)
Mean 22 (range 160)
Excellent (75); poor (25)
Significant improvement
in wellbeing score
Significant improvement
in symptom score
Significant improvement
in quality of life
Excellent/good (87);
fair/poor (13)
Excellent (65);
fair (21.5); poor (13.5)
Excellent (89);
fair (11)
Not mentioned
17.1 ( 11.8
0
0
Intraoperative, 13.6;
postoperative, 4.5
Intraoperative, 44.4;
postoperative, 44.4
0
Intraoperative, 30.4;
postoperative, 20
0
Intraoperative, 18
Intraoperative, 2.6;
postoperative, 5
Intraoperative, 16;
postoperative, 38
Intraoperative, 46;
postoperative, 21
"3
Median 29 (range 1245)
Not clear
Mean 26.5 (range 4101)
Mean 20 ( 14
34
35
36
37
38
39
40
41
42
43
sensory function of the proximal stomach. Br J Surg 2000; 87:
33843.
Dallemagne B, Weerts JM, Jehaes C, Markiewicz S. Causes of
failures of laparoscopic antireflux operations. Surg Endosc 1996;
10: 30510.
Soper NJ, Dunnegan D. Anatomic fundoplication failure after
laparoscopic antireflux surgery. Ann Surg 1999; 229: 66976.
Frantzides CT, Carlson MA. Prosthetic reinforcement of posterior
cruroplasty during laparoscopic hiatal herniorrhaphy. Surg Endosc
1997; 11: 76971.
Paul MG, DeRosa RP, Petrucci PE. Laparoscopic tension-free repair
of large paraesophageal hernias. Surg Endosc 1997; 11: 3037.
Johnson AB, Oddsodottir M, Hunter JG, et al. Laparoscopic Collis
gastroplasty and Nissen fundoplication. A new technique for the
management of esophageal foreshortening. Surg Endosc 1998;
12: 105560.
Ritter MP, Peters JH, DeMeester TR, et al. Treatment of advanced
gastroesophageal reflux disease with Collis gastroplasty and
Belsey partial fundoplication. Arch Surg 1998; 133: 5239.
Awad ZT, Mittal SK, Roth TA, et al. Esophageal shortening during
the era of laparoscopic surgery. World J Surg 2001; 25: 55861.
Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and
fundoplication for complex reflux problems. Ann Surg 1987;
206: 47381.
Skinner DB. Surgical management of esophageal reflux and hiatal
hernia: long term results with 1,030 patients. J Thorac Cardiovasc
Surg 1967; 53: 3354.
Orringer MB. Long-term results of the Mark IV operation for hiatal
hernia and analyses of recurrences and their treatment. J Thorac
Cardiovasc Surg 1972; 63: 2533.
Hill LD. Management of recurrent hiatal hernia. Arch Surg 1971;
102: 296.
Polk HC. Jejunal interposition for reflux esophagitis and
esophageal stricture unresponsive to valvuloplasty. World J Surg
1980; 4: 731.
Henderson RD, Marryatt G. Recurrent hiatal hernia. Management
by thoracoabdominal total fundoplication gastroplasty. Can J Surg
1981; 24: 1517.
Maher JW, Hocking MP, Woodward ER. Reoperation for
esophagitis following failed antireflux procedures. Ann Surg
1984; 201: 7237.
Little AG, Ferguson MK, Skinner DB. Reoperation for failed
antireflux operations. J Thorac Cardiovasc Surg 1986; 91:
51117.
Stirling MC, Orringer MB. Surgical treatment after the
failed antireflux operation. J Thorac Cardiovasc Surg 1986; 92:
66772.
Pearson FG, Cooper JD, Patterson GA, et al. Gastroplasty and
fundoplication for complex reflux problems. Ann Surg 1987; 206:
47381.
Low DE, Anderson RP, Ilves R, Hill LD. 15 to 20 year results after
the Hill operation. J Thorac Cardiovasc Surg 1989; 98: 444.
Siewert JR, Stein HJ, Feussner H. Reoperations after failed
antireflux procedures. Ann Chir Gynaecol 1995; 84: 122.
Stein HJ, Feussner H, Siewert JR. Failure of antireflux surgery:
causes and management strategies. Am J Surg 1996; 171: 3640.
Ellis FH, Gibb SP, Heatley GJ. Reoperation after failed antireflux
surgery: review of 101 cases. Eur J Cardiothorac Surg 1996;
10: 22533.
Deschamps C, Trastek VF, Allen MS, et al. Long term results after
reoperation for railed antireflux procedures. J Thorac Cardiovasc
Surg 1997; 113: 54551.
OReilly MJ, Mullins S, Reddick EJ. Laparoscopic management of
failed antireflux surgery. Surg Laparosc Endosc 1997; 7: 903.
Watson DI, Jamieson GG, Game PA, et al. Laparoscopic reoperation
following failed antireflux surgery. Br J Surg 1999; 86: 98101.
30
Reoperation for recurrent gastroesophageal
reflux disease
THOMAS R. EUBANKS
Characterizing failure
Patient selection
Operative strategy
227
230
230
Successful reoperative anti-reflux procedures are based
on three principles: precise characterization of the original procedures failure,
appropriate patient selection, and
operative intervention capable of repairing the failure.
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
13.5 per cent of patients,13 thus 5001750 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 charac
terized 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.
Conclusion
References
234
234
Esophagitis confirms uncontrolled acid reflux. A tortuous path of the distal eso
phagus implies abnormalities
of fundoplication position. In some cases, a large paraesophageal hernia can be
documented (Figure 30.1).
CHARACTERIZING FAILURE
The objective assessment of a patient being considered
for reoperative treatment should include endoscopy,
esophagography, esophageal physiological studies, and,
when indicated, solid-phase gastric-emptying studies.
Endoscopy is useful to assess the state of the esophageal
mucosa and the orientation of the fundoplication.
Figure 30.1 Retroflexed view of the gastroesophageal junction
at endoscopy. The lesser curve is at the bottom of the photograph.
The bulging mucosa above the crus is caused by extrinsic
compression of the heart on the herniated stomach. This is a
large para-esophageal hernia after an anti-reflux operation.
previously dissected mediastinal esophagus, the fundus should be freed from the
cardioesophageal junction. With the bougie still in place,
the surgeon elevates the right aspect of the fundoplication while the assistant
provides counter-traction on the
cardia and the anterior vagus. The right portion of the
(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)
fundus is freed from the anterior aspect of the cardia and
esophagus, preserving the anterior vagus (Figure 30.11).
This dissection is carried as far posteriorly as possible.
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
space, the entire fundus and gastric body are freed from
the hiatal defect (Figure 30.12).
Dissection of the left aspect of the fundoplication does
not involve as much work as the right aspect, but it is just
as important. The assistant provides the traction on the
fundus and the surgeon provides the traction on the
Figure 30.12 Series of photographs demonstrating the extent
of stomach herniation. The grasper in (a) remains attached to
the same portion of stomach throughout the series. The hiatal
defect can be appreciated in (c).
cardia. Once the fundus is restored to its anatomical position, the cardiac notc
h should be clearly identifiable, as
should the smooth transition from the right edge of the
esophagus to the lesser curve of the stomach. Hopefully,
the anterior and posterior vagii are visible and intact.
With traction applied to the esophagus using surgical
tubing, the esophagus is mobilized from its mediastinal
31
Results of laparoscopic treatment
of hiatal hernias
PATRICK R. REARDON AND STIRLING E. CRAIG
Type I hiatal hernia repair
Types II, III and IV hiatal hernia repair
235
236
Four types of hiatal hernias exist. With type I or sliding
hiatal hernias, the most common type, the gastroesophageal junction is displaced
cranially into the chest. Type II
and type III hiatal hernias are para-esophageal hernias. In
type II hiatal hernias, the gastroesophageal junction is in its
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
mixed para-esophageal hernias. In these hiatal hernias,
both the gastroesophageal junction and a large portion of
the stomach have rolled into the mediastinum. Type IV
hiatal hernias include the spleen, the colon, or some other
intra-abdominal organ within the hernia.
When discussing outcomes for laparoscopic repair of
hiatal hernias, the results should focus on two groups of
patients. The first group comprises patients with type I
hiatal hernias, which account for 9095 per cent of all
hiatal hernias. These hernias are generally asymptomatic
and do not require repair. They are repaired primarily as
part of a fundoplication to treat gastroesophageal reflux
disease. Most surgeons mobilize the distal esophagus in
order to achieve intra-abdominal esophageal length. This
process destroys the phreno-esophageal ligament. At this
point, the anatomy resembles the anatomy in the repair of
a small type I hiatal hernia. Therefore, the outcomes for
the repair of these hernias are essentially the same as outcomes for laparoscopi
c 360-degree fundoplication. The
second group comprises patients with types II, III or IV
hiatal hernias. These tend to be larger hernias occurring
in an older patient population and have different outcomes. In an online PubMed
literature search using the
keywords hiatal hernia and laparoscopic, 220 citations
References
237
were returned. There were no results that dealt specifically
with type I hiatal hernias. There were multiple articles on
type II, type III, and giant hiatal hernias.
TYPE I HIATAL HERNIA REPAIR
Intraoperative complications reported during laparoscopic
360-degree fundoplication include esophageal perforation,13 gastric perforation,1
,2 pneumothorax,2 bleeding,2
and conversion to open procedure.24 These complications
should not be affected by small hiatal hernias. The intraoperative complications
of type I hiatal hernia repair are
outlined in Table 31.1. Postoperative complications include
1.09
7.4,18 2.321
0.8,32 0.512
2.0,9 0.512
4.621
1.09
1.333
2.715
3.6,13 10.0,14 8.0,8 1.0,9
3.5,10 1.112
2.4,32 0.512
GERD symptoms
Early satiety
Gas bloat
Hyperflatulence
Mediastinal seroma
Transient cervical emphysema
Breast mastalgia
Pneumothorax
Atelectasis
Pneumonia
ARDS
Pleural effusion
Respiratory failure
Deep vein thrombosis
Pulmonary embolus
Myocardial infarction
Atrial fibrillation
Cardiac arrhythmia
Congestive heart failure
Cardiac tamponade
Stroke
Hematoma
Hemothorax
Bleeding
Retroperitoneal bleeding
Need for transfusion
Urinary retention
Transient renal failure
Urinary-tract infection
Mediastinal abscess
Intra-abdominal abscess
Wound infection
Clostridium difficile colitis
Fever of unknown origin
Incisional hernia
Postoperative herniation
Death
Superscript figures indicate references.
achieve a tension-free repair. Recently, there have been
increasing reports in the literature of the use of mesh in an
attempt to decrease the recurrence rate following repairs of
hiatal hernias.16,2028 The mesh may be placed centrally as a
bolster to an already closed hiatus.16,23,26,28 The mesh may
be used to span the hiatal defect to create a truly tensionfree repair.16,20,29
The mesh may also be used to close a
relaxing incision placed laterally in the tendinous
diaphragm.
32
Complications and their management
SANTIAGO HORGAN AND ROBERT BERGER
Intraoperative complications
Postoperative complications
239
243
Numerous reports detail the benefits of laparoscopic fundoplication, including d
ecreased pain, quicker return to
normal daily activities, and shorter hospital stay. However,
there are also complications related to the treatment of
gastroesophageal reflux disease (GERD). Mortality reports
range from zero to two per cent for initial repairs, increasing to five per cent
for second operations.1,2 The morbidity, and likewise failure, of laparoscopic
fundoplication is
dependent on its definition and length of follow-up. Most
large, single-institution studies report morbidities of two
to 26 per cent, with specific identification of failed surgery
occurring in four to eight per cent.24 Table 32.1 displays
the reported causes and frequencies of these failures (see
also Chapter 29). This chapter discusses the more common intraoperative and post
operative complications associated with laparoscopic fundoplication, their preve
ntion,
the appropriate work-up for their diagnosis, and the
appropriate course of action. In addition, any reoperation,
whether laparoscopic or open, is known to have a higher
incidence of complications as well as a higher risk of
recurrence.57 It should be stressed that conversion from a
laparoscopic to open surgery for patient safety should not
be considered a complication if performed at the appropriate time.
INTRAOPERATIVE COMPLICATIONS
The ability to adequately visualize and identify the anatomy
required for performance of a Nissen fundoplication
cannot be overemphasized. These concepts are discussed
elsewhere and will not be re-addressed here. It is prudent,
however, to state that our typical fundoplication is performed using a left crus
approach, as described by Horgan
Conclusion
References
247
247
and Pellegrini.8 The left crus is initially identified, and the
short gastric vessels are divided using an ultrasonic shears.
A no-touch technique for esophageal dissection is used to
minimize traumatic manipulation of the esophagus. This
requires the crura to be separated from the esophagus, and
not vice versa. After visualizing the right crura, circumferential dissection of
the esophagus proceeds cephalad while
using a Penrose drain to manipulate the esophagus.
The posterior crura should be re-approximated with interrupted, nonabsorbable su
tures to create a snug fit over a
56 French Maloney bougie placed within the esophagus.
A short, floppy, 2-cm fundoplication with three sutures is
et restrictions and activity limitations will avert many from overzealous eating
or
exercising. During questioning, often the surgeon can
identify whether the patient has eaten certain foods
(breads, meats, raw vegetables) at too early a time and
may be experiencing obstruction, or whether they have
overexerted themselves (weight-lifting, heavy manual
labor, etc.) too early (before two months). For patients
who complain of these symptoms, the easiest and most
prudent study to obtain is a barium swallow. This reveals
the anatomy responsible for the majority of early complications. If the barium s
wallow study is equivocal, then
it is reasonable to undertake an EGD examination if the
symptoms persist after six to eight weeks. Repeat studies
of 24-hour pH monitoring and esophageal manometry
may be pursued if the symptoms of reflux, asthma,
cough or hoarseness persist after a trial of antisecretory
medication. Finally, persistent gastric bloating may
necessitate gastric emptying studies.
Bloating/nausea/epigastric pain/increased
flatulence
A majority of patients will return to the clinic with specific
complaints of feeling bloated, occasional nausea, epigastric pain, and generally
an increased incidence of flatulence. This is due to the patients habit of swall
owing saliva
and air to neutralize the presence of acid in the esophagus.
Once a fundoplication is performed, this air progresses
through the bowel rather than retrograde through the
esophagus, as before surgery. This is an expected event
postoperatively. Because of this, it is important to inform
the patient in preoperative counseling to decrease anxiety
levels when it does occur. Most patients will have significant improvement in th
ese symptoms with just several
weeks of expectant management, which includes a critical
review of their current diet. One important question to
ask patients postoperatively is whether their symptoms of
reflux have been treated. Often, reflux patients are of the
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
or the patient has persistent nausea and vomiting, then
the surgeon should obtain a barium swallow as an initial
diagnostic test to evaluate the post-surgical anatomy. If
no gross abnormality is seen, an EGD may be warranted.
Some patients will self-medicate with previous antacids
or proton-pump inhibitors as they are almost dependent
most cases are probably the result of inadequate preoperative evaluation. Treatm
ent for achalasia is dilation,
botulism toxin injection, or cardiomyotomy. If a surgical
cure is undertaken, then the fundoplication will need to
be taken down completely, cardiomyotomy performed,
and a partial fundoplication carried out.
Radiographic evidence of a wrap that is too tight is
best appreciated with a barium marshmallow-swallow
study. Liquids may pass easily through the wrap, but
foods with thicker consistency may become lodged above
the wrap. The best therapy is an initial attempt at dilation using either pneuma
tic dilatation or bougies of an
increasing diameter. Most frequently, this will be successful if the complaint o
f dysphagia presents within the first
three months. If the complaint of dysphagia arises more
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 dysphagia following fundoplicat
ion. If the crura are approximated
too tightly, then complaints will be almost immediate following surgery. Several
authors have reported scarring at
the hiatal opening, causing a stricture seen on postoperative barium swallow.17
It is suspected that the use of
diathermy near the diaphragm is the source of injury.
Treatment involves surgical incision of the scarred
diaphragm to release the tension at this site.
Complications arising more than 30 days after successful fundoplication may orig
inate from anatomical
failure or from functional problems. Anatomical failures
include essentially the same difficulties listed above, in
the early categories. Regardless of the timing of presentation, a barium swallow s
hould be the first test obtained,
followed by esophageal manometry, 24-hour pH studies,
or EGD, depending upon the symptoms of the patient.
The management of these problems is similar to those
presented above.
Recurrent reflux
Patients who return with complaints of persistent or
unrelenting reflux warrant a thorough work-up to
ensure adequate anatomical integrity and functional
success of the fundoplication. Again, start with a barium
swallow study to assess anatomical changes and any evidence of herniation of the
stomach or the wrap itself. If
this appears normal, then a 24-hour pH study may show
objective data relative to a functional failure of the fundoplication. Finally,
EGD may show persistent irritation
of the esophagus from refluxate as well as confirm proper
PART
5
Laparoscopy in the pediatric
hernia patient
33 History
34 Anatomy and physiology
251
255
35 Diaphragmatic herniation
36 Complications and their management
257
261
33
History
RAJEEV PRASAD AND THOM E. LOBE
Pediatric laparoscopy
Laparoscopic exploration of the contralateral groin
251
251
Laparoscopy in pediatric hernia patients has undergone
a rapid, albeit delayed, evolution. While laparoscopic
herniorrhaphy was being popularized in adults, the
approach was considered to be cumbersome, unnecessary, and even contraindicated
in children. The perception that a child would outgrow the repair, particularly
one involving mesh, dominated early thoughts about the
laparoscopic approach. Other considerations, such as the
physiological stress of laparoscopy in infants and children
and the size and availability of appropriate instruments,
initially precluded pediatric laparoscopic herniorrhaphy.
However, once these barriers were overcome in other
pediatric surgical maladies, it was inevitable that herniorrhaphy would be revis
ited. With steady progress, pediatric
surgeons have applied their endoscopic skills to pediatric
hernia patients, and today many surgeons prefer this
approach for the repair of inguinal, ventral and diaphragmatic hernias in infant
s and children.
PEDIATRIC LAPAROSCOPY
Gans and Berci were among the first to describe
laparoscopy in pediatric patients when they published
their experience with visualization of the contents of the
peritoneal cavity by means of a small telescope introduced
through the anterior abdominal wall after establishment
of pneumoperitoneum.1 Since then, this approach has
been rediscovered. New instruments and techniques have
been developed, and there is a greater understanding of
the physiological impact of pneumoperitoneum in infants
and children.
Laparoscopy in general has experienced a huge
growth in its application in pediatric surgery. This is a
Laparoscopic inguinal herniorrhaphy
References
252
254
relatively recent advance. While initially used solely for
diagnosis, its use has expanded. It is now used routinely
for cholecystectomy, appendectomy and pyloromyotomy, as well as more complex pro
cedures, including
fundoplication, colectomy, and pull-through procedures
for Hirschsprungs disease and high imperforate anus.
Initially, herniorrhaphy was not considered an appropriate laparoscopic procedur
e in infants and children.
Pediatric surgeons believed that a child would outgrow
herniorrhaphy as it was applied in adults because the
child had not reached its full development and size. Also,
the physiological impact of the procedure in infants and
n, the
procedure was limited to girls to avoid the risk of possible damage to the sperm
atic cord in boys.
Montupet and Esposito were the first to report
successful laparoscopic herniorrhaphy in boys.16 They
specifically applied the laparoscopic approach to boys to
avoid the risks of inadvertent removal of a segment of the
vas deferens, as well as the possible risk of testicular damage (atrophy or high
position in the scrotum), which can
occur with the traditional open repair. In their series, 45
boys underwent laparoscopic repair in which an intracorporeal purse-string sutur
e was placed around the
neck of the hernia sac. There were no intraoperative or
post-surgical complications, but two patients developed
a recurrent hernia that required a second laparoscopic
repair. Schier reported his further experience of laparoscopic hernia repair in
2000, concluding that the technique was simple for the experienced laparoscopist
, that
cosmesis was superb, and that the procedure was safe in
both sexes.17
Other reports have described the utility of laparoscopy
for direct inguinal hernias and suspected recurrent hernias.18,19 Schier reporte
d that the laparoscopic approach
allowed for easier detection of direct hernias as compared
with the traditional open approach. Out of 109 patients,
five (4.5 per cent) had a direct inguinal hernia. Most of
these hernias were in boys and were on the right side. The
prevalence of direct hernias was higher in this series as
compared with the traditionally accepted rate (0.20.9
per cent) based on two large series of open hernia
repairs,20,21 suggesting that direct hernias may go unrecognized during open rep
air, and that these cases may
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
than open surgery as it is unlikely that an incorrect diagnosis will be made usi
ng laparoscopy. Regarding recurrent hernias, Perlstein and Du Bois noted that 44
per
cent of children undergoing laparoscopy for recurrent
inguinal hernias were found to have unsuspected findings, including indirect (mi
ssed sacs and true recurrences), direct (unilateral and bilateral), and femoral
(all
bilateral) defects.19
Innovative techniques have recently been described for
use in pediatric laparoscopic inguinal hernia surgery. Endo
and Ukiyama introduced the endo-needle, a 19-gauge
hollow needle with a notched tip and pre-attached suture
designed specifically for laparoscopic extraperitoneal
closure of the patent processus vaginalis.22 They used this
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.
Figure 33.2 Close-up view of the ligature-passer used in
laparoscopic herniorrhaphy.
recurrences. Lee and Liang performed micro-laparoscopic
high ligation in 450 patients, with good results.23 They
reported no complications of the surgery and a remarkably low recurrence rate (0
.88 per cent).
In 2001, we began to use a unique technique using
miniature laparoscopic equipment in which a curved
stainless steel awl is used to pass a ligature circumferentially around the neck
of the hernia sac. A 1.7-mm needle
scope is introduced through a 2-mm port in or near the
umbilicus, and the abdomen is insufflated with carbon
dioxide gas to 12 mmHg (Figure 33.1). We place a second
2-mm port in the right lateral abdomen. We find this position to be the most use
ful for traction for both right- and
left-sided hernias. A 1.7-mm laparoscopic grasper, placed
through this second port, is used to manipulate the peritoneum near the hernia d
efect (right and/or left sides).
The suture-passer (Figure 33.2), introduced through a
stab incision anterolateral to the internal ring, is used to
place a 2-0 nonabsorbable ligature circumferentially at the
neck of the hernia sac. To accomplish this, the suturepasser, with the tie in pl
ace through its eyelet, is passed
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
instrument using the grasper so that it can be withdrawn
externally. The ligature is tied extracorporeally, completing
an extraperitoneal high ligation of the sac (Figure 33.4).
The vas deferens and spermatic vessels are seen easily during the ligature place
ment in males, and it is a relatively
straightforward task to find the tissue plane between
these structures and the hernia sac, ensuring that they
are not included in the ligature. After cutting the excess
suture, the knot retracts subcutaneously. Steri-Strips
(3M Healthcare) are all that are required for skin closure.
The technique adheres to the essential principles of
hernia surgery. We reliably identify and ligate the hernia sac at the level of t
he internal ring. Additionally, there
is no disruption of the tissues of the inguinal canal.
In males, the spermatic vessels and vas deferens are well
visualized during the circumferential passage of the
22
23
Powell RW. Intraoperative diagnostic pneumoperitoneum in
pediatric patients with unilateral inguinal hernias: the Goldstein
test. J Pediatr Surg 1985; 20: 41821.
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: 44851.
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: 41518.
Brown RK. Hernia diagnosis by transperitoneal probing of the
contralateral groin. Surg Gynecol Obstet 1964; 118: 123.
Lobe TE, Schropp KP. Inguinal hernias in pediatrics: initial
experience with laparoscopic inguinal exploration of the
asymptomatic contralateral side. J Laparoendosc Surg 1992;
2: 13540.
Wolf SA, Hopkins JW. Laparoscopic incidence of patent processus
vaginalis in boys with clinical unilateral inguinal hernias. J Pediatr
Surg 1994; 29: 111821.
Chu C, Chou C, Hsu T, et al. Intraoperative laparoscopy in
unilateral hernia repair to detect a contralateral patent processus
vaginalis. Pediatr Surg Int 1993; 8: 3858.
Feunfer MM, Pitts RM, Georgeson KE. Laparoscopic exploration
of the contralateral groin in children: an improved technique.
J Laparoendosc Surg 1996; 6 (suppl 1): S14.
Zitsman JL. Transinguinal diagnostic laparoscopy in pediatric
inguinal hernia. J Laparoendosc Surg 1996; 6 (suppl 1): S1520.
Saad SA, Goldfarb MA, Danikas D. Groin laparoscopy in pediatric
patients with clinical unilateral hernia: an improved technique
using the bronchoscope. Pediatr Endosurg Innov Tech 1999;
3: 5965.
El-Gohary MA. Laparoscopic ligation of inguinal hernia in girls.
Pediatr Endosurg Innov Tech 1997; 1: 1858.
Schier F. Laparoscopic herniorrhaphy in girls. J Pediatr Surg 1998;
33: 14957.
Montupet P, Esposito C. Laparoscopic treatment of congenital
inguinal hernia in children. J Pediatr Surg 1999; 34: 4203.
Schier F. Laparoscopic surgery of inguinal hernias in children
initial experience. J Pediatr Surg 2000; 35: 13315.
Schier F. Direct inguinal hernias in children: laparoscopic aspects.
Pediatr Surg Int 2000; 16: 5624.
Perlstein J, Du Bois JJ. The role of laparoscopy in the management
of suspected recurrent pediatric hernias. J Pediatr Surg 2000;
35: 12058.
Fonkalsrud EW, de Lorimier AA, Clatworthy HW. Femoral and
direct hernias in infants and children. JAMA 1965; 192: 1013.
Wright JE. Direct inguinal hernia in infancy and childhood.
Pediatr Surg Int 1994; 9: 1613.
Endo M, Ukiyama E. Laparoscopic closure of patent processus
vaginalis in girls with inguinal hernia using specially devised
suture needle. Pediatr Endosurg Innov Tech 2001; 5: 18791.
Lee Y, Liang J. Experience with 450 cases of micro-laparoscopic
herniotomy in infants and children. Pediatr Endosurg Innov Tech
2002; 6: 258.
34
Anatomy and physiology
RAJEEV PRASAD AND THOM E. LOBE
Anatomy
Physiology
255
255
ANATOMY
A comprehensive review of the anatomy of the inguinal
canal is beyond the scope of this chapter. Chapter 6
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
the context of laparoscopy. The layers of the abdominal
wall must be traversed during port placement. The initial
port that we place is the infra-umbilical port through
which the 1.7-mm telescope is placed. We choose to place
this in an infra-umbilical position to reduce the risk of
infection. Ideally, the port traverses the midline. The fascia
of the external abdominal oblique, internal abdominal
oblique, and transversus abdominus muscles, which join
anterior to the rectus muscles inferior to the arcuate line,
are penetrated. The urachus, or median umbilical ligament, is in this area and s
hould be avoided. The lateral
port, through which a grasper is placed for traction,
traverses the same muscles. Structures near the internal
inguinal ring, where the hernia sac is ligated, must be considered. In our techn
ique, the suture is passed through all
layers of the abdominal wall that are superficial to the peritoneum or hernia sa
c. In males, the spermatic vessels, the
genital branch of the genitofemoral nerve, and the vas deferens pass superficial
to the sac, and great care is taken not
to include these structures in the ligature. The external
iliac vessels are near but deep to the ligature. They should
be visualized and, obviously, avoided. Similarly, the inferior epigastric vessel
s, which are branches of the external
iliac vessels, are easily identified and avoided. Once tied
and cut, the permanent suture that we use to perform the
high ligation of the sac retracts into the subcutaneous
References
256
tissue and has not caused any wound complications in our
experience.
PHYSIOLOGY
Physiological factors to consider during pediatric laparoscopic hernia surgery a
re essentially identical to those for
any other intra-abdominal laparoscopic procedures performed in children. The car
diovascular and respiratory
effects of pneumoperitoneum are the issues that most
often raise interest for the surgeon and anesthesiologist
alike. The extremes of patient positioning, postoperative
pain management, and postoperative nausea and vomiting also deserve consideratio
n.
Insufflation of carbon dioxide gas is essential for
35
Diaphragmatic herniation
RAJEEV PRASAD AND THOM E. LOBE
History
Patient selection
Surgical technique: Bochdalek hernia
257
257
257
HISTORY
In 1848, the anatomist Vincent Bochdalek described
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.
Thereafter, there was a steady increase in the success of
repair of diaphragmatic hernias up to the 1970s, when
survival reached a plateau and the physiological effects
of persistent pulmonary hypertension and bilateral pulmonary hypoplasia were bet
ter appreciated. Since then,
there has been slower progress in the surgical approach to
this disease. The greatest advance has been with the application of extracorpore
al membrane oxygenation (ECMO).
The most significant change in the postnatal management
of diaphragmatic hernias since ECMO has been the advent
of minimally invasive techniques of repair. In 1995, van
der Zee and Bax described the laparoscopic repair of a
posterolateral diaphragmatic hernia in a six-month old
infant.1 Since then, anterior Morgagni and posterolateral
Bochdalek defects have been treated with minimally invasive techniques by experi
enced laparoscopists in stable, less
critically ill infants.
PATIENT SELECTION
The minimally invasive approach to diaphragmatic hernias should be considered on
ly in infants who are hemodynamically stable, who are without signs of pulmonary
Surgical technique: Morgagni hernia
Results
References
258
259
259
hypertension, and who are on either oxygen by nasal cannula or minimal conventio
nal ventilator settings. Older
children who present either incidentally or with minimal
symptoms are also suitable candidates.2
SURGICAL TECHNIQUE: BOCHDALEK
HERNIA
Posterolateral Bochdalek hernias may be approached
through either the chest or the abdomen, depending on
the preference of the surgeon. Supporters of the thoracoscopic route state that
the herniated viscera are reduced
easily with carbon dioxide insufflation.3,4 Those who
support the laparoscopic approach state that the instruments are manipulated mor
36
Complications and their management
RAJEEV PRASAD AND THOM E. LOBE
Anesthetic complications
Surgical complications
Recurrence
261
261
262
ANESTHETIC COMPLICATIONS
Anesthetic complications include deleterious cardiovascular and respiratory effe
cts, such as decreased cardiac
output, hypercapnea, shunting and atelectasis due to peritoneal insufflation, an
d the extremes of patient positioning.1 Premedication, which includes the use of
atropine,
may alleviate these effects. The choice of anesthetic agent
may differ in laparoscopic hernia surgery. For instance,
nitrous oxide is avoided due to the increased incidence of
bowel distention, which will obscure the view during
laparoscopy. A balanced anesthetic technique using controlled ventilation with i
nhalation agents (sevoflurane,
desflurane or isoflurane), intravenous opioids, and nondepolarizing muscle relax
ants is preferred.2 Patient selection is important, and those patients at greate
r risk than
usual for the above complications, such as premature
infants or children with cardiopulmonary disease, should
not be considered for laparoscopic herniorrhaphy.
SURGICAL COMPLICATIONS
Adherence to meticulous technique is the best way to
prevent surgical complications. The laparoscopist should
consider their experience and level of comfort before
embarking on or continuing difficult operations. One
should attempt more complex operations only after simpler operations are mastere
d. Also, one should always
consider the option to open when difficulty is encountered. Of course, this poss
ibility should always be presented to the patient and family preoperatively.
Hydrocele and testicular atrophy
References
262
262
Chen and colleagues reviewed the surgical complications that occurred in all pat
ients undergoing laparoscopy
or thoracoscopy over a five-year period.3 Thoracoscopy
was performed in 62 children, with a 13 per cent rate
of conversion to thoracotomy, and laparoscopy was
performed in 574 children, with a 2.6 per cent rate of
conversion to laparotomy. The reasons for conversion to
laparotomy included hemorrhage, esophagotomy during
fundoplication, and malpositioned fundoplication. A case
of a gastric volvulus after fundoplication and gastrostomy
required a laparotomy in the postoperative period and
was the result of a malpositioned gastrostomy tube. Other
complications in the postoperative period included two
PART
6
Future considerations
37 Robotics and hernia surgery
265
38 Socioeconomic issues
273
37
Robotics and hernia surgery
AMIT TRIVEDI AND GARTH H. BALLANTYNE
AESOP robotic arm
Da Vinci and Zeus tele-robotic systems
Tele-robotic laparoscopic ventral and
incisional hernia repair
265
268
Conclusion
References
272
272
270
Over the past several years, there has been an ever-increasing presence of robot
ics in the operating room. These
devices have been designed to help the surgeon overcome
the limitations of conventional open surgery and laparoscopic surgery. These lim
itations range from the decreasing availability of qualified surgical assistants
, through the
limited dexterity offered by conventional laparoscopic
instruments, to the lack of a three-dimensional operating
field.1 The potential advantages of such systems set the
stage for the next major change in the field of surgery. As
availability increases and costs decline, proficiency with
such devices will be required by all future generations of
surgeons. Additionally, the demands of patients for a
robotic operation are expected to increase as more media
attention is placed on this technology.
Currently there are three Food and Drug Administration (FDA)-approved devices on
the market that facilitate
surgery: the AESOP robotic arm (Computer Motion,
Inc.), the da Vinci tele-robotic system (Intuitive Surgical),
and the Zeus tele-robotic system (Computer Motion
Inc.). The use of these devices has a definite learning
curve that often deters busy surgeons from investing the
time required to become proficient in this technology.2
This chapter aims to serve as an introduction to the use
of robotic devices in laparoscopic hernia surgery by outlining the potential adv
antages of the technology. The
aforementioned devices have been used in inguinal, ventral and diaphragmatic her
nias. The frequency with which
these cases are encountered by the general surgeon makes
hernia surgery an ideal platform on which to develop and
refine the skills needed to perform more challenging cases
with the use of robotics.
AESOP ROBOTIC ARM
The AESOP robotic arm uses proprietary speechrecognition technology as the inter
face between the surgeon and the robotic arm. Simple voice commands are
used to direct the field of view of the laparoscope. The
advantages of this technology include 24-hour availability, thereby eliminating
the need for an assistant to hold
(b)
Figure 37.9 Robotic scissors and atraumatic Cadierre grasper.
The adhesions are divided with robotic instruments. The Cadiere
grasper retracts the bowel, and the adhesions to the abdominal
wall are divided with scissors.
Figure 37.10 Passing sutures through the abdominal wall to fix
the dual-sided mesh in place. The da Vincis stereoscopic view
facilitates passing the sutures. A suture-passer drags the sutures
through the abdominal wall (a). Two robotic graspers are used to
hand the sutures to and from the suture-passer (b).
6
7
8
Many surgeons perform advanced laparoscopic operations with standard twentieth-c
entury technologies.
Nonetheless, standard laparoscopy presents certain
limitations that impede the learning of advanced skills
and prevent many surgeons from performing advanced
laparoscopic operations. Robotics offers technological
solutions to some of these shortcomings. We have found
that AESOP provides a stable camera platform, maintains
a stable relationship with the horizon, adequately replaces
a human camera-holder, and lets the surgeon stand in an
ergonomically comfortable position. Voice-control systems help to integrate the
operating room and to keep the
surgeon in control of an ever more complicated operating
environment. In our hospital, robot-assisted laparoscopic
pre-peritoneal inguinal hernia repair in an integrated
operating room is our standard of care. We believe that
this technique permits the surgeon the best opportunity
to replicate the operation in a high-volume mode with
excellent clinical outcomes.
9
10
11
12
13
14
15
Ballantyne GH. The pitfalls of laparoscopic surgery: challenges for
robotics and telerobotic surgery. Surg Laparosc Endosc Percutan
Tech 2002; 12: 15.
Talamini MA. Surgery in the 21 century [editorial]. Ann Surg 2001;
234: 89.
Fan P. Surgical grand rounds presentation: laparoscopic hernia
repair. Hackensack University Medical Center, April 3, 2001.
Merola S, Weber P, Wasielewski A, Ballantyne GH. Comparison of
laparoscopic colectomy with and without the aid of a robotic
camera holder. Surg Laparosc Endosc Percutan Tech 2002; 12:
4651.
Felix EL. Laparoscopic extraperitoneal hernia repair. In: Eubanks
SW, ed. Mastery of Endoscopic and Laparoscopic Surgery.
Philadelphia: Lippincott Williams & Wilkins, 2000: 44355.
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: 47181.
Marescaux J, Leroy J, Gagner M, et al. Transatlantic robot-assisted
telesurgery. Nature 2001; 413: 37980.
Ballantyne GH, Kelley WE, Jr. Granting clinical privileges for
telerobotic surgery. Surg Laparosc Endosc Percutan Tech 2002;
12: 1725.
Hourmont K, Pereira S, Wasielewski A, et al. Robotic versus
telerobotic laparoscopic cholecystectomy: duration of surgery and
outcomes. Surg Clin North Am 2003; in press.
Cadiere GB, Himpens J, Vertruyen M, Favretti F. The worlds first
obesity surgery performed by a surgeon at a distance. Obes Surg
1999; 9: 2069.
Cadiere GB, Himpens J, Vertruyen M, et al. Evaluation of
telesurgical (robotic) Nissen fundoplication. Surg Endosc 2001;
15: 91823.
Gould JC, Melvin WS. Computer-assisted robotic antireflux
surgery. Surg Laparosc Endosc Percutan Tech 2002; 12: 269.
Shah J, Rockall T, Darzi A. Robot-assisted laparoscopic Hellers
cardiomyotomy. Surg Laparosc Endosc Percutan Tech 2002; 12:
3032.
Horgan S, Vanuno D, Benedetti E. Early experience with robotically
assisted laparoscopic donor nephrectomy. Surg Laparosc Endosc
Percutan Tech 2002; 12: 6470.
Ballantyne GH, Hourmont K, Wasielewski A. Telerobotic
laparoscopic repair of incisional ventral hernias using intraperitoneal prosthet
ic mesh (Stoppa technique): report of two
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
Economics of day-case surgery
Incentives and day-case hernioplasty
Return to normal activity and work
274
275
276
276
Economic evaluations of new and existing healthcare
interventions are an essential input into decision-making.
Healthcare systems around the world face steady increases
in expenditure as a result of demographic change and
improvements in medical technology. Increasingly, payers
must choose which interventions will be provided and
which will not be reimbursed from limited public or private funds. This creates
difficult choices, as systems are no
longer limited by what is technically possible to improve
the health of patients but by what is practically possible
given resource constraints. In a situation where resources
are scarce, all choices about who will be treated have an
opportunity cost the value of the benefit foregone. Health
economics and the techniques of economic evaluation aim
to maximize the amount of health that is produced within
the scarce resources available. In the UK, the National
Institute for Clinical Excellence (NICE) synthesizes evidence and reaches a judg
ment as to whether on balance the
intervention can be recommended as a cost-effective use of
National Health Service (NHS) resources.1 In 2000, NICE
published recommendations for the use of laparoscopic
hernia surgery. It recommended its use outside centers of
expertise only in cases of bilateral inguinal hernia or recurrent inguinal herni
a. In the UK in 1996, approximately ten
per cent of hernia repairs were carried out laparoscopically.2 Since the publica
tion of the NICE guidelines, this figure has decreased dramatically and supports
the concept
that the application of clinical pathways can reduce costs.
Such measures are important in the UK, where the numbers of medical staff and th
e annual NHS budget are well
below those in other European countries, Organization for
Economics of laparoscopic surgery
Payment changes
Conclusion
References
278
280
281
281
Economic Cooperation and Development (OECD) countries, and the USA.3
It is no longer sufficient to consider the clinical or
therapeutic effects of healthcare interventions: purchasing
choices will be predicated on studies that identify, measure
7299*
N/A
N/A
N/A
12 461
*Statistically significant difference.
Laparoscopic
repair
70211*
45170
30180
18225
N/A
128.5*
95.4
87
58
N/A
N/A
117*
115*
N/A
0.53*
1.6
3.4*
2.23*
1.7
0.8*
15
17.9*
10
N/A
1
11
0
2.5
4.8
35555235*
N/A
N/A
N/A
532311 223
4395*
N/A
N/A
N/A
8273
Ref.
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
54
55
53
56
16
PAYMENT CHANGES
Despite the points discussed above, the financial realities
of governmental reimbursement in the USA have declined
continuously. We selected the comparison of the payments
from Medicare in the USA since 1993 for four hernia operations (Figure 38.1). Un
less noted otherwise, all of these
are inguinal hernia repairs. It is readily apparent that these
levels of payment have not changed significantly in nine
years. These payments do not reflect the inflationary
increases in office overheads and the enormous elevations
in the cost of medical liability insurance. Additionally, the
payment for the repair of bilateral inguinal hernias is 1.5
times the payment for the repair of a single hernia. Because
of this, some surgeons simply cannot afford to repair bilateral hernias at the s
ame time. Instead, these are repaired
sequentially in two separate procedures. It is particularly
disturbing that payment for the repair of an incisional
hernia (US$636.69) is less than the repair of a recurrent
incarcerated inguinal hernia (US$644.07). The differences
US dollars
Table 38.1 Results of comparative analysis of open and
laparoscopic incisional and ventral herniorrhaphy
evaluated the cost of the repair.16,54 In both papers, the
laparoscopic method was associated with less cost than
the open repair. This is based primarily upon the
Recurrent
incarcerated
Incisional
Laparoscopic
inguinal
Laparoscopic
recurrent
inguinal
Figure 38.1 Medicare reimbursement in real dollar values
from 1993 to 2002.